bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 16055: Marantic Endocarditis - A Rare Paraneoplastic Presentation of Ovarian Carcinoma
Authors: Haider Mobeen , Khalil Muhammad Hasib , Khalid Yousra , Rahman Saad Ur U , Bodine Christopher
Published: December 2023

Introduction:
Nonbacterial thrombotic endocarditis (NBTE) or Marantic endocarditis, involves formation of sterile platelet & fibrin thrombi on undamaged cardiac valves & adjacent endocardium. The vegetation is associated with embolization.

Case presentation:
A middle-aged female without cardiac history presented to the ED with blurred vision & fatigue for 3 days. The patient was afebrile with a BP of 183/97mmHg. Physical examination showed decreased visual acuity in the left eye. The EKG was normal. The patient underwent a CT scan brain that showed suspicion of bilateral occipital strokes. MRI brain revealed multiple small acute infarcts in the bilateral cerebral hemispheres & cerebellum. Blood cultures were negative. Telemetry did not show atrial fibrillation. Given a suspicion of cardioembolic stroke, the patient underwent a transesophageal echocardiogram (TEE) which demonstrated a trileaflet aortic valve (AV) with abnormal irregular thickening of leaflets, concerning for vegetation & moderate-severe aortic regurgitation (AR). figure 1. Our patient was diagnosed with marantic endocarditis based on TEE & serial negative cultures. Apixaban was started. Further workup of the patient revealed bilateral pulmonary emboli. Abdominal imaging revealed a pelvic mass, ultimately diagnosed as clear-cell ovarian cancer. Interval TEE at 3 months demonstrated complete resolution of vegetations with preserved cusp motion & mild AR. A shared decision was made to continue lifelong anticoagulation.

Discussion:
NBTE commonly involves mitral & AV. Risk factors include trauma, circulating immune complexes, hypercoagulability, malignancy & acute inflammation. Symptoms result from embolization, valve dysfunction, or impaired cardiac function. It is based on imaging after ruling out infectious etiologies. Management is anticoagulation & valve replacement with the treatment of the underlying etiology. Valve replacement prevents future embolic complications.
Abstract 16063: African American's Are Prescribed Direct Oral Anticoagulants at Lower Rate Than White Patient's in an Inpatient Cohort With Diagnosis of Atrial Fibrillation
Authors: Safren Lowell , Hunter Krystal , Russo Andrea M
Published: December 2023

Introduction:
Previous studies have demonstrated racial disparities in the treatment of atrial fibrillation (AF). Potential explanations for disparities in care include cost and insurance coverage issues. This has not been examined in relation to anticoagulation (AC) therapy for thromboembolic prophylaxis of AF in a more contemporary practice using an inpatient cohort.
Hypothesis:
For hospitalized patients with AF, is there disparity in the rate of prescription of direct oral anticoagulant (DOAC) therapy at discharge for Black compared to White patients?

Methods:
A single-center retrospective query of all patients hospitalized at a University Hospital with a primary or secondary diagnosis of “AF” in 2022 and a prescription for AC at time of discharge was performed using EPIC. Baseline characteristics and AC prescription were compared between Black and White patients using the χ2 test for categorical variables and t test for continuous variables.

Results:
There were 275 patients that met the inclusion criteria. Demographics were 38.2% female, 66.5% White, and 14.9% Black (Table). DOAC was prescribed at discharge for 66.1% of White and in 55.0% of Black patients (p=0.01). The distribution of type of AC prescribed at discharge is shown (Figure).
Conclusions:
There is an ongoing racial disparity in the rate of DOAC prescription in hospitalized patients with AF, despite similar insurance status. Further investigation into underlying reasons for these differences and ways to eliminate disparities is warranted.
Abstract 16069: Patient Education and Medication Checklists for Optimization of Guideline-Directed Medical Therapy
Authors: Tang Amber B , Dermenchyan Anna , Melton Chidinma , Cho David , Bokhoor Pooya , Yaw Richard , Gaspar Julie , Delavin Nina Lou , Fonarow Gregg C
Published: December 2023

Introduction:
Despite strong evidence on the benefits of guideline-directed medical therapies (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF), the use of GDMT remains suboptimal in clinical practice.

Hypothesis:
We hypothesized that patient educational videos, coupled with an interactive medication checklist provided to patients, would improve prescription of GDMT in outpatient cardiology clinics.

Methods:
Patients over the age of 18 years with a diagnosis of HFrEF and a cardiology clinic appointment during the study period were included. Electronic health record communications were sent to patients the week prior to their scheduled cardiology appointments. The communication included (1) short videos on GDMT and (2) a medication checklist to be completed by the patient and brought to their upcoming appointment. The primary outcomes were initiation and uptitration of GDMT.

Results:
A total of 253 patients (mean age 67 +/- 14 years) were included, of which 69% were male, 10% black, and 11% Hispanic. At baseline, 86% of patients were on an evidence-based beta-blocker, but only 17% were at goal doses (Figure). Additionally, only half of eligible patients were on a mineralocorticoid receptor antagonist (MRA) or sodium-glucose cotransporter-2 inhibitor (SGLT2i). Post-intervention, there was a significant increase in the number of patients on a renin-angiotensin-aldosterone inhibitor (75.9% to 78.3%, p=0.04) and SGLT2i (50.2% to 52.7%, p=0.04). There was also a 0.8% increase in the number of patients on target doses of MRAs, although this did not reach statistical significance.

