bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P247: Dietary Intake and Peripheral Arterial Disease Incidence in Middle Aged Adults: the Atherosclerosis Risk in Communities Study (ARIC)
Authors: Ogilvie Rachel P , Lutsey Pamela L , Heiss Gerardo , Folsom Aaron R , Steffen Lyn M
Published: July 2021

Background:
Peripheral arterial disease (PAD) is a costly source of morbidity and mortality among older persons in the United States. Dietary intake plays a role in the development of atherosclerotic cardiovascular disease; however, few studies have examined the relation of food intake or diet patterns with PAD.

Objectives:
We examined the relationship between habitual dietary intake at midlife and incident PAD over approximately 20 years of follow-up.

Methods:
Among 14,082 participants enrolled in the Atherosclerosis Risk in Communities (ARIC) study initially free of PAD, dietary intake was assessed at baseline in 1987-1989 using a Harvard food frequency questionnaire. Food groups were created and principal components analysis was used to develop “healthy” and “Western” dietary patterns; both were categorized into quintiles or quartiles. Incident PAD was defined by an ankle-brachial index (ABI) measure of < 0.90 at either of two subsequent exams (1993-1995, 1996-1998), or a hospital discharge diagnosis of PAD, leg amputation, or leg revascularization procedures through 2012. Cox proportional hazards models adjusted for relevant confounders assessed the relations of each food group or diet pattern with incident PAD.

Results:
During a mean follow up of 19.9 years, 1569 participants developed incident PAD. A total of 64.7% of cases had their incident event defined via ICD-9 codes, while 35.3% had incident PAD defined by ABI. In models adjusted for demographics, behaviors, and food groups, the hazard ratios for incident PAD increased across quintiles of meat consumption (Q2 vs. Q1 1.38 [95% CI 1.16, 1.64], Q3 vs. Q1 1.40 [1.18, 1.67], Q4 vs. Q1 1.47 [1.23, 1.77], Q5 vs. Q1 1.66 [1.36, 2.03], p for trend <0.001). Compared to those who drank no alcohol, those who had 1-6 drinks per week had a lower risk of incident PAD (HR=0.78 [95% CI 0.68, 0.89]). For coffee, there was a modest inverse association with incident PAD (Q5 vs. Q1 0.84 [0.75, 1.00], p for trend = 0.014). There was no association between other food groups or patterns and incident PAD.

Conclusions:
In this prospective population-based cohort study, greater meat consumption was associated with higher risk of incident PAD, while both moderate alcohol consumption and coffee consumption were associated with lower risk of incident PAD. Whether these associations are causal remains to be seen.
Abstract P270: Long-Term Benefits of Blood Pressure Lowering in Young Adulthood: A Computer Simulation Study
Authors: Kohli-Lynch Ciaran N , Thanataveerat Anusorn , Vittinghoff Eric , Pletcher Mark J , Moran Andrew E
Published: July 2021

Introduction:
Extended periods of exposure to elevated blood pressure (BP) in early adult life contribute independently to later life coronary heart disease (CHD) risk. Currently, there are significant gaps in hypertension awareness, treatment, and control in young adults. The long-term health benefits of controlling high BP in young adults have not previously been quantified.

Objective:
This study aimed to project CHD prevention benefits from controlling raised blood pressure starting in early adulthood compared with control at age 40 or older.

Method:
A state-transition microsimulation model estimated individual-level CHD outcomes, dependent on risk factors exposures and accounting for competing risk of stroke or non-cardiovascular death. Risk for first CHD event after age 40 was conditioned both on time-weighted average of early adult (ages 20-39) diastolic blood pressure (DBP), and raised DBP or systolic blood pressure (SBP) at age ≥ 40. We simulated CHD outcomes in a cohort of US adults with DBP ≥ 85 mmHg any time in young adulthood in 3 scenarios: no treatment, later life SBP control alone, or early DBP control plus later life BP control.

Results:
By age 39, 2.2% of the CVD-free young adult U.S. population was estimated to have early elevated DBP and was eligible for treatment. With follow up until age 69 years, early BP control prevented twice the number of primary CHD events (Table).

Conclusion:
This study quantifies the opportunity cost of failing to control hypertension identified in young adulthood. It is unclear whether early blood pressure control should be achieved by lifestyle or pharmacological intervention.
Abstract P273: Longitudinal Association Between Body Weight Change and 6-year Change of Blood Pressure in Japanese Men
Authors: Nagasawa Shin-ya
Published: July 2021

Objective:
Overweight is associated with increases in the risks of hypertension and cardiovascular disease. However, long-term and especially repeated measures analysis about relationship between body weight (BW) change and blood pressure (BP) change is only a little. We investigate the longitudinal relationship between BW change and years-long change of BP in a prospective cohort study.

Participants:
A total of 2546 male employees aged 25-53 years without use of antihypertensive drug in a metal products factory in Japan.

Measurements:
The BP was annually measured once in the right arm after 5 min of rest in a seated position, by well-trained nurses using a standard mercury sphygmomanometer from 2003 (baseline) to 2009. Physical examinations and information on lifestyle and use of medicine were annually measured or confirmed during the same period. The associations between difference of BW from 2003 to 2008 and 6-years change of systolic and diastolic BP from 2003 to 2009 were analyzed with generalized estimating equation models. Covariates in full adjusted model were age, body mass index, and smoking and drinking status in baseline.

