bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 225: A Novel SELF-Pathway for Management of Patients Presenting with Unexplained-Syncope Appropriately Identify High Risk Patients as Validated by the OESIL Score
Authors: Aziz Emad F , Pamidimukala Chaithanya K , Park Terrence , Bastawrose Joseph H , Pokal Mythri , Siripuram Chandu , Wei Helen , Reddy Rashmi C , Alwood Darcie , Rittenhouse Chelsea , Pratap Balai , Herzog Eyal
Published: March 2022

Background:
The OESIL risk score for the evaluation of syncope is widely used and is based on the presence of 4 risk factors: abnormal ECG, a previous history of cardiovascular diseases, absence of prodromal symptoms, and age greater than 65 years. We assessed the appropriateness of our novel SELF-SYNCOPE pathway in comparison to this score.

Methods:
According to the design of our syncope pathway, patients are risk stratified twice using the acronyms of SELF-A (Short period, Early-rapid onset, Loss of consciousness, Full recovery) and SELF-B (Structural heart disease, abnormal Ecg, and arrhythmia Fib/FL). 1462 patients were prospectively followed and were divided into four groups according to having SELF-A and SELF-B criteria. 762 patients met group I (SELF A+/B+) and group IV (SELF A-/B-) and were compared to the OESIL risk score.

Results:
Group I patients were older and more likely to have hypertension (74% vs. 45%), diabetes (25% vs. 16%), heart failure (9% vs. 3%), and coronary disease (21% vs. 4%); p<0.001. During hospital stay group I patients had 58 (11%) procedures vs. 7 (4%) in group IV patients; p<0.001. Patients in group I had the highest risk validation according to the OESIL risk score, accounting for 90% of OESIL score 4 or higher (Figure).

Conclusions:
Using a simple novel pathway for patients presenting with unexplained syncope effectively identifies high risk patients as validated by the OESIL risk score.
Abstract 229: Concern about Medication, Nuisance Bleeding and Adherence to Clopidogrel
Authors: Kimble Laura P , Momary Kathryn M , Grason Sharon A , Sponsel Kevin , Goux Stephen , Daehler Annette
Published: March 2022

Introduction and purpose:
Nuisance bleeding is a common side effect of antiplatet drug therapy with clopidogrel and has been implicated in the high rates of patients’ self- discontinuation of the drug. The purpose of this study was to characterize nuisance bleeding in patients taking clopidogrel and examine predictors of adherence.

Methods:
Cardiovascular patients residing in the community with a self-report of current prescription for clopidogrel were recruited via print advertising and subsequently completed a battery of mailed questionnaires. The presence and severity of different types of nuisance bleeding were assessed with a modified BleedScore and concerns about clopidogrel and beliefs about its necessity were measured with the Beliefs about Medications Questionnaire (BMQ). Adherence was measured with the Morisky Scale.

Results:
The sample (N=103) were primarily white (91.3%), males (58.3%) with a mean age of 72.3 (SD 10.1) years. Reported reasons for taking clopidogrel included following coronary stenting (51.5%) or other diagnosis of CAD (16.5%), following CVA or TIA (13.6%), and for peripheral arterial disease (4.9%). Nuisance bleeding was prevalent (88.3%), with the most commonly reported type of nuisance bleeding as easy bruising (72.8%) and bruising on hands and arms (64.1%). Low adherence (modified Morisky < 6) was reported by 55.3%. Multiple linear regression was used to assess predictors of adherence. The model accounted for 33.5% (p < .001) of the variance in adherence. Age, gender, depression (PHQ-9), and beliefs about medication necessity were not significant predictors of adherence. Lower concern about clopidogrel (p < .001) and greater severity of nuisance bleeding predicted better adherence (p < .05).