Conclusions:
Educational materials and checklists provided to patients prior to clinic appointments were associated with improved initiation and uptitration of GDMT. This intervention may be a scalable and low-cost way of engaging patients in their medical care and encouraging shared decision making, although further study is needed.
Abstract 16139: Rising Cardiovascular Mortality in Prostate Cancer Patients: Results From Surveillance, Epidemiology and End Results (SEER) Database
Authors: Niroula Shailesh , Bhatia Unnati , Prasai Astha , Baral Nischit
Published: December 2023

Introduction:
Prostate cancer is the second most common cancer in men and the fifth leading cause of cancer related mortality. Advancement in therapy has led to improved survival among patients, however, there has been increased incidence of cardiovascular events among cancer survivors.

Objective
To observe the trend of cardiovascular specific death rate among patient with prostate cancer as compared to death due to cancer

Methods:
Patients with prostate cancer registered in SEER database from 2005 to 2020 were included. Prostate cancer specific mortality rate, cardiovascular (CV) specific mortality rate and all-cause mortality rate were analyzed using SEER*Stat version 8.4.1 software in the rate session. Joinpoint version 5.0.2 was used to create annual log-linear time trends.

Results:
The study included 857,410 patients diagnosed with prostate cancer from 2005 to 2020. The average annual percentage change (AAPC) of prostate cancer showed decreased incidence by 2.8 % (95% CI 1.8% to 4.1%, p<0.05) from 2005 to 2020 with significant decrease in annual percent change (APC) from 2005 to 2014 by 4.9% (95% CI 2.9 % to 12.5, p<0.05). AAPC of prostate cancer specific mortality rate increased by 1.8% ( 95% CI 1.3% to 2.9%, p<0.05) from 2005 to 2020 with significant increase in APC by 2.4% (95% CI 1.3% to 9.2%, p<0.05) from 2005 to 2018. AAPC of CV specific mortality rate increased by 4.4% (95% CI 4.1% to 4.9%, p<0.05) from 2005 to 2020 with significant increase in APC by 7.1% (95% CI 6% to 9.2%, p<0.05) from 2005 to 2011 and 2.6% (95% CI 2% to 3.1%, p<0.05) from 2011 to 2020 (Figure 1).

Conclusions:
Around 2009, the cardiovascular specific mortality rate became higher than cancer specific mortality rate among prostate cancer patients and this trend has been consistent since then. It highlights advancement in treatment which has increased survival from prostate cancer, however it has increased cardiovascular mortality in patients due to advancing age as well as direct toxicity of treatment.
Abstract 16147: Racial and Ethnic Differences in the Diagnostic Yield of Cardiomyopathy, Aortopathy, and Arrhythmia Genetic Testing and Frequency of Family Variant Screening
Authors: Carter Spencer V , Grodin Justin L , Morales Oyarvide Vicente , Peterson Eric D , Khan Sadiya S , McKnight Dianalee , Morales Ana , Russell Emily , Ting Yi-Lee , Navar Ann Marie M
Published: December 2023

Introduction:
Genetic testing for individuals with inherited cardiovascular conditions can guide treatment and aid in family screening. However, the diagnostic yield of pathogenic or likely pathogenic (P/LP) variants may differ by race and ethnicity because of a lack of diversity in population-based genomic databases.

Methods:
We evaluated the diagnostic yield (% tests with P/LP variants) of genetic testing for cardiomyopathy, aortopathy, and arrhythmia among probands undergoing testing at a large commercial laboratory (Invitae Corp.) from 9/2015-7/2022 for the most common racial and ethnic groups: Hispanic, Non-Hispanic (NH) Black, and NH White individuals. We used multivariable logistic regression to evaluate for differences in diagnostic yield by race and ethnicity adjusting for age, sex, payer, and number of genes tested. The ratio of the number of persons undergoing family variant testing (FVT) to the number with positive tests was determined, with Chi-square tests to evaluate for differences by group.

Results:
We identified 129,565 persons undergoing diagnostic genetic testing (n=9,157 Hispanic, n=16,287 NH Black, and n=78,740 NH White). Compared with White persons, the odds of a positive test were higher in Black and Hispanic persons for cardiomyopathy (OR 1.2, 95% CI 1.2-1.3, p <0.001 and OR 1.3, 95% CI 1.2-1.4, p <0.001, respectively) and aortopathy (OR 2.1, 95% CI 1.8-2.5, p <0.001 and OR 1.9, 95% CI 1.7-2.2, p <0.001, respectively), and higher for Hispanic persons for arrhythmia (OR 1.2, 95% CI 1.1-1.3, p <0.001). The ratio of FVT to positive tests was significantly (p < 0.001) lower for Black and Hispanic persons than White persons for cardiomyopathy (0.32, 1.19, and 1.51, respectively), aortopathy (0.77, 1.62, and 2.34, respectively), and arrhythmia (1.47, 2.23, and 3.33, respectively).

Conclusion:
Despite being underrepresented in population genomic databases, the diagnostic yield of genetic screening for cardiomyopathy and aortopathy was higher in Black and Hispanic persons compared with White individuals. The relative frequency of family variant testing was lower in Black and Hispanic than in White persons, indicating an opportunity to improve cascade screening in these groups.
Abstract 16148: Calculating Indexed Aortic Root Diameters With Ideal Body Weight Leads to Significant Reclassification in Overweight and Obese Patients
Authors: John Kevin , Ghosalkar Radhika , Li Jing , Steinhauer Rachael , Wessler Benjamin , Patel Ayan , Downey Brian
Published: December 2023

Introduction:
Indexed Aortic root diameter (AoR diam) measured by transthoracic echocardiography (TTE) using body surface area (BSA) is important in children, adolescents, and small adults in whom non-indexed values may under detect dilation. However, indexed AoR diam may lead to misleading results in obese individuals as the AoR diam does not increase in proportion to body weight.

Hypothesis:
We hypothesize that using ideal body weight (IBW, using the Devine formula) in place of actual weight in BSA calculation reclassifies a significant proportion of indexed AoR diam in overweight and obese patients.

