bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 231: Under Utilization of Aspirin for Primary Prevention
Authors: Gopalakrishnan Mukesh , Silva-Palacios Federico , Villines Dana , Klein Lloyd
Published: July 2021

Background:
Aspirin is beneficial for reducing the incidence of myocardial infarctions and ischemic strokes and has been recommended by United States Preventive Services Task Force (USPSTF) as a primary prevention strategy for men above the age of 45 years and women above the age of 55 years until the age of 80. This study was intended to evaluate the use of aspirin as a discharge medication for primary prevention in patients who have been assessed for cardiovascular risk in hospital.

Methods:
Data was collected prospectively over a period of six successive months from 250 consecutive patients who were admitted with chest pain without a history of coronary artery disease and had their cardiovascular risk assessed in hospital by means of patient history, physical exam, laboratory work and a stress test. Inclusion criteria included age within the USPSTF recommendations, not taking aspirin at the time of admission, a 10 year coronary heart disease risk and 10 year stroke risk greater than the risk of bleeding from the use of aspirin. Exclusion criteria included existing indication for aspirin use, contraindication to its use including documented allergy and already on other antiplatelet agents or anticoagulants. Predictors of discharge on aspirin where assessed with Logistic Regression. Statistical significance was determined at p ≤ 0.05. Data analysis was performed using SPSS 18.0
®
(SPSS, Inc., Chicago, IL).

Results:
Of the 250 patients, 120 patients fulfilled the existing recommendations for the use of aspirin for primary prevention as per USPSTF guidelines. Amongst the study population, 57.9% (33 of 57) men and only 42.9% (27 of 63) of the women were discharged home on aspirin. Having diabetes (OR 3.87; CI 1.39 - 10.77; p=0.01) and being older (OR 0.93; CI 0.87 - 0.89; p=0.003) played a significant role in being discharged on aspirin when using multivariate analysis. However a specific cut off age was not discernible. Amongst women, apart from diabetes (OR 7.85; CI 1.26 - 49.1; p=0.028) and age (OR 0.83; CI 0.74 - 0.93; p=0.002) with elderly patients more likely to be discharged on aspirin, hypertension (OR 4.16; CI 1.04 - 16.7; p=0.044) also played a significant role under multivariate analysis. Other factors including dyslipidemia, family history of cardiovascular disease, tobacco use and racial differences did not play a significant role.There were no such clinical predictors for men that was statistically significant.

Conclusion:
Aspirin is being under-utilized as part of primary prevention strategy. The presence of diabetes and an elderly patient often prompts a recommendation for aspirin use. A conscious effort should be made by hospital based care providers to ensure that the appropriate preventive strategies are part of their discharge medication list.
Abstract 236: Poor Recurrent Stroke Prevention Knowledge in High Risk Stroke Survivors
Authors: Scobie Janice V , Fei Kezhen , Negron Rennie , Turhim Stanley , Boden-Albala Bernadette , Horowitz Carol R
Published: July 2021

Stroke is highly prevalent. Control of hypertension, hyperlipidemia and appropriate antithrombotic use are important in preventing recurrent stroke. Inadequate control of cardiovascular (CV) risk factors and poor stroke knowledge among transient ischemic attack (TIA) and stroke survivors impact stroke recurrence.

We used a community-based participatory approach to recruit TIA/stroke survivors from community and clinical sites into a randomized controlled stroke prevention educational intervention trial. We conducted a cross-sectional analysis of baseline survey responses describing demographics, clinical characteristics, and stroke knowledge.

The sample (n=600) had a mean age of 63 and was mostly female (60%), Black or Hispanic (81%), and insured (98%). 72% had 2 or more CV risk factors: hypertension (33%), high low-density lipoprotein levels (43%), obesity (41%), and tobacco use (17%). 47% had 2 or more poorly controlled risk factors, and 65% did not have controlled blood pressure and cholesterol levels and antithrombotic use. Stroke knowledge of effective stroke prevention measures was poor. Most believed that diet (60%), exercise (36%), and stress reduction (36%) were most important for stroke prevention. Despite poor risk factor control and stroke prevention knowledge, 82% had a doctor and 2 or more visits in the past 6 months.

Inadequate control of CV risk factors and poor stroke knowledge is widely prevalent among TIA/stroke survivors. A silent high risk for progression of recurrent strokes and CV comorbidities persists despite regular medical care. Interventions that improve knowledge, support behavioral change, and improve patient self-management skills are critical for effective secondary stroke prevention.
Abstract 260: Risk Factors for Readmission from Medical Cardiology Services. A Medication Reconciliation Perspective.
Authors: Disdier Moulder Magali , LaRock Jenna , Garofoli Adrian C , Foley David
Published: July 2021

BACKGROUND:
Hospital readmissions for cardiac diseases have a strong socio-economic impact. Medication reconciliation is one of the current interventions intended to improve quality of care, in which pharmacists play an important role. We aimed to determine risk factors and identify patients who are at risk of re-hospitalization by gathering data from the medication reconciliation process.

METHODS:
We included adults from our local community admitted to a medical cardiology service from September 2011 to August 2012. Two pharmacists led interviews within 48 hours of presentation. In addition to a rigorous medication reconciliation evaluation at admission and discharge, we assessed medication handling habits, adherence, familiarity with prescriptions, health literacy and reading impairment. We determined Potential Adverse Drug Events (PADE) by assessing discrepancies within medication records. Multivariate analyses were performed to look for association among factors and outcomes.