Results:
Mean ± standard deviation (SD) of age, height, and BW in 2003 was 39.3 ± 8.0 years, 170.6 ± 6.0 cm, and 68.2 ± 9.9 kg, respectively. Mean ± SD of BW in 2008 was 68.8 ± 10.2 kg. Mean ± SD of systolic and diastolic BP in 2003 were 119.7 ± 14.6 and 74.3 ± 11.3 mmHg, respectively. Systolic and diastolic BP in 2009 were 120.5 ± 15.1 and 76.4 ± 10.9 mmHg, respectively. In full adjusted model, 1 kg increase of BW in 5 years was significantly associated with 0.17 mmHg higher systolic BP (
P
= 0.024) and 0.113 mmHg diastolic BP (
P
= 0.012) in 6 years.

Conclusions:
Beyond relevant covariates, increasing BW significantly elevated both systolic and diastolic BP.
Abstract P303: High Birth Weight Modifies Estimated Effects of Physical Activity on Cardiometabolic Health in Females
Authors: Jeanne Thomas L , Sacks Rebecca , Nguyen Thuan , Messer Lynne , Boone-Heinonen Janne
Published: July 2021

Background:
Birth weight and physical activity are independently associated with cardiometabolic health outcomes. Low or high birth weight are indicators of adverse prenatal development, which may alter physiological response to physical activity later in life. However, few studies have explored the potential interaction between birth weight and physical activity as determinants of cardiometabolic health.

Objective:
We evaluated the hypothesis that high or low birth weight modifies the association of early life physical activity with cardiovascular disease or diabetes later in life.

Methods:
We analyzed data from the National Longitudinal Study of Adolescent and Adult Health (Add Health), a nationally representative cohort of US adolescents followed into adulthood (
n
=20,745) with four data collection waves between 1994 and 2008. Outcomes were assessed in early adulthood: (1) predicted 30-year cardiovascular disease (CVD) risk, computed by a validated algorithm based on objective measures, and (2) prevalent pre-diabetes and diabetes. Using gender-stratified multivariable regression on multiply imputed data, we modeled (1) log-transformed 30-year CVD risk (linear regression) and (2) prevalent pre-diabetes and diabetes (PDM/DM; ordinal regression) each as a function of birth weight (low, normal, high; LBW, NBW, HBW) and self-reported moderate-to-vigorous physical activity frequency (MVPA) in adolescence and young adulthood, adjusting for age, smoking, and sociodemographic factors.

Results:
A greater proportion of women born at LBW had diabetes than NBW and HBW women (10.8% versus 5.9% and 5.4%, respectively). In adjusted analyses, MVPA in adolescence (MVPA1) and early adulthood (MVPA3) were not significantly associated with predicted CVD risk and prevalent pre-diabetes diabetes in men or women overall. However, greater MVPA1 was associated with lower predicted 30-year CVD risk in HBW females (estimated effect coefficient -0.02 [95% CI: -0.03, -0.005,
p
=0.02],
p
=0.05 for HBWхMVPA1 interaction), and the HBWхMVPA1 interaction on PDM/DM approached significance in females (
p
=0.12). In females and males of LBW or NBW, MVPA1 was not significantly associated with predicted 30-year CVD risk or PDM/DM and LBWхMVPA1 interactions were not significant.

Conclusions:
Greater adolescent physical activity was most strongly associated with lower 30-year CVD risk in young women born at HBW. A similar association with prevalent DM/PDM approached significance, with greater adolescent physical activity most strongly associated in HBW women. Females born at HBW may be especially sensitive to the effects of physical activity on reducing risk of cardiometabolic disease later in life, with important implications for disease prevention and health policy.
Abstract P348: Incidence of Chronic Kidney Disease (CKD) and Association of Major Cardiovascular Risk Factors With CKD in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)
Authors: Ricardo Ana C , Loop Matthew , Cedillo-Couvert Esteban , Chen Jinsong , Flessner Michael , Franceschini Nora , Gonzalez Franklyn , Mattix-Kramer Holly J , Moncrieft Ashley E , Talavera Gregory A , Daviglus Martha L , Lash James P
Published: July 2021

Background:
The prevalence of major cardiovascular risk factors and chronic kidney disease (CKD) is high in U.S. Hispanics/Latinos.

Hypotheses:
We assessed the hypotheses that the incidence of CKD will vary by Hispanic/Latino heritage, and that cardiovascular risk factors will be associated with incident CKD among Hispanic/Latino adults.

Methods:
We used data from HCHS/SOL, the largest community-based cohort of 16,415 self-identified Hispanic/Latino adults from diverse backgrounds in the U.S., aged 18-74 years at visit 1 (baseline, 2008-2011), and ongoing second clinic examination (2014-2017). This preliminary analysis describes results from 7,144 adults who attended visit 1 and 2 by September 2016, and did not have CKD at baseline. Incident CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73m
2
and eGFR decline ≥1 ml/min/year, or urine albumin-to-creatinine ratio (UACR) ≥30 mg/g. Incidence rates for CKD and incidence rate ratios (RR) for the association between cardiovascular risk factors at baseline and incident CKD were estimated using Poisson regression with robust variance while accounting for the complex sampling design of HCHS/SOL.

Results:
In 5.7 years mean follow-up, 430 individuals developed CKD (61.2% women). The age- and gender-adjusted incidence rate of CKD ranged from 6.0% (South Americans) to 14.9% (Puerto Ricans) per 1000 person-years (Table). Higher systolic blood pressure (RR, 95% CI, 1.02, 1.01-1.02, per one mm Hg increment), glycated hemoglobin (1.17, 1.07-1.27, per one percentage point increment), and log-UACR (3.29, 2.60-4.16, per one unit increment) were significantly associated with incident CKD. LDL and HDL cholesterol were not significantly associated with incident CKD.