Methods:
We performed a retrospective review of all patients with a TTE at Tufts Medical Center in 2022 and Ao root diam >4 cm for men and >3.6 cm for women. We excluded patients < 20 years old and those with inadequate TTE images or missing aortic measurements. TTE data and baseline characteristics were recorded. Indexed AoR diam was calculated using both actual and ideal body weights. The thresholds for for mildly, moderately, and severely dilated indexed AoR were ≥2.2, ≥2.4, and ≥2.6 in men, and ≥2.3, ≥2.4, and ≥2.6 in women, respectively.

Results:
456 patients (400 males, 56 females) met our inclusion criteria, with a subset of 331 patients (72.6%) with BMI ≥25. When ideal body weight was used for indexing AoR diam, 58.7% of patients initially classified as having 'normal' indexed AoR diam were reclassified as at least 'mildly dilated' (p<0.001). Patients with a BMI ≥25 were more often reclassified as at least ‘mildly dilated’ compared to those with lower BMI (64.6% vs. 13.3%, p<0.001). In stratified analysis, upward reclassification occurred in 31.9% of patients with 'mildly dilated' AoR diam (45.8% in BMI ≥25) and 35.2% of patients with 'moderately dilated' AoR diam (80% in BMI ≥25).

Conclusions:
The use of ideal body weight instead of actual body weight for indexing AoR diam changes risk-stratification in over half of the patients with an abnormal AoR. This is more pronounced in patients with a BMI ≥25 and may have significant management implications. Further studies are needed to investigate if the use of actual weight in Ao root indexing systematically underestimates Ao root dilation in overweight and obese patients and if the use of IBW can improve risk assessment.
Abstract 16165: Implicit Bias and Unintentional Harm in Vascular Care: The Case for Intervention
Authors: Kalbaugh Corey A , Howard Kerry , Beidelman Erika , Witrick Brian , McGinigle Katharine , Minc Samantha , Alabi Olamide , Hicks Caitlin W , Gonzalez Andrew A , Cykert Samuel
Published: December 2023

Introduction.
Unconscious, or implicit, bias may influence physician treatment decisions and contribute to healthcare disparities.

Research Questions.
Is implicit bias associated with inappropriate care for claudication and 1-year major amputation?

Methods:
All vascular interventionists of the Society for Vascular Surgery Vascular Quality Initiative (VQI) were invited to take the race Implicit Association Test (IAT). The IAT asks participants to classify sequential images of African American (Black) and European American (White) faces to positive and negative attributes and groups them by racial preference based on reaction time. IAT results were weighted and linked to VQI peripheral revascularization data to test the association between implicit bias with patient race and performance of below-knee procedures for claudication, a measure of inappropriate care. We assessed the association of below-knee procedures and patient race with odds of 1-yr amputation, using physician implicit bias as a moderator.

Results:
Among the 218 physicians that completed the IAT, physicians with White preference (70%) were more likely to perform a below-knee procedure on Black patients (
Fig A
) and their Black patients had increased odds of 1-yr amputation compared to White patients (OR: 3.0, 95%CI: 1.7-5.4). Physicians with no preference (20%) had no variability in below-knee procedures by patient race and fewer 1-yr amputations. A below knee procedure for claudication (ref: above-knee) was associated with increased odds of 1-year amputation, but the effect was greater among physicians with White bias (OR: 8.2;4.7-14.5) compared to no bias (OR: 3.6;1.4-9.7) (
Fig B
).

Conclusions:
Implicit bias is associated with inappropriate treatment selection, especially for Black patients. These results suggest the need for system level interventions that transparently identify procedures that are not aligned with best practices to reduce the negative effect of implicit bias.
Abstract 16189: Using Vectorcardiography to Predict Prognosis in Patients With STEMI and Heart Failure
Authors: Perkins Sidney , Monovoukas Demetri , Chopra Zoey , Powell Corey , Vejalla Anuush , Asthana Vishwaratn
Published: December 2023

Introduction:
There is an unmet need for a non-invasive and cost-effective surveillance tool for characterizing the severity and progression of heart failure (HF) to guide evidence-based therapies. We hypothesize that changes over time in unique parameters extracted using vectorcardiography (VKG) have the potential to predict clinical outcomes in patients with HF. The pathophysiology of HF involves abnormal remodeling and a loss of cardiomyocytes, which may alter the strength and direction of the net depolarization signal. These subtle changes can be elucidated using VKG and correlated with prognosis. We hypothesize a similar approach can be utilized for patients post-STEMI as the underlying pathophysiology - loss of myocardium - is comparable and could serve as an initial proof-of-concept.

Methods:
We identified 209 patients discharged from Michigan Medicine between 2016 and 2021 with a diagnosis of acute STEMI. For each patient, a single 12-lead EKG pre-STEMI and >1-week post-STEMI were collected. A set of 60 VKG parameters were derived by analyzing features of the QRS complex. We used LASSO regression analysis incorporating clinical variables and VKG parameters to create a predictive model for the composite outcome of mortality or HF at 90 days post-STEMI. Model accuracy was determined by randomly partitioning the data into five folds and running the logistic regression model on all folds but one.

Results:
Comorbid diabetes (OR = 3.04, p = 0.06), QTc post-STEMI (OR = 2.44, p <0.05), and P wave onset pre-STEMI (OR = 0.41, p < 0.05) were consistently predictive. A logistic regression with just these variables has a raw accuracy of 80.3% and cross-fold validation accuracy of 79.4%. Future work aims to create one of the largest pre-/post-STEMI ECG databases, with over 1,200 patients, which will be used to corroborate the above results and serve as a tool for other investigators to explore.