Conclusion:
The data from this cross-sectional study suggest that concerns about clopidgrel play an important role in clopidogrel adherence. Further research is warranted to elucidate the nature of patients’ concerns about clopidogrel so that effective patient-focused interventions to address concerns and support adherence can be developed. In addition, longitudinal studies are needed to examine if nuisance bleeding may lead to deterioration of adherence over time.
Abstract 230: Exploring the Prevalence and Factors that Affect Patients with Both Diabetic and Myocardial Infarction: Teaching Versus Non-Teaching Hospitals
Authors: Okunji Priscilla O , Daniel Jonnie , Wutoh Anthony K
Published: March 2022

Background:
There has been an increasing prevalence of myocardial infarction (MI) inpatients with type 2 diabetes (T2D). Relatively very little research has been reported on the health services outcomes differences between teaching and non teaching hospitals with regards to length of stay (LOS) of inpatients with both MI and T2D. This study examined factors that affect the LOS differences of inpatients with both MI and T2D in teaching and non teaching hospitals. These factors include patient characteristics (age, gender, ethnicity, education, income, insurance, cost, comorbidities, MI severity, treatment procedures) and hospital characteristics (bed size, location, ownership and region).

Method:
Data from 2008 National Inpatients Statistics (NIS) under the Agency for Healthcare Research and Quality (AHRQ) was retrospectively analyzed. We identified 4,444 patients with diabetic myocardial infarction and seven categories of length of stay in days (1 day or less than one day; 2 days; 3 days; 4 days; 5 to 6 days; 7 to 13 days; 14 days or longer) were used for the analyses.

Result:
Overall, patients stayed shorter in non teaching hospitals than in teaching hospitals. Age group 65 - 74 was significant (X
2
= 37.294, df = 6, p = .000) for longer stay in teaching hospitals

with more females staying longer in teaching (24.9%) than in non teaching (21.3%) hospitals. White ethnic group stayed shorter in non-teaching hospitals than other ethnic groups while patients with income lower than $39,000 stayed longer in non-teaching hospitals than those with higher income. Only Medicare was significant (X
2
= 24.975, df = 6, p = .000) amongst the patients payment methods. Patients with hypertension stayed longer than patients with other comorbidities while severe loss of function for MI severity remained significant (X
2
= 15.181, df = 6, p = .019). Furthermore, length of stay and hospital characteristics for medium and large bed size, urban, government and private-owned, Northeast and Western hospitals were significant (p <.013).

Conclusion:
In conclusion, this study has shown that there is a significant difference between teaching and non teaching hospitals and these differences are large enough to affect policy changes and this may all be attributed to age, income, and insurance possession. Understanding the relationship between MI and T2D will enable the healthcare professionals to start screening diabetic patients for any coronary artery diseases in order to prevent prolonged length of stay in teaching hospitals. Shorter length of stay equates lower cost of stay, hence availability of needed budget for preventive measures.
Abstract 231: Coronary Artery Bypass Grafting is Superior to Percutaneous Coronary Intervention for Multivessel Coronary Disease in Chronic Kidney Disease
Authors: Chang Tara I , Leong Thomas K , Kazi Dhruv S , Hlatky Mark A , Go Alan S
Published: March 2022

Introduction:
Randomized clinical trials comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) have generally excluded patients with chronic kidney disease, and observational comparisons have been inconclusive.

Hypothesis:
We examined whether initial revascularization with CABG is associated with lower risks of death and coronary events compared with PCI among patients with chronic kidney disease and multivessel coronary disease.

Methods:
We identified adults aged ≥30 years in Kaiser Permanente of Northern California with multivessel coronary disease who underwent initial revascularization between 1996 and 2008. Patients were followed for the outcomes of death, acute coronary syndrome, or repeat revascularization until December 31, 2008. We calculated the estimated glomerular filtration rate (eGFR, in mL/min per 1.73 m2) using the CKD-EPI equation and stratified the cohort into three eGFR categories: ≥60, 45-59, and <45. Patients on maintenance dialysis were excluded. We used Cox regression and adjusted for age, sex, race, Hispanic ethnicity, cardiovascular and other comorbidities, medication use, smoking status, dipstick proteinuria, hemoglobin, cholesterol, index year and local health care facility.