RESULTS:
We included 258 patients, mean age 70.5, 52 % male, 19% received help with medications, 83 % were adherent, 14% reported reading impairment, 40% heart failure (HF). The mean number of prescriptions was 7.5 and the mean Charlson comorbidity index 3.5. Medication errors reached 39% of patients on admission and 20% at discharge; no clinical complications were detected. The number of prescriptions was associated with PADEs at admission (p=0.0001) and discharge (p=0.03). Presence of PADE on admission or discharge did not affect the readmission rate.

At 30 days 18% of 258 patients were readmitted, 9% visited the Emergency Department (ED) and 2.3% died; meanwhile at 6 months 38% were hospitalized, 46% went to the ED and 5.8% died. We identified a diagnosis of HF and the need for help handling medications at home as the strongest predictors of readmission at both 1 and 6 months. Other factors associated with higher readmissions rates and ED visits were the number of prescriptions, number of hospitalizations within the prior year, lack of familiarity with medical regimen and reading impairment.

HF was associated with lower adherence (p=0.025); more admissions in the previous year (p=0.002), higher number of medications (p=0.001), reading impairment (p=0.02), higher readmissions at 1 and 6 months (p=0.003 and 0.0008 respectively) as well as ED visits (p=0.016) at 6 months compared with non-HF subjects.

CONCLUSION:
We found several characteristics, key examples being presence of HF and receipt of help with medications, that may warrant formal assessment during medication reconciliation as they seem associated with re-hospitalization. These patients may benefit from close follow-up during and post hospitalization.
Abstract 264: Pulse Pressure and Type A Acute Aortic Dissection Outcomes: Insights from the International Registry of Acute Aortic Dissection
Authors: Hoff Emily C , Eagle Taylor F , Pyeritz Reed E , Ehrlich Marek P , Voehringer Matthias , Bossone Eduardo , Hutchison Stuart , Peterson Mark D , Suzuki Toru , Greason Kevin , Forteza Alberto , Montgomery Daniel G , Isselbacher Eric M , Nienaber Christoph A , Eagle Kim A
Published: July 2021

Background:
Little is known about the relationship between Type A Acute Aortic Dissection (TAAAD) and pulse pressure (PP), defined as the difference between systolic and diastolic blood pressure. This study explores the association between PP and presentation, complications and outcomes of TAAAD patients.

Methods:
PP at hospital presentation was used to divide 1,960 non-iatrogenic TAAAD patients into quartiles: narrowed (≤39 mmHg; n=430), normal (40-56 mmHg; n=554), mildly elevated (57-75 mmHg; n=490) and markedly elevated (≥76 mmHg; n=486). Variables relating to index presentation and in-hospital outcomes were analyzed.

Results:
TAAAD patients (patients) in the narrowed PP quartiles were more frequently older and Caucasian while patients with markedly elevated PPs tended to be male and have a history of hypertension. Patients who demonstrated abdominal vessel involvement more commonly demonstrated elevated PPs whereas patients with narrowed PPs were more likely to have periaortic hematoma and/or pericardial effusion. Narrowed PPs were also correlated with higher incidences of hypotension, cardiac tamponade and mortality. TAAAD patients who were managed with endovascular and hybrid procedures and those with renal failure tended to have elevated PPs. No difference in aortic regurgitation at presentation was noted between groups.

Conclusions:
TAAAD patients in the middle two PP quartiles had better in-hospital outcomes than patients in the outer quartiles. Patients with narrowed PPs experienced more cardiac complications, particularly cardiac tamponade, while those with elevated PPs were more likely to have abdominal aortic involvement. Presenting PP offers a clue to different manifestations of AAD that may facilitate initial triage and care.
Abstract 286: Inverse Relationship Between Body Mass Index And Glomerular Filtration Rate Following Contrast Media Administration In Patients With Primary Percutaneous Coronary Intervention
Authors: Valadri Ravinder R , Thondapi Chandra , Veledar Emir , Gadesam Radhika , Singh Jagdeep , Gooray David
Published: July 2021

Background:
Renal dysfunction following contrast (CM) media administration carries poor prognosis and less predictable in patients undergoing Primary percutaneous Coronary Intervention (PPCI). Although obesity is a known risk factor for renal failure, its prognostic significance in renal dysfunction following CM administration in the setting of PPCI is less explored. Therefore we sought to investigate the relationship between obesity as measured by body mass index (BMI) and renal function after CM administration during PPCI.

Methods:
Cohort consisted 113 patients at our institution who underwent PPCI from 01/2009 to 11/2012 as per evidence based guidelines. Obesity was defined as BMI ≥30 kg/m2. Patients with hemodynamic instability (intra aortic balloon pump use) and end stage renal failure (GFR<15 mL/min/m2 or on chronic dialysis) were excluded. Glomerular filtration rates (GFR) at baseline, at 24 hours post PPCI and before hospital discharge were calculated with modified diet in renal disease (MDRD) equation. The relationship between BMI and GFR was assessed in stepwise multiple linear regression analysis (MLRA)