Conclusions:
ECG changes before and after a STEMI event can be used to assess the risk of mortality or HF and help guide management. The composite outcome appears to be dominated by variables that are primarily associated with arrhythmogenic death. Future work will focus on pump failure alone and determine VKG parameter predictiveness in HF specifically.
Abstract 16195: Burden of Mental Illness Among Hospitalization for Heart Failure in the United States - Nationwide Study
Authors: Kaur Jaspreet , Sharma Aditya , Costa Filho Francisco Flavio , Zahid Ibrahim , Mishra Tushar
Published: December 2023

Introduction:
There is limited data regarding the burden of severe mental health illness (SMI) among patients admitted with heart failure (HF) exacerbation.

Hypothesis:
We sought to determine the characteristics and outcomes of hospitalization for HF among patients with SMI in the United States.

Methods:
A retrospective analysis of the National Inpatient Sample database from January to December 2019 was done to identify HF hospitalizations. SMI was defined by ICD10-CM codes for secondary diagnoses of schizophrenia or other psychoses, bipolar disorder, and depression. Using logistic regression, we assessed the odds of in-hospital mortality and use of invasive ventricular support device.

Results:
Out of 1,295,395 hospitalizations with heart failure were identified from January to December 2019, 13.4% had a diagnosis of SMI. Most common SMI was depression (11.6%), followed by bipolar disorder (1.3%), and schizophrenia (0.7%). Patients with SMI were younger (mean age 68 vs 71 years, p<0.05), more likely to be women (58% vs 45%, p<0.05), and more likely to have diabetes, chronic pulmonary disease, hypertension, dyslipidemia, and obesity. The adjusted odds of in-hospital mortality in patients with SMI was 13% lower than those without SMI (OR 0.87, 95% CI, 0.79 - 0.96, P=0.004). Patients with SMI had 26% lower odds (OR 0.74, 95% CI, 0.59 - 0.93, P=0.009) to receive an invasive ventricular support device (IABP, PVAD, LVAD, or ECMO) than those without SMI.

Conclusions:
Patients with SMI were younger and carried a higher burden of comorbidities. We found a lower short-term risk mortality in patients with SMI and HF exacerbation.
Abstract 16212: Sex-Based Statin Utilization and Cardiovascular Disease Outcomes: A Real World Secondary Prevention Cohort
Authors: Mumtaz Maha , Hay Eli , Zhu Jianhui , Thoma Floyd W , Koczo Agnes , Reis Steven , Saeed Anum , Mulukutla Suresh R
Published: December 2023

Introduction:
Current guidelines recommend using high-intensity statins in patients with clinical ASCVD.However, real world adherence to GDSI use and recurrent events remains less known. Sex difference in statin use have been previously reported. We evaluated sex-based disparities in GDSI use and recurrent ASCVD outcomes in a large healthcare network.

Methods:
Using EMR, we assessed statin use and intensity amongst patients with established prior ASCVD events (MI, ischemic stroke/TIA) and PAD from 2010-2022. Statins were categorized into GDSI (high intensity), <gdsi (moderate="" or="" low="" intensity)="" or no statin use. Outcomes of interest included repeat MI, stroke/TIA and all-cause mortality. Incident rates (IR) and Cox regression hazard ratios (HR) of ASCVD outcomes were calculated across statin categories stratified by sex.

Results:
Amongst 45,949 patients,31% were women. Women had more diabetes (29% vs 24%) and higher LDL-C (94.9 ± 40.8 vs 87.6 ± 37.1 mg/dL) than men. During a follow-up period of 5 years, women were less likely to be started on GDSI (61.6% vs 65.8%, p<0.01) and achieve LDL-C<70mg/dL (41% vs and 49%, p<0.01) as compared to men. GDSI use lowered IRs for all outcomes in both sexes
(Table 1).
Women on GDSI had higher risk of MI (HR 1.21 [1.12-1.31)],stroke (1.21 [1.08-1.34] and mortality (1.12 [1.05-1.20]), all p<0.01) than men.

Conclusions:
In a contemporary cohort of secondary prevention patients, women were less likely to be prescribed GDSI than men and less likely to achieve guideline concordant LDL-C<70mg/dL. This was associated with a higher risk of recurrent ASCVD events in women as compared to men. More sex specific interventions are needed to ensure adequate preventive treatment for both sexes.

Abbreviations: Atherosclerotic cardiovascular disease (ASCVD), guideline directed statin intensity (GDSI), Electronic medical records (EMR),Myocardial Infarction (MI), Peripheral arterial disease (PAD), Transient Ischemic attack (TIA)
Abstract 16214: Prescription of Teratogenic Medications for Reproductive-Age Women With Heart Failure With Reduced Ejection Fraction in a Safety-Net Health System
Authors: Neela Niharika , Carter Spencer , Hendren Nicholas , Das Sandeep R
Published: December 2023

Introduction:
Angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), angiotensin receptor blocker-neprilysin inhibitors (ARNI), and mineralocorticoid receptor antagonists (MRA) have been proven to improve morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF); however, they have known teratogenic effects. It is uncertain how often reproductive-age women are prescribed these medications and whether they are prescribed contraception.

Methods:
We included all patients in our health system with documented left ventricular ejection fraction ≤45% within the past 2 years. Patients were excluded from the present study if they had a creatinine ≥2.0 mg/dl (women) or ≥2.5 mg/dl (men), as these are contraindications to MRA. Individuals were stratified into reproductive-age women (age ≤45), women age >45, and men (any age). Contraception prescription was queried via chart review for all reproductive-age women. Rates of ACEi/ARB/ARNI, and MRA, were then compared across 4 subgroups.

