bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 313: Rates of All-cause Mortality, Myocardial Infarction and Coronary Revascularization Stratified by Appropriate Use Criteria in Coronary Artery Disease Patients Managed with Optimal Medical Therapy
Authors: Saini Vikas , Mamuya Wilfred , Carolan Padraig , Aggarwal Deepa , Bilchik Brian , Blatt Charles , Ravid Shmuel
Published: March 2022

Appropriate use criteria (AUC) have been developed for guiding clinical decision-making for coronary revascularization (revasc). We studied a prospective cohort of 693 pts initiated in 1992 and managed with optimal medical therapy (OMT). AUC scores could be calculated using noninvasive test results and coronary angiographic data in 230 pts, which constitute the study group. When non-invasive findings were discordant, patients were put in the higher risk stratum. Revasc status and myocardial infarction (MI) events were ascertained as of June 2005. Mortality status was ascertained as of December 31, 2008. Based on AUC scores, pts were classified as Appropriate (A), Inappropriate (I), or Uncertain (U) for revasc. Decisions to pursue invasive evaluation and revasc were based solely on stability of symptoms, LV function, and exercise duration. Survival analysis and stepwise Cox modeling was used to assess AUC class as a predictor of outcomes.

Results:
The majority of pts, 53% (121 of 230), were AUC Class A, with almost all the remainder in Class U, 34% (79 of 230). The mean age of the study group was 66.0 years. The annual incidence of all-cause mortality over a mean follow up period of 12.1 years was 3.6%. A total of 99 deaths occurred. There were no significant differences in the mortality curves of the 3 AUC classes.

The annual incidence of non-fatal MI over a mean follow up of 6.45 years was 2.2%. AUC class A was not a predictor of non-fatal MI.

The annual incidence of revasc over a mean follow up period of 5.38 years was 6.5%. Multivariate stepwise Cox models showed AUC class A was a significant predictor of revasc, along with diabetes mellitus. Beta-blocker therapy at entry was protective. Kaplan-Meier curves confirmed the findings for revasc and nonfatal MI.

Conclusions:
In an OMT cohort initiated in 1992, 53% of pts in whom AUC scores were calculable were deemed appropriate for revasc but were managed with OMT alone. Low annual incidence of mortality and rates of eventual revascularization were observed. Retrospective stratification showed no adverse mortality experience with OMT by AUC class.

AUC Class A pts had a significantly higher rate of revasc during OMT, reflecting the goals of the AUC system, yet the annualized rates of death and MI in this class were comparable to the rates in the medical arms of recent RCT’s of OMT.

These findings suggest that contemporary AUC classification may permit revasc in OMT pts without distinguishing that subset with a future mortality risk on OMT alone. AUC Classification of pts for revasc may require further refinement to enhance the selection of mortality benefit over OMT.
Abstract 315: Feasibility of outpatient ambulatory ECG monitoring to screen for silent atrial fibrillation: Pilot Findings from Screening Trial for Undiagnosed Atrial Fibrillation (STUDY-AF)
Authors: Ullal Aditya J , Hoang Donald D , Than Claire , Heidenreich Paul A , Miller Jared D , Friday Karen , Froelicher Victor F , Turakhia Mintu P
Published: March 2022

INTRODUCTION:
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, accounting for up to one in five strokes. Identification of silent AF could reduce the total burden of stroke, particularly with newer, low-cost noninvasive methods of screening. We therefore performed a pilot study of ambulatory ECG monitoring to screen for AF.

METHODS:
We performed a prospective screening study by enrolling patients from May 2012 to January 2013 in outpatient clinics for cardiology, echocardiography, and stress testing at the VA Palo Alto Health Care System. Patient inclusion criteria were age ≥ 55 years and at least two of the following risk factors: coronary disease, congestive heart failure (CHF), hypertension, diabetes, and sleep apnea. We excluded patients with 1) a history of AF, supraventricular tachycardia, stroke, transient ischemic attack, systemic embolism, implantable pacemaker or defibrillator; 2) palpitations or syncope in the prior year. All patients received a small, wearable patch-based ambulatory ECG monitoring device (Zio® Patch, iRhythm Inc., San Francisco, CA) for up to two weeks of uninterrupted monitoring. The primary outcome was proportion of patients with AF. Secondary outcomes were prevalence of sustained and non-sustained ventricular tachycardia (NSVT) and supraventricular tachycardia (SVT).

RESULTS:
Among 57 patients (age 68 ± 7.4 years, 0% women), 53 (93%) completed ambulatory monitoring. The highest sites of enrollment were in cardiology clinic (47%) and echocardiography (46%). Atrial fibrillation was detected in three subjects (5.7%), who had a mean AF Burden of 4.2%. Common asymptomatic arrhythmias detected were SVT of ≥ 4 beats (N=37; 70%), ≥ 8 beats (N=24; 45%), and ≥ 60 seconds (N=4, 7.5%). Asymptomatic NSVT of ≥ 4 beats (N=16; 30%) and ≥ 8 beats (N=5, 9.4%) were also detected.