Results:
Cohort dominated by PPCI performed for ST segment elevation myocardial infarction (STEMI) (104; 92%), African American race (70; 61%) and male gender (77; 68%). When compared to non obese [median BMI (IQR) = 25 (23.2-28.1) kg/m2], obese [median BMI (IQR) = 33.5 (31.9-35.7) kg/m2] had greater proportion of patients with dyslipidemia [30% (16) vs. 51% (25); P=0.026]. Other covariates were similarly distributed between both groups. BMI was negatively correlated with GFR 24 hours post PPCI (r= -0.206; P=0.043) and GFR prior to hospital discharge (r= -0.209; P=0.038) (Graph 1). MLRA adjusted for factors known to influence renal function showed that BMI was negatively associated with GFR prior to hospital discharge: r square =0.427;β=- 2.98; t= - 2.98 P=0.005. (Table 1)

Conclusions:
BMI increase is independently associated with GFR decline following CM administration in patients with PPCI. Clinical guidelines at present do not account for BMI during CM administration. These data suggest the need for CM dose adjustment according to individual’s BMI. Further studies are needed.
Abstract 308: iHeart Failure: Using Innovative Methodologies From Technology And Manufacturing Companies To Reduce Readmissions
Authors: Johnson Amber , Eid Shaker M , Winner Laura , Hody Robert , Simmons Tanya , Sampedro Angel , Sylvester Carol , Parakh Kapil
Published: July 2021

Background:
Heart failure patients have high 30-day readmission rates with high cost and poor quality of life. To address this issue, we created a framework using Lean Sigma (developed by Toyota and Motorola to improve efficiency and reduce defects), design thinking (championed by Apple and IDEO to improve user experience), and Lean Startup (pioneered in Silicon Valley to create technology companies). We assessed the impact of this approach on all-cause 30-day readmissions in heart failure.

Methods:
We used Lean Sigma’s Define Measure Analyze Improve Control or DMAIC framework to define the scope of the problem, measure key determinants and analyze root causes. A design thinking workshop held with support from IDEO augmented the improve phase to brainstorm possible interventions. A Lean Startup approach was also leveraged to create minimal viable products to test the promising interventions. The most viable interventions were piloted and scaled up including improvements in access to care, patient self-management, treatment algorithms, and patient education and provider training.

Results:
At baseline (fiscal year [FY] 2011), the readmission rate was 24.9% among 631 HF discharges (average age 70 (± 15) years, 53% women, length of stay 5.3 days (± 5) and 50% diabetes). Interventions were implemented in the second quarter of 2012, and the 30-day readmission rate declined to 19.3% in the subsequent three quarters (p<0.01). As a result, an estimated 35 readmissions prevented annually, saving payers about $419,000, much lower than the annual cost of implementation ($200,000, p<0.01). Further reductions in readmissions are expected in the coming quarters as more interventions move beyond the pilot phase.

Conclusion:
Methodologies from technology and manufacturing companies cost-effectively reduced 30-day readmissions in heart failure demonstrating their potential to improve chronic disease care.
Abstract 31: Patterns Of Healthcare Resource Utilization Among Adults With Type 2 Diabetes Mellitus At Risk Of Cardiovascular Events In The Large Population-based Study To Help Improve Early Evaluation And Management Of Risk Factors Leading To Diabetes (SHIELD)
Authors: Fox Kathleen M , Wu Ying , Kim Jennifer , Grandy Susan
Published: July 2021

Objectives:
Patterns of healthcare resource utilization (HRU) among patients with type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) are not well studied in large epidemiological studies. Using a large US population-based study, SHIELD, this study quantified the HRU over 3 and 5 years among adults with T2DM at high risk for CVD.

Methods:
SHIELD is a 5-year (2004-2009) prospective survey-based study of adults with and without T2DM. Respondents with T2DM were stratified into 2 cohorts: (1) established CVD with age ≥40 years, prior MI, prior stroke, atherosclerosis, or peripheral vascular disease, and (2) multiple risk factors (men ≥55 years and women ≥60 years and ≥1 risk factors of hyperlipidemia, hypertension, currently smoking, without prior history of CVD). Number of hospitalizations, emergency room (ER) visits, and physician office visits were tabulated for respondents who did and did not report a new CVD event (MI, stroke, angioplasty, or heart bypass surgery) in each cohort for up to 3 and 5 years of follow-up.

Results:
Frequencies of hospitalization, ER visit, and physician visit within 3 and 5 years of follow-up were significantly higher among those who reported a new CVD event over 3 and 5 years for both cohorts compared with respondents without a new CVD event, p <0.05 (Table). Median number of hospitalizations, ER visits, and physician visits were significantly higher for respondents reporting a new CVD event compared with respondents with no new CVD events for both cohorts, p <0.01 (Table).

Conclusions:
CVD events among T2DM patients continue to represent a very high economic burden on the healthcare system. HRU is very high among adults with T2DM at-risk of CVD events and significantly higher among those who had a new CVD event within 3 and 5 years compared with those who did not have a new CVD event.
Abstract 319: Hospital Variation in Carotid Artery Stenting Outcomes: An NCDR® Analysis
Authors: Hawkins Beau M , Kennedy Kevin , Aronow Herbert D , Nguyen Louis , White Christopher J , Rosenfield Kenneth , Normand Sharon-Lise T , Spertus John A , Yeh Robert W
Published: July 2021

Introduction:
Given the increased use and dissemination of carotid artery stenting (CAS) throughout the United States, examining hospital-level variation in patient outcomes can form the foundation of quality improvement efforts. We examined hospital variation for in-hospital stroke and death (S/D) rates to examine the potential of such an outcome to serve as a performance measure of hospital quality.

