bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P165: Assessment of Lipid Abnormalities: Prevalence and Attainment of Lipid Goals/Normal Levels Among Adults in Hong Kong
Authors: Bash Lori D , Sazonov Vasilisa , Lau Yuk-Kong , Tse Hung-Fat , Tomlinson Brian , Ambegaonkar Baishali M
Published: March 2022

Background:
Despite effective lowering of low density lipoprotein cholesterol (LDL-C) with statin for prevention of cardiovascular events, residual risk remains high in those patients with mixed dyslipidemia.

Methods:
We examined the prevalence of lipid disorders before and after utilization of lipid modifying therapies (LMT) in 706 patients (mean age 65 years, 99% Chinese and 59% men) with dyslipidemia in Hong Kong. Between January 2004 and December 2006, patients ≥35 years who initiated a LMT had 1) at least one lipid abnormality; 2) follow-up > 12 months after initiating LMT, and had a complete lipid panel (LDL-C, high density lipoprotein cholersterol [HDL-C] and triglycerides[TG]) before and 12 months after therapy were recruited. Patients with coronary heart disease (CHD), type 2 diabetes or a 10 year CHD risk>20% were classified as high (cardiovascular) risk patients. Threshold levels for LDL-C, HDL-C and triglycerides were specified as per NCEP ATPIII Guidelines.

Results:
At baseline, most (97%) patients were näive for LMT, 72% exhibited elevated LDL-C, 25% had elevated TG, 32% experienced low HDL-C, and 36% had elevated LDL-C coupled with low HDL-C and/or elevated TG. Among high-risk pts (n=548), 73%, 26% and 36% exhibited elevated LDL-C, elevated TG and low HDL-C, respectively; while 40% had elevated LDL-C, low HDL-C and/or elevated TG. Among patients on LMT, statin (91%); fibrates (5%) or both (3%) were used. After 12 months of follow-up, there were substantially improved lipid profiles. However, 23%, 12% and 32% of patients still had elevated LDL-C, elevated TG and low HDL-C, with 11% having elevated LDL-C coupled with low HDL-C and/or elevated TG. High-risk patients had similar degrees of persistent dyslipidemia with 25%, 13%, and 36% experiencing elevated LDL-C, elevated TG, elevated LDL-C and low HDL-C; and/or elevated TG.

Conclusions:
In this Chinese cohort, there was a substantial improvement in LDL-C levels after therapy, while improvement of TG and HDL-C levels was moderate and negligible, respectively. Despite LMT, nearly a quarter of high-risk patients still had elevated LDL-C, more than one third had low HDL-C, and >12% had multiple lipid abnormalities. These patients may potentially benefit from other types of LMT in addition to statins.
Abstract P169: Incidence and Predictors of Outpatient Heart Failure in a Large Insured Population
Authors: Norton Catherine , Goyal Abhinav , Thomas Tracy , Butler Javed , Vaccarino Viola , Davis Robert , Wilson Peter W
Published: March 2022

Background:
While the determinants of inpatient heart failure (HF) have been described, less is known about the incidence and predictors of HF diagnosed in outpatient settings.

Methods:
We analyzed data from 359,948 adults (≥18 yrs old) without HF at baseline and who were enrolled in Kaiser Permanente Georgia any time during calendar years 2000-2005. Diagnosis of incident HF required one inpatient or two outpatient visits with an ICD-9 code for HF. We developed separate models for incident HF diagnosed in either the outpatient or inpatient setting using multivariable logistic regression with repeated measures to assess the association of incident HF with the following antecedent risk factors: coronary artery disease (CAD), hypertension (HTN), diabetes mellitus (DM), atrial fibrillation (AF), and valvular heart disease.

Results:
During 1,015,794 person-yrs follow-up, there were 4,001 new cases of HF (50% in women). Two-thirds of all cases were diagnosed in the outpatient setting (n=2,639; 66%). The prevalence for each risk factor was lower in outpatients compared with inpatients: HTN (74% vs. 87%), DM (27% vs. 39%), CAD (19% vs. 30%), AF (6% vs. 15%), and valvular heart disease (6% vs. 15%). The adjusted odds ratios for most factors were higher for HF diagnosed in the inpatient compared with the outpatient setting (Table), but all factors together yielded good discrimination (C index > 0.85) in both inpatient and outpatient settings.

Conclusion:
In our population, twice as many incident HF cases were diagnosed in the outpatient compared with the inpatient setting. Further research on HF in outpatient settings is essential to reduce the growing burden of HF on society.

Table:

Multivariable predictors of incident heart failure diagnosed in the outpatient compared with the inpatient setting.
*

Adjusted odds ratio (95% confidence interval)
†

Risk Factor

Model for Outpatient HF
‡

Model for Inpatient HF
‡

Age (per 10-yr increase)
1.99 (1.93 - 2.05)
1.85 (1.78 - 1.93)

Female sex
0.81 (0.75 - 0.88)

0.95 (0.85 - 1.07)
§

Hypertension
3.23 (2.92 - 3.57)
5.58 (4.69 - 6.66)

Diabetes mellitus
1.82 (1.66 - 1.99)
2.75 (2.45 - 3.08)

Coronary artery disease
2.00 (1.80 - 2.23)
2.68 (2.35 - 3.05)

Atrial fibrillation
1.76 (1.47 - 2.10)
3.78 (3.18 - 4.46)

Valvular heart disease

1.35 (1.13 - 1.61)
¶

2.63 (2.22 - 3.11)

Model C-statistic
0.859
0.869

*

Outpatient and inpatient incident HF cases were mutually exclusive. A patient who was initially diagnosed with outpatient HF but then subsequently had inpatient HF was counted as having incident HF as an outpatient only, and vice versa.