CONCLUSION:
Ambulatory screening of asymptomatic arrhythmias using the Zio® Patch is feasible; however the diagnostic yield for silent AF may be low, even among patients with established AF risk factors. Our study found a high prevalence of incidental asymptomatic SVT and NSVT. A larger trial with more targeted enrollment may be required to demonstrate the value of screening for AF. The impact of detecting incidental NSVT or SVT, which themselves could prompt evaluation and may be relevant to development of AF, requires further investigation.
Abstract 328: Coronary Artery Disease Performance Measures And Statin Use Between Patients With Recent Percutaneous Coronary Intervention (PCI)and Patients With Recent Coronary Artery Bypass Grafting (CABG): An Analysis From The NCDR®.
Authors: Bandeali Salman J , Gosch Kensey , Negi Smita I , Alam Mahboob , Kayani Waleed T , Wilson James M , Chan Paul S , Maddox Thomas M , Virani Salim S
Published: March 2022

Background:
Although rates of medication treatment for coronary artery disease (CAD) have improved, the association between coronary revascularization method and compliance with coronary artery disease (CAD) performance measures (PMs) is unknown.

Methods:
Our analysis included patients enrolled in the Practice Innovation and Clinical Excellence (PINNACLE®) registry who underwent coronary revascularization in the 12 months prior to their index outpatient visit in 2011. Baseline characteristics between the two groups were compared. One-to-one propensity score matching was performed to control for differences between groups. Achievement of CAD PMs and statin use were compared between the propensity-matched groups.

Results (Table):
Our study cohort consisted of 112,969 patients. Among these, 80,753 patients underwent PCI and 32,216 patients underwent CABG in the 12 months prior to their index visit. Successful propensity matching occurred in 43,484 patients (21,742 in each group). The resulting sample was well matched for all baseline characteristics except for age, peripheral arterial disease (PAD) and prior stroke. After conditionally adjusting for age, PAD, and prior stroke; a higher proportion of PCI patients, compared to CABG patients, met the CAD PMs for blood pressure control, tobacco use query and antiplatelet therapy. Statins were prescribed more often in CABG patients compared to PCI. CAD PMs of lipid control, symptom and activity assessment, beta-blocker therapy, ACE inhibitor/ARB therapy and smoking cessation intervention were not significantly different among the two groups. Only 23.7% CABG patients met between75-100% of all eligible PMs compared with 22% PCI patients; 50% met 50-74% of eligible PMs in CABG vs. 54.1% in the PCI group, and 25.8% met 0-49% of the eligible PMs in CABG group vs. 24% in the PCI group (p value for trend <0.0001).

Conclusion:
Although overall compliance with CAD PMs between patients undergoing recent CABG compared to recent PCI is similar, only about one-fourth of patients in both groups met between 75-100% of eligible CAD PMs. Furthermore, distinct gaps were noted for specific PMs in the recent CABG group. Our study highlight areas for future quality improvement initiatives aimed at improving compliance in PMs in patients who have undergone recent revascularization.
Abstract 33: Incidence Of Urinary Tract Infection Among Patients With Acute Cerebrovascular Accidents: A Possible Trigger For Stroke
Authors: kali Maher , Kuruvilla John , Lucas Dan , Broce Mike , Seybold Dara , Reyes Bernardo
Published: March 2022

Background:
Acute infections and other inflammatory stimuli have emerged as important triggers of vascular events. Previous studies have reported 25 to 35% antecedent infection rates among patients with acute cerebrovascular accidents (CVA). The mechanisms involved in acute infection include immunological mediated activation of platelets and endothelial dysfunction. The incidence of antecedent UTI has not been reported and could establish an important relationship between UTI and CVA.

Objective:
The aim of the current study was to determine and compare the incidence of antecedent UTI among CVA patients to reported UTI rates among the general population.

Methods:
This was a retrospective review of 1295 medical records for CVA from the emergency department in a high volume tertiary care center. Our cohort included CVA patients that also had urinalysis within 72 hours prior to or less than 24 hours after admission. Patients with bacteriuria without any of the additional findings were excluded. The incidence of UTI was compared to the infection rate calculated for a hypothetical equal size comparison group based on previously reported literature (i.e., historical controls).

Results:
Thirty-seven percent (476/1295) of the patients met inclusion criteria of simultaneous CVA and urinalysis. The overall crude incidence of UTI was 39.3% (187/476). Ischemic strokes accounted for a larger percentage of abnormal urinalysis (74.9%), when compared to hemorrhagic strokes (25.1%). Nonetheless, patients suffering hemorrhagic strokes had similar rates of UTI (40.2%) versus Ischemic Stroke Patients (38.7%). The incidence of UTI was significantly higher than reported infection rates of general population controls (187/476=39.3% versus 52/424=10.9%, p<0.001).

Conclusion:
Our findings provide some evidence that the incidence of UTI is significantly higher for patients with CVA than is found in the general population
Abstract 331: Effect of Operator and Hospital Experience on Mortality for Balloon Aortic Valvuloplasty
Authors: Shah Neeraj , Chothani Ankit , Patel Nileshkumar J , Grover Peeyush , Mehta Kathan , Deshmukh Abhishek , Rathod Ankit , Ghatak Abhijit , Singh Vikas , Badheka Apurva , Gupta Sandeepkumar J , O’Neill William W , De Marchena Eduardo , Cohen Mauricio G
Published: March 2022

Background:
Utilization of balloon aortic valvulopasty (BAV) has increased in recent years. We aimed to explore the relationship between hospital and operator experience on mortality.