Methods:
Hospitals participating in the CARE Registry
®
contributing >5 CAS procedures from 2005-2012 were eligible for inclusion. We estimated risk-standardized rates of in-hospital S/D for each participating hospital using a previously validated prediction model and applying hospital-level random effects. Observed-expected (O/E) ratios were generated for each hospital by comparing rates of observed and expected S/D. Outliers were identified as facilities with O/E ratios whose confidence intervals excluded 1.0.

Results:
There were 173 hospitals contributing 15,683 CAS procedures during the period of interest. Risk-standardized rates of S/D ranged from 1.2% to 5.3%. Mean procedural volumes were low irrespective of hospital performance (procedures per quarter: 6.1 +/- 5.7 for hospitals with O/E >1.2, 9.4 +/- 9.1 for hospitals with O/E <0.8). Only 2 hospitals had risk-adjusted outcomes worse than expected, while 3 hospitals performed better than expected (Figure 1).

Conclusions:
Though substantial variation in CAS outcomes exists, wide confidence intervals resulting from low event rates and low hospital volumes prevent risk-adjusted outcomes from being a sensitive discriminator of performance for most hospitals. The development of additional performance measures may be needed to gauge CAS quality.
Abstract 32: Is the Seattle Angina Questionnaire suitable for Chinese patients?
Authors: Zhang Hui Y , Yu Li , Lju Mei J , Yu Chang H , Chen Zhi H , Ma Yuan , Yang Guan L
Published: July 2021

Background:
The Seattle Angina Questionnaire (SAQ) has been widely used in China since it was introduced in 1996. However, the validity and reliability of the translated SAQ has never been assessed in published papers. Even worse, when we use the translated SAQ in clinical studies, we found some patients have difficulty upon understanding some items due to the translation and cultural inadaptation. In this study, we are going to find out if the SAQ is suitable for Chinese patients.

Methods:
Step one: to assess the psychometric properties of SAQ, 1787 angina patients’ data of our previous cross-section study was used. Exploratory Factor Analysis (EFA) was used to evaluate the construct validity, and internal consistency (Cronbach’s alpha coefficient) was used to evaluate the reliability, and t-test was used to discriminate patients with different Canadian Cardiovascular Society Classification (CCSC) levels. Step two: to find out which item is unsuitable, semi-structured individual patient interview was used. Patients were asked to complete a copy of SAQ first, and then were asked did they encounter difficulties on understanding the items and why.

Results:
Step one: Cronbach’s alpha coefficient was 0.885, but 0.605 for the quality of life domain. EFA showed 4 factors and couldn’t match the original five domains. More than 50% of patients give the same answer “mostly satisfied” to item 6-8 about treatment satisfaction, and these items can’t detect the differences among patients with different CCSC levels. Item 5 “bothersome of taking pills” is highly correlated with Quality of life domain other than the treatment satisfaction domain it is intended to measure. The correlation between item 6 and 8 is 0.816, which shows a redundancy. The reliability and validity of the translated SAQ is not satisfied. Step two: 92 out of 112 invited patients participated in the interview, 39 (42.39%) couldn’t understand item 10, and 7 (7.61%) of item 6. As to item 10, “feeling of the current angina if long-lasting”, patients were confused of the answer “level of satisfaction”, which result a low internal consistency of Qol. As to item 6, “everything is done for treatment”, 75 (81.52%) patients thought it’s the same meaning with item 8 “satisfaction with current treatment.” Maybe influenced by Confucian, patients chose “satisfaction” even their angina getting worse. Among the 1787 patients, 131 (7.33%) patients took nitros when angina attacked; however, 234(13.09%) patients took Chinese herbal medicine. So they couldn’t answer item 4 “frequency of nitros taken for angina” correctly.

Conclusions:
The currently used SAQ is unsuitable for Chinese patients. It doesn’t completely capture the characteristics and conditions of Chinese patients. Further study is needed to adapt both, the translation and culture of the SAQ.
Abstract 324: Medical Decision-Making: Preferences and Practices in the Year following Acute Myocardial Infarction
Authors: Spatz Erica S , Matlock Daniel D , Li Yan , Spertus John A , Krumholz Harlan M
Published: July 2021

Background:
Patients vary in their desire to participate in medical decision-making (MDM), with some preferring passive roles and others preferring shared or autonomous roles. Yet little is known about the stability of patient preferences over time and whether patient preferences are aligned with how they actually experience the MDM process. We sought to determine the stability of MDM preferences for patients hospitalized with an AMI and assess whether there is concordance between the patient’s preference and their experience with care.

Methods:
In TRIUMPH, a 24-center, prospective US study of AMI patients, MDM preferences were assessed both at the time of hospitalization and one year later (n=2071). MDM preferences were assessed by the question, “Given the information about the risks and benefits of the treatment options, who should decide which treatment option should be selected? We categorized responses from a 5-item Likert scale into: passive (“doctor alone/mostly the doctor”), or shared/active (“doctor and you equally/mostly you or you alone”) and compared responses between baseline and 12-months following AMI. We assessed concordance between baseline MDM preferences with the patients’ perceived level of participation in MDM at 1 month with the question, “Who was responsible for making health decisions regarding the current treatment of your heart condition?” using the same 5-item Likert scale and categorization.

