bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P111: Relationship of Vitamin D Status to Cardiac Arrhythmias in Veterans
Authors: Islam Tareq M , Bailey Beth , Ferdous Chowdhury , Finton Chris , Manning Todd , Peiris Alan
Published: July 2021

Relationship of Vitamin D status to cardiac arrhythmias in Veterans Islam T. MD MPH, Bailey B. PhD, Ferdous C. MD, Finton C. MD, Manning T. and Peiris A.N. MD PhD

Introduction.
Vitamin D deficiency is widespread and is associated with coronary artery disease. However, few studies have examined the link between Vitamin D status and cardiac arrhythmias. The present study was undertaken to explore this relationship.

Method.
We studied 34580 veterans in the southeastern USA and evaluated the relationship of Vitamin D status to both atrial and ventricular arrhythmias by retrospective chart review. Approximately 34.8 % (12030) patient were Vitamin D deficient (25(OH)D < 20 ng/ml). This group was more likely to be younger, have a significantly greater body mass index, more likely to be female and belong to a racial minority when compared to the Vitamin D replete group. The Vitamin D deficient group was also more likely to have hyperlipidemia, diabetes, hypertension and be tobacco users.

Result.
The presence of arrhythmias varied between 0.3 % (ventricular) to 25 % (Any arrhythmia plus heart block). Atrial and ventricular arrhythmias were significantly greater in the vitamin D deficient group. Vitamin D deficiency remained significantly associated with atrial and ventricular arrhythmias after adjusting for other variables through multivariate logistic regression analysis.

Conclusion.
To our knowledge, this is the first report indicating a significant link between vitamin D status and cardiac arrhythmias in Veterans. Vitamin D remained a significant predictor of this relationship even after adjusting for other variables. Emerging evidence suggest that Vitamin D replacement can improve cardiac ejection fraction. The potential for Vitamin D replacement to reduce an underlying arrythmogenic propensity is an exciting area for future research.

Adjusted logistic regression model predicting atrial and ventricular arrhythmia by vitamin D level.

Atrial Arrhythmia

Present
Absent
p-value

Vitamin D treated as

Continuous variable, beta estimate
-0.006
0 (ref.)
0.001

Categorical (low versus replete), odds ratio
1.18
1.00 (ref.)
<0.001

Ventricular Arrhythmia

Present
Absent
p-value

Vitamin D treated as

Continuous variable, beta estimate
-0.020
0 (ref.)
0.042

Categorical (low versus replete), odds ratio
1.48
1.00 (ref.)
0.055
Abstract P117: Frailty and Outcomes among Heart Failure Patients in the Community
Authors: McNallan Sheila M , Dunlay Shannon M , Singh Mandeep , Chamberlain Alanna M , Redfield Margaret M , Weston Susan A , Moraska Amanda R , Roger Véronique L
Published: July 2021

Objective:
To determine among community heart failure (HF) patients whether frailty is associated with an increased risk of hospitalization, emergency department (ED) visits and death, independently of comorbidities.

Background:
Frailty is associated with adverse outcomes in some populations; however the prognostic value of frailty among HF patients is not fully documented, particularly for healthcare utilization.

Methods:
Olmsted, Dodge and Fillmore County residents with HF between 10/2007 and 12/2010 were prospectively recruited to undergo frailty assessment. Frailty was defined as 3 or more of the following: unintentional weight loss >10 lbs. in 1 year, physical exhaustion, weak grip strength, and slowness and low activity measured by the SF-12 physical component score. Intermediate frailty was defined as having 1-2 components. To account for repeated events, Anderson-Gill modeling was used to determine if frailty predicted hospitalization or ED visits. Cox proportional hazards regression examined associations between frailty and death.

Results:
Among 409 patients (mean age 73±13, 58% male), 19% were frail and 55% had intermediate frailty. Within one year, 449 hospitalizations, 523 ED visits and 34 deaths occurred. There was a positive graded association between frailty and hospitalization and ED visits (Table). After adjustment for age, sex, ejection fraction and comorbidity, frailty was associated with an 80% increased risk of hospitalization and a 60% increased risk of ED visits. Frailty was also associated with more than a 2-fold increased risk of death after adjustment.

Conclusion:
In the community, frailty is prevalent and is a strong and independent predictor of hospitalizations, ED visits and death among HF patients. As it is independent from coexisting comorbidities, frailty defines new avenues for intervention and should be formally assessed clinically.

Hazard Ratios (95% CI) for Hospitalizations, Emergency Department Visits and Death by Frailty Status

Not Frail
Intermediate Frail
Frail
P for trend

Hospitalization

Crude
1.00
1.46 (1.05-2.02)
2.15 (1.45-3.19)
<0.001

Fully-adjusted
1.00
1.29 (0.94-1.77)
1.82 (1.22-2.73)
0.005

Emergency Department Visits

Crude
1.00
1.59 (1.14-2.21)
1.88 (1.22-2.90)
0.002

Fully-adjusted
1.00
1.46 (1.05-2.05)
1.58 (1.01-2.48)
0.034

Death

Crude
1.00
1.40 (0.73-2.69)
3.98 (2.01-7.90)
<0.001

Fully-adjusted
1.00
0.87 (0.44-1.73)
2.42 (1.19-4.95)
0.003
Abstract P155: Implementing an Innovative Consent Form: Barriers and Successes
Authors: Decker Carole J , Gialde Beth , McCartan John , Chhatriwalla Adnan , Spertus John A
Published: July 2021

Purpose:
The consent form and process are highly variable from hospital to hospital, as well as from physician to physician. We created an evidence-driven, web-based tool, PREDICT (Patient Refined Expectations for Deciding Invasive Cardiac Treatments) which redesigns the procedure consent for patients undergoing percutaneous coronary intervention (PCI). We prospectively evaluated the challenges and successes of implementing such an evidence-based information technology (IT) decision support.