Results:
Of 3,003 patients who met the inclusion criteria, 130 were women ≤45y, 709 were women > 45y, and 2164 were men. Among the 81/130 (62%) reproductive-aged women not prescribed contraception, 78% had an active prescription for either an ACEi, ARB, or ARNI and 56% had an active MRA prescription (Figure). Comparing reproductive-age women not on contraception with all other groups, the ACEi/ARB/ARNI prescription rates were 78% vs. 78% (p = 0.36) and the MRA prescription rates were 56% vs 49% (p = 0.16).

Conclusions:
In a large safety net health system, most reproductive-aged women with HFrEF, were not prescribed contraception, yet they were commonly prescribed teratogenic heart failure medications. This is an important safety concern that should be addressed at the health system level.
Abstract 16244: Oncologic Disease and In-Stent Restenosis: A Nationwide Analysis
Authors: Diaz Saravia Sara , Choi James , Kong Darren , Matthews Christopher , Omar Alaa
Published: December 2023

Introduction:
Recent studies have shown that Ischemic Heart Disease (IHD) is leading cause of cardiovascular mortality in cancer patients. There is little information about In-Stent Restenosis (ISR), one complication of IHD treatment. ISR has been associated with the presence of underlying risk factors but there is no clear association between cancer and ISR.

Methods:
A retrospective cohort study was made selecting a sample of adult patients using the National Inpatient Sample (NIS) database from January 2017 to December 2019. Patients with cancer were identified and stratified by 5 main sites: lung, breast, gastrointestinal, prostate, and hematological tissue. Main outcome was odds of ISR in the oncologic population. Secondary outcomes were Major Adverse Cardiovascular Events (MACE) and mortality in patients with ISR, stratified by presence or absence of cancer. Univariate and multivariate analysis were done, adjusting for possible confounders.

Results:
A total of 90,900,000 adults were identified, of which 4,888,734 had cancer. From the adult population, 197350 patients with ISR were identified. Primary analysis revealed that cancer is not associated with increased odds of ISR but rather decreased, adjusted for other comorbidities, with an OR=0.181(IC95%=0.167-0.198, p=0.001). Paradoxically, secondary analysis of the ISR subpopulation showed statistically significant differences between cancer and non-cancer patients in the rate of composite MACE, and other cardiovascular outcomes such as Heart Failure, Atrial Fibrillation, and other arrhythmias (Table 1).

Conclusions:
The present study shows that cancer is associated with decreased odds for ISR, but in with patients with ISR cancer was associated with higher prevalence of composite MACE, mainly due to arrhythmias and heart failure. Further studies are needed to explain the dynamic relationship between cancer and endothelial dysfunction.
Abstract 16250: Latent His-Purkinje Disease Unmasked by Beta Blocker Overdose
Authors: Narowska Gabriela , Cooper Joshua M , Basil Anuj
Published: December 2023

Background
Symptomatic bradycardia usually has a single mechanism and treatment modality. Identifying the culprit mechanism can be challenging, especially when faced with concurrent pathologies. We present a case of severe symptomatic bradycardia where appropriate management of one mechanism unmasked a second mechanism, with a need for pacemaker placement.

Case Presentation
A 56-year-old patient presented with beta blocker overdose and severe bradycardia. The initial ECG showed sinus bradycardia with a sinus cycle length of 2060ms and 2:1 AV conduction, with each conducted P wave preceded by a long-coupled junctional escape beat. Atropine resulted in shortening of the junctional escape interval but had no effect on the sinus rate. There was now 1:1 AV conduction, with each P wave being preceded by a faster junctional escape beat. Glucagon resulted in acceleration of the sinus rate to a cycle length of ~820ms (73 bpm) with return of 1:1 AV conduction, a PR interval of 200ms, and no junctional beats. Conducted beats showed a right bundle branch block and left axis deviation. The dependence of AV conduction on a preceding QRS complex within a certain window of time highly suggested infranodal conduction disease manifesting as phase 4 AV block. While normal sinus rates and 1:1 AV conduction were restored with glucagon, the presence of infranodal disease warranted dual chamber pacemaker implantation. In follow-up, with atrial pacing support, there was < 1% ventricular pacing.

Discussion
Two causes of bradycardia were simultaneously present - sinus bradycardia due to beta blocker overdose, and 2nd degree AV block due to His-Purkinje disease. Phase 4 AV block is a mechanism of paroxysmal AV block (PAVB) in patients with diseased His-Purkinje system. Spontaneous depolarization occurs in diseased fibers during prolonged periods of ventricular pause, such as with slowing of the sinus rate. The sodium channels are blocked during phase 4 of the action potential and therefore the conduction system is incapable of depolarizing due to low resting membrane potentials. In this case, AV 1:1 conduction can only be restored with a premature ventricular contraction. This is an overall under-recognized entity and should be managed with pacemaker implantation.
Abstract 16252: A Survival Analysis in Patients With Tricuspid Regurgitation and Cardiac Resynchronization Therapy
Authors: Muuse Janelle , Bashir Hanad , Siddiqui Muhaimen , Menon Santosh
Published: December 2023

Introduction:
Cardiac resynchronization therapy (CRT) is a well established treatment in heart failure with reduced ejection fraction. It involves simultaneous pacing of the left and right ventricles to restore ventricular synchrony, leading to increased cardiac output and contractility. The impact of CRT on tricuspid regurgitation (TR) severity has not been evaluated. Studies have shown that up to 22% of CRT recipients have significant TR, and of these patients only 41% will improve to no or mild TR. For a majority of patients who have persistent significant TR despite CRT, long term outcomes are put into question.

Hypothesis:
Tricuspid regurgitation adversely affects the response and survival of CRT patients.