Conclusions:
The incidence of CKD varies markedly by Hispanic/Latino heritage. Systolic blood pressure, glycated hemoglobin and albuminuria are important in the development of CKD in this population. Future work will focus on further evaluation of these differences/associations.
Abstract P360: 24-hour Blood Pressure Profiles Associated With Sleep Duration
Authors: Grandner Michael , Cohen Debbie L , Townsend Raymond R
Published: July 2021

Introduction:
Insufficient sleep is associated incident hypertension. Because blood pressure (BP) varies across 24h, shorter sleep may be associated with increased BP across all 24h. Additionally, we evaluated whether BP variability was also associated with shorter sleep.

Methods:
Participants were adults with untreated prehypertension or stage-1 hypertension assessed at baseline as part of a clinical trial. Recordings took place during overnight visits in a Clinical Research Center. Sleep was reported by nurses continuously monitoring patients. Those with <7h sleep were classified “shorter” (N=13) and the rest “longer” (N=30). BP was assessed with a Spacelabs ambulatory monitor. Linear regression models evaluated effect of group on day, night, and 24h systolic and diastolic BP and heart rate (HR).

Results:
The “shorter” group slept for M=370 (SD=87) minutes and the “longer” group slept for M=521 (SD=51) mins. Results for day, night, and 24h systolic and diastolic blood pressure and heart rate are reported in the Table. Also, higher 24h variability in systolic BP (B=1.2, p=0.03), diastolic BP (B=1.4, p=0.002), and HR (B=1.3, p=0.03) were demonstrated. This was reflected in higher variability during daytime for systolic BP (B=1.1, p=0.04), diastolic BP (B=1.5, p=0.001), and HR (B=1.2, p=0.05); no differences in variability were seen during the night.

Conclusions:
Shorter sleep duration is associated with higher systolic BP and HR across 24h (day and night), as well as increased variability in systolic and diastolic BP and HR across 24h (during the day in particular). This could provide additional insight in to how sleep duration is associated with hypertension incidence.
Abstract P362: Significant Positive Association Between Alcohol Consumption and Advanced Aortic Calcification in an International Multiethnic Cohort of 1335 Men Aged 40-49 Years: The ERA JUMP Study
Authors: Mahajan Hemant , Guo Jingchuon , Shangguan Siyi , Willcox Bradley , Miura Katsuyuki , Okamura Tonomori , Fujiyoshi Akira , Choo Jina , Evans Rhobert , Barinas-Mitchell Emma , Kuller Lewis , Shin Chol , Masaki Kamal , Ueshima Hirotusugu , Sekikawa Akira
Published: July 2021

Introduction:
Aortic calcification (AC) is a less widely used measure of atherosclerosis, has been linked to cardiovascular (CV) morbidity and mortality. A J-shaped association of alcohol consumption with CHD has been consistently reported in epidemiological studies. However, scanty literature is available describing the association of alcohol consumption and AC.

Hypothesis:
We hypothesized that alcohol consumption has a J-shaped association with advanced AC.

Method:
ERA JUMP is a population-based study of subclinical atherosclerosis in 1335 men aged 40-49 years without CVD (310 European American, 107 African American, 303 Japanese American, 313 Japanese in Japan and 308 Korean in South Korea). Participants were examined for AC, alcohol consumption, CV risk and other factors in 2002-07 with rigorous standardization. AC was assessed by electron-beam CT and quantified using the Agatston method. Advanced AC was defined as Agatston calcium score ≥300. Alcohol consumption was categorized into four groups: 0 (non-drinkers), <1 (light drinkers), > 1 to < 3 (moderate drinkers) and >3 drinks per day (heavy drinkers) (1 drink=12.5 grams of ethanol). Multivariable logistic regression was used to assess the relationship between AC with alcohol consumption adjusting for age, race, CV risk and other factors.

Results:
Among 1299 studied participants, after excluding participants with missing values for AC (n=36), 70.3% (913 of 1299) were current drinkers and 10.9% (142 of 1299) had advanced AC. Prevalence of advanced AC among non, light, moderate, and heavy drinkers was 7.25% (28 of 386), 10.89% (43 of 395), 9.06% (28 of 309), and 20.57% (43 of 209) respectively. Alcohol consumption had a positive association with advanced AC with a significant cubic trend (p<0.01). There was no significant interaction on advanced AC between race and alcohol consumption.

Conclusion:
A significant positive association between alcohol consumption and advanced AC was observed in this cross-sectional study of an international multi-ethnic cohort.
Abstract P375: Coronary Artery Structural Remodeling by Computed Tomography and Cardiovascular Disease; the Coronary Artery Risk Development in Young Adults (CARDIA) Study
Authors: Carr J J , Ge Yaorong , Kabagambe Edmond K , Terry James G , Lloyd-Jones Donald , Papayannis Aristotelis , Duprez Daniel A , Rana Jamal S , Sidney Stephen , Jacobs David R
Published: July 2021

Background:
Glagov identified cross-sectional enlargement and maintenance of the lumen of the coronary artery (CA) in post-mortem studies as an early feature of atherosclerotic coronary heart disease (CHD) that precedes the development of stenosis, coronary artery calcium (CAC) and plaque rupture. This structural change in the CA wall has been termed positive remodeling. We hypothesized that larger CA cross-sectional areas, consistent with positively remodeled CA, is associated with prevalent or soon-to-be incident coronary heart disease (CHD) and cardiovascular disease (CVD) events.