Methods:
We conducted qualitative, in-depth interviews with clinicians at 5 U.S. hospitals within 6 weeks of implementation of the new PREDICT individualized consent form. PCI volumes at each hospital ranged from 60 to 120 per month thus allowing for a sufficient number of consent forms to be generated and evaluated. Collected data was content analyzed, categorizing response as either supporting or impeding the implementation.

Results:
We interviewed 61 clinicians (minimum of 8 per site; 50 registered nurses, 6 care technicians, and 5 nursing managers). The majority described the new consent form process as a positive experience, commenting that patients benefited from the individualized information. Additionally, facilitators and barriers were identified (see Table).

Conclusions:
This implementation study identified tasks to ease implementation (facilitators) as well as anticipating and strategizing to diminish impedance (barriers) to the integration of an improved PCI consent form and process. The need for a strong, visible clinical champion was identified as a strong influencer in both categories.
Abstract P156: Dyspepsia and Disease Burden among Patients with Atrial Fibrillation
Authors: LaMori Joyce , Gross Hillary J , Patel Aarti A , Crain Melanie , DiBonaventura Marco D , Mody Samir H , Schein Jeff R
Published: July 2021

Objective:
Many agents used in treating atrial fibrillation (AF) have potential gastrointestinal (GI) tolerability issues. Treatment-related adverse GI events are a common reason for noncompliance to treatment. The current analysis describes the prevalence of dyspepsia in relation to anticoagulant use among AF patients.

Methods:
Data were obtained from the 2009 National Health and Wellness Survey (N=75,000), an annual cross-sectional Internet-based survey of US adults. Respondents answered general demographic and health-related questions. A CHADS
2
score (an index of stroke risk) was calculated for each patient using demographic and clinical characteristics.

Results:
A total of 1297 patients (1.7%) reported a diagnosis of AF. Of these patients, 41% (n= 535) also reported a physician-diagnosed GI condition; 84% of these (n=449) were consistent with dyspepsia (ulcers, abdominal bloating, abdominal pain, gastroesophageal reflux disease/acid reflux, or heartburn). Compared with AF patients without dyspepsia (n=848), those with dyspepsia were younger (mean 62.9 vs 66.0 years,
p
<0.05) and more likely to be female (43% [193 of 449] vs 31% [260 of 848],
p
<0.05). AF patients with dyspepsia were in poorer health than those without dyspepsia, as evidenced by a higher CHADS
2
score (1.9 vs 1.4,
p
<0.05); this difference was more pronounced in patients aged >65 years and in those with CHADS
2
score >2. Despite this, significantly fewer AF patients with dyspepsia, than those without, were taking a prescription medication to treat their AF (67% [300 of 449] vs 73% [619 of 848]),
p
<0.05) or an anticoagulant for stroke prevention (35% [158 of 449] vs 47% [394 of 848]),
p
<0.05.

Conclusions:
One-third of AF patients in this analysis had dyspepsia. These patients reported a greater disease burden and stroke risk relative to AF patients without dyspepsia. Significantly fewer AF patients with dyspepsia, than those without, were taking a prescription to treat AF or an anticoagulant for stroke prevention. Poor GI tolerability may be significant in the AF population and should be considered when adherence to medication is critical, such as in high-risk populations.
Abstract P184: Reduction in Atherosclerotic Events Through Use of Aggressive Risk Factor Reduction Medications in an Outpatient Cardiology Practice
Authors: Lai Hoang M , Mercando Anthony D , Aronow Wilbert S , Kalen Phoenix , Desai Harit V , Gandhi Kaushang , Sharma Mala , Amin Harshad , Lai Trung M
Published: July 2021

Background
: Although atherosclerotic disease cannot be cured, risk of recurrent events can be reduced by application of evidence based treatment protocols involving aspirin, beta blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statin medications.

Purpose
: To compare atherosclerosis event rates in a patient population treated before and after the development of aggressive risk factor reduction treatment protocols.

Methods
: A retrospective chart review study of patients presenting for follow-up treatment of coronary artery disease in a community cardiology practice, comparing event rates and medication usage in a 2 year treatment period prior to 2002 to a 2 year treatment period in 2005-2008. Standard care was provided in both the early treatment era and the later era by board-certified cardiologists in a 7 physician suburban cardiology practice. Medication usage was compared in both treatment eras. The primary outcome was a composite event rate of myocardial infarction, cerebrovascular events (transient ischemic attacks or cerebrovascular accident), and coronary interventions (percutaneous or surgical). The outcome measures were identified before data collection or analysis were performed.

Results
: 357 patients were studied for 2 year periods in each era, with a total follow-up duration of 12.1 (± 3.5) years. There were 132 composite events in 104 patients (29.1%) in the early era compared to 40 events in 33 patients (9.2%) in the later era (p< 0.0001). This result was driven mostly by a reduction in percutaneous and surgical coronary interventions between the 2 eras. From the early to the late eras, there was an increase in the use of beta blockers (66% to 83%, p<0.0001), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (34% to 80%, p<0.0001), and statins (40% to 90%, p<0.0001); although aspirin usage did not increase, it was prescribed frequently in both eras (78% and 79%).

Conclusions
: Application of aggressive evidence-based medication protocols for treatment of atherosclerosis is associated with a significant decrease in events or need for coronary intervention.
Abstract P187: Prognostic Importance of Type D Personality and Shocks in Patients with an Implantable Cardioverter-Defibrillator
Authors: Denollet Johan , Tekle Fetene , Pedersen Susanne S , van der Voort Pepijn H , Alings Marco , van den Broek Krista C
Published: July 2021

Background
. Implantable cardioverter defibrillator (ICD) treatment has been studied primarily in clinical trials. We examined the age-dependent importance of shocks and psychological distress in patients seen in clinical care, and the importance of these factors among younger patients in particular.