†

Each risk factor is adjusted for all the other listed risk factors.

‡

Corresponding P values for all odds ratios are < 0.0001, except where otherwise indicated.

§

P value > 0.40

¶

P value = 0.0007
Abstract P170: Relationship of Patient Characteristics, Fast Food and Non-Fried Fish Intake With Omega-3 Index in Patients With Acute Myocardial Infarction
Authors: Salisbury Adam C , Gosch Kensey L , Amin Amit P , Chan Paul S , Harris William S , Rich Michael W , Spertus John A
Published: March 2022

Background:
Low red blood cell omega-3 (ω3) index (eicosapentaenoic acid + docosahexaenoic acid) is associated with sudden cardiac death and increased mortality in pts with coronary artery disease. Methods are needed to identify pts in need of assessment and treatment of ω3 levels, but few available data describe the association of patient characteristics, including diet, with ω3 levels.

Methods:
Using two questions, dietary habits were assessed by asking patients the frequency of fast food and non-fried fish intake, among 1493 patients in the 24-center TRIUMPH registry who had omega-3 index collected at the time of acute myocardial infarction (AMI). We used linear regression to identify independent correlates of ω3 levels.

Results:
The proportion of pts with an unfavorable ω3 index (<4%) increased across each category of fast food intake (<1x monthly 18.9% (102/541), 1-3x monthly 28.6% (121/423), 1-2x weekly 28.8% (85/295), ≥3x weekly 37.6% (88/234), p<0.001) and decreased with increasing fish intake (<1x monthly 35.1% (199/567), 1-3x monthly 24.9% (125/502), 1-2x weekly 16.1% (57/353), and ≥3x weekly 21.1% (15/71), p<0.001). Fish intake, older age, non-white race and ω3 supplements were independently associated with higher ω3 index while frequent fast food intake, smoking and diabetes were associated with lower ω3 index (Figure).

Conclusions:
Simple screening questions about fast food and non-fried fish dietary patterns are independently associated with ω3 fatty acid levels in AMI patients. Routine screening may identify patients who can benefit from assessment of ω3 levels, dietary intervention and omega-3 supplementation.
Abstract P173: Risk Factor Analysis of Clinically Significant Improvements in Quality of Life Measures for Stable Coronary Patients
Authors: Zhang Zugui , Kolm Paul , Teo Koon , Spertus John A , Maron David J , O'Rourke Robert A , Hartigan Pamela , Boden William E , Weintraub William S
Published: March 2022

Background:
The COURAGE trial compared percutaneous coronary intervention (PCI) plus optimal medical therapy (OMT) to OMT alone in reducing the risk of cardiovascular events in 2287 patients with stable coronary disease. We examined the impact of PCI and other risk factors on clinically significant improvements in quality of life measures.

Methods:
Angina-specific and overall health status were assessed with the Seattle Angina Questionnaire (SAQ) and RAND-36 respectively, at baseline and at 1, 3, 6 and 12 months followed by annual evaluations. Scores range from 0 to 100; higher scores indicate better health status. Clinically significant improvement from baseline within individual patients was defined as score increases of ≥8, ≥25, ≥20, ≥12, and ≥16 for physical limitation, angina stability, angina frequency, treatment satisfaction, and quality of life domains respectively in SAQ and ≥ 10 for each domain in RAND-36.

Results:
Adjusted for other demographic and comorbidity risk factors, adding PCI to OMT resulted in clinically significant improvements in physical limitation from 1 to 6 months, angina stability from 1 to 3 months, angina frequency from 1 to 36 months, treatment satisfaction no time, and quality of life from 1 to 6 months in SAQ (p-value<0.05); For RAND-36, adding PCI to OMT resulted in clinically significant improvements in physical functioning from 1 to 6 months, energy/fatigue from 1 to 3 months, emotional well-being from 1 month to 3 months, pain at 1 month, but no time in other domains. Overall important interactions between treatment (adding PCI to OMT) and follow-up time were found in all domains of SAQ except in angina stability, but not found in all domains of RAND-36, indicating that the impact of PCI on angina specific health varies over time. Age and historic clinical events such as previous diabetes, congestive heart failure, or myocardial infarction previous were also shown to be important risk factors for clinically significant improvements, especially after loss of the influence of PCI.

Conclusions:
Adding PCI to OMT significantly improved angina-related health clinically from 3 to 6 or 12 months, but less for overall general health status. There was no advantage to PCI after about 1 year in any clinically significant improvement.
Abstract P176: Does Family History of Coronary Artery Disease Affect Prognosis in Hospital Survivors of a First Acute Myocardial Infarction?
Authors: Charlap Esti , Reid Kimberly J , Taub Cynthia , Srinivas V.S.
Published: March 2022

Background:
Family history (FH) of Coronary Artery Disease (CAD), a well known risk factor for development of CAD, is often elicited in patients presenting with acute myocardial infarction (MI). However, whether a positive FH determines prognosis following MI is unknown.

Methods:
In a prospective 24-center registry of AMI (Translational Research Investigating Underlying disparities in recovery from acute Myocardial infarction: Patients' Health status [TRIUMPH]), all hospital survivors of a first MI, aged <= 70 years were categorized either with a positive FH of CAD (N=800) or not (N=1993). Positive FH was defined as CAD in a father or brother <55 years of age or a mother or sister <65. Multivariable site-stratified proportional hazards regression, adjusting for GRACE risk score, tested the independent association of a FH of CAD with one year mortality. A subset analysis was performed of those patients who themselves presented with premature CAD (men<55 and women<65).