Results:
Among 22,361 adults receiving CABG (n=16,219) or PCI (n=6142), 26% had baseline eGFR 45-59, and 15% had baseline eGFR <45. Patients receiving PCI were more often female and more often had a history of acute myocardial infarction. The median follow-up was 5.3 years for CABG patients and 3.7 years for PCI patients. CABG was associated with significantly lower risks of death, acute coronary syndrome and repeat revascularization at all levels of kidney function, even after adjustment for potential confounders and longitudinal use of cardiovascular medications (Figure).

Conclusions:
Among adults with chronic kidney disease and multivessel coronary disease, initial revascularization with CABG is associated with lower risks of death and coronary events compared with PCI. Our findings support conducting adequately-powered randomized clinical trials comparing coronary revascularization strategies specifically in patients with chronic kidney disease.
Abstract 243: Comparing the Major Adverse Cardiovascular Event Risk of Treatment and Titration Sequences Using Atorvastatin and Rosuvastatin: a Simulated Study
Authors: van Herick Andrew , Schuetz Andy , Alperin Peter , Bullano Michael , Gandhi Sanjay
Published: March 2022

Objective:
Using simulation modeling, we compared the effects of initiating statin therapy with atorvastatin and rosuvastatin on a population of patients with LDL-C levels above goal.

Methods:
Using the Archimedes Model, a clinically detailed simulation model of human physiology, disease progression, and healthcare delivery, two treatment scenarios were simulated in which patients initiated atorvastatin (10, 20, 40, or 80 mg) or rosuvastatin (10, 20, or 40 mg), and then periodically intensified treatment at rates determined from US pharmacy claims. Simulated individuals (derived from NHANES 1999-2006) were aged 45 to 70 years and had LDL-C exceeding Adult Treatment Panel (ATP) III goal. Initial statin doses were conservatively assigned based on each individual's LDL-C, their LDL-C goal, and the expected treatment effect. Patients not reaching goal either intensified the current statin dose or switched to an appropriate rosuvastatin dose. Occurrence of major adverse cardiovascular event (MACE), comprising MI, stroke, or cardiovascular (CV) death, was tracked for 10 years for all patients and several high-risk subpopulations, including those with diagnosed diabetes and with prior CV disease (CVD). Statin effects were modeled using biomarker results from the STELLAR trial and outcomes data from the JUPITER trial (rosuvastatin) and the CARDS, ASCOT, and TNT trials (atorvastatin).

Results:
At baseline, the study population (n=50,025) had a mean age of 57.3 [SD: 6.9] years, were 56% male, and had average LDL-C of 166.6 [41.3] mg/dL, HDL-C 49.3 [13.7] mg/dL, total cholesterol 252.0 [50.2] mg/dL, BMI 30.2 [6.6] kg/m2, 26% had diagnosed diabetes, 58% had hypertension, and 25% were current smokers. Initiating treatment with rosuvastatin versus atorvastatin provided a significant reduction in MACE: the 5- and 10-year relative risk of MACE for the overall population was 0.92 (95% CI: 0.90[[Unsupported Character - ]]0.94) and 0.92 (95% CI: 0.91-0.93), respectively; with prior diabetes, 0.90 (95% CI: 0.86[[Unsupported Character - ]]0.94) and 0.91 (95% CI: 0.88-0.93); and with prior CVD, 0.93 (95% CI: 0.90[[Unsupported Character - ]]0.97) and 0.95 (95% CI: 0.93-0.97); all p<0.05.