Methods:
We queried Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) between 1998 and 2010 using the ICD9 procedure code of 35.96 for valvuloplasty. The NIS represents 20% of all hospitals in the US. Patients with age > 60years with aortic stenosis were included and those with concomitant mitral, tricuspid or pulmonic stenosis were excluded. Severity of co-morbid conditions was defined with Deyo modification of Charlson’s comorbidity index. Primary outcome was in-hospital mortality. Annual operator and hospital procedure volume were calculated based on the unique operator and hospital identification numbers and were split into tertiles of the total volume per year. Mixed effects logistic regression modeling incorporating hospital ID as random effects was constructed to find out the independent predictors of in-hospital mortality.

Results:
A total of 2,127 BAV (weighted n= 9,686) were identified for hospital volume analysis and 1,030 BAV (weighted n = 5,125) were available for both operator and hospital volume analysis. In models incorporating either operator or hospital volume alone (hazard ratio (HR), 95% CI, p value) both operator volume (HR 0.5 per every unit increase in operator volume, 0.3-0.9, p<0.05) and hospital volume (0.8 per every 10 unit increase in hospital volume, 0.8-0.9, p <0.05) were independently associated with decreased mortality. However in a model incorporating both operator and hospital volume, only increasing operator volume was associated with decreased mortality (0.85, 0.73-0.98, p=0.03) and influence of hospital volume was no longer statistically significant. Relative risk reduction of mortality was 51% when BAV was performed in the highest tertile of both hospital and operator volume (p=0.05).

Conclusion:
We demonstrated that both annual operator and hospital procedure volume significantly impact in-hospital mortality for BAV, with operator volume playing a more significant role.
Abstract 34: Assessment Of Early Myocardial Deformation Changes In Dyslipidemic Children By Three-dimensional Speckle Tracking Imaging
Authors: Vitarelli Antonio , Martino Francesco , Capotosto Lidia , Caranci Fiorella , De Cicco Valentina , Martino Eliana , Colantoni Chiara , Zanoni Cristina , Bruno Pasqualina , D’Ascanio Michela
Published: March 2022

Background.
Dyslipidemia is considered a strong risk factor for premature atherosclerotic cardiovascular disease and increased morbidity and mortality and may have an adverse effect on left ventricular (LV) performance. Three-dimensional speckle tracking imaging (3D-STI) provides information regarding different echocardiographic parameters of LV myocardial deformation.

Purpose.
Our aim was to assess the presence of early myocardial deformation abnormalities in nonselected dyslipidemic children free from other cardiovascular risk factors.

Methods.
Twenty-four consecutive nonselected hypercholesterolemic children (TC above the 95th percentile for age and gender, mean age 11.3 ± 2.16 years) and 24 healthy age-matched children were enrolled. None of them had any other cardiovascular risk factors. Obesity (body mass index >75th percentile for age and gender) as well as other diseases were excluded. Every subject underwent 2D- and 3D-STI. Volumes were measured from 3D datasets. Global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS), and global radial strain (GRS) were computed at end-systole. GAS was calculated as the percentage variation in the surface area defined by the longitudinal and circumferential strain vectors. Data analysis was performed offline (EchoPAC BT11, 4D Auto LVQ, GE).

Results.
Mean percentage intraobserver variability was 7% for GLS, 9% for GCS, 6% for GAS, and 11% for GRS. Comparison between 2D and 3D GLS showed high correspondence (r = 0.89, y = 1.13x - 0.78). The mean time of analysis was of 149 ± 27 sec for 3D analysis, which was 17% less than for 2D analysis (p<0.05). The following strain values were obtained in hyperlipidemic patients compared to controls: 3D GLS (-14.7±2.5% vs -16.8±2.7%, p <0.005), 3D GCS (-28.1±3.6% vs -29.6±4.2%, p <0.01), 3D GRS (29.6±9.2% vs 30.2±9.7%, p =NS), and 3D GAS (-39.8±3.4% vs -43.2±3.2%, p <0.001). On multivariate logistic regression analysis, the strongest relationship with dyslipidemia was found for LV GAS (β- coefficient= 0.74, r
2
= 0.61, p= 0.002).

Conclusions.
Dyslipidemia is associated with myocardial deformation changes independently from any other cardiovascular risk factor or any structural cardiac abnormalities.
Abstract 341: The Revascularization Heart Team: Feasibility and Cross-sectional Patient Profile in a Large Academic Center
Authors: Dota Anthony P , Badhwar Vinay , Sanchez Carlos , Lee Joon S , Marroquin Oscar C , Smith Anson J , Chu Danny , Wei Lawrence , Toma Catalin , Khandhar Sameer J , Bhama Jay , Esper Stephen , Rapsinski Rosalyn , Mulukutla Suresh
Published: March 2022

The American College of Cardiology guidelines assign a Class IC recommendation for the use of a Heart Team approach in the treatment of complex coronary artery disease (CAD). However, doubts remain regarding the practical application and functionality of this method in providing routine cardiovascular care. We sought to assess the feasibility of the Heart Team approach to adjudicate complex CAD through analyzing personnel participation, as well as anatomic and comorbid patient characteristics.

From May to October, 2012 we convened a daily Heart Team meeting to discuss evidence based management of patients with complex CAD. All cases were comprehensively reviewed by a team of interventional cardiologists, non-invasive cardiologists, cardiac surgeons, and anesthesiologists within 72 hours of angiography in our health system.