Results:
Patients with a FH of CAD were younger (53.2 vs. 54.9, p<.001), more were women (35.5% vs. 28%, p<.001), and white (69.8% vs. 65.9%, p<.01). They had a higher prevalence of dyslipidemia (46.5% vs. 41.2%, p<0.02) and were more likely to have prior angina (9.0% vs. 6.7%, p<0.05). They had lower baseline SF-12 Physical & Mental Component scores (p<.04) and lower Angina Quality of Life scores (p<.03). However, there were no differences in multivariable adjusted one year mortality observed in those with and without a positive FH of CAD (Hazard Ratio [HR] 1.34; 95% Confidence Interval [CI] 0.86-2.10). Similarly, there were no differences in one-year mortality when patients presenting with premature CAD were separated by FH status (HR 1.39; 95% CI 0.77-2.51).

Conclusion:
Although a positive FH of CAD is a predictor for developing CAD, it is not associated with prognosis after an initial MI. Therefore, the usefulness of including a FH of CAD in stratifying the post-MI population is unclear.
Abstract P179: Depression Increases All-Cause Mortality in Post Cardiac Surgery Patients: A Meta-Analysis of Prospective Cohort Studies
Authors: Marzouka George R , Martinez Claudia , Tamariz Leonardo
Published: March 2022

Background:
Studies have shown that depression is a prevalent condition among cardiac patients, especially after cardiac surgery, and that it's presance has been related to negative outcomes. The purpose of this study was to perform a meta-analysis to evaluate depression as a risk factor for all-cause mortality in patients status post cardiac surgery.

Methods:
A search of MEDLINE (1966 - October 2009) database was performed and we selected all prospective cohort studies in which depression was measured pre-operatively, postoperatively, or both by an established depression index with all-cause mortality recorded after a minimum follow up of 1 year. The pooled relative risk (RR) with corresponding 95% confidence interval (CI) was calculated for all cause mortality using the fixed effects method to evaluate the effects of depression on all-cause mortality in post cardiac surgery patients.

Results:
Our search strategy yielded 144 studies, of which only 6 met our inclusion criteria. The studies comprised of 1,906 patients, predominately white, males who have undergone coronary artery bypass grafting (64% or 1228 of 1906) or cardiac valve replacement (36% or 678 of 1906) and where evaluated for depression. The RR of all-cause mortality was 1.8; 95% CI (1.4-2.5) for patients with significant depression compared to patients without.

Conclusion:
Depression is associated with higher all-cause mortality in patients status-post cardiac surgery. All patients should be evaluated for depression after cardiac surgery and treated aggressively.
Abstract P18: Place of Service, Risk of Stroke, and Perceived or Actual Barriers to Warfarin (OAC) Use for Patients with Atrial Fibrillation in Real-World Practice
Authors: Rosenman Marc , Simon Teresa A , Teal Evgenia , Jackson Joseph
Published: March 2022

Background:
Clinical trials often enroll subpopulations which do not represent the larger, diverse mix of people prescribed a medication once it is on the market. Healthcare of patients with AF may vary by setting.

Methods:
We searched the Regenstrief Medical Record System (RMRS, a state-of-the-art inpatient and outpatient system in a public hospital and its community clinics) for patients > 18 years old with new onset atrial fibrillation and/or flutter (AF) from 1998 to 2007. Patients with valve replacement, hyperthyroidism, or no clinical visit within one year after first AF diagnosis were excluded. Oral anticoagulant (OAC) exposure was defined as any warfarin after the first (index) AF diagnosis in RMRS. Patients were classified into one of four clinic categories visited during the year after the AF index event -- anti-coagulation clinic (ACC), cardiology, general internal medicine, or other (those who had electronic records only for locations such as the emergency department, pharmacy, nursing home, mental health clinics, etc.) CHADS2 risk scores were calculated. Potential barriers to warfarin use (gastrointestinal or genitourinary hemorrhage, alcohol abuse, renal insufficiency, predisposition to falls, cirrhosis/hepatitis, intracranial hemorrhage, and other hemorrhage) were defined by ICD9 codes or RMRS diagnoses recorded on or before the AF index event.

Results:
Among 3329 subjects with AF (mean age 65, 47% women, 56% white), 1507 (45%) had at least one prescription or order for OAC on/after the AF index event; 1305 (87%) of these 1507 had CHADS2 > 0. The % of patients on OAC varied by clinic category, while among patients on OAC, the % with a history of a perceived or actual barrier to the use of OAC was consistently 30-40% (Table).

Conclusion:
In one real-world practice, many patients on OAC have “contraindications” that would have excluded them from clinical trials. Many patients eligible for OAC did not receive it. In ACC 99%, and in cardiology 62%, received OAC.

N with Exposure to OAC by Place of Service, CHADS2 score, and Perceived or Actual Barrier

Clinic Category
Anti Coagulation Clinic
Anti Coagulation Clinic
Cardiology
Cardiology
Internal Medicine
Internal Medicine
Other
Other

Exposure
OAC N=358
No OAC N=4
OAC N=345
No OAC N=215
OAC N=329
No OAC N=482
OAC N=470
No OAC N=1126

CHADS2>0 N= 2751
312
3
303
167
285
402
405
874

Perceived or Actual barrier N=1357
140
1
141
94
115
135
203
528
Abstract P196: Impact of Medicare Part D Donut-Hole on use of Antihypertensive or Antilipidemic Drugs in Patients With Diabetes or Coronary Heart Disease
Authors: Li Pengxiang , McElligott Sean , Bergquist Henry , Schwartz Sanford , Doshi Jalpa
Published: March 2022

OBJECTIVES:
The impact of Medicare's Part D coverage gap (donut hole) on antihypertensive and antilipidemic drug utilization was examined among patients with diabetes or coronary heart disease (CHD) and compared to changes in drug use for symptomatic (GI, depression, and pain) conditions.