Methods
. This real-world study (n=589) included 134 older (>70y, m=74.3) and 455 younger (≤70y, m=59.1) ICD patients. At baseline, vulnerability for psychological distress was measured by the 14-item Type D (distressed) personality scale. Cox regression analyses were used to examine the importance of shocks and distress; endpoints were all-cause and cardiac death.

Results
. After a median follow-up of 3.2 years, 94 patients (16%) had died (67 cardiac death), 61 patients (10%) had experienced an appropriate shock and 28 (5%) an inappropriate shock. Appropriate shocks (HR=2.60, 95%CI 1.47-5.58, p=0.001) and Type D personality (HR=1.85, 95%CI 1.12-3.05, p=0.015) independently predicted an increased mortality risk, adjusting for covariates. Other predictors were age, cardiac resynchronization therapy (CRT) and diabetes. Appropriate shocks and Type D personality also predicted an increased risk of cardiac death. Inappropriate shocks were not associated with all-cause (p=0.52) or cardiac (p=0.99) death. Older patients had more advanced heart failure, and CRT and diabetes were the only prognostic factors in this age group. In younger patients, however, appropriate shocks and Type D personality predicted an increased risk of all-cause and cardiac death, adjusting for covariates.

Conclusion
. This real-world study confirmed the importance of ICD shocks, showed that Type D personality has incremental prognostic value, and revealed important age-dependent differences in risk.
Abstract P195: Long-Term Outcomes Associated with Hospital-Acquired Thrombocytopenia Among Patients with Acute Coronary Syndrome
Authors: Chenier Michael S , Schulte Phillip J , Goodman Shaun , Peterson Eric D , Pieper Karen , Jolicoeur E Marc , Lopes Renato D , Mahaffey Kenneth W , White Harvey , Wang Tracy Y
Published: July 2021

Background
Prior studies demonstrated that the development of thrombocytopenia (platelet count drop to <100x10
9
/L) during an ACS hospitalization is associated with adverse outcomes. The long-term prognosis associated with thrombocytopenia of milder severity (100-149x10
9
/L) is less clear.

Methods
We examined 7,435 ACS patients enrolled in the SYNERGY trial (a randomized comparison between unfractionated and low molecular weight heparin) who had normal platelet counts (≥150x10
9
/L) at admission. Mild thrombocytopenia was defined as a platelet count drop to a nadir of 100-149x10
9
/L; moderate-severe thrombocytopenia was defined as <100x10
9
/L. Patients with nadir platelet counts occurring after in-hospital CABG were excluded. Cox models were used to compare risks of 30-day GUSTO moderate-severe bleeding and 1 year mortality between groups after adjusting for baseline clinical factors.

Results
Overall, 720 patients (9.7%) developed mild thrombocytopenia and 83 (1.1%) developed moderate-severe thrombocytopenia. Nadir platelet counts occurred at a median of 1.4 days (interquartile range 0.7 - 2.5) after admission. Patients who developed thrombocytopenia were older (median age 71 vs. 67 years, p<0.001) and more often male (71% vs. 63%, p<0.001). Compared with non-thrombocytopenic patients, patients with mild thrombocytopenia were as likely to be prescribed aspirin (90.6% vs. 90.1%) and clopidogrel (65.2% vs. 64.9%) at discharge, whereas patients with moderate-severe thrombocytopenia were less likely to receive aspirin (66.2%) and clopidogrel (44.6%) therapy (both p<0.001). Thrombocytopenia was associated with increased 30-day GUSTO moderate-severe bleeding and 1-year mortality risks (Table) compared with no thrombocytopenia.

Conclusions
Thrombocytopenia occurs in more than 1 of 10 ACS patients. Our findings suggest that even mild thrombocytopenia is clinically relevant and associated with increased downstream bleeding and mortality risks.

Risks of Adverse Events

Unadjusted Rate
Adjusted Hazard Ratio (95% confidence interval)

30-day GUSTO mod-severe bleeding

No thrombocytopenia
5.9%
Reference

Mild thrombocytopenia
10.0%
1.83 (1.34 - 2.51)

Mod-severe thrombocytopenia
34.3%
6.88 (4.08 - 11.59)

1-year Mortality

No thrombocytopenia
6.5%
Reference

Mild thrombocytopenia
9.8%
1.30 (1.00 - 1.69)

Mod-severe thrombocytopenia
27.7%
5.02 (3.22 - 7.84)
Abstract P199: Randomized Comparison of the DAWN AC Computer Program and a Simple Manual Nomogram for Quality of Warfarin Dosing
Authors: Nieuwlaat Robby , Hubers Lowiek , Spyropoulos Alex C , Stehouwer Alexander , Van Spall Harriette G , Eikelboom John W , Schulman Sam , Connolly Stuart J
Published: July 2021

Background
In patients receiving warfarin, the quality of anticoagulant control as measured by the time-in-therapeutic range (TTR) for the International Normalized Ratio (INR) is a key determinant of risk for thromboembolic and bleeding events. Computer programs can assist physicians in optimizing TTR, but are expensive. The purpose of this study was to determine whether a computer system (DAWN AC) was non-inferior to a two-step manual nomogram used in a hospital anticoagulation clinic.

Methods
Stable anticoagulated patients receiving warfarin with target INR range 2-3 in the anticoagulation clinic were randomized to management with the newly acquired DAWN AC computer system or the clinic's standard of care, a simple manual dosing nomogram. After an initial run-in phase, study data collection started on February 1
st
2010 and was completed on August 8
th
2010. Primary outcome was the mean TTR calculated by the Rosendaal linear interpolation method. The non-inferiority margin was set at 4.5% lower TTR for DAWN AC compared with the nomogram.