Goals:
To analyze the prevalence of TR in a cohort of patients admitted to The Christ Hospital who have undergone CRT. To assess the association between TR after CRT and long-term survivability.

Methods:
This is a retrospective cohort study conducted at The Christ Hospital in Cincinnati Ohio. 13292 patients diagnosed with tricuspid regurgitation (mild to severe) in total were included. 184 of these patients underwent CRT, and survival probability was measured against the no CRT group. Kaplan meier method was used for analysis.

Results:
Survival probabilities at 1 year, 2 years, and 3 years for patients with CRT = 0.769, 0.661, and 0.558 respectively. Patients without CRT = 0.911, 0.863, and 0.826 respectively. Hazard ratio = 2.84 (2.33, 3.47) compared to solely tricuspid regurgitation.

Conclusions:
Patients with TR without CRT had greater survival rates up to three years compared to TR with CRT. The risk of death in the TR with CRT was 2.84 times higher than the no CRT group. It can be further investigated why the no CRT group had a greater survival rate than CRT. Limitations include variable assessments of TR due to the subjective nature of grading TR. Future research could investigate the difference between primary (device-related) and secondary TR in this cohort.
Abstract 16255: Unraveling the Complex Interplay: Atrial Flutter in a Patient With Prior Double Outlet Right Ventricular Repair
Authors: Majmundar Vidit , mehra kriti , Mohamed Ahmed , Ramsaran Eddison , Hadley Michelle
Published: December 2023

Introduction:
Double Outlet Right Ventricle (DORV) is a rare complex congenital heart disease (CHD) in which both the great arteries arise predominantly or entirely from the right ventricle. It is one of the rare CHD lesions with a prevalence of about 0.9%. These patients have complex anatomy, which increases their risk of recurrent arrhythmias. We present a challenging case of Atrial Flutter (AFL) in a patient with DORV.

Case:
A 31-year-old male with a history of DORV repair presented with palpitations and chest pain for 2 days. His heart rate (HR) was 240 bpm. EKG showed AFL with variable block [Figure 1]. Labs were unremarkable. The patient remained in AFL with HR above 120 bpm despite receiving diltiazem and adenosine. Considering his underlying complex anatomy, ablation was deferred, and the patient was cardioverted to sinus rhythm [Figure 1]. A loop monitor was placed and was started on flecainide with outpatient follow-up at a higher centre.

Discussion:
Infundibulotomy, removal of obstructive muscle bundles, and a patch to widen the passageway from the right ventricle to the pulmonary arteries are all steps in DORV repair. These surgeries result in scar tissue, an akinetic right ventricular outflow tract, and pulmonary valve insufficiency. Reentrant tachycardias may form due to surgical scars. In DORV patients, Atrial tachyarrhythmias have undesirable outcomes resulting in congestive heart failure, stroke, and mortality. Antiarrhythmics and cardioversion are the cornerstones of managing AFL in patients with DORV due to increased failure rates of catheter ablation.

Conclusion:
This case illustrates persistent atrial arrhythmias more likely due to DORV repair, resulting in cardiac remodeling. The abnormal anatomy makes localization of irritated ectopic foci and ablations ineffective and difficult.
Abstract 16304: Contemporary Practice Patterns and Opportunities to Improve Type 2 Diabetes (T2D) Therapy in Patients at Elevated Cardiovascular and/or Kidney Risk
Authors: Blood Alexander J , Chang Lee-Shing , Colling Caitlin , Stern Gretchen , Gabovitch Dan , Zelle David , Zacherle Emily , Noone Josh , Robar Carey , Matta Lina , Aronson Samuel , Gaziano Thomas , Plutzky Jorge , Cannon Christopher P , Wexler Deborah , Scirica Benjamin
Published: December 2023

Background:
Evidence-based SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP-1 RA) reduce cardiovascular (CV) events and improve kidney outcomes in patients with type 2 diabetes (T2D) who are at elevated cardiac or renal risk; however, prescription rates are low despite guidelines recommending their use. We aimed to evaluate the eligibility for, and utilization of, SGLT2i and GLP-1 RA in real-world practice in a large, integrated, multicenter health system.
Aim:
To determine the prevalence of CV and kidney comorbidities in patients with T2D and current medication use patterns within a large, urban healthcare system.

Methods:
In this cross-sectional analysis of the Mass General Brigham healthcare system from 2020-2023, we identified all patients with T2D meeting current guideline eligibility criteria for SGLT2i and/or GLP-1 RA. Indications for therapy included ASCVD, heart failure, kidney disease, or high risk for developing ASCVD - determined by EHR data. High risk for developing ASCVD and ASCVD were mutually exclusive, however other indications were reported as identified comorbidities by patient. Demographics, medications, laboratory values, and comorbidities were assessed.

Results:
There were 148,046 people with T2D and an HbA1c within 3 years: mean age 68 years, HbA1c 7.3%, 53% male, 28% non-white, 12% non-English language preferred. 122,202 (83%) patients had
>
1 CV or kidney comorbidity: 60,168 (41%) high risk for developing ASCVD, 51,014 (34%) ASCVD, 17,875 (12%) HF, 63,996 (43%) kidney disease, and 60,947 (41%) with ≥ 2 comorbidities. Of the 122,202 patients with an indication, 20,475 (17%) were prescribed an SGLT2i, 27,188 (22%) a GLP-1 RA, and 7,255 (6%) both (
Figure 1
.)