Methods:
In 2946 black and white male and female CARDIA participants aged 42-56 years, who had thin-slice (<1 mm), ECG gated, non-contrast coronary CT in 2010-2011, we measured CA cross-sectional area (CSA) in the proximal epicardial CA at 24 pre-specified locations. The mean of all measurements was calculated to provide a summary of all CA (CA
CSA_all
). We performed logistic regression with medical-record adjudicated CVD prevalence (n=96) or incidence in the following 3 years (n=27) as the outcome, predicted from this estimate of positive remodeling adjusting for age, race, sex, presence of coronary artery calcium (CAC), and amount of pericardial fat as covariates.

Results:
CA
CSA_all
had a mean ± SD 21.2 ± 6.7 mm
2
. The adjusted odds ratio (OR) for having any CVD was 1.06 (95% CI 1.03-1.09, p<0.0001) per mm
2
(Table). ORs for CVD increased across quartiles of CA
CSA_all
. Corresponding OR for any coronary heart disease (n=66) was not significant, but was significant for stroke (n=42) and for heart failure (n=27). Further adjustment for traditional risk factors assessed in 2010-2011 did not alter these estimates substantially.

Conclusion:
Individuals with larger CA cross-sectional areas had increased odds of CVD, stroke, and heart failure, but not CHD, independent of CAC and pericardial fat. CA
CSA_all
may be an imaging biomarker of coronary positive remodeling and provide new insight into progression from subclinical to premature clinical CVD.
Abstract 105: The Relationship Between Public Reporting of Outcomes and the Use of Coronary Angiography for Patients With Cardiac Arrest
Authors: Nathan Ashwin S , Shah Rohan M , Khatana Sameed , Groeneveld Peter W , Waldo Stephen , Yeh Robert W , Giri Jay
Published: July 2021

Background:
Despite advances in post-arrest management, cardiac arrest is frequently fatal and is often associated with high morbidity in survivors. Though there is evidence supporting the use of immediate coronary angiography (CA) and percutaneous coronary intervention among patients with ST elevation myocardial infarction (STEMI) complicated by cardiac arrest, the majority of patients that are successfully resuscitated from cardiac arrest do not have ST segment elevations on EKG. Among survivors of cardiac arrest without ST segment elevations on EKG, there are observational analyses that suggest benefit with early coronary angiography. Risk aversion has been previously demonstrated in patients with acute myocardial infarction complicated by cardiogenic shock in states with public reporting. Given concerns of risk aversion in high-risk patients, we utilized the Nationwide Inpatient Sample (NIS) to identify whether there was evidence of risk avoidant behavior in performing coronary angiography on patients with cardiac arrest in states that participate in public reporting.

Methods:
We performed a cross-sectional analysis of all adult patients (age≥18 years) with in-hospital and out-of-hospital cardiac arrest between 2005 and 2011 in states with public reporting (New York and Massachusetts) and surrounding states without public reporting (Delaware, Connecticut, Maine, Maryland, Rhode Island and Vermont) in the NIS. Adjusted logistical regression models were used to assess the relationship between public reporting and CA with clustering by hospital. The association between public reporting and in-hospital mortality was assessed using logistical regression models adjusted for the same set of demographic and clinical characteristics. An interaction term was used to assess whether the association between public reporting and in-hospital mortality differed based on the performance of CA.

Results:
We analyzed 75,080 patients with cardiac arrest between 2005 and 2011 in the selected states. There was a trend towards decreased utilization of CA in states with public reporting (adjusted OR 0.82, 95% CI 0.67-1.00, p=0.055), but significantly lower use of CA in those patients presenting with STEMI (adjusted OR 0.65, 95% CI 0.44-0.96, p=0.032). There was no association between public reporting and in-hospital mortality (adjusted OR 0.99, 95% CI 0.85-1.14, p=0.841) and no significant interaction of CA on the relationship between public reporting and in-hospital mortality (p=0.273).

Conclusion:
There is a trend towards risk-avoidant behavior in the performance of CA on patients with cardiac arrest, and patients with STEMI and cardiac arrest are less likely to undergo CA in states with public reporting. Overall, there is no difference in mortality for patients with cardiac arrest in states with and without public reporting, and there was no interaction with CA.
Abstract 132: Endovascular First Treatment is Associated With Improved Amputation Free Survival in Patients With Critical Limb Ischemia
Authors: Lin Jonathan , Brunson Ann , Romano Patrick , Pevec William , Humphries Misty
Published: July 2021

Objective:
Critical Limb Ischemia (CLI) remains a difficult disease to treat with limited level-1 data. The BEST-CLI trial is attempting to answer whether initial treatment with surgical bypass or endovascular therapy improves outcomes. Although still in the enrollment phase, this study aims to compare amputation free survival (AFS) and reintervention in patients treated with initial open surgical bypass or endovascular intervention for ischemic ulcers of the lower extremities.

Methods:
Using statewide data, all patients were identified with lower extremity ulcers and a diagnosis of peripheral arterial disease that underwent a revascularization procedure from 2005- 2013. Propensity scores were formulated from baseline patient characteristics. Inverse probability weighting was used within Kaplan Meier analysis to determine AFS and time to reintervention for open vs. endovascular treatment. Cox proportional hazards modeling was used to adjust for access to care and hospital revascularization experience.