Conclusion:
In this simulation model, initial treatment with rosuvastatin versus atorvastatin lowered the incidence of MACE across the overall study population and in patients with prior diabetes or CVD.
Abstract 246: Emergency Medical Services and Hospital Collaboration in the Care of Patients with Acute Myocardial Infarction
Authors: Landman Adam B , Spatz Erica S , Cherlin Emily , Krumholz Harlan M , Bradley Elizabeth H , Curry Leslie A
Published: March 2022

Background:
High quality emergency medical services (EMS) care is important for the care of patients with acute myocardial infarction (AMI). Evidence suggests that active collaboration between EMS and hospital clinicians caring for patients with AMI is significantly associated with AMI mortality rates; however, the nature of such collaborations has not been examined. We sought to understand collaborations between EMS and hospitals in the care of patients hospitalized with AMI.

Methods:
We performed a qualitative study of key clinical and administrative hospital staff most closely involved with AMI care. We arrayed hospitals based on their 30-day risk-standardized AMI mortality rates (RSMRs) using Centers for Medicare and Medicaid Services data from 2005-2007. We selected hospitals that ranked in the top 5% and bottom 5% of performance for both years. We conducted site visits and in-depth interviews (n=158) until successive site visits generated no new concepts, which occurred after 11 site visits. A multidisciplinary team analyzed the data using the constant comparative method to generate recurrent themes. Atlas Ti software facilitated data organization and retrieval.

Results:
Although both high and low performing hospitals perceived that EMS plays an important role in AMI care, high performing hospitals reported a close collaborative relationship that differed in nature and intensity from that described by the low performers in several aspects: 1) high level of respect for EMS as valued professionals and colleagues; 2) investment in diverse strategies to facilitate communication between the hospital and EMS, such as employing a hospital-based EMS liaison to provide training and support to prehospital providers and to ensure smooth and timely flow of information; and 3) active engagement of EMS in AMI care quality improvement efforts, including providing data feedback to EMS agencies on their performance.

Conclusion:
The relationship between EMS and the AMI care teams differed between high and low performing hospitals, with the high performing hospitals describing multifaceted strategies to support collaboration with EMS in providing AMI care. These strategies may be useful for hospitals seeking to improve the care of patients with AMI.
Abstract 250: Gender Differences in Health Status Amongst Patients with Peripheral Artery Disease
Authors: Dreyer Rachel , Van Zitteren Moniek , Beltrame John , Fitridge Robert , Denollet Johan , Vriens Patrick , Spertus John , Smolderen Kim
Published: March 2022

Aim: Unlike other cardiovascular disorders, few studies have examined gender differences in health outcomes in peripheral artery disease (PAD) patients. This study assessed whether gender was an independent determinant of health status at (a) initial diagnosis of PAD, (b) 12-month follow-up, or (c) the rate of change over a 12-month period, with the hypothesis that women's PAD health status will be comprised at both time points.

Methods: From March'06 to November '10, 588 patients (381 men, 207 women) with newly diagnosed PAD (Rutherford stages I-III) were consecutively enrolled from two vascular clinics in the Netherlands. Clinical details were recorded and patients completed the Short Form 12 (SF-12) questionnaire at baseline and 12 months later. Physical (PCS) and mental component summary (MCS) scores were calculated and compared by gender at each time point and median values were used due to non-normally distributed data. Multivariable linear regression models adjusting for demographics, cardiovascular risk factors, co-morbidities and depression quantified the independent association of gender with health status.

Results: Women had poorer PCS (36±10 vs. 40±10, P<0.001) and MCS (46±12 vs. 49±11, P<0.001) scores at diagnosis (baseline) as compared with men (
Figure 1
). Independent correlates of poorer baseline PCS included age, body mass index, prior cardiovascular history, chronic obstructive pulmonary disease (COPD), and depression. For baseline MCS scores, indicators of poorer outcomes included female gender, age, COPD, and depression. Although PCS scores improved for both genders over 12 months (P<0.001 for men; P<.0.001 for women), 12-month MCS scores did not significantly change in men (P=0.14) or women (P=0.12) (
Figure 1
). At 12 months, both PCS and MCS were worse in women, as compared with men (PCS [41+12 vs. 46+11, P=0.05], MCS [43+14 vs. 49+12, P=0.002]). Independent predictors in the rate of improvement in PCS scores included age, diabetes, and PCS-12 at baseline, but not gender, with no independent predictors for the MCS scores.