Results:
Over 2/3 of patients preferred shared/active MDM both at the time of their AMI (1446, 69.8%) and 1 year later (1411, 68.1%). However, individual preferences varied over time. Among patients with a baseline preference for shared/active MDM, 374 (25.9%) preferred passive participation 1 year later. Among patients preferring passive participation at the time of their AMI, 339 (54.2%) preferred a shared/active participatory role 1 year later. Comparing desired and perceived roles in MDM, only 54.5% of patients reported, at 1 month, an MDM process that was concordant with their baseline preferences. Among patients with a baseline preference for shared/active MDM, 48.3% reported experiencing a passive role in MDM 1 month following AMI. Among patients preferring a passive role at baseline, 39.3% reported experiencing a shared/active MDM process.

Conclusion:
Individual preferences for participation in MDM during and after AMI vary, with the majority preferring a shared/active role. These preferences change over time, highlighting the need for continual assessment. In the month following an AMI, half of patients experienced an MDM process that was not consistent with their stated preferences.
Abstract 327: Gender Differences In The Association Between Hemoglobin Change After Acute Myocardial Infarction And Outcomes
Authors: Thompson Lauren E , Masoudi Frederick A , Gosch Kensey L , Peterson Pamela N , Salisbury Adam C , Kosiborod Mikhail , Daugherty Stacie L
Published: July 2021

Background:
Hemoglobin decline following acute myocardial infarction (AMI) is associated with long-term morbidity. Since women have lower baseline hemoglobin levels than men, whether the same absolute change in hemoglobin after AMI similarly affects outcomes in women and men is unknown.

Methods:
We examined patients discharged after AMI in the TRIUMPH registry between 2005 and 2008 who had admission and discharge hemoglobin levels. We compared the relationship between absolute change in hemoglobin during hospitalization with 6- and 12-month mortality and re-hospitalization by gender after adjusting for clinical variables including admission hemoglobin.

Results:
Of the 4,243 patients with AMI, 33% (1,400 of 4,243) were women. Women were older, had more co-morbidities, and were less likely to present with STEMI, or receive catheterization. Women had lower admission hemoglobin (12.9 g/dL ± 1.9 vs 14.5 ± 2.0, p= <0.01) and a smaller mean absolute change in hemoglobin during hospitalization (-1.5 g/dL ± 1.8 vs -1.6 ±1.8, p = 0.01) compared to men. The association between hemoglobin declines during hospitalization and mortality and re-hospitalization rates at 6 and 12-months were of a similar magnitude between men and women (all interaction p > 0.05). (Figure 1)

Conclusion:
Although women with AMI had lower admission hemoglobin values, similar declines in hemoglobin during hospitalization were associated with increases in mortality and re-hospitalization in women and men. These findings suggest that absolute change in hemoglobin is equally important at predicting outcomes in women and men, regardless of admission hemoglobin levels.
Abstract 342: Variation In Contrast Volumes For Percutaneous Interventions Across Hospitals In Northern New England: It Is Not Just Patient And Procedural Characteristics
Authors: Lee Regina C , Bohn Chad M , Malenka David J ,   Northern New England Cardiovascular Disease StudyGroup
Published: July 2021

Background:
Contrast volume (CV) is an important risk factor for acute kidney injury following PCI.

Hypothesis:
Hospitals participating in a regional PCI registry differ in their use of CV and this difference is a consequence not only of patient characteristics but of modifiable site-specific practices.

Methods:
Data from 4110 consecutive PCIs performed during 2011 at 7 member sites of the Northern New England Cardiovascular Disease Study Group PCI Registry. Contrast volume was categorized into 100ml increments. Ordered multivariate logistic regression identified patient characteristics associated with CV and compared site use of CV after controlling for them. Then, procedural characteristics significantly associated with CV were added to the model and the influence of site reassessed.

Results:
CV differed across sites (Figure 1). Patient characteristics significantly associated with CV included age, sex, body mass index, prior CABG or PCI, ejection fraction, and pre-procedure estimated GFR. After adjusting for patient characteristics there remained a significant difference in CV use with Site 7 (OR 0.45, p<0.01) and Site 3 (OR 0.25, p<0.01) using less contrast volume than referent Site 4. Available procedural characteristics significantly associated with CV included access site (OR 0.73), Ad Hoc PCI (OR 3.65), CTO PCI (OR 2.1), number of vessels intervened on (OR 0.67-0.99) and number of lesions attempted (OR 1.59-9.40). After controlling for patient and procedural characteristics, 4 of 7 sites (Sites 3, 5, 7, and 10) were found to use significantly less contrast volume than referent Site 4. A ’Chi-Pie’ model showed that 16% of the variation was explained by patient characteristics, 45% by procedure characteristics, and 39% by site-specific factors.

Conclusions:
Even after controlling for patient and procedural characteristics, there remains significant variation in CV across northern New England PCI sites. Some of the known procedural characteristics may be modifiable. In addition, as yet unmeasured site-specific characteristics (e.g., method of assessing EF, catheter size, automatic vs hand injections) contribute to 39% of the variation. A better understanding of what drives the use of CV represents an opportunity for some sites in northern New England to decrease CV and improve PCI outcomes.
Abstract 63: The Smoking Paradox in Patients Hospitalized with Coronary Artery Disease: Findings from Get With The Guidelines - CAD
Authors: Ali Syed F , Smith Eric E , Bhatt Deepak L , Pan Wenqin , Fonarow Gregg C , Schwamm Lee H
Published: July 2021

Introduction:
Despite evidence of smoking as a potent risk factor for coronary artery disease (CAD), there have been reports of lower in-hospital mortality among smokers hospitalized for CAD events.