Results
Of the 1,298 patients initially randomized, 1,127 were still managed by the clinic after the run-in phase and entered the study on February 1
st
; 564 were managed with DAWN AC, and 563 with the manual nomogram. The mean age of study patients was 69 ± 14 years and 62% were male. Main indications for anticoagulation were atrial fibrillation (48%) and prosthetic heart valves (25%). Mean follow-up was 172 days, encompassing 8,344 INR values and 155,041 patient days. Adherence to recommended warfarin doses was higher in the DAWN AC than in the nomogram group (99 vs. 90%; p<0.0001), the average interval between INR measurements was similar in the two groups (21 ± 12 vs. 21 ± 13 days; p=0.1987). In the primary analysis, mean TTR in the DAWN AC group was non-inferior to mean TTR in the nomogram group (71.0% ± 23.3 vs. 71.9% ± 22.9; non-inferiority p=0.0052).

Conclusion
Among stable patients receiving warfarin with a target INR of 2-3 in an anticoagulation clinic, quality of anticoagulant control with the DAWN AC computer program was non-inferior to a simple two-step manual dosing nomogram. The nomogram could be a useful dosing tool for physicians without access to a computerized warfarin dosing system.
Abstract P210: Cardiovascular Safety of Dementia Drugs Among Medicare Beneficiaries
Authors: Fosbol Emil L , Peterson Eric D , Zhang Yinghong , Curtis Lesley H , Iwata Isao , Setoguchi Soko
Published: July 2021

Background:
A recent randomized clinical trial raised a concern about the safety of rivastigmine, one of the drugs used to treat dementia. We examined the comparative cardiovascular safety of dementia medications in a sample of Medicare patients.

Methods:
We identified a cohort of new-users of dementia medications (donepezil, galantamine, rivastigmine, or memantine) aged 65 years or more in the national 5% Medicare sample (July 1, 2006 to December 31, 2007). We assessed the association between use of dementia drugs and subsequent myocardial infarction (MI), heart failure (HF), or atrioventricular (AV) block/syncope hospitalizations Patients were censored at death or at the end of the study period; Cox proportional hazard model was used to compare cardiovascular events among users of the individual dementia medications on an intention-to-treat approach. We also conducted a sensitivity analysis using a time-varying exposure approach.

Results:
Overall, 19,844 initiators of dementia drugs were identified; donepezil (n= 13,179), galantamine (n=709), rivastigmine (n=1,030), memantine (n=3578), or a combination of these (n= 1348). Median age was 82 years (interquartile range [IQR] 77-87); most patients were women (74%) and Caucasian (80%). During a median follow-up of 230 days (IQR: 112-355), 741 CV composite events were identified. The initiation of rivastigmine was not associated with increased CV risk relative to initiating donepezil (adjusted hazard ratio [HR] 0.89, 95% confidence interval [CI]: 0.62-1.27). Similarly, initiation of galantamine (HR 0.70, CI: 0.45-1.09), memantine (HR 0.84, CI: 0.69-1.02), or a combination (HR 1.19; CI: 0.91-1.55) was not associated with increased CV events relative to donepezil. The results were similar among subgroups of patients with HF or MI and in the sensitivity analysis modeling time-varying exposure.

Conclusions:
In a large cohort of Medicare beneficiaries, we observed no increased risk of cardiovascular events in patients who initiated rivastigmine. All currently marketed dementia drugs had a similar cardiovascular safety within one year of their initiation. Further long-term monitoring of these agents is indicated.Funding(This research has received full or partial funding support from the American Heart Association, National Center)
Abstract P260: Mind the Time: A Quality Improvement Project to Increase the Percent of Ischemic Stroke Patients Receiving Intravenous Tissue Plasminogen Activator within 60 Minutes after Arrival at the Emergency Department
Authors: Mazabob Janine M , Brown Gerard , Livesay Sarah , Freeborg Sue , Suarez Jose , Bershad Eric , Smirnakis Stelios
Published: July 2021

Background and Purpose:
Stroke is the third leading cause of death and leading cause of long term disability in the USA. Intravenous administration of tissue plasminogen activator (t-PA) is the only FDA approved medical therapy for treatment of patients with acute ischemic stroke. It is recommended by the American Heart Association that earlier treatment with t-PA within 90 minutes of symptoms may result in a more favorable patient outcome. Initiating t-PA for ischemic stroke patients within 60 minutes after Emergency Department (ED) triage is an indicator tracked by the Get With The Guidelines database. The purpose of our project was to increase the number of ischemic stroke patients receiving t-PA within 60 minutes after triage.

Methods:
The Six Sigma® process model was applied in order to develop an understanding of variations in the times of triage to initiation of IV t-PA data. We assembled a multidisciplinary team to develop and measure aspects of our current protocols, analyze data, investigate and identify the causes of delays and form action plans to enhance our new process. We tracked the patient flow from first responder contact to thrombolysis time. As a result the team acknowledged that it was imperative to impact the early recognition of ischemic stroke patients in the field. This led to local and regional stroke educational programs. Our neuroscience team of physicians and nurses proceeded to educate over 850 emergency responders.

Results:
Initial analysis of the baseline data showed that 56 % (5 of 9) of the ischemic stroke patients received intravenous t-PA within 60 minutes of triage. Once the stroke code process was implemented, 79 % (15 of 19) of ischemic stroke patients received intravenous t-PA within 60 minutes after triage. These results were obtained within 9 months of process implementation. Specific process changes included the use of a standard time clock, shorter CT scan turn around times, dedicated 24/7 ED pharmacists, quicker availability of medication administration pumps and ongoing feedback by all team members on the acute stroke process.