Results:
A total of 16,800 patients were identified. Open surgical bypass was the initial treatment in 5,970 (36%) patients while 10,830 (64%) underwent endovascular interventions. Patients in the endovascular group were slightly younger compared to the open group (70 vs. 72 years, sd = 12 years, p<0.001). Endovascular patients were more likely to have renal failure (36 % vs. 24%) and coronary artery disease (34 % vs. 32%), while patients in the open bypass group were more likely to have diabetes mellitus (30% vs. 44%, all p values <0.05). After propensity weighting, open first treatment was associated with lower rates of reintervention (hazard ratio [HR]: 0.87; 95% confidence interval [CI]: 0.83 to 0.91); however, surgery first was associated with a lower AFS (HR; 1.16, 95% CI: 1.12- 1.2). (Image) Initial treatment at a high-volume center was associated with improved amputation free survival compared to medium (HR 1.3, CI: 1.21-1.36) or low (1.2, CI: 1.1-1.3) volume centers.

Conclusions:
Patients with CLI have multiple comorbidities, and initial surgical bypass is associated with poorer quality of amputation free survival compared to an endovascular first approach. Treatment in high volume centers improves amputation free survival. This may be due to improved resources at high volume centers.
Abstract 138: Wooden Chest Syndrome Complicated by Cardiopulmonary Arrest: A Rare Case of Fentanyl Toxicity
Authors: Ogbuka Ifeoma C , Egbuche Obiora , King Marshaleen H
Published: July 2021

Background:
Wooden chest syndrome (WCS) is a known manifestation of fentanyl toxicity, especially with high doses used for anesthetic induction in rapid sequence intubation (RSI). We present a rare case of WCS leading to cardiopulmonary arrest (CPA) following administration of low dose fentanyl.

Case Report:
A 37-year-old woman with no past medical history was admitted for management of septic abortion complicated by respiratory failure requiring mechanical ventilation. With clinical improvement, a spontaneous breathing trial (SBT) was attempted. Given respiratory acidosis during SBT, mechanical ventilation was continued. 25 micrograms (mcg) IV fentanyl bolus was given for analgesia. A few minutes later, she developed abdominal and chest wall rigidity with agonal breathing, culminating in CPA. Telemetry rhythm strip revealed asystole. Cardiopulmonary resuscitation (CPR) was initiated. She had absent breath sounds and high airway resistance causing difficulty with bag-mask ventilation. Arterial blood gas revealed hypoxia and hypercapnia. She achieved return of spontaneous circulation within a few minutes of CPR. CXR ruled out pneumothorax. She received 25mcg IV fentanyl bolus for sedation while undergoing CT chest and had another episode of chest wall rigidity. Cisatracurium was started. Her chest wall rigidity resolved and she was extubated the next day.

Discussion:
Our patient likely had WCS from fentanyl toxicity demonstrated by recurrence of chest wall rigidity with fentanyl doses. WCS should be suspected in patients who develop chest wall rigidity following fentanyl administration. It should be managed with ventilator support and reversal with naloxone or a short acting neuromuscular blocker.

Conclusion:
CPA is a rare but fatal complication of WCS. WCS can occur with low doses of fentanyl even in patients who have previously tolerated higher doses.
Abstract 147: Impact of Risk Factor Modification in Improving Quality of Life and Arrhythmia Symptoms in Patients With Atrial Fibrillation
Authors: Yaeger Amaryah , Cash Nancy R , Parham Tara , Pathak Rajeev , Frankel David S , Schaller Robert , Santangeli Pasquale , Callans David J , Marchlinski Francis E , Kolansky Daniel M , Mora Jorge , Schwab Richard , Pack Allan , Dixit Sanjay
Published: July 2021

Objective:
The desired goal of atrial fibrillation (AF) management is maintenance of sinus rhythm in order to improve quality of life (QoL) and arrhythmia symptoms (AS). Although obesity and obstructive sleep apnea (OSA) are known risk factors for development of AF, these remain inadequately treated. We report the impact of prospectively modifying these risk factors on QoL and AS in AF patients (pts).

Methods:
AF pts with obesity (body mass index (BMI) ≥30kg/m
2
) and/or the need for OSA management (high-risk as per Berlin Questionnaire or untreated OSA) were voluntarily enrolled in a nurse-led risk factor modification (RFM) program at their arrhythmia clinic visit. RFM entailed patient education, lifestyle modification counseling, coordination of care with appropriate specialists, and longitudinal care management. Progress with weight loss (WL) and OSA treatment was monitored via monthly follow-up calls and/or downloads from continuous positive airway pressure (CPAP) units for up to 12 months. QoL and AS were determined with the SF-36 and AF Severity Scale (AFSS) respectively, and were assessed at baseline, 6 months, and 12 months. Student t-test and chi-square tests were used to compare continuous and dichotomous variables.

Results:
From 11/1/16 to 10/31/17, 252 pts (age 63±11 years; male=179; paroxysmal AF=126) were enrolled as follows: 189 for obesity and 93 for OSA. The mean WL was 2.7±3.8% from baseline and 78% (n=126 of 162 pts with available data) of enrolled obese patients achieved WL. Among 93 pts at risk for OSA, 70 completed sleep studies and 50 were identified with OSA. Majority of these patients (76%; n=38 of 50) started CPAP therapy and have remained full (57%; n=17 of 30 pts with available CPAP data) and partial (13%; n=4 of 30) users. Table shows that SF-36 and AFSS scores improved for most measures of QoL and AS from baseline to 6 months.