Conclusion:
Ongoing limited use of agents with proven CV and kidney benefit exists among commonly encountered patients with T2D despite guideline recommendations; novel strategies are needed to overcome the barriers that keep patients from improved outcomes.
Abstract 16305: Closing the Disparities Gap for Heart Transplant Patients Bridged to Transplant With Temporary Mechanical Circulatory Support
Authors: Galani Jemi , Steinberg Rebecca , Wang Jeffrey , Patel Krishan , Okoh Alexis
Published: December 2023

Background:
There are known disparities in waitlist outcomes by race and sex among patients bridged to heart transplant (BTT) with durable mechanical circulatory support (MCS). With the increasing use of temporary MCS devices (tMCS), we examined waitlist and post-transplant outcomes of patients who had BTT with tMCS.

Methods:
Data from the United Network for Organ Sharing (UNOS) database was used to identify patients BTT with tMCS between 2008 and 2018. Patients were stratified by race and sex. Primary outcomes were waitlist mortality within 1 year of listing and 1 year post-transplant mortality among those who successfully reached transplant. Survival was examined with the Kaplan Meier method and Cox proportional hazard modeling.

Results:
A total of 997 patients received tMCS as BTT, including 606 white, 203 Black, 119 Hispanic, 56 Asian, 13 other race, and 302 (30%) female patients. Baseline hemodynamics were comparable among groups. Waitlist mortality within 1 year of listing was 35.8% overall and similar for all races (p=0.418) and both sexes (p=0.617). Among those who successfully reached transplant, there were no differences in 1 year post-transplant survival by race (p=0.722) or sex (p= 0.475). On multivariable Cox proportional hazard modeling, neither race nor sex was associated with waitlist or post-transplant mortality (p=NS). Level of education (<high school) was independently associated with 1 year waitlist mortality (HR 1.49, 95% CI 1.06 - 2.06). History of diabetes (HR 1.38, 95% CI 1.07-1.74) and post-transplant dialysis (HR 1.66, 95% CI 1.18-2.29) were associated with 1 year post transplant mortality.

Conclusions:
Unlike in BTT with durable MCS, we did not find differences in outcomes associated with race and sex among patients BTT with tMCS. Given the sharp increase in tMCS use after the 2018 U.S. allocation change, it will be important to closely monitor that access to transplantation and outcomes of BTT with tMCS patients continue to be equitable.
Abstract 16309: Impact of the Pandemic on AMI Hospitalizations and Outcomes: A Comprehensive Medicare Fee-for-Service Analysis
Authors: Sawano Mitsuaki , Xin Xin , Lu Yuan , Caraballo Cesar , Khera Rohan , Murugiah Karthik , Lin Zhenqiu , Krumholz Harlan M
Published: December 2023

Introduction:
Studies suggest hospitalizations for acute myocardial infarction (AMI) declined early in the COVID-19 pandemic, but national patterns during the entire pandemic are not well characterized. This study aims to characterize the changes in AMI hospitalizations and 30-day mortality rates among Medicare Fee-For-Service (FFS) beneficiaries during the pandemic.

Methods:
We used Medicare FFS Part A data from March 2014 to November 2021 consisting of people aged ≥65 years. The dataset was divided by quarters each representing the four seasons, March 2014 to February 2020 defined as the prepandemic phase, March 2020 to May 2020 defined as the early pandemic phase, and June 2020 to August 2021 as the late pandemic phase. Patients with a principal discharge diagnosis of AMI were identified using ICD-9 and 10 codes. The number of AMI hospitalizations and crude 30-day mortality was calculated for each quarter.

Results:
Before the pandemic, number of AMI hospitalizations in the US were gradually declining from 48,258 per quarter in Q2 2017 to 42,639 in Q2 2019 (12 % decrease compared with 2017) with regular seasonal increases during the winter months (Q1). Thereafter, a sharp decline to 29,446 in Q2 2020 (31% decrease compared with 2019) was observed followed by a return to 34,105 in Q2 2021 (20% decrease compared with 2019). The crude 30-day mortality rate was 12.3% in the 12 months before the pandemic but increased to 13.3% in Q2 2020 during the early pandemic and remained the same at 13.3% after Q3 2020.

Conclusions:
In the US Medicare fee-for-service population, the number of AMI hospitalizations was in a steady decline before the pandemic, but dramatically declined during the first 3 months of the pandemic. In contrast, the crude 30-day mortality increased during the pandemic. Why these changes occurred remains a source of continuing investigation.
Abstract 16312: Sex-Based Differences in Response to Interleukin-1 Blockade With Anakinra in Patients With ST-Segment Elevation Myocardial Infarction
Authors: Corna Giuliana , Golino Michele , Talasaz Azita , Moroni Francesco , Del Buono Marco , Damonte Juan Ignacio , chiabrando juan guido , TRANKLE Cory R , Thomas Georgia , MARKLEY ROSHANAK , Canada Justin M , Turlington Jeremy , Van Tassell Benjamin W , Abbate Antonio
Published: December 2023

Introduction:
Interleukin-1 blockade with anakinra reduces C-reactive protein (CRP) levels and prevents heart failure (HF) events after ST-segment myocardial infarction (STEMI). Sex-based differences in STEMI patients have been reported, but no data are available regarding response to anakinra in this setting.

Methods:
We analyzed sex-based differences in the systemic inflammation (CRP levels) and composite end-point of new-onset HF or death in patients with STEMI from three different Virginia Commonwealth University Anakinra Response Trial (VCU-ART) randomized clinical trials. Data are reported as median and interquartile range [IQR] or number and percentage (%). Kaplan-Meier curves for event-free survival were constructed for the time-dependent composite endpoint and compared using the log-rank analysis.