Conclusions:
The stroke team was able to identify barriers, institute process changes and ensure the implementation of change from the prehospital community setting to the acute inhospital care.
Abstract P267: Does Admission for Transient Ischemic Attack Lead to Differences in 1-Year Outcomes?
Authors: Cheng Eric , Cline Michael , Robinson Joshua , Myers Laura , Lincoln Flossy , Bravata Dawn
Published: July 2021

Background:
A new transient ischemic attack (TIA) is a risk factor for a future vascular event. Reducing that risk requires a timely diagnostic workup and delivering secondary stroke preventive services. It is unknown whether such care should be performed in the inpatient or outpatient setting.

Methods:
Using administrative databases, we identified all veterans with a diagnosis code for TIA assigned in the emergency department or urgent care setting in the Veterans Health Administration during fiscal year 2008. We calculated the proportion who were admitted and predictors of admission. At one-year after presentation of TIA, we examined the proportion who were assigned a new diagnosis code for stroke, myocardial infarction, or death. We then determined whether admission was associated with outcomes using chi-square and multivariate logistic models.

Results:
The sample consisted of 2247 persons with a new diagnosis of TIA, and 35% were admitted within one day of presentation. The mean age was 68, and 25% had a prior history of stroke or TIA. At one-year, 12.1% developed the composite outcome of stroke, myocardial infarction, and death. Older age, history of hypertension, atrial fibrillation, and diabetes were associated with admission (p<0.05). In unadjusted analyses, the composite outcome was not significantly different among persons admitted vs. not admitted (13.1% vs. 11.6%, p=0.29). In multivariate analyses, admission was not significantly associated with the composite outcome (see
Table
).

Discussion:
Persons admitted for TIA are more likely to possess stroke risk factors than those who were not admitted. The decision to admit was not associated with differences in one-year outcomes. Ongoing work will compare the completeness and timeliness of the diagnostic work-up of TIA as well as long-term control of stroke risk factors among persons admitted versus persons not admitted.

Predictors of 1-year stroke, myocardial infarction, or death among persons with TIA

Odds ratio [95% CI]
p-value

Hospital admission within one day
1.0 [0.8 - 1.4]
0.7

Age
1.0 [1.0 -1.0]
<0.001

History of hypertension
1.2 [0.9 - 1.7]
0.2

History of atrial fibrillation
1.5 [1.1 - 2.0]
<0.05

History of diabetes
1.2 [0.9 - 1.5]
0.3

History of stroke
1.8 [1.3 - 2.5]
<0.001

History of TIA
0.7 [0.5 - 1.1]
0.1

History of myocardial infarction
2.9 [1.3 - 6.1]
<0.01
Abstract P31: Long-Term Outcomes Among Nonagenarians with Non--ST-Segment Elevation Myocardial Infarction
Authors: Lopes Renato D , Holmes DaJuanicia N , Wang Tracy Y , Roe Matthew T , Peterson Eric D , Alexander Karen P
Published: July 2021

Background:
Age is a key determinant of adverse acute events following non-ST-segment elevation myocardial infarction (NSTEMI), but the influence of age on longer-term outcomes in hospital survivors has yet to be explored.

Methods:
Our population included NSTEMI patients aged ≥65 years in the CRUSADE registry who were treated from 2/2003-12/2006 and linked to Medicare claims data for longitudinal follow-up. In-hospital and 1-year mortality rates (among hospital survivors calculated using the Kaplan-Meier method) are shown for nonagenarians and younger elderly-aged groups. Cox proportional hazard modeling was used to adjust for baseline characteristics, discharge medications, and procedures.

Results:
Of 36,711 NSTEMI hospital survivors aged ≥65 years, 58.8% (21586/36711) were 65-79 years old, and 7.6% (2794/36711) were ≥90 years old. Compared with younger elderly adults (ages 65-79), nonagenarians had lower prevalence of diabetes but higher prevalence of congestive heart failure, hypertension, prior stroke, and renal insufficiency (all p<0.0001). The qualifying NSTEMI was more likely to be a first cardiac event (no prior MI, PCI, or CABG) for nonagenarians than for younger elderly adults (59.7% [1669/2794] vs. 51.0% [11002/21586], p<0.0001). Nonagenarians were less likely to receive revascularization (10.3% [289/2794] vs. 56.7% [12238/21586], p<0.0001) and evidence-based discharge medicine, and had high mortality (Table). One-year mortality remained higher for nonagenarians after adjustment (HR 2.15, 95% CI 1.99-2.32, reference age 65-79).

Conclusions:
Nonagenarians with NSTEMI experience 2-fold higher mortality following discharge compared with younger elderly adults, with a mortality rate approaching 50% at 1 year. This hazard persists after adjustment, suggesting the role of unmeasured competing risks in this vulnerable population.

Table.

Discharge medication, in-hospital mortality, and 1-year mortality rates by age category

Discharge medications (%)
65-79 Years
80-84 Years
85-89 Years
≥90 Years
P-value

Aspirin

94.9 19085/21586
93.2 6166/7324
92.6 4118/5007
91.2 2198/2794
<0.001

Clopidogrel

71.5 13677/21586
67.8 4205/7324
64.0 2643/5007
58.2 1220/2794
<0.001

Beta-blocker

92.1 18352/21586
91.7 6119/7324
92.3 4131/5007
92.2 2229/2794
0.942

Statin

80.9 16514/21586
74.2 5018/7324
67.1 2998/5007
56.0 1297/2794
<0.001

ACE inhibitor or ARBs

66.4 13624/21586
65.9 4493/7324
64.2 2891/5007
61.4 1477/2794
<0.001

In-hospital mortality

4.4 996/22582
7.1 560/7784
9.2 509/5516
11.1 348/3141
<0.001

1-year mortality

13.2 2853/21586
23.8 1740/7324
33.5 1676/5007
45.6 1275/2794
–
Abstract P4: Does the Expected Reduction in Restenosis from Drug-Eluting Stents Predict Actual Use? An Assessment of Treatment-Risk Paradox Using the C-Statistic
Authors: Yeh Robert W , Normand Sharon-Lise T , Mauri Laura , Wolf Robert E , Cohen David J , Ho Kalon K , Spertus John A
Published: July 2021

Background:
Beneficial treatments are often least prescribed to patients at highest risk for poor outcomes. Quantitative assessments of “treatment-risk paradox” have relied on comparisons across risk strata defined by single variables or arbitrary categories of predicted risk. We examined whether DES were preferentially used in patients at highest risk for target vessel revascularization (TVR) after PCI using a novel quantitative method.