Conclusion:
Participation in a risk factor modification program targeting obesity and obstructive sleep apnea can improve quality of life and arrhythmia symptoms in patients with atrial fibrillation. The impact of this strategy on long-term maintenance of sinus rhythm remains to be determined.
Abstract 162: Does a Telehealth “Virtual Consult” Including Referring Physicians, Specialist Physicians and Patients Increase Shared Decision Making for Patients With Heart Disease?
Authors: Coylewright Megan , Sherman Ariel , Grande Stuart W , Xu Keren , Kirk John , Dillon Gerard , O’Neill Elizabeth , Elwyn Glyn
Published: July 2021

Background:
Shared decision making (SDM) is highly recommended but difficult to implement for patients with severe heart disease referred for cardiac intervention. This study utilized telehealth (TH) to bring referring physicians and their patients together with a specialist physician to exchange treatment options and patient preferences via a triadic “virtual consult”. This study explores the impact of this innovative approach on SDM and patient decisional conflict.

Methods:
Two cohorts were included: usual care (UC) and TH. UC patients were seen in a clinic with one of 4 participating physicians, and visits were recorded. Telehealth patients met with their local referring physician in the office, and connected remotely with the specialist physician. One of two decision aids (DA) was used: HealthDecision, an electronic health record-integrated DA for atrial fibrillation, or AS Choice, a paper-based DA for severe aortic stenosis. Patient characteristics were collected via surveys. SDM was measured via Observer OPTION-5, a tool used to rate audio or video-taped clinical encounters, with raters’ agreement being assessed by the Bland-Altman analysis (2-rater pairs). Decisional conflict was measured by a 4-item survey, SURE. Data from two cohorts were compared using the Fisher exact test and the Student’s t test.

Results:
Twenty UC visits (5 per physician) were compared with 7 telehealth visits from 4 clinical sites. Patient mean age was 84.3 years and 52% were women. UC patients were older than telehealth patients (87.6 vs. 74.9, p=0.002). Patient decisional conflict was significantly different between the two groups (p=0.02). Telehealth visits had higher OPTION-5 scores than UC visits (99.3 vs. 19.0, p<0.001). (Figure) Rater pairs were used for each observation with evidence of lack of strong agreement in 2 pairs (95% limits of agreement in 3 pairs: [-6.0, 8.8], n=7; [-24.3, 20.7], n=11; [-34.2, 18.7], n=9).

Conclusions:
A combined clinical visit with both the referring and specialist physicians, along with their patient in a “virtual consult,” led to decreased patient decisional conflict. Higher OPTION-5 scores were suggested, indicating improvement in the presence of SDM; lack of strong agreement between raters limits this finding and larger studies are needed.
Abstract 174: Clinical Redesign Project to Improve Troponin Utilization at a University affiliated Community Hospital
Authors: Kataria Rachna , Barsky Lili , Vazquez Guillamet Laia Jimena , Sikorsky Linsley , Hajdasz David , Zarich Stuart
Published: July 2021

Background:
Cardiac troponin (CTn) is central to the diagnosis of acute coronary syndromes (ACS), however, in patients with low pre-test probability, the specificity of a positive CTn assay diminishes significantly. Overutilization of CTn assay is a rather prevalent problem and doctors often order further expensive testing for non-specific elevation in CTn.

Methods:
A clinical redesign team, formed in October 2015, defined four appropriate indications for ordering CTn assays, namely, chest pain, new EKG changes, cardiac arrest and angina equivalents such as shortness of breath and fatigue. We started by administering anonymous questionnaires, pertaining to CTn ordering practices, to different groups of healthcare providers at our hospital. Upon obtaining results of the questionnaire we executed a multifaceted intervention, including educational seminars and insertion of prompts in the electronic medical record system. We divided our study period into pre- and post-intervention periods of 1-year duration each and included a 17-week post-intervention interim analysis. We used Pearson’s correlation to test the null hypothesis that the pre- and post-intervention CTn assay volumes were not correlated and we used ANOVA to compare mean CTn assay volumes in the 38-week pre- and 17-week post-intervention period.

Result:
Overall: there was a 4% increase in ED patient volume and a 14% decrease in the total cTn order volume. Average cTn assays per ED patient decreased by 19%, from 0.26 to 0.21. The proportion of appropriate cTn assays increased post-intervention (45 vs 40% p=0.03). Interim analysis revealed a statistically significant decrease in weekly cTn order volume (r=0.903, p=0.0001). Percentage of cTn assays associated with a discharge diagnosis of ACS increased from 5.1% to 5.8% post-intervention (p= 0.001).

Conclusion:
cTn utilization can be effectively addressed by an organized multifaceted step-wise approach. Inappropriate utilization of cTn assays comes with associated cost implications due to the cost of the assay (nearly $50,000 cost savings in a year alone). It is quintessential to understand cTn ordering attitudes among different groups of healthcare providers. Our study also highlights the relevance of pre-test probability of ACS in any given patient before ordering cTn.
Abstract 179: Temporal Trends and Clinical Consequences of Wait-Times for Trans-Catheter Aortic Valve Replacement: A Population Based Study
Authors: Elbaz -Greener Gabby , Masih Shannon , Fang Jiming , Ko Dennis T , Lauck Sandra B , Webb John G , Nallamothu Brahmajee K , Wijeysundera Harindra C
Published: July 2021

Background:
Trans-catheter aortic valve replacement (TAVR) represents a paradigm shift in the therapeutic options for patients with severe aortic stenosis. However, rapid and exponential growth in TAVR demand may overwhelm capacity, translating to inadequate access and prolonged wait-times. Our objective was to evaluate temporal trends in TAVR wait-times and the associated clinical consequences.

Methods:
In this population-based study in Ontario, Canada, we identified all TAVR referrals from April 1, 2010 to March 31, 2016. The primary outcome was the median total wait-time from referral to procedure. Piecewise regression analyses were performed to assess temporal trends in TAVI wait-times, before and after provincial reimbursement in September 2012. Clinical outcomes included all-cause death and heart failure hospitalizations while on the wait-list.