Meetings occurred on average 3.5 days per week and included an average of 4 physicians from the multidisciplinary team. Patient profiles are detailed in Table 1. Recommendations for treatment were made based on a consensus decision amongst the group, and ultimately 20% of patients received medical therapy, 26.4% underwent percutaneous coronary intervention (PCI), 38.2 % had coronary bypass with or without valve repair or replacement, 0.9% went for minimally invasive direct coronary artery bypass, and 2.7% were treated with a hybrid procedure including PCI followed by surgery.

We found a structured Heart Team approach to be feasible, and effective in formulating revascularization strategies for individual patients. This represents a successful model for the implementation of the Heart Team in routine care, which has great potential to positively influence quality of care. Further analyses are being explored to evaluate the impact of the Heart Team on patient outcomes.
Abstract 344: Interoperator Variability and Physician Learning with Medical Devices: Experience with Three New Vascular Closure Devices
Authors: Sarma Aartik , Normand Sharon-Lise T , Hatfield Laura A , Matheny Michael E , Resnic Frederic S
Published: March 2022

Background:
Clinical outcomes following medical device deployment depend on device design, patient traits, and operator experience. We use data from the Massachusetts PCI registry to compare freedom from vascular complications as a function of physician experience for three new vascular closure devices (VCDs): AngioSeal VIP , Mynx, and StarClose.

Methods:
Patients were included if they received a VCD between January 5, 2006 and June 27, 2009, received only one method of hemostasis after PCI, did not receive intra-aortic balloon pump, and had only one PCI during admission. The primary outcome was a composite of successful VCD deployment and absence of vascular complications before discharge. Physician experience with specific VCDs was calculated using all PCI meeting inclusion criteria. A generalized linear mixed effects model controlling for 12 patient characteristics and 6 procedure medications was used to determine the role of operator experience on outcomes. Early experience was defined as the first 20 deployments. The effect of experience was defined as the odds ratio of successful vs. unsuccessful deployment for each additional deployment for a device. Interoperator variability was defined as the odds ratio for successful deployment for an operator one standard deviation above average vs. an operator one standard deviation below average.

Results:
Patient, physician, and hospital characteristics are described in detail in Table 1. Interoperator variability was greater for StarClose (OR 9.4) and Mynx (4.22) than for AngioSeal VIP (1.00). There was a positive but not statistically significant association between experience and outcome for StarClose (OR 1.21, 95% CI: 0.98-1.49) and AngioSeal VIP (1.02, 0.85-1.23), and a statistically significant negative association for Mynx (0.66, 0.45-0.97).

Conclusion:
Interoperator variability was significant for devices with a new design (Mynx and StarClose) and not observed for a device based on an existing design (AngioSeal VIP). Physician experience has differing effects on vascular complications following VCD deployment. This likely reflects both design features and changes in patient selection between early and late deployments of the devices, including unobserved patient characteristics that may explain worsening outcomes with experience for Mynx.
Abstract 352: A Multimodal Radiation Reduction Intervention for Intra-procedural Radiation Exposure in Patients Undergoing Cardiac Catheterization in Veterans Affairs Hospitals
Authors: Valle Javier A , Petrich Megan , Carey Evan P , Bradley Steven M , Gurm Hitinder S , Varosy Paul D , Grossman P M , Maddox Thomas M , Duvernoy Claire S , Nallamothu Brahmajee K , Rumsfeld John S , Ho P M , Tsai Thomas T
Published: March 2022

Background:
Radiation exposure to patients from invasive cardiac procedures is substantial and contributes to a significant portion of overall radiation exposure from medical testing. Efforts to minimize intra-procedural radiation exposure are important for patient safety. This pilot study evaluated the effectiveness of a multimodal radiation intervention to reduce intra-procedural radiation exposure.

Methods:
Two VA cardiac catheterization laboratories (Site 1, Site 2) were evaluated for baseline radiation dosing use over a three month period. Following this initial run-in period, the operators and cath lab staff underwent a three-tiered intervention: 1) radiation safety and minimization education, 2) an in-lab radiation monitoring protocol with verbal feedback at pre-specified radiation doses and 3) monthly site and provider-specific report cards comparing radiation dose at the site and provider level within the VA system. Radiation dosing (RD, measured as Dose-Area-Product [Gy*cm2]) was then measured following this intervention at monthly intervals over a three-month period.

Results:
We examined 624 cases at Site 1 and 258 cases at Site 2 in the pre-intervention period, and 502 (site 1) and 208 (site 2) in the post-intervention period. Site 1 did not differ significantly in median RD following intervention (71.9 Gy*cm2 [IQR 48.0-114.0] pre-intervention versus 79.5 Gy*cm2 [IQR 50.0-124.8] post-intervention, p=0.34; see Fig 1). Site 2 showed a significant decrease in median radiation dose following intervention (118.72 Gy*cm2 [IQR 73.6-190.0] vs. 92.8 Gy*cm2 [IQR 56.6-158.3], p = 0.004, Fig 1). The national median radiation dose over the same time interval did not change significantly (91.53 Gy*cm2 [IQR 58.0-145.4] pre-intervention versus 90.0 Gy*cm2 [IQR 56.3-142.0] post-intervention, p=0.47, Fig 1).