METHODS:
The sample consisted of beneficiaries from the 5% Medicare A, B, and D files who had diagnoses for hypertension and/or hyperlipidemia and diagnosis of diabetes and/or CHD in 2005. Eligibility criteria also included a full-year (2006) of enrollment in a Medicare fee-for-service plan, Medicare Part D and data on low-income subsidy (LIS) or non-LIS eligibility. Study outcomes included the impact of entering the donut hole on any drug use, adherence (percent days covered (PDC) >= 0.8), and discontinuation ( >= 30-day continuous gap). The study employed a quasi-experimental design using pre- (prior to donut hole, total drug costs < $2,250) and post- (during donut hole) periods, comparing non-LIS patients, who had no drug coverage during the donut hole, with LIS patients, who had drug coverage in the donut hole. A difference-in-difference approach was used with multiple regressions adjusting for demographic characteristics, Medicare entitlement status, area-level information, and clinical risk. Analyses were limited to enrollees with at least 4 months of observation in the pre- and post-donut hole periods to ensure sufficient time frames to identify changes in study outcomes. Sensitivity analyses were performed on patients with 2 months or more in each of the pre- and post-donut hole periods.

RESULTS:
The donut hole was associated with decreased (p < 0.01 for all results) drug use (1.1% to 4.8%) and PDC adherence (5.5% to 13.1%), and increased likelihood of discontinuation (5.0% to 14.4%) for lipid lowering and antihypertensive drugs, respectively. The donut hole had no impact on drug utilization for symptomatic drugs (anti-ulcer agents, antidepressants, and pain-killers). Sensitivity analyses were consistent with the main results.

CONCLUSIONS:
The donut hole was associated with statistically significant but modest drops in the use of drugs for asymptomatic conditions, but had no impact on drugs for symptomatic conditions.
Abstract P198: Is Directly Measured LDL Clinically Equivalent to Calculated LDL
Authors: Baruch Lawrence , Agarwal Sanjay , Gupta Bhanu , Haynos Ann , Johnson Swapna , Kelly-Johnson Katelyn , Eng Calvin
Published: March 2022

Background:
LDL cholesterol can either be calculated or measured directly. Clinical guidelines recommend using calculated LDL to guide therapy, as the evidence base for lipid management is derived almost exclusively from trials using calculated LDL, with direct measurement of LDL being reserved for those not fasting or significant hypertriglyceridemia. Our aim was to determine the clinical equivalence of directly measured LDL and fasting calculated LDL.

Design:
Eighty-one subjects had at least 1 calculated and direct LDL performed simultaneously; 64 had a repeat lipid assessment after 4 to 6 weeks of therapy, resulting in 145 pairs of calculated and direct LDL. Correlation between direct and calculated LDL was determined using Pearson's correlation coefficient. The relationship between direct and calculated LDL was also evaluated from a clinical perspective. Direct and calculated LDL were considered
“clinically concordant”
when the difference between calculated and direct LDL fulfilled 3 criteria: 1) < 6% difference (incremental LDL lowering provided by 1 titration of statin dose, e.g. simvastatin 20 to 40 mg), 2) < 10 mg/dL difference, and 3) placement in the same ATP III LDL cut points (e.g. <100, 100-129). Direct and calculated LDL
were considered “clinically discordant”
when the difference between calculated and direct LDL fulfilled 3 criteria: 1) ≥ 12% difference (incremental LDL lowering provided by 2 statin titration steps, e.g. from simvastatin 20 to 80 mg), 2) ≥ 10 mg/dL difference, and 3) placement in different ATP III LDL cut points.

Results:
There was significant correlation between direct and calculated LDL(r=0.93). Clinical

concordance

between calculated and direct LDL was present in 40% of patients. Clinical

discordance

was noted in 25% of patients. One-third of patients had > 15 mg/dL difference between direct and calculated LDL, while 25% had > 20 mg/dL difference. In 47% of subjects, the difference between direct and calculated LDL at baseline and follow-up changed by a minimum of 10% or 10 mg/dL.

Conclusion:
Our findings suggest that directly measured LDL is not clinically equivalent to calculated LDL. This puts into question the current recommendation of using direct LDL in situations where calculated LDL would be inaccurate.
Abstract P200: Mortality Difference and Adherence to QOM Meds for Heart Attacks at Hospitals Capable of Performing Primary PCI With Versus Without Cardiac Surgery On-Site
Authors: Bujarski Stephen R , Patel Vikas , Kao John
Published: March 2022

Background
ACC/AHA guidelines recommend primary PCI with available cardiac surgery on site. Despite this, the number of hospitals performing primary PCI without on-site CT surgery has been increasing. The goal of this analysis is to 1) quantify the number of hospitals in the US performing primary PCI without CT surgery on site and 2) evaluate differences in reported mortality for patients presenting with heart attacks to hospitals capable of performing primary PCI with or without CT surgery on site.

Methods
Retrospective data was obtained from the Hospital Compare Database. Hospitals reporting DTB times were extrapolated to identify 1488 hospitals capable of performing primary PCI procedures. Hospital IDs were then cross referenced with hospitals coding MS-DRG IDs for CABG in order to identify 516 hospitals with on site CT surgery vs. 972 hospitals that do not. The risk adjusted 30 day mortality rate between 7/05-6/08 for “Heart Attack” were compared.