Methods:
We used a validated model to predict TVR at 1 year for all PCI hospitalizations in MA between 10/04 and 9/07. For each patient, we calculated predicted absolute risk reduction (ARR) in TVR assuming treatment with DES (vs. BMS). Using logistic regression, we assessed the association between predicted ARR and observed stent treatment for the entire population and each of 21 hospitals, and calculated the c-statistics for each as a measure of the extent to which predicted benefit discriminated observed DES use.

Results:
A total of 21933 (80.9%) PCIs with DES and 5174 (19.1%) PCIs with BMS were included. The predicted ARR in TVR associated with PCI ranged from 1.2% to 15.9%. Overall, predicted benefit from DES poorly discriminated receipt of DES (c-statistic 0.545, 95% CI 0.537 - 0.554). Of 22 hospitals, 15 had c-statistics with CIs that crossed 0.5, implying no relationship between predicted benefit of DES and stent selection. (Figure)

Conclusions:
We observed a minimal relationship between predicted benefit from DES and actual DES use. The c-statistic and ROC curve may be a useful metrics to assess the relationship between predicted benefit and observed receipt of therapies, and identify potential areas for quality improvement.
Abstract P44: Assessing the Risk of Hospital Readmission in Patients with Congestive Heart Failure: A Comparison of 4 Risk Scores
Authors: Njeim Mario , Alaali Yathreb , Assaad Mahmoud , Ambulgekar Nikhil , Bou Malham Sarah , Abas Mustafa , Hudson Michael
Published: July 2021

Background:
Readmission within 30 days of a prior hospitalization for congestive heart failure (CHF) has emerged as a major marker of quality improvement and payment reform. Whereas a number of interventions are available to improve outcomes and reduce readmission rates, there remains an urgent need for accurate risk stratification tools that could be used to build cost-effective and personalized CHF management programs.

Methods:
We conducted a retrospective cohort study on patients discharged from a major urban hospital between June 2009 and October 2009 with a primary diagnosis of CHF. Patients were followed until their first all-cause hospital readmission. We made minor modifications to 4 different readmission risk scores in order to assess and compare their ability to estimate the risk of hospital readmission at 30 days from discharge. Three of the scores (Chin and Goldman 11 point scoring, Philbin and DiSalvo 15 point scoring and Krumholz et al 4 point scoring) were retrieved from reviewing the literature. The fourth tool (Henry Ford score) is an internal non-validated computed calculator based on 8 predictive factors, previously derived within our institution. The scores were compared by logistic regression and area under the ROC curve.

Results:
285 patients were included in the study. The readmission rate at 30 days was 23.5% (67 of 285). A logistic regression revealed that both Chin and Goldman and Philbin scores were poor and statistically non-significant predictors of 30-day all-cause readmission (p-values = 0.784 and 0.165 respectively). When compared by logistic regression and area under the ROC curve, Henry Ford tool (p-value = 0.003; AUC = 0.64) performed the best followed by the Krumholz score (p-value = 0.017; AUC = 0.60).

Conclusions:
In an era where there is an urgent need to improve and personalize heart failure management programs, simple scores can be used to stratify patients according to their risk of re-hospitalization. Krumholz and Henry Ford scores are both accurate tools for the prediction of 30-day all-cause readmission. Krumholz score relies on 4 easily retrievable risk factors while the Henry Ford tool is a computed model that integrates 8 different factors.
Abstract P50: Early Nonadherence to Antihypertensive Medications
Authors: Schroeder Emily B , Ellis Jennifer L , Carroll Nikki M , Bayliss Elizabeth A , Raebel Marsha A
Published: July 2021

Background:
Medication adherence is extremely important in the treatment of hypertension. Most medication adherence metrics are based on refill rates from pharmacy claims databases and require at least two drug dispensings for the calculations. Little is known about individuals who demonstrate early non-adherence to antihypertensive medications, either by never filling a prescription (primary non-adherence) or by filling a prescription only once (early non-persistence).

Methods:
We conducted a retrospective cohort study of 6,393 Kaiser Permanente Colorado enrollees with hypertension who received a first prescription for an antihypertensive medication between January 1, 2007 and June 30, 2008. We linked prescription orders to medication dispensings and then classified patients into primary non-adherent, early non-persistent, or ongoing dispensings groups. Multivariate logistic modeling was performed to investigate potential predictors of primary non-adherence compared to ongoing dispensings.

Results:
Five percent (331 of 6,393) of patients were primarily non-adherent, 26% (1,672 of 6,393) demonstrated early non-persistence, and 69% (4,390 of 6,393) received ongoing dispensings. In a multivariate model, the following characteristics were associated with a higher likelihood of exhibiting primary non-adherence compared to receiving ongoing dispensings: Hispanic (OR 1.74, 95% CI 1.20-2.52) or other racial/ethnic minority (1.48, 1.13-1.95), an enrollment period less than 10 years (1.28,1.00-1.62), more than four comorbidities compared to no comorbidities (1.76, 1.02-3.02), and fewer than five health care contacts in the six months after the medication was prescribed (1.31, 1.02-1.67). The copayment amount for office visits or medications was not associated with primary non-adherence. The c-statistic for the model containing demographic characteristics, comorbidities, and health care plan information was 0.63.