Conclusion:
A three-tiered, multi-modal radiation reduction intervention was associated with reduced radiation exposure in a laboratory with high baseline radiation utilization. Similar reductions were not observed in a laboratory with low baseline radiation utilization. These findings suggest that radiation reduction interventions targeted at higher radiation use centers may result in meaningful decreases in patient radiation exposure.
Abstract 353: Variations in Implantable Cardioverter Defibrillator (ICD) Utilization in the Louisiana Health System
Authors: Ferguson Tekeda F , Zhang Lu , Brashear Meghan M
Published: March 2022

The emergence of implantable cardiac device technology has rapidly changed the way in which patients with chronic ventricular dysfunction are evaluated and medically treated. Effectiveness of cardioverter defibrillator (ICD) devices across patient subgroups such as age needs more evaluation. Several clinical variables have been associated with lack of survival benefit despite the overall 5-7% mortality rate over a period of 2- 4 years.

The overall objective of this Quality Improvement Initiative is to investigate the prevalence and variation in ICD utilization by hospital characteristics, income, or cardiovascular risk factor prevalence, as well as the related survival outcome among heart failure patients in the Louisiana State University health system.

All patients diagnosed with chronic heart failure between 1999 through June 30, 2012 within Louisiana State University Health Care Services Division (LSUHCSD) were selected from the Disease Management Evaluation Database (DMED). Seven hospitals in Louisiana contribute to the patient population. Prevalence was calculated for heart failure and ICD utilization; chi square test were used to explore the variation of ICD utilization by hospital characteristics and multiple cardiovascular risk factors.

There have been approximately 39,830 patients diagnosed with heart failure in the LSUHCSD hospitals over the last 13 years. Among heart failure patients identified, 3.6% have an ICD. There is slightly higher proportion of females than males with heart failure in the population; however, ICDs are higher among men (p-value <0.001). African-Americans have a higher rate of heart failure in the population and receipt of ICD than Whites (p-value = 0.005). Approximately 67% of the population has 2 or more listed comorbidities, with 12% having 5 or more comorbidities. The incidence of heart failure patients in LSU HCSD has decreased; however, the rate of ICD has increased over the last decade. The facility with the most heart failure and ICD patients identified is the largest facility, the Public Hospital in New Orleans, LA. However, the rate of ICD among heart failure patients is highest at the Medical Center, in Bogalusa, LA (17.3% compared to 12.4%). This facility has the highest proportion of Medicare patients.

Underutilization of ICDs can be identified in the LSUHCSD system. Variability for medical care including interventions can have multiple causes including market factors that reflect hospital attributes such as the type of cardiac services provided, managed care penetration, socioeconomic status and disease burden including risk factors such as those for cardiovascular disease (like obesity and tobacco use). This area holds much potential for gaining an understanding about allocation of resources in Louisiana in heart failure care and as a consequence to policy development for standardized patient treatment and improved care.
Abstract 354: Large Variation In Contrast Use During PCI - An Important Opportunity For Reducing Acute Kidney Injury
Authors: Amin Amit P , Bach Richard G , Kosiborod Mikhail , Kennedy Kevin , Tsai Thomas T , Brown Jeremiah R , Chhatriwalla Adnan K , Cohen David J , Spertus John A
Published: March 2022

Introduction:
Acute Kidney Injury (AKI) is common, morbid, costly, increases patients’ mortality risk, and may be mitigated by limiting contrast use. Our objective was to examine variation in CI-AKI across physicians and the proportion of this variation explained by differences in contrast, after adjusting for patient characteristics.

Methods:
Using the NCDR CathPCI Registry data (2009-12, N=1346932 PCIs), we defined CI-AKI by Acute Kidney Injury Network criteria and used hierarchical regression to identify a) variation in CI-AKI rates by physicians performing > 50 PCI/yr, b) variation in their contrast use and c) variation in CI-AKI rates explained by variation in contrast use, after adjustment for patient and hospital characteristics.

Results:
Among >1.3M PCIs, CI-AKI occurred in 94,584 (7%). We observed a large variation in AKI rates across individual physicians, from 0% to 30% (unadjusted) (Fig1) and an adjusted 43% excess likelihood of AKI for identical patients presenting to 2 random NCDR physicians. We also observed large variation in physicians’ mean contrast volume, ranging from 79 - 487 ml with an intraclass correlation coefficient of 0.23, implying a 23% variation in contrast volume across physicians’, after adjustment. Variation in contrast volume (per 75 ml) explained an excess 14.3% increased variation in AKI rate.

Conclusions:
AKI rates vary greatly among physicians, largely due to variation in their contrast use. Our study underscores an important opportunity to reduce AKI by reducing the variation in contrast volumes across physicians.
Abstract 47: Presentation and Outcomes of Women Veterans with Suspected Ischemia and Nonobstructive Coronary Artery Disease: Insights from the VA Clinical Assessment Reporting and Tracking Program.
Authors: Nkonde-Price Chileshe , Plomondon Meg , Maddox Thomas M , Rumsfeld John , Duvernoy Claire
Published: March 2022

Background:
Chest pain in the presence of non-obstructive coronary artery disease (CAD) is a common clinical scenario. Prior non-VA studies have shown that symptomatic women with non-obstructive coronary disease have a high rate of re-hospitalization for chest pain, and are at increased risk for cardiovascular events. To date, the presentation and outcomes of women veterans with non-obstructive CAD is unknown.