Results:
The study cohort included 4,461 referrals, of which 50% led to a TAVR, 39% were off-listed for other reasons and 11% remained on the wait-list at the conclusion of the study. For patients who underwent a TAVR, the estimated median wait-time in the post-reimbursement period stabilized at 82-84 days, and has remained unchanged since September 2012. The cumulative probability of wait-list mortality and heart failure hospitalization was 4.3% and 14.7% respectively, with a relatively constant increase in events with increased wait-times.

Conclusion:
Post-reimbursement wait-time has remained unchanged for patients undergoing a TAVR procedure, suggesting the increase in capacity has kept pace with the increase in demand. The current wait-time of almost 3 months is associated with important morbidity and mortality, suggesting a need for greater capacity and access.
Abstract 185: Outcome Differences Associated With STEMI Diagnostic Delay: Disparities on the Frontlines of STEMI Care
Authors: Yiadom Maame Y , Baugh Christopher W , Jenkins Cathy A , Tanski Mary , Mumma Bryn E , Vogus Timothy J , Miller Karen F , Jackson Brittney E , Lehmann Christoph U , Dorner Stephen C , West Jennifer L , Olubowale Olayemi O , Wang Thomas J , Collins Sean P , Dittus Robert S , Bernard Gordon R , Storrow Alan B , Liu Dandan
Published: July 2021

Background:
AHA/ACC/ESC practice guidelines advise an ECG within 10 minutes for all patients with symptoms suggestive of ST-segment elevation myocardial infarction (STEMI). This facilitates early diagnosis and timely treatment. Earlier treatment, particularly percutaneous coronary intervention (PCI), has been associated with better clinical outcomes. Our objective was to quantify the impact of delayed screening on timely treatment and determine if there may be race, sex or presenting complaint disparities.

Methods:
We examined the association between time-to-first ECG (door-to-screening, or D2S) and time-to-PCI in a 3-center 1-year retrospective cohort study including all emergency department (ED) patients with acute STEMI per hospital discharge diagnosis who underwent catheterization for PCI. The primary outcome was door-to-balloon time (D2B) and the ED-centric secondary outcome was door-to-cath-lab arrival time (D2CAR).

Results:
Of 161,920 patients seen in the 3 EDs, 137 (0.08%) were diagnosed with STEMI. Of the 137, 75 (55%) underwent emergent PCI, and 31 (41%) of the ED STEMI PCI patients did not receive an ECG within 10 minutes. These 31 patients were more commonly female (55% vs. 19%, p=0.001), non-white (87% vs. 65%, p =0.028), and reported chest pain or shortness of breath less frequently (55% vs. 94%, p<0.001). In patients with D2S greater than 10 minutes, median D2CAR was longer (159 vs. 50 minutes, p=0.004) as was median D2B time (207 vs. 93 minutes, p=0.048).

Conclusion:
A significant proportion of ED patients with STEMI did not receive an ECG within 10 minutes of arrival resulting in a 2.2 fold increase in D2B time. They were more likely to be female, non-white, and with atypical chief complaints. Normalizing screening criteria for presentation diversity could improve more equitable access to timely STEMI treatment
Abstract 220: Impact of a Cardiology-managed, Non-emergency Department, Outpatient Observation Unit
Authors: Cajiao Karen , Wallins Joseph , Zimetbaum Peter , Gavin Michael
Published: July 2021

Background:
With the progress emergency department (ED) observation units have made in reducing admissions for cardiac conditions, we previously reported a discharge rate of only 23.7% (n=1,549/6,546) from our ED, without an observation stay, for these patients. We opened a Cardiac Direct Access (CDAc) unit at a tertiary care urban medical center hypothesizing that cardiologists can reduce testing and observation stays for appropriate cardiac patients.

Methods:
Patients are referred to the CDAc for evaluation on an emergent (same day) or urgent (within 7 day) basis. We performed a retrospective review of 629 consecutive patients referred to the CDAc between November 2016 and June 2017. Final disposition was determined using charge data. The 30-day return rate to an ED, hospital, or the CDAc was determined by follow-up phone calls and chart review.

Results:
Patients were referred by non-cardiologists (n=403/629, 64%) and cardiologists (n=226/629, 36%). The most common indications for evaluation were chest pain, arrhythmia, and suspected heart failure. Disposition of patients evaluated in the CDAc are reported in the figure. The mean length of stay in CDAc observation was 22+/-13 hours. Among the 574 patients discharged from the CDAc, 62 (11%) were seen in an ED and/or hospitalized, while 31 (5.4%) were seen in the CDAc within 30 days.

Conclusion:
A CDAc unit may serve as a high value alternative to the ED. Further research can help assess comparative cost-effectiveness and refine patient selection.
Abstract 240: Association of Depression Risk With Patient Experience, Healthcare Expenditure and Health Resource Utilization Among Adults With Atherosclerotic Cardiovascular Disease
Authors: Okunrintemi Victor , Valero-Elizondo Javier , Michos Erin , Salami Joseph , Ogunmoroti Oluseye , Osondu Chukwuemeka , Tibuakuu Martin , Benson Eve-Marie , Pawlik Timothy , Nasir Khurram
Published: July 2021

Background:
Approximately 20% of patients with atherosclerotic cardiovascular disease (ASCVD) suffer from depression. Currently, these two conditions are the most common causes of disability in high-income countries and projected to become so for all countries by 2030. Depression is a risk marker for ASCVD and associated with worse health outcomes. In a nationally representative US adult population, we evaluate patient experience, healthcare expenditure and resource utilization among non-depressed ASCVD patients based on their risk for depression.