Conclusions:
A substantial number of individuals newly prescribed an antihypertensive medication exhibited early non-adherence. Our multivariate model had limited discrimination, indicating that further research is needed to better characterize these individuals and explore barriers to early adherence.
Abstract P99: Risk of Hospitalization Among Patients with Heart Failure Within the Veterans Health Administration (VHA)
Authors: Wang Li , Sun Haili , Lowy Elliott , McDonell Mary , Bryson Christopher , Frisbee Kathleen , Shawn Loftus , Nielson Christopher , Maynard Chuck , Fihn Stephan D
Published: July 2021

Background:
Patients with heart failure (HF) are at high risk of hospitalization and death. VHA has developed a population-based predictive model to identify high risk patients for case management.

Methods:
Using clinical and administrative databases, we identified all VA patients with a diagnosis of HF between June, 2008 and May, 2009, then followed the total of 194,062 HF patients for the subsequent 12 months. We used multinomial regression to model the outcome of hospitalization and death jointly. Candidates for predictor variables were related to demographics, medical history, vital status, health care utilization and medication. We randomly split the data 50% to 50% into a training sample and a validation sample. We derived the 30-day and 1-year predictive models from the training sample and validated the models on the other sample.

Results:
The C-statistics for 30-day and 1-year outcomes were 0.82 and 0.81 for hospitalization, 0.79 and 0.76 for hospitalization or death, respectively. Model calibration was excellent (Figure). For each outcome we stratified patients into 20 risk percentile categories. Risk stratification details were listed (Table).

Conclusions:
Predictive models can correctly stratify HF patients into risk categories for hospitalization and death.
Table
Risk Stratification by Outcomes

30-Day Outcomes
1-Year Outcomes

Risk
Hospitalized
Hospitalized/Died
Hospitalized
Hospitalized/Died

Category

N (%
*
)

N (%
*
)

N (%
*
)

N (%
*
)

1
5(0.05%)
36(0.4%)
51(0.5%)
535(5.5%)

2
9(0.1%)
72(0.7%)
121(1.2%)
824(8.5%)

3
21(0.2%)
99(1.0%)
223(2.3%)
1051(10.8%)

4
38(0.4%)
112(1.1%)
337(3.5%)
1254(12.9%)

5
51(0.5%)
117(1.2%)
472(4.9%)
1420(14.6%)

6
64(0.7%)
123(1.3%)
677(7.0%)
1628(16.9%)

7
93(1.0%)
185(1.9%)
907(9.3%)
1871(19.3%)

8
109(1.1%)
200(2.1%)
1105(11.4%)
2079(21.4%)

9
156(1.6%)
222(2.3%)
1397(14.4%)
2260(23.3%)

10
172(1.8%)
255(2.6%)
1664(17.1%)
2538(26.2%)

11
231(2.4%)
305(3.1%)
1980(20.4%)
2818(29.0%)

12
273(2.8%)
365(3.8%)
2306(23.8%)
3020(31.1%)

13
333(3.4%)
462(4.8%)
2589(26.7%)
3502(36.1%)

14
419(4.3%)
451(4.6%)
3057(31.5%)
3766(38.8%)

15
480(4.9%)
591(6.1%)
3423(35.3%)
4206(43.3%)

16
639(6.6%)
717(7.4%)
3989(41.1%)
4691(48.4%)

17
764(7.9%)
891(9.2%)
4446(45.8%)
5208(53.7%)

18
977(10.1%)
1126(11.6%)
5004(51.6%)
5819(60.0%)

19
1296(13.4%)
1458(15.0%)
5775(59.5%)
6619(68.2%)

20
2208(22.7%)
2580(26.6%)
6898(71.1%)
7812(80.5%)

All
8338(4.3%)
10367(5.3%)
46421(23.9%)
62921(32.4%)

*Observed event rate per risk category of the corresponding outcome
Abstract 110: Quality of life in Beta Thalassemia
Authors: Merella Pierluigi , Melis Marco , Culeddu Chiara , Meloni Ivan , Casu Gavino
Published: July 2021

Numerous scientific evidence support that quality of life of the patients have significant prognostic impact in various heart's diseases. Studies on quality of life in general population have led to the validation of different questionnaires. Currently there are no specific questionnaires for assessing the quality of life in thalassemic patients. Questionnaire on health status SF-36 is a validated and simple tool that, through two synthetic indices, which refers to physical (Physical Component Summary, PCS) and psychic health's domain (Mental Component Summary, MCS), provides important information on quality of life. PCS reflects concepts related to physical morbidity, while the index MCS reflects psychological or mental morbidity. Questionnaire SF-36 requires an assessment of the patient's activities of daily living (personal hygiene wait, walk, climb stairs, carry weight, etc.), subjective health status, emotional state, on social life and relationships. The aim of our study was to assess whether, in this population, the derived indices have diverged significantly from the healthy reference population and, if so, whether there was a correlation with the severity of underlying heart disease. To assess quality of life in a population of patients (n. 46) with thalassemia major and/or intermediate followed at our center, we administered the Italian version of the questionnaire SF-36 (Apolone, 2005), relating derived indexes with the main clinical and instrumental parameters, especially functional NYHA class, ejection fraction and indices of left ventricular diastolic function, T2* values, echocardiographic signs of pulmonary hypertension and right ventricular dysfunction, such as PAPs values and RV FAC. The mean values of the indices PCS and MCS in the entire study population were, respectively, 47.50 and 51.24, overlapping those of healthy reference population (Survey on health status of Italians, ISTAT 1999-2000). Subgroup analysis showed that the presence of pulmonary hypertension and/or right ventricular dysfunction was associated with a significant deterioration in the perception of physical health (PCS 35.9 versus 48.3 in patients without pulmonary hypertension). The analysis of correlation between PCS and clinical-instrumental variables studied has also returned frankly negative values with the values of PAPs (r -0.86), confirming the negative impact of the presence of pulmonary hypertension on health's perception. No other significant association was identified. In conclusion, our study highlighted how detection of pulmonary hypertension in an unselected population of patients with beta-thalassemia has a detrimental impact on perceived quality of life.
Abstract 134: Stress MPI is the Most Frequent Index Cardiac Diagnostic Test for a Commercially Insured Population
Authors: Song Ji Y , Chen Jersey , Nallamothu Brahmajee K , Reeves Mathew J , Santer Emily , Goldman Beth , Wasilevich Elizabeth A
Published: July 2021