Method:
We analyzed all consecutive CAD admissions (n=158,054) without a prior history of Stroke/TIA from 2002-2008 in Get With The Guidelines (GWTG)-CAD. Categorical data were analyzed by Pearson Chi-square and continuous data by Wilcoxon test. Multivariable models with generalized estimating equations for in-hospital clustering were used to estimate odds ratios of in-hospital mortality. All significant predictors on univariate analysis were included in the multivariable model.

Results:
Among all CAD patients, 30.4% were current smokers, defined as any cigarette use in the past year. Smokers were substantially younger (12 years), more often male and less often had pre-existing hypertension, dyslipidemia, heart failure, renal failure and atrial fibrillation, and more often had COPD/Asthma. Smokers were more likely to be admitted to large, academic hospitals, and more often in the South. Smokers had shorter length of stay in hospital and were more often discharged home. In-hospital mortality was lower in smokers as compared to non-smokers (Table 1). The significant univariate mortality difference attenuated dramatically after adjusting for age and other covariates in the multivariable model, OR increased from 0.57 (0.53, 0.61) on univariate analysis to 0.88 (0.81, 0.95) on multivariable model. Other independent predictors of mortality were increasing age [1.51 (1.46, 1.56)], history of diabetes mellitus [1.25 (1.18, 1.33)], Asthma/COPD [1.30 (1.23, 1.38)], peripheral vascular disease [1.34 (1.24, 1.44)], heart failure [1.48 (1.38, 1.58)] and renal insufficiency [1.61 (1.48, 1.74)].

Conclusion:
Smoking continues to be a major risk factor for presenting with CAD at a much younger age and with fewer risk factors. It is likely that the continued modest association with lower in-hospital mortality in smokers in this analysis after adjustment reflects residual or unmeasured confounding. This apparent smoker’s paradox in CAD should not be interpreted as a benefit of cigarette smoking.
Abstract 67: Level of Participation in Health Screenings as a Predictor of Behavioral Outcomes in Middle School Children: A Report from Project Healthy Schools
Authors: Sylvester Rachel , Corriveau Nicole , Gurm Roopa , Jones Anne , March Michelle , Stasiak Ashley , DuRussel-Weston Jean , Kline-Rogers Eva , Goldberg Caren , Eagle Kim A , Jackson Elizabeth A
Published: July 2021

Background:
Previous research has shown that parents influence their children’s eating behaviors. However, associations between the consent of both parent and child to health screenings and the child’s health behaviors have not yet been determined. This study aims to determine the effect of participation in a health screening and education program on the self-reported behaviors of middle-school students.

Methods:
Data were collected from 3049 middle-school students enrolled in Project Healthy Schools (PHS). Students were assigned a group based on their level of participation in a health screening. Group 1 (n=608) was defined as students and parents who consented to a finger stick to obtain a lipid profile, blood pressure, resting and recovery heart rate, and a behavioral survey. Group 2 (n=149) was defined as students and parents who agreed to all aspects of the screening except the lipid profile (finger stick). Group 3 (n=2292) was defined as students (+/- parents) who chose not to be screened but did complete the behavioral survey. The primary outcome examined was the change in health habits from baseline to post intervention.

Results:
At baseline Group 1 reported eating more vegetables (p=.044), drinking less high-sugar, non-soda beverages (p=.012), participating in more school-sponsored sports (p≤.001), and demonstrating less sedentary screen time (p≤.001) than students in Groups 2 and 3. Post PHS wellness intervention, Group 3 reported the largest decrease in soda consumption (p=.010) and sedentary behaviors (TV time (p=.001), video game time (p≤.001), and computer time (p=.003)).

Conclusion:
Parental consent was shown to be associated with higher levels of healthy behaviors at baseline. However, the group without parental consent demonstrated significant positive changes in health behaviors, suggesting a school-based intervention is particularly important amongst children with potentially less parental involvement. Further research is warranted to determine the extent to which parental participation, attitude and knowledge affects children’s health behaviors.
Abstract 79: Reasons for Warfarin Discontinuation in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF)
Authors: O’Brien Emily C , Holmes DaJuanicia , Allen Larry A , Singer Daniel E , Fonarow Gregg C , Kowey Peter , Thomas Laine , Ezekowitz Michael D , Mahaffey Kenneth W , Chang Paul , Piccini Jonathan P , Peterson Eric D
Published: July 2021

Background.
Warfarin reduces the risk of thromboembolic events associated with atrial fibrillation (AF), but therapeutic persistence is suboptimal. Few studies have investigated the reasons for warfarin discontinuation in community practice.

Methods.
We used data from ORBIT-AF, the nation’s largest AF database, to examine patterns of warfarin discontinuation over a one-year period. Patients transitioned to non-warfarin oral anticoagulation therapy were excluded. We compared patient and provider characteristics between individuals who discontinued warfarin and those who persisted.