Methods:
The 2004-2015 Medical Expenditure Panel Survey (MEPS), a nationally representative sample was the basis for our study. We included adults ≥18 years with a diagnosis of ASCVD, ascertained by ICD9 codes and/or self-reported data and excluded those with a diagnosis of Depression, identified by ICD9 code 311. Individuals were stratified by depression risk (based on the Patient Health Questionnaire-2): Two-part econometric model was used to study cost data, and regression models for all other associations, adjusted for ASCVD risk factors.

Results:
The study sample consisted of 16,136 ASCVD patients without the diagnosis of depression (aged 67 ± 10 years, 55% male), translating into 179.2 million US adults, of which 8.6% (15.5 million US adults) had a high risk for depression. Individuals with high vs. low risk for depression had higher overall and out-of-pocket healthcare expenditures ($1,200 & $353, respectively; both p < 0.001). Additionally, those with high risk had higher odds for hospitalizations [OR 1.75 (1.75, 2.32)], poor self-perceived health status [OR 4.83 (3.28, 7.12)], poor patient-provider communication scores [OR 2.44 (1.93, 3.09)], poor patient satisfaction [OR 3.33 (1.64, 6.77)], and significantly worse healthcare-related quality of life measures than those with low risk for depression (Table).

Conclusion:
Among ASCVD patients without a diagnosis of depression, individuals with a greater risk for depression were more likely to report worse healthcare experience, increased resource utilization and higher healthcare spending. To enhance health outcomes and increase healthcare efficiency, more aggressive screening for depression risk to promote improved recognition and intervention are needed among this vulnerable population.
Abstract 25: Accuracy of Patient Identification of Atrial Fibrillation in the Clinic Setting
Authors: Turner Jeffrey L , Hardisty Benjamin E , Kaur Gagandeep , Shah Rashmee U , Chelu Mihail G , Han Fred T , Marrouche Nassir F , Steinberg Benjamin A
Published: July 2021

Background:
Atrial fibrillation (AF) related symptoms are commonly reported but often difficult to directly correlate with arrhythmia. Given that symptoms largely drive management, correct patient awareness of AF is critical to implementation of appropriate therapy.

Objective:
To determine accuracy of patient identification of their own atrial rhythm.

Methods:
All AF patients in our center undergo patient reported outcome assessment with the Toronto AF Severity Scale (AFSS) immediately prior to clinic visit. Using the validated questions from the AFSS, we assessed if patients were able to accurately determine their rhythm (AF or not) compared to an electrocardiogram (ECG) during the same clinic visit.

Results:
We identified 254 unique patients (Table 1) with interpretable ECG and AFSS data available from the same visit. Based on ECG, 81% (n=206) were not in AF. 20 of these 206 patients (9.7%) incorrectly identified themselves in AF (Figure 1). Patients who incorrectly thought they were in AF were significantly older (p<0.05). Of the 48 (18.9%) that were in AF by ECG, 15 (31.2%) incorrectly identified themselves in sinus rhythm. There was no significant difference between sex, age or mean heart rate in patients in AF. Overall 14% (35 of 254) provided an assessment that was inconsistent with their ECG.

Conclusion:
Approximately one of ten patients incorrectly identified themselves as being in AF despite being in sinus rhythm. Without a standardized method to confirm if symptoms truly correlate with AF these patients may be at risk for unnecessary antiarrhythmic therapies. On the contrary, nearly a third of patients were unaware of AF which reemphasizes the incidence of asymptomatic AF.
Abstract 250: Antiplatelet Therapy in Post-Acute Coronary Syndrome: Effect of Education on Physician Knowledge and Competence
Authors: O’Neil Thomas , Guedj Philippe , Hughes Suzanne
Published: July 2021

Background:
Decreasing hospital readmission rates resulting from suboptimal antiplatelet therapy requires education to diminish an gap in physician knowledge/competence. We sought to determine if online medical education could improve clinical knowledge/competence regarding dual antiplatelet therapy (DAPT) in post-acute coronary syndrome (ACS) patients among non-United States (US) cardiologists.

Methods:
The educational activity was a 30-minute online video discussion between 4 experts with synchronized slides. Educational effect was assessed using a 4-question repeated pairs pre-/post-assessment and McNemar’s chi-squared test. P values are shown as a measure of significance; P values <.05 are statistically significant. Cramer’s V statistic indicated the effect size (<0.05 no effect; 0.06-0.15 small effect, 0.16-0.30 medium effect, >0.30 large effect). The activity launched August 23, 2016; data were collected through December 20, 2016.

Results:
117 non-US cardiologists completed the study. The change in correct responses from pre- to post-assessment achieved statistical significance (P<.05) for 2 of 3 questions. An average of 26% of cardiologists selected the best response at pre-assessment (range, 9% to 38%); this figure improved to an average of 35% at post-assessment (range, 22% to 55%). Specific improvements were observed in the following areas: The relationship between platelet reactivity and stent thrombosis with DAPT post-drug eluting stent implantation (90% improvement, 29%pre vs 55%post, P = <.001) Optimal treatment strategy with adenosine diphosphate platelet receptor (P2Y12) inhibition in patients with unstable angina or non-ST segment myocardial infarction (144% improvement, 9%pre vs 22%post, P =.007)

Conclusion:
Participation in a 30-minute online video discussion with synchronized slides resulted in statistically significant improvement in non-US cardiologists’ knowledge and competence regarding DAPT in patients with post-ACS.