Methods:
Using data from the VA Clinical Assessment Reporting and Tracking (CART) Program, a national clinical quality program that collects data on coronary procedures performed in the VA, we analyzed clinical characteristics between men and women veterans who presented for initial cardiac catheterization due to suspected ischemia between 10/1/2007 and 9/30/2011, and were found to have angiographically non-obstructive CAD. In addition, rates of death, stroke, and readmission for chest pain among women were calculated and presented. Suspected ischemia was defined by an angiogram indication of chest pain, acute coronary syndrome or a positive functional study. Non-obstructive CAD was defined at the time of catheterization by the primary operator.

Results:
Overall, 53,806 patients underwent coronary angiography in this period, of which 3.4% (1848 of 53,806) were women .There were 9608 (18.5%, 9608 of 51,958) men and 429 (23.2%, 429 of 1848) women who underwent angiography for suspected ischemia had non-obstructive CAD. Compared to men, women veterans were significantly younger (56.9 vs 61.9 yrs p <0.0001), had more depression (49.0%, 210 of 429 vs 32.5%, 3118 of 9608, p< 0.001), and obesity (56.2% 241 of 429 vs 45.1% 4335 of 9608, p<0.001). Women veterans had less hypertension (82.8%, 355 of 429 vs 86.3% 8287 of 9608, p=0.04), diabetes (33.6%, 144 of 429 vs 38.8% 3731 of 9608, p=0.03), and peripheral vascular disease (7.0% 30 of 429 vs 12.0% 1155 of 9608, p=0.002). Over a median follow up of 21 months, death occurred in 1.2% (5/429) women, stroke in 3.7% (16 of 429), and hospital readmission for chest pain in 1.9% (8 of 429).

Conclusion:
Between October 2007 and September 2011, 23% of women veterans undergoing catheterization for suspected ischemia had non-obstructive CAD. In contrast to non-VA studies, adverse clinical outcomes and re-hospitalization rates for chest pain were less frequent. These findings may represent systematic differences in treatment and follow-up care of women veterans between VA and non-VA healthcare systems.
Abstract 50: Cardiovascular Event Rates Among Adults with Type 2 Diabetes Mellitus at Risk of Cardiovascular Events in the Large Population-based Study to Help Improve Early Evaluation and Management of Risk Factors Leading to Diabetes (SHIELD)
Authors: Fox Kathleen M , Wu Ying , Kim Jennifer , Grandy Susan
Published: March 2022

Objectives:
This study ascertained the incidence and time to first non-fatal myocardial infarction (MI), stroke, heart bypass surgery, or angioplasty among adults with type 2 diabetes mellitus (T2DM) at high risk for cardiovascular disease (CVD) over 3 and 5 years using a large US population based study.

Methods:
A retrospective cohort study used data from the US population-based SHIELD, a 5-year prospective survey-based study of adults with and without T2DM. Respondents with T2DM were stratified into 2 cohorts: (1) established CVD cohort, with age ≥40 years, prior MI, prior stroke, atherosclerosis, or peripheral vascular disease, and (2) multiple risk factors cohort (men ≥55 years and women ≥60 years and ≥1 risk factors of hyperlipidemia, hypertension, currently smoking, without prior history of CVD). Proportion of respondents self-reporting a new MI, stroke, angioplasty, or heart bypass surgery was calculated and multivariate discrete logistic hazards models for 3 and 5 years of follow-up were developed.

Results:
Among 2122 T2DM respondents, 56.5% had established CVD (mean age = 65 years, 45% male); 43.5% had no established CVD but multiple risk factors (mean age = 68 years, 49% male). The established CVD cohort had a new MI, stroke, or revascularization event rate of 26.3% during a 3 year follow-up period and 31.2% during the 5 years of follow-up. For the multiple risk factors cohort, 18.8% within 3 years and 26.0% within 5 years had an incident MI, stroke, or revascularization. After adjusting for gender, age, obesity, duration of diabetes, and comorbidities, the risk of incident MI was 2.1 times higher (95% CI: 1.6-2.8) within 3 years and 1.9 times higher (1.5-2.4) within 5 years of follow-up among the established CVD cohort than multiple risk factors cohort (p<0.001). Risk of incident stroke was 2.2 (1.4-3.5) and 1.8 (1.2-2.7) times higher within 3 and 5 years, respectively, after adjustment among the established CVD cohort than multiple risk factors cohort (p <0.01). Risk of incident heart bypass surgery was 2.6 (1.7-4.2) and 2.5 (1.7-3.8) times higher, and risk of incident angioplasty was 3.9 (2.7-5.9) and 3.2 (2.3-4.5) times higher within 3 and 5 years, respectively, among the established CVD cohort than multiple risk factors cohort (p <0.001).

Conclusions:
T2DM individuals at risk for CVD events had significant incidence of MI, stroke, and revascularization in this large US population-based study. T2DM adults with established CVD are at higher risk of CVD events than those with no CVD but have multiple risk factors.
Abstract 7: Reduced Hospitalization For Transient Ischemic Attack In The United States Over The Past Decade
Authors: Sanossian Nerses , Ramirez Lucas , Kim-Tenser May A , Cen Steven , Wen Ge , Towfighi Amytis , Ne Shuhan , Adamczyk Peter , Mack William J
Published: March 2022

BACKROUND:
A paradigm shift in the diagnosis, evaluation and management of transient ischemic attack (TIA) over the last decade has resulted from deeper understanding of risks and use of newer tissue-based diagnostic criteria. We evaluated the rates of TIA and ischemic stroke hospitalization per 100,000 population over the past decade in a representative national database.