Results
972 hospitals without CT surgery on-site are performing primary PCI, which represents 65% of all hospitals performing primary PCI within the database. Hospitals with and without on-site CT surgery had a statistically significant difference in rates of risk adjusted 30 day mortality. Both groups performed equally well in quality care measures except ASA at time of discharge.

Conclusion
Despite current guidelines, a majority of hospitals capable of performing primary PCI are doing so without available CT surgery on site. Patients with “Heart Attack” conditions presenting to sites with primary PCI capabilities without on site CT surgery have worse outcomes. This difference in outcomes warrants continued research.

Table 1:

Data Comparison for SOS vs. No SOS

No SOS
SOS
Total
P Value
NNTH

# Hospitals
972 (65%)
516 (35%)
1488

# Procedures
279799 (63%)
164558 (37%)
444357

30 Day Risk Adjusted Mortality
16.21
15.98
16.13
.0263 (95% CI 0.027,0.430)
434

Table 2

- Hospital Adherence to QOM Meds

Medications
No SOS
SOS
P-Value

ASA Upon Admit
98
98
.45

ASA at D/C
97
98
.04

ACE-i or ARB at D/C
94
94
.25

BB at D/C
98
98
.24

DBT < 90 Min
77
78
.48
Abstract P201: Impact of Special Populations on Thromboprophylaxis and Clinical Outcomes of Patients Undergoing Knee Replacement Surgery in the US
Authors: Deitelzweig Steven , Lin Jay , Lin Grace
Published: March 2022

Background:
New anticoagulants are evaluated in clinical trials which often initially focus on prevention of venous thromboembolism (VTE) after major orthopedic surgery. Unlike clinical trials, real-world surgical patients include special populations of patients with comorbidities or concomitant drug use.

Objective and purpose:
To evaluate the proportion of special patient groups in a real-world population undergoing knee arthroplasty, and to assess their thromboprophylaxis status and clinical outcomes.

Methods:
Data were extracted from the IMS' PharMetrics® Patient-Centric database for patients aged ≥ 18 years and undergoing knee arthroplasty during 2007. The primary efficacy end point was the overall rate of hospital acquired VTE as one of the secondary hospital discharge reasons. The overall rate of adverse bleeding events was one of the secondary hospital discharge reasons as the primary safety end point.

Results:
Of the 19,390 knee arthroplasty patients included in the analysis, 3,279 (17%) were aged ≥ 75 years, 4,368 (23%) used a CYP3A4 inhibitor, and 1,882 (10%) used warfarin chronically. Smaller proportions had atrial fibrillation (AF; 1,334; 7%), renal insufficiency (766; 4%), used antiplatelet drugs (621; 3%), had hepatic impairment (320; 2%), or had a history of acute coronary syndromes (ACS; 288; 2%). Pharmacologic thromboprophylaxis was prescribed to 47% (9,063 of 19,390) of patients. In a logistic regression model, the likelihood of VTE events was increased significantly (all
P
< 0.05) with AF (odds ratio [OR] 1.41; 95% confidence interval [CI] 1.06-1.88), chronic warfarin use (OR 1.33; 95% CI 1.03-1.72), and each increasing year of age (OR 1.01; 95% CI 1.00-1.02). ACS increased the odds of bleeding events (OR 1.50; 95% CI 1.14-1.97;
P
< 0.05). The likelihood of rehospitalization for ACS was increased in patients with a history of ACS (OR 5.47; 95% CI 1.93-15.54).

Conclusion:
Special populations are prevalent in everyday knee surgery patients and certain comorbidities or drug use can be associated with increased odds of VTE events or bleeding. Additional studies on the effects of different patient characteristics on clinical outcomes are warranted, particularly for new anticoagulants where little real-world data exist.
Abstract P217: Recovery From a Coronary Event: Understanding the Nature of the Patient's Journey
Authors: Rossi Laura P , Traynor Kathleen C , Clark Jack
Published: March 2022

Introduction:
As new technology has improved the diagnosis and treatments of acute coronary syndrome (ACS), our understanding of how patients recover and return to their daily life remains limited. Life after ACS and current treatment may be very different from prior understandings of recovery after a heart attack. Patients' trajectories involve complex physical, emotional and social impacts over time. This study explored the trajectory of recovery following an acute coronary event from patients' viewpoints and identified implications for effective care planning.

Methods:
Qualitative interviews were conducted with 20 patients (men 11; women 9) (mean age 60 ± 10 years) at four time points over the six months following admission for ACS to elicit accounts, thoughts, and feelings about recovery. A grounded theory approach was used to code and analyze verbatim transcripts.

Results:
Most patients (85%) described emotional and/or physical burdens associated with recovery. Physical burdens included concerns about activity progression (80%), symptom recognition & management (65%), and incision care (10%); emotional burdens included ongoing uncertainty (90%), difficulty managing competing priorities (80%) and a sense of vulnerability (45%). Three patterns of recovery were identified:
Seamless
(15%) in which patients encountered few, if any, burdens,
Burdened but manageable
(35%) in which patients managed burdens with systems of care available, and
Burdened requiring resources
(50%) in which patients encountered burdens for which resources were unavailable or inaccessible. While 11 subjects were referred for cardiac rehabilitation, 7 reported delays in participation. Only 36% of those referred reported appreciating benefits; others were concerned about timing and attention to individual concerns.