Introduction:
While stress MPI is a commonly used non-invasive diagnostic test (NIDT) in the clinical setting, it is unclear whether this test is also the most prevalent “index” NIDT among a non-Medicare insured population. Identifying patients’ index NIDT is the first step in characterizing the subsequent cardiac diagnostic-therapeutic cascade in coronary artery disease. Our objective was to determine the frequency distribution of the type of index NIDT in adults aged <65 years from a commercial insurance provider in Michigan.

Methods:
The study population included commercially insured Michigan adults, aged 18-64, who received at least one NIDT over a 2-year period (Oct. 2008 - Sept. 2010). Stress EKG, stress Echo, stress MRI, stress MPI, and CCTA were considered as eligible index NIDT. Using historic administrative facility and professional claims data, an index test was defined as the first NIDT for members with a negative 6-month history of cardiac-related diagnostic and revascularization services and continuous enrollment in the prior 11 months. We determined the frequency distribution of the type of index test for the total population and stratified by age and sex. The association between age group and type of index test was determined using Pearson’s chi-square. The Cochran-Mantel-Haenszel statistic was used for stratified analysis of this relationship by gender.

Results:
Among the study population, 122,800 (71.7%) had an index NIDT (53.7% men, 46.3% women). The median age for those with an index NIDT was 55 years. The most frequent index NIDT was stress MPI (45.1%) followed by stress EKG (34.3%), stress Echo (18.7%), and CCTA (1.8%). Among those with a single test as the index test, age and gender were statistically associated with type of test administered (
p
<0.01 for both). Women were more likely to receive stress Echo than men. Stress EKG was the most frequently used index NIDT for ages 18-34 (46.1%), while stress MPI was the most frequently used index NIDT in both 35-54 and 55-64 year olds. The association between age group and type of index NIDT remained strong after adjusting for gender (
p
<0.01).

Conclusions:
We found that stress MPI is the most frequently used NIDT for diagnosing cardiac disease in middle to older age adults while stress EKG was used more frequently in patients under 35 years. Further studies are ongoing to characterize subsequent testing and therapy after the index NIDT for the purpose of designing provider based interventions.
Abstract 137: Efficacy and Cost Savings Realized through Validation of a Tool to Identify Low Risk STEMI Patients not Requiring CCU Care
Authors: Downey William E , Cassidy Lara M , Liebner Kerstin , Magyar Robyn , Humphrey Angela D , Cedarholm John C , Rose Geoffrey A , Kowalchuk Glen J , Rinaldi Michael J , Haber Robert H , Wilson B. Hadley
Published: July 2021

Introduction
In the early 1960s, the creation of Cardiac Care Units (CCUs) led to a 50% reduction in the in-hospital mortality of acute myocardial infarction (AMI). Prompt application of closed chest cardiac resuscitation and external defibrillation -- then new technologies -- served to reduce the consequences of the event. Over the ensuing four decades, therapeutic advances in the treatment of AMI (e.g. prompt reperfusion strategies) have favorably altered its natural history, potentially obviating the need for CCU care. Since such care is expensive, identification of a low risk cohort of patients in whom this care is not necessary could allow substantial improvements in the cost of cardiac care.

Hypothesis
Existing risk models can be used to accurately identify low risk STEMI patients who do not require CCU care after primary PCI.

Methods
We performed a retrospective chart review of all STEMI cases from 2010 at Carolinas Medical Center. We then assessed them using the TIMI STEMI risk score and a risk assessment algorithm for uncomplicated STEMI developed at Brigham and Women's Hospital (BWH). The BWH STEMI Care Redesign defines low risk STEMI patients as those who are promptly revascularized via successful single vessel PCI with (1) no evidence of ongoing ischemia, (2) EF>40%, (3) absence of CHF, hemodynamic or electrical instability, and (4) who are awake without need of respiratory support. Cost data (fixed and variable) from Quality Advisor™, a product by Premier, was abstracted for each STEMI case, examining specific resources used in CCU and non-CCU units.

Results
Among 310 consecutive STEMI patients, in-hospital mortality was 3.9%. The BWH risk score identified 46.4% of these patients as low-risk. Among these patients, in-hospital mortality was 0%. Only one of these 144 low-risk patients required subsequent CCU care. None required CPR or defibrillation after revascularization. The TIMI STEMI risk score <2 classified 26.1% of the patients as low-risk. Among these patients, in-hospital mortality was 0%. However, 3.7% of these "low-risk" patients had ventricular arrhythmias or respiratory decompensation during or shortly after PCI. None of the 3.7% were classified as "low-risk" by the BWH model. CCU care added $723 in fixed costs and $340 in variable costs per hospital day.

Conclusion
The BWH model, but not the TIMI STEMI risk score, accurately predicted a sizable cohort of STEMI patients at very low risk of in-hospital death and complications. These patients may be appropriate for admission to non-CCU level care immediately following primary PCI. Doing so would be projected to yield a cost savings of >$1000 per patient.