Results.
From June 2010 to August 2011, 10,126 AF patients 18 years or older were enrolled at 176 ORBIT-AF practices. Of these, 6,559 (64.8%) were taking warfarin at baseline and have follow-up data; 514 (7.8%) of these switched to dabigatran and were excluded from the analysis. Additionally, two patients without follow-up warfarin data were excluded from the analysis. Over one year, 587 patients (9.7%) discontinued warfarin therapy. Compared to persistent users, patients who discontinued warfarin were younger, less likely to be white, had lower stroke risk (CHADS
2
<2), were more likely to follow a rhythm control strategy, and were less likely to be managed in an anticoagulation clinic (Table 1). The most commonly reported reasons for warfarin discontinuation were physician preference (31.0%), other (18.7%), patient refusal/preference (13.6%), bleeding event (13.3%), frequent falls/frailty (7.3%), high bleeding risk (6.6%), and patient inability to adhere to/monitor therapy (2.9%).

Conclusions.
Discontinuation of warfarin is common among patients with atrial fibrillation. Patient and physician preference are major contributors to persistence on warfarin therapy.
Abstract 8: Get With The Guidelines-Stroke Program Participation and Clinical Outcomes for Medicare Beneficiaries
Authors: Song Sarah , Fonarow Gregg , Pan Wenqin , Olson DaiWai , Hernandez Adrian F , Peterson Eric , Reeves Mathew , Smith Eric , Schwamm Lee , Saver Jeffrey
Published: July 2021

Background:
Get With The Guidelines (GWTG)-Stroke is a national, hospital-based quality improvement program developed by the American Heart Association. While studies have shown a beneficial effect of hospital participation in GWTG-Stroke upon processes of care, whether there are associated improvements in clinical outcomes has not been previously investigated.

Methods:
From among all acute care US hospitals, we matched 366 hospitals that joined the GWTG-Stroke program between April 2004 and December 2007, with 366 hospitals that did not. Matching was based on ischemic stroke case volume, calendar year, baseline hospital post-stroke 1-year all-cause mortality rates, teaching status, and geographic region. Outcomes of all acute ischemic stroke (AIS) patients admitted to the study hospitals were abstracted from the CMS administrative claims database (65 years and older). Outcomes at matched hospitals were compared in the PRE-GWTG-Stroke period (-540 to -181 days before program launch), RUN-UP period (-180- to -1 day), EARLY period (0 to 180 days) and SUSTAINED period (181 to 540 days). Additional analysis was performed of the entire BEFORE (-540 to -1 days) and AFTER periods (0 to 540 days). The main analytical approach was stratified Cox proportional hazard modeling, with matched site ID at stratum. We adjusted for patient characteristics (age, gender, race, medical history) and hospital characteristics (rural vs. urban, # beds, annual IS discharges.)

Results:
The study analyzed 88,584 AIS admissions at the 366 GWTG-Stroke hospitals and 85,401 admissions at the 366 matched non-GWTG-Stroke hospitals. In adjusted analysis comparing BEFORE and AFTER periods, GWTG-Stroke hospitals achieved reduced 30 day mortality (30M - HR 0.911, p<0.0001), reduced 1 year mortality (1YM - HR 0.902, p<0.0001), reduced 30 day all-cause rehospitalization (HR 0.956, p=0.013), reduced 30 day stroke rehospitalization (HR 0.927, p=0.038), and reduced 1 year all-cause rehospitalization (HR 0.972, p=0.007). Conversely, matched, non-GWTG-Stroke hospitals showed only reduced 30M (HR 0.954, p=0.010) between the BEFORE and AFTER periods. Comparing the degree of change at GWTG-Stroke with non-GWTG Stroke hospitals, there were greater improvements in discharge to home (DCH), 30M, and 1YM at GWTG-Stroke hospitals in each of the intervention periods: EARLY: DCH, HR 1.090, p<0.0001; 30M, HR 0.894, p=0.0006; 1YM, HR 0.889, p<0.0001; SUSTAINED: DCH, HR 1.097, p<0.0001; 30M, HR 0.934, p=0.004; 1YM, HR 0.918, p<0.0001.

Conclusions:
Hospitals joining the GWTG-Stroke quality improvement program between 2004-2008 achieved significantly greater improvement in stroke patient outcomes than matched hospitals not joining the program, with lower all-cause mortality at 30 days and 1 year and higher rates of discharge directly to home.
Abstract 1: The Value of Adding Laboratory Data to Coronary Artery Bypass Graft Surgery Registry Data to Improve Models for Risk-Adjusting Provider Mortality Rates
Authors: Qian Feng , Hannan Edward L , Pine Michael , Dennison Barbara A
Published: July 2021

Background:
Clinical registry data for coronary artery bypass graft (CABG) surgery are currently being used in a few states and by the Society for Thoracic Surgeons to calculate provider risk-adjusted mortality rates. However, very little laboratory data are contained in these databases for purposes of risk-adjustment. The objective of this study was to examine whether adding laboratory data to New York’s CABG registry data will identify laboratory variables that are significant independent predictors of in-hospital/30-day mortality, and if so, whether the risk adjustment model containing these laboratory variables will significantly alter the quality assessments of New York hospitals where CABG surgeries are performed.

Methods:
New York hospitals that performed CABG surgery in 2008-2010 were recruited into a study that required submitting data for 32 laboratory tests which were combined with CABG registry data. Statistical models were developed, with and without laboratory data, to compare risk-adjusted mortality rates. Discrimination, calibration, correlation in hospital risk-adjusted mortality rates, and differences in hospital quality outlier status were examined for both registry and registry/laboratory models.