Conclusions:
As providers plan care, they should be attentive to the level of burden imposed by the diagnosis and prescribed regimen in relation to the internal and external resources available to each patient. Despite positive procedural results, physical and emotional burdens have an important impact on the process and outcomes of recovery. Administrators should examine the availability and access of services to support patients during recovery.
Abstract P220: Interim Results of the Registry to Evaluate Anticoagulation in Atrial Fibrillation (REAL-AF)
Authors: Matchar David , Ezekowitz Michael , Garcia David A , Samsa Gregory P , Sander Stephen , Su Zhaohui , VanderMaelen Cam
Published: March 2022

BACKGROUND:
Warfarin reduces the risk of ischemic stroke in patients (pts) with atrial fibrillation (AF) by >50% compared to aspirin in clinical trials, but is underutilized and can be difficult to manage.

METHODS:
REAL-AF is an observational registry that consists of retrospective and prospectively-enrolled pts with newly-diagnosed nonvalvular AF from 250 community-based US practices. This interim analysis focuses only on the retrospective arm, with six months of follow-up data. For all pts, baseline demographics were collected. Healthcare utilization, time to reach and time within target therapeutic range (TTR) were analyzed in pts on warfarin. For those not on warfarin, reasons for not prescribing were collected by selecting from a list of commonly-cited reasons. Multivariate models were used to assess factors associated with use of anticoagulation.

RESULTS:
Of 961pts observed to date, the mean age was 71.2±12.5 years; 51.5% male; 71.8% (654/911) white. Of the 68.4% (657/961) that received warfarin, 71% (3810/5356) of INR tests were conducted in the physician's office with about half (2501/5356) requiring further action such as a dose adjustment, more frequent monitoring, or physician or hospital visit. On average, pts had 13 INR tests (5070/390) and 4.5 dose adjustments (972/216) over a 6-month period. Mean TTR was 52.1% (N=348 pts). Median time to reach stable therapeutic range (3 consecutive INRs between 2.0 and 3.0) was 17.9 weeks (N=339 pts). High variability of INR values was associated with higher healthcare utilization (r=0.25, p=0.004). Physician-perceived “low stroke risk” (45%; 136/304) and “high bleed risk” (22%; 68/304) were the most common reasons for no anticoagulation. Excessive fall risk (OR 0.069, 95% CI 0.036-0.133) and full-time employment (OR 0.61, 95% CI 0.40-0.94) were significant predictors for warfarin non-use, based upon multivariate analysis.

CONCLUSIONS:
Non-therapeutic INR values and warfarin dose adjustments are common among newly diagnosed AF pts who have little or no previous exposure to anticoagulation therapy. From this retrospective analysis it appears that the current use of anticoagulation therapy in pts with AF is not optimal.
Abstract P223: Clinical Referral Patterns for Carotid Artery Stenting Versus Carotid Endarterectomy: Results From the CARE Registry
Authors: Longmore Ryan B , White Christopher J , Rosenfield Kenneth , Anderson H. Vernon , Ho Kalon K. L , Longmore Lance S , Kennedy Kevin F , Spertus John A
Published: March 2022

Background:
Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are two alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. It has been noted that substantial differences in clinical characteristics between patients referred for CAS vs. CEA may preclude direct comparisons of effectiveness. We sought to rigorously examine the clinical profiles of patients referred for CAS vs. CEA.

Methods:
We assessed clinical characteristics of 12,701 patients referred for CAS or CEA from the NCDR-CARE multi-center prospective registry. We compared 44 clinical and demographic variables, and used these to create a propensity score for referral for CAS. To explore the comparability of CAS and CES patients, we stratified the cohort into quintiles of propensity score to determine the degree of overlap between CAS and CEA patients.

Results:
Among the 8,069 patients referred for CAS and 4,632 patients referred for CEA, the CAS patients were much more likely to have significant comorbidities. (Figure) While the propensity model balanced most covariates, the pooled standardized differences remained >10% for: CAD, MI within 6 weeks, prior seizure, and CAS and CEA restenosis, all of which were more common in the CAS group. After propensity matching and stratification by quintile, CEA patients comprised 70% of the lowest quintile but only 6% of the uppermost quintile.

Conclusion:
Clinical characteristics of patients referred for CAS differ markedly from those referred for CEA. Due to the clinical disparities between these patient groups, comparative analyses performed to date outside of prospective randomized controlled trials may be invalid.
Abstract P243: Potential Cost Savings With CMR-Guided Selective Invasive Strategy in Non-ST Elevation Acute Coronary Syndrome
Authors: Satiani Anand , Davis Richard B , Raman Subha V
Published: March 2022

Background
We have previously shown that rapid cardiac magnetic resonance imaging (CMR) to identify myocardium at risk predicts the need for subsequent coronary revascularization in low and moderate risk patients with NSTE-ACS. The current standard diagnostic approach routinely employs invasive coronary angiography with attendant costs and risks, even though large randomized trial suggest that 50% may not have coronary stenoses requiring revascularization. We describe the potential cost savings associated with a CMR-guided strategy that reserves invasive angiography for patients with myocardium at risk in NSTE-ACS.

Methods
Revascularization outcome was recorded in 712 patients admitted with NSTE-ACS referred for coronary angiography identified as part of an IRB-approved protocol. The study population included those who had a catheterization with no subsequent revascularization procedure, and those who had a catheterization with subsequent percutaneous or surgical coronary revascularization. Standard costs of $2,000 for CMR and $15,000 for coronary angiography were applied to both groups to project the cost savings of using CMR as the initial diagnostic modality. If no revascularization was required, a cost savings equal to the difference between the cost of CMR and angiography was computed. If revascularization was performed, a cost increase by adding CMR to the angiography cost was computed.