Results:
We analyzed 139 patients from three VCU-ART trials, 29 (21%) were women while 110 (79%) were men. Baseline CRP was higher in women compared to men (8.9 [5.2-13.5] vs 4.2 [2.1-7.7] mg/L, P<0.001). Twenty-two (75%) women and 62 (56%) men were treated with anakinra. Area under the curve (AUC)-CRP at 14 days was numerically lower in patients receiving anakinra versus placebo both in men (86 [37-130] vs 223 [119-374] mg day/L) and in women (73 [46-313] vs 242 [102-988] mg day/L) (P<0.001 at ANOVA for multiple groups, P for interaction 0.22)
Figure A
. The incidence of the composite endpoint was also numerically lower in the anakinra group compared to placebo, both in men (4 [6.4%] vs 14 [29.1%]) and in women (3 [13.6%] vs 2 [28.5%]) (P=0.019 at ANOVA, P for interaction 0.44)
Figure B
. There were no statistically significant differences between women and men in AUC-CRP and HF events when comparing separately the anakinra and placebo groups (all P>0.05).

Conclusions:
Women were underrepresented in the VCU-ART trials, they appeared to have higher CRP levels at time of presentation, yet to benefit similar to men by treatment with anakinra in STEMI.
Abstract 16329: Statin Prescription and ASCVD Outcomes in a Secondary Prevention Cohort Stratified by Race
Authors: Hay Eli , Mumtaz Maha , Zhu Jianhui , Thoma Floyd W , Johnson Amber E , Countouris Malamo , Al Rifai Mahmoud A , Saeed Anum , Mulukutla Suresh R
Published: December 2023

Introduction:
Racial disparities in ASCVD outcomes and statin prescription have been previously described. However, disparities in utilization of statin therapy in real-world practice persist. We evaluated the association of statin prescription and incident ASCVD outcomes stratified by race in a large healthcare system.

Methods:
Statin prescription in Black and White patients with ASCVD was evaluated (2013-2022). Guideline Directed Statin Intensity (GDSI) was defined as high intensity and “<GDSI” as low or moderate intensity. Statin prescription (at index and follow-up) and ASCVD outcomes (CAD, stroke, mortality) were assessed via electronic health care records using ICD-9 and 10 codes. Cox regression models, adjusted for CVD risk factors, were used to calculate HRs for the association between statin prescription and incident ASCVD events, stratified by race.

Results:
Of a total 44,632 patients, 5.8% identified as Black and 94.2% as White with a similar proportion of statin therapy prescribed at baseline (47% vs. 48%, p > 0.05). Black patients without statin were initiated on <GDSI [2.3 vs. 1.5mo] and GDSI [3.8 vs. 2.3mo] later than White patients (all p<0.05) in a 5-year time frame. When comparing no statin use to <GDSI, there was a ~two-fold increase in IR of stroke (51.2 vs. 25.4 per 1000-person yrs) in Black patients versus White (23.4 vs. 16.9). GDSI was associated with lower risk of all ASCVD outcomes in patients of both races. Black patients had a greater relative benefit from GDSI for stroke than White patients. (HR
stroke
0.38[0.27-0.53] vs 0.55[0.49-0.63]; p-interaction <0.01) (Table).

Conclusions:
In a large healthcare system, only ~half of Black and White patients with history of ASCVD received GDSI. Although it took longer to start Black patients on GDSI, GDSI was associated with less recurrent ASCVD outcomes in both races more than <GDSI or no statin use. The relative benefit of stroke prevention from GDSI was higher among Black patients.
Abstract 16336: Efficacy and Safety of Saroglitazar in the Management of Atherogenic Dyslipidemia: An Updated Meta-Analysis of Randomized Clinical Trials
Authors: Oliveira Vinicius M , Oliveira Izadora C , da Silva Menezes Junior Antonio
Published: December 2023

Background:
Saroglitazar is a novel drug used in the treatment of atherogenic dyslipidemia. However, its effect on this condition remains uncertain. Herein, we performed a systematic review and meta-analysis to assess the efficacy and safety of saroglitazar in the management of atherogenic dyslipidemia.

Methods:
PubMed, Scopus and Embase were systematically searched for randomized controlled trials (RCTs) comparing saroglitazar 4 mg, saroglitazar 2 mg, and placebo in the treatment of atherogenic dyslipidemia. A random-effects model was used to compute the pooled mean difference (MD) for continuous outcomes, with 95% confidence interval (CI). Heterogeneity was assessed with I
2
statistics.

Results:
We included 7 RCTs with 1,095 patients, of whom 340 (31.0%) were randomized to saroglitazar 2 mg; 513 (46.8%) to the 4 mg dose; and 242 (22.11%) to placebo. Mean age ranged from 40.2 to 62.6 years, and 436 (39.8%) were women. Saroglitazar 4 mg significantly lowered triglycerides (MD -51.18 mg/dL; 95% CI -66.80 to -35.55 mg/dL; p<0.001; figure 1A) and LDL-cholesterol levels (MD -9.15 mg/dL; 95% CI -10.52 to -7.77 mg/dL; p<0.001; figure 1B) when compared with placebo. Moreover, saroglitazar 4 mg minimally increased HDL-cholesterol (MD 2.73 mg/dL; 95% CI 0.49 to 4.97 mg/dL; p=0.02) in comparison with placebo. There were no significant differences between groups in the alanine aminotransferase levels (MD -26.40 U/L; 95% CI -72.15 to 19.36 U/L; p=0.26). There was a slight increase in body weight in the saroglitazar 4 mg group when compared with placebo (MD 0.90 Kg; 95% CI 0.31 to 1.48 Kg; p=0.003). In the comparison of saroglitazar 4 mg vs. 2 mg, the higher dose significantly outperformed the lower dose with regards to reduction in triglycerides (MD -32.38 mg/dL; 95% CI -53.62 to -11.14 mg/dL; p=0.003).

Conclusion:
Our findings suggest that saroglitazar 4 mg is effective for the reduction of triglycerides and LDL-C, with a small increase in body weight relative to placebo.