Results:
There were 9,958 patients who underwent isolated CABG surgery at 15 participating hospitals during the study period. Discrimination of statistical models was very similar (C = 0.783 for the registry model and 0.812 for the registry/laboratory model, P = 0.26). Most of the non-laboratory variables in the two models were identical, except that the registry model contained diabetes requiring medication and the registry/laboratory model included recent congestive heart failure and renal dialysis. The registry/laboratory model also included two laboratory variables: Aspartate Aminotransferase (AST) > 50 U/L, and International Normalized Ratio (INR) >1.5. The addition of laboratory data did not affect the quality outlier status of hospitals, and had minimal effect on the tertile of risk-adjusted mortality of New York hospitals.

Conclusion:
Clinical models with and without laboratory data had similar discrimination, hospital risk-adjusted mortality rates were essentially unchanged, and hospital outlier status was identical. Two laboratory variables, AST and INR, were significant independent predictors of mortality and might be valuable additions to CABG clinical registry data. The benefits and practical challenges of adding key laboratory variables to CABG registry data should be carefully considered.
Abstract 137: Anticoagulation clinic provider’s perspective on management of patients on target specific oral anticoagulants: insights from the Veterans Affairs Health Care System
Authors: Shore Supriya , Ho P. Michael , Lambert-Kerzner Anne , Cunningham Fran , McCarren Madeline , Longo Lisa , Barón Anna , Plomondon Meg , Maddox Thomas M , Rose Adam J , Turakhia Mintu
Published: July 2021

Background:
Patients on target specific anticoagulants (TSOACs) such as dabigatran do not require routine laboratory testing and dose adjustment. In the Veterans Health Administration (VHA), anticoagulation clinics (ACCs) may elect to follow and manage patients on TSOACs, but whether it is needed or the optimal duration of follow-up is unknown. Our objective was to assess the perspective of anticoagulation clinic providers on follow-up care for dabigatran patients and to identify site-level practices associated with improved adherence to dabigatran.

Methods:
We ascertained ACC providers’ perspectives through semi-structured interviews by a single, trained internist. Purposive sampling was utilized to recruit senior ACC providers or supervisors at VHA sites with over 20 patients on dabigatran. We stratified sites into high and low performing sites based on whether sites had ≥ 75% of their patients adherent, based on a proportion-of-days-covered calculation. Data from the interviews was analyzed by 2 reviewers in an iterative process to identify recurrent and unifying themes. Constant comparative method of qualitative data analysis was used to identify best practices across various sites.

Results:
We interviewed ACC providers from 39 sites - including 18 providers at 16 high-performing sites and 25 providers at 23 low-performing sites. Follow-up practices for dabigatran varied across sites, with 6 sites not providing any follow-up, 14 sites following-up patients for less than 3 months, 9 sites following-up patients for 6 months, and 10 sites following-up patients indefinitely. During these follow-up visits, patients were contacted at regular intervals, mostly via telephone, by ACC providers to provide education, assess side-effects and adherence. Key strategies implemented at high-performing sites compared to low-performing sites included (1) examining adherence to other twice daily medications prior to approving dabigatran (2) education of patients by ACC providers prior to dabigatran initiation (3) continued telephone follow up by ACC staff despite no need for INR checks. Over a third of ACC providers expressed concerns regarding patient adherence to dabigatran. Most common reasons for this concern included its special storage requirements and high incidence of gastrointestinal side effects leading to high discontinuation rates.

Conclusion:
Dedicated follow-up of patients on dabigatran is associated with improved adherence. A multi-disciplinary approach involving anti-coagulation clinic providers to provide education and follow-up may be beneficial in management of TSOACs. Future work should compare the apparent benefit of this strategy with its non-trivial cost.
Abstract 161: Atrial Fibrillation in India: Insights from the PINNACLE India Outpatient Registry
Authors: Glusenkamp Nathan T , Risch Samantha A , Kerkar Prafulla , Kumar Ganesh , Oetgen William J
Published: July 2021

Background:
Atrial fibrillation (AF) is the most common arrhythmia worldwide. Most studies of AF focus on white populations in North America or Europe.
Less is known about prevalence, etiology and treatment patterns of AF in India. To better understand the disease burden, we examined data from the PINNACLE India registry.

Methods:
PINNACLE India is the first cardiovascular data collection and reporting program in India. Data are collected by transmission from paper scanners and an electronic data collection tool. Patients are followed longitudinally if they return to a data collecting site.

Results:
AF is recorded in 0.39% (246) unique patients and 0.59% (865) of all encounters. The gender breakdown among AF patients is consistent with literature, but prevalence is low compared to other countries. Although we suspect that the diagnosis or documentation of AF is low, it appears that those diagnosed get treatment, since 35.77% are on Warfarin, 4.07% are on Dabigatran, and a substantial proportion is on other antithrombotic therapies.

Conclusion:
AF is tough to diagnose since it is often asymptomatic and clinicians need many tests to confirm diagnosis. Lack of documentation or detection of AF and its associated conditions is a concern. AF can lead to life threatening problems such as stroke and heart failure.
The surveillance of AF in India is important in order to identify opportunities for intervention. Continued data collection through the use of a cardiovascular registry can improve the understanding of AF in India.