METHODS:
We performed a retrospective review of the Nationwide Inpatient Sample from 2000 to 2010 (n=86,622,872) to identify cases of primary TIA (ICD-9 codes 435.0-9 and 326.34) and primary ischemic stroke (ICD-9 codes 434.00-99) discharge diagnoses.

RESULTS:
The number of TIA hospitalizations in the United States decreased linearly from 101 per 100,000 in the year 2000 to 80 per 100,000 in 2010. On average, TIA hospitalizations for a given year were 0.98 (0.95-1.00) times as high as the prior year (p=0.06). As the number of TIA hospitalizations was decreasing, ischemic stroke hospitalizations increased from 144 per 100,000 in 2000 to 184 per 100,000 2010. On average, the stroke hospitalizations for a given year were 1.03 (1.02-1.05) times as high as the prior year (p<0.01).

CONCLUSION:
TIA hospitalizations in the United States decreased from 2000 to 2010 as the number of ischemic stroke hospitalizations increased. This may be a result of increased imaging utilization and use of tissue-based diagnosis of TIA. Cases of cerebral ischemia with resolved symptoms coded as TIA in the past may be coded as ischemic stroke with MRI imaging evidence of brain injury, yet further study is needed to confirm this finding.
Abstract 74: Identifying Barriers to Adoption of New Interventional Techniques: Transradial Coronary Angiography (TRA) as a Case Study
Authors: Rao Sunil V , Robinson Caroline O , Pancholy Samir B , Gilchrist Ian C , Nevins Holder , Kearns Charles F
Published: March 2022

Background:
TRA is associated with reduced vascular complications and costs; however, studies show low adoption of TRA in the United States (US) relative to other countries. The underlying reasons for this are unclear.

Methods:
Applying the framework of the Theory of Planned Behavior (TPB), a psychological construct that links attitudes, perceptions, & behavior, we developed a survey to identify factors associated with TRA use. TPB has 3 domains: attitudes (beliefs about TRA outcomes), normative beliefs (perceptions of how other physicians judge TRA use), and control beliefs (awareness of factors that facilitate or impede TRA use). A survey that included questions specific to each domain was developed, tested for construct & content validity, & administered to 201 US interventional cardiologists with varying self-reported rates of TRA use. Multivariable logistic regression was used to determine factors associated with TRA use; the model included domains of TPB and characteristics of the respondents.

Results:
The mean time since completion of interventional training for the study sample was 14.4 ± 10.2 yrs. The mean number of patients/week was 69, with 32% requiring catheterization, & 25% requiring PCI. Factors associated with TRA use included physician attitudes toward TRA, practice environment (e.g. support from the hospital or colleagues) and to a lesser extent, patient volume and number of operators using the catheterization laboratory (Table).

Conclusions:
Using principles from TPB, we identified factors associated with TRA use. These data are useful in refining TRA educational initiatives and suggest that broadening the scope beyond individual providers may increase TRA adoption. In addition, this methodology may provide a future model for initiating the adoption of other novel techniques into interventional cardiology practice.

Table.
Significant predictors of TRA use
Abstract 75: Which Is The Best Strategy To Predict Mortality In Elderly Stable Patients Suffering From Heart Failure ?
Authors: scardovi angela beatrice , Carboni Gian Piero , De Maria Renata , Ferraironi Alessandro , Boccanelli Paolo Alessandro , Ricci Roberto
Published: March 2022

Background:
Predicting mortality is still a thorny issue in a population of elderly heart failure (HF) patients (pts). Moreover the prognostic value of the six-minute walking test (6MWT) and of the cardiopulmonary exercise testing (CPX ) has not been fully assessed yet in elderly outpatients.

Aims:
Our goal was to compare the prognostic ability of these two functional tests.

Patients:
We studied 143 outpatients with all-cause chronic HF, mean age 72+-11 years, 70% males.

Methods:
In all patients were evaluated left ventricular ejection fraction (EF) with echocardiography, 6 MWT distance in meters (m), peak oxygen consumption ( peak O2) and the rate of increase in ventilation per unit of carbon dioxide production (VE/VCO2 slope) on CPX. New York heart association class (NYHA), brain natriuretic peptide (BNP) and body mass index (BMI) values were also evaluated. Survival was then evaluated with a median follow-up of median 33 months.

Results:
Overall pts, in 26(18%) occurred cardiac death. The receiver operating characteristic curve analysis determined the following criterion values in predicting mortality: age value under 70 years, 6MWT value under 250m, EF value under 49%, peak O2 value under 13.2 ml/kg/min, VE/VCO2 slope value over 33.5, N.Y.H.A. class value over 2(p<0.01 for all), BNP value over 293 pg/mL and a BMI value over 28 kg/m2 , p = 0.9. However, only age, EF and 6MWT distance in m were significantly (p=0.0001) associated with mortality on a Cox stepwise model. Moreover, the combined criterion values of age, EF and 6MW, better stratified individuals for survival with Kaplan Meier curves (Fig. 1).