Results
49.6% of study patients did not undergo revascularization after invasive angiography. Assuming that only patients with CMR-identified myocardium at risk would undergo angiography, the net cost reduction equated to a $3.9MM (36.2%) in this cohort. Initial analysis suggests similar rates of catheterization-related complications in both groups.

Conclusion
Using CMR to identify myocardium at risk in low-to-moderate risk NSTE-ACS patients may realize significant cost savings while insuring appropriate invasive care for patients most likely to benefit. A prospective, randomized study is warranted to better quantify the impact of a CMR-guided strategy on outcomes and cost in NSTE-ACS.
Abstract P248: Regional, Gender and Racial Variance in Utilization of Implantable Cardiac Devices
Authors: Armbrecht Eric S , Behera Anit , Hauptman Paul J
Published: March 2022

The volume of initial and replacement procedures for implantable cardiac devices for defibrillation (ICD) and/or resynchronization (CRT-D or CRT-P) has increased over the last decade. However, unlike diagnostic catheterization, little is known about the utilization of cardiac implant devices by gender, race and geographic area. Therefore, we examined these relationships using MICA, a nationally-recognized surveillance data system managed by the Missouri Department of Health and Senior Services.

Methods:
Using the most recent three-year period which includes 22,205 ICD and/or CRT procedures (2005-2007), our analysis compared crude procedure rates by gender and race (White and Black) for residents living in the 20 largest Missouri counties which account for 70% of State population. We also analyzed procedure rates for coronary artery bypass graft (CABG) and diagnostic catheterization/coronary arteriography (DCCA). We developed a linear regression model to explore the relative contribution of heart disease burden, race, and income on county-level procedure rate.

Results:
Whites were 1.73 times more likely than Blacks to have an ICD and/or CRT procedure (p < 0.0002): 26.4 vs. 15.2 per 10,000 person-years. Similar statistically significant differences were calculated for CABG and DCCA. We observed a 3.2-fold difference in ICD and/or CRT procedure rate between residents from low and high counties (mean 20.3 ± 5.5, range: 11.4 to 37.0 per 10,000 person-years). A regression model (R
2
: 0.41) indicated positive association with heart disease burden (p = 0.036) and negative association of similar magnitude with race (e.g., percent Black) (p = 0.028).

Conclusions:
There is substantial variance in cardiac device utilization by key factors including race within the sample under study. Additional research designed to understand the distribution of devices in terms of medical and social factors is warranted.

Cardiac Procedure Rates (per 10,000 person-years), 2005-2007 for 20 Largest Counties in Missouri

ICD or CRT
CABG
Diagnostic cath /arteriography

White Men
29.3
29.7
281.4

White Women
23.5
11.3
192.9

Total White
26.4
20.3
236.3

Black Men
15.4
10.7
176.0

Black Women
15.1
7.2
189.4

Total Black
15.2
8.9
183.2
Abstract P249: Patient Centered Care: Baseline Demographics Data From a Stage I Hypertension Clinical Trial
Authors: Memon Nabeel , Kashem Abdul , Gupta Ankur , Gonzalez Jorge , Alkhouli Mohamad , Hewitt Valaine , Scheiring Kristy , Bove Alfred A
Published: March 2022

Background:
Hypertension is highly prevalent in underserved communities and is associated with excess cardiovascular mortality. Patient Centered Care (PCC) programs are essential to achieve adequate blood pressure control and modify CVD risk. Use of the Internet to report self measured BP is one method to achieve better BP control. However, in underserved populations, Internet access is limited. We tested whether low income and lack of home Internet access limits BP management with a telemedicine program.

Methods:
Inner-city, primarily African-American (AAs) patients (N=130) with uncontrolled HTN (BP>140/90 mmHg) who are followed by primary care physicians were randomized to usual care or Telemedicine plus usual care. BP, weight, BMI, blood glucose, lipids, tobacco use, and physical activity were measured at baseline and at 6 months. Income level and availability of Internet were recorded for each patient. We divided the income level in five groups: 1) $15,000-$24,999, 2) $25,000-34,999, 3) $35,000-44,999, 4) $45,000-54,999, and 5) >$55,000. We correlated each group with Internet availability at home, age, sex, race, blood pressure, smoking, and hyperlipidemia.

Results:
Baseline demographics include age 58±17 years, BMI 33±8 kg/m
2
, SBP: 152±13 mmHg, DBP: 86±11 mmHg, FBS: 112±46 mg/dL, HbA1C: 6.3±1.6%, total cholesterol: 178±47, HDL: 50±16, LDL: 99±47. Sixty eight %were African American, 19% were smokers, 32% diabetics, and 42% had hyperlipedemia. Home internet was available to 46%. 52% fell under the low income groups (1+2). When compared between the income groups, group 1 and 2 showed significant differences (p=0.004 and p=0.013) with group 5 (p=0.002) in terms of availability of Internet at home. Patients with no internet access used inter-active computerized telephone system for communication with our center.

Conclusions:
Many inner city patients could not utilize Internet based telemedicine to take a more active role in their own health care through self-monitoring, education, reinforcement and feedback. They were able to use telephone based communication to benefit from patient centered care.
Abstract P251: Gender and Age Influence the Utilization of Recommended Medications at Discharge in Post Myocardial Infarction Population
Authors: Patel Manishkumar C , Nicholson David J , Patel Parag
Published: March 2022

Background:
ACC/AHA guidelines strongly recommend the use of aspirin, beta blockers, clopidogrel, statin, and angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB) in post myocardial infarction (MI) patients. Reductions in mortality have been demonstrated with consistent administration of recommended therapies. Patients who discontinue taking evidence-based medications are at increased mortality risk. The purpose of this study was to identify gender and age based differences in drug therapies at discharge in post MI patients at a tertiary care teaching hospital.