Conclusions:
In elderly pts reduced EF values and decreased exercise capacity on 6MWT may predict mortality as reflect irreversible failure of LV Frank-Starling contractile reserve. Such mechanism might be understimated by the reduced peak O2 and the enhanced VE/VCO2 slope values failing to predict mortality in this population. Combination of 6MWT and echocardiography proved to be superior to CPX alone in predicting mortality in pts aged more than 70 years.
Abstract 76: Relationship between Lipid Reduction and Progression of Coronary Atherosclerosis in Chinese Patients with Established Coronary Artery Disease
Authors: Huang Huiling , Liu Dan , Chen Yili , Dong Yugang
Published: March 2022

Background:
The current National Heart, Lung, and Blood Institute’s Adult Treatment Panel (ATP) III Guidelines place high priority on reaching target low-density lipoprotein cholesterol (LDL-C) levels for coronary artery disease (CAD) prevention. However, the percentage reduction in LDL-C in relation to the progression of coronary atherosclerosis in patients with established CAD remains uncertain, especially among Chinese population.

Methods:
We performed retrospective chart review of 318 statin naïve Chinese patients with established CAD who underwent 2 coronary angiographies at least six months apart. Progression of coronary atherosclerosis was defined as in-stent restenosis, or increasing stenosis of 20% or more than baseline.

Results:
After a median follow-up of 24 months between coronary angiographies, 147(46.2%) patients developed progressive coronary atherosclerosis. There were no significant differences in baseline total cholesterol (TC), total triglycerides (TG), high-density lipoprotein cholesterol (HDL-C) and LDL-C among patients with and without progression of coronary atherosclerosis. The use of statins, aspirin, clopidogrel, beta-blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers were also similar between two groups from baseline to follow-up. However, the mean TC (4.83±1.32 vs. 3.99±0.93 mmol/L), TG (1.83±1.16 vs. 1.79±1.80mmol/L) and LDL-C (3.09±1.15 vs. 2.33±0.77 mmol/L) were significantly higher in patients with progressive disease than those in the stable group (all p value <0.01), although there is no difference in HDL-C (1.04±0.25 vs. 1.02±0.25 mmol/L, p=0.66). After multivariate adjustment accounting for age, gender, smoking, number of diseased vessels, stent implantation, serum LDL-C level and LDL-C reduction, achieving LDL-C reduction of 50% or more showed significantly reduced progression of coronary atherosclerosis (Odds ratio [OR] 0.24, 95% confidence interval [CI], 0.06-0.91, p<.05). Other risk factors associated with coronary atherosclerosis progression include heavy smoking (20 cigarettes per day for a minimum of 30 years, OR, 3.88, 95CI, 1.56-9.66. p=.003), the level of LDL-C (≥3.0mmol/l,OR, 4.03, 95CI, 1.79-9.09. p<.001) and number of diseased vessels at baseline (OR, 3.94, 95CI, 1.98-7.84. p<.001).

Conclusions:
The current study suggests that the benefit of lipid-lowering therapy in progression of coronary atherosclerosis is in proportion to the reduction in LDL-C. Patients with established coronary artery disease may benefit from intensive LDL-C lowering therapy regardless of their baseline LDL-C levels.
Abstract 78: The Association of Home Warfarin Therapy with Acute Treatment Patterns and Bleeding Risk in Patients Presenting with ST-Elevation Myocardial Infarction: Results from the NCDR
®
Authors: Karrowni Wassef , Wang Tracy Y , Chen Anita Y , Thomas Laine , Saucedo Jorge F , El Accaoui Ramzi N
Published: March 2022

Introduction:
Bleeding complications during acute coronary syndrome care are independent predictors of adverse outcomes. Patients presenting with ST-elevation myocardial infarction (STEMI) receiving warfarin therapy at home represent a management challenge especially in the absence of specific recommendations in current guidelines. Given the paucity of data, this study aims to describe the acute treatment patterns and bleeding risk in STEMI patients treated with primary percutaneous coronary intervention (PCI).

Methods:
We examined 120,270 STEMI patients treated with primary PCI at 586 ACTION Registry
®
-GWTG
TM
hospitals between 2007- 2012, excluding patients who died within the first 24 hours. A total of 3,101 patients (2.6%) were on home warfarin. Antiplatelet and anticoagulant regimens within the first 24 hours of admission were compared between patients taking and those not taking warfarin at home. The association between home warfarin therapy and risk of in-hospital major bleeding was analyzed using multivariable logistic generalized estimating equations method.

Results:
STEMI patients on home warfarin were older and had higher prevalence of co-morbid conditions such as hypertension, diabetes, and renal disease compared with those not taking warfarin; at presentation only 35.6% of patients had INR ≥2.0. They were less likely to receive prasugrel and heparin, but more likely to receive clopidogrel and bivalirudin compared with those not on home warfarin (Table). Glycoprotein IIbIIIa inhibitors were also less commonly administered to patients taking warfarin at home (Table). Door-to-balloon ≤90 minutes for direct arrivals and ≤120 minutes for transfers were less likely to be achieved in patients on home warfarin (83.5% vs. 88.5%, p<0.0001 and 47.5% vs. 57.1%, p<0.0001, respectively). Home warfarin therapy was associated with significantly higher risk of in-hospital major bleeding (17.0% vs 10.1%; adjusted odds ratio 1.26 [1.13-1.40]).

Conclusions:
In STEMI patients treated with primary PCI, home warfarin therapy is associated with significant increase in the risk of in-hospital major bleeding despite the less frequent use of treatment regimens associated with higher bleeding risk. Future studies are needed to identify bleeding avoidance strategies in this high-risk population.