Methods:
We retrospectively analyzed data of 610 consecutive patients admitted with MI from 2006 to 2007. The use of appropriate discharge medications was compared using chi-square test.

Results:
There were 371 males (60.8%) with mean age 65.4 ±13 years and 239 females (39.2%) with mean age 73 ±12 years.

Medications
Male (%)
Female (%)
OR (CI)
p value

Aspirin
97.9
93.2
3.4 (1.3-8.5)
0.006

Clopidogrel
77.6
63.6
1.98(1.4-2.87)
<0.001

Beta blocker
94.6
84.4
3.2 (1.75-5.9)
<0.001

Statin
88
79
1.9 (1.2-3.1)
0.006

ACEI/ARB
70
58.5
1.66(1.15-2.3)
0.006

Clopidogrel use was 59% and 84.4% in patients greater than 70 years and less than 70 years respectively (OR= 0.26, CI 0.18-0.39, p = <0.001). There was no difference in use of other medications by an age cut off of 70 years.

Conclusions:
In an era of evidence-based guidelines and quality improvement initiatives, there is still under utilization of recommended medications in women even though they receive same treatment benefit. Elderly patients in spite of being at high risk for recurrent events were less likely to be discharged with dual antiplatelet therapy.
Abstract P253: Ethnic Disparities in Referral to and Enrollment Among Patients in Cardiac Rehabilitation
Authors: Reddy Bharathi , Rullo Nancy , Lee Kiseok , Nicholson John P , Candy Donna C
Published: March 2022

Background:
Despite the convincing evidence and practice guidelines for cardiac rehabilitation (CR), it has been consistently documented that 20% of eligible patients actually enroll in CR. Studies have shown multiple reasons for this non-utilization, but few have documented enrollment ethnicity differences.

Objective:
The purpose of this study is to document ethnic disparities deter enrollment of patients to CR. We speculate that maybe ethnic, cultural, and language are barriers to enrollment into CR.

Methods:
The study sample comprised of five hundred ninety-six adult patients (age 65.47 ± 12.02) discharged from New York Hospital Queens, community-based hospital serving a multi-diverse population in Queens, New York following acute myocardial infarction (MI), percutaneous coronary intervention (PCI), and/or coronary artery bypass surgery (CABS) in the year 2009. All patients were referred through liaison referral. Data was obtained from the Register database (gender, age, clinical information).

Results:
Of the 596 patients referred to our CR program, one hundred five patients (17.5%) enrolled in CR. Of the total number of patients referred (n= 596), Asian (n=177, 29.7%), Caucasians (n=246, 41.3%); African Americans (n=49, 8%), Hispanics (n=107 18%), Others (American Indian, Middle-Eastern, etc.) (n=17, 3%), significant disparities among the ethnic groups were noted respectively, Asian (n=14, 7.9%), Caucasian (n= 51, 20.7%), African-American (n=17, 34.7%), Hispanic (22, 20.6%), and Others (n=1, 5.9%). The most remarkable and profound difference was in the Asians enrolled (7.9%, 14/77). This was in sharp contrast as compared to the other ethnic groups enrolled into CR.

Conclusions:
The results show substantially lower levels of CR participation among Asians. We surmise that language barriers, ethnic and cultural perceptions, and physician referral patterns in Asians, may be among the factors that create this barrier to entry. Future CR efforts should be directed to breaking down these ethnic barriers thereby allowing higher participation rates by patients that belong to these ethnic groups.
Abstract P26: 30-Day Risk Standardized Mortality and Readmission After Ischemic Stroke by Hospital Minority Volume
Authors: Lichtman Judith H , Jones Sara B , Watanabe Emi , Leifheit-Limson Erica C , Wang Yung , Goldstein Larry B
Published: March 2022

Background:
Risk-standardized 30-day mortality (RSMR) and readmission (RSRR) rates in part reflect hospital-based and immediate post-discharge care. Differences in rates across hospitals based on the race-ethnic composition of their patient populations may indicate disparities in care. We examined whether hospital 30-day RSMRs and RSRRs after ischemic stroke vary by the proportions of African-Americans (AA) admitted at hospitals in 1994, 2000, and 2006.

Methods:
We used Medicare claims data to determine the hospital-level RSMR for any cause 30 days after the index admission and RSRR for any cause within 30 days of discharge among surviving fee-for-service Medicare patients >= 65 years of age discharged with a primary diagnosis of ischemic stroke (ICD-9 433, 434, 436) in 1994, 2000, and 2006. Hierarchical regression models calculated the RSMR and RSRR for hospitals, adjusting for patient demographics and clinical characteristics. Hospitals were grouped into quartiles based on the proportion of AA admitted. Mixed models and quantile regression models examined the relationship between AA volume and outcomes.

Results:
The RSMR decreased as the proportion of AA increased, whereas the RSRR increased as the proportion of AA increased (figure). These relationships were consistent within each year, and the variability lessened over time. Quantile regression confirms that the relationship persists across the distribution of RSMR and RSRR.

Conclusions:
RSMR and RSRR varied by hospital race-ethnic volume, but differences in outcome lessened over time. Identifying factors contributing to these differences may identify opportunities to improve stroke care among the elderly.