Conclusion: Women with lower-extremity PAD have poorer physical and mental health status scores both at baseline and 12 months, however, improvement 12 months following diagnosis was independent of gender.

Figure 1.

Median PCS and MCS Scores at Baseline and 12-Month Follow-Up by Gender
Abstract 267: Cost-Effectiveness of Transradial PCI: A Decision-Analytic Model
Authors: Amin Amit P , Marso Steven P , House John , Chhatriwalla Adnan K , Safley David , Mills Rebecca , Salisbury Adam C , Spertus John A , Cohen David J , Baklanov Dmitri
Published: March 2022

Introduction:
Transradial percutaneous coronary intervention (TRI) is associated with reduced bleeding rates and length of stay (LOS), compared to transfemoral PCI (TFI). However, TRI requires specialized guide catheters, access equipment and costs attributable to a ‘learning curve’ in the US. The cost-effectiveness of transradial vs. transfemoral PCI in contemporary real-world US practice is unknown.

Methods:
We developed a decision-analytic model (Figure) of costs and bleeding events of transradial vs. transfemoral PCI using inputs from a hospital system, and direct PCI costs from each hospital’s respective cost accounting system. Independent costs of radial PCI, urgent vs. elective PCI indication and bleeding complications were identified by a linear regression model and used as model inputs. The efficacy measure was major bleeding as defined by the NCDR.

Results:
Cost and clinical data were derived from the 2,972 consecutive PCI procedures (TRI N=559) performed in 6/2009-3/2011. TRI was associated with a shorter LOS (1.4 ± 1.4 days) vs. TFI (1.9 ± 2.3 days), P< 0.001. Although procedural day costs were similar in the 2 groups - $12,949 ± 3932 for TRI vs. 13,104 ± 3325 for TFI, post-procedural day costs were lower in the TRI groups ($1524 ± 4108 vs. TFI group $ 2798 ± 9076), primarily from a reduced LOS. Hence, total costs were lower with TRI ($14,468 ± 5442) vs. TFI ($15,608 ± 6920), P<0.001, by $1,140. There was a trend towards reduced bleeding with TRI (1.1%) vs. TFI (1.9%), P=0.159. In economic analysis, TRI was a dominant strategy. In probabilistic sensitivity analyses (with 1000 simulations to account for variation in clinical practice) the decision-analytic model projected that TRI would remain economically dominant in 96.3% of simulations.
Cost data from 4 additional high volume centers will be included prior to the AHA QCOR presentation.

Conclusions:
This is the first decision-analytic modeling study which shows TRI is an economically dominant strategy with lesser costs and a trend towards greater efficacy (less bleeding), when compared against TFI. Cost savings resulting from TRI are large and exceed $800/patient undergoing PCI. Apart from the known advantages of patient convenience and reduced bleeding complications, increased adoption of TRI may result in significant cost-savings to hospitals and ultimately the U.S. healthcare system.
Abstract 271: An Electronic, Point-of-Care Cath Lab Clinical Application Provides High Validity, Completeness, and Timeliness Compared to Traditional Medical Charting
Authors: Byrd James B , Vigen Rebecca , Rumsfeld John S , Tsai Thomas T , Gethoffer Hans , Fihn Stephan D , Jesse Robert , Maddox Thomas M
Published: March 2022

Background:
Beginning in 2005, an electronic, point-of-care clinical application (CART-CL) was implemented in all 78 VA cardiac catheterization laboratories. CART-CL collects pre-procedural and procedural data in a standardized format that is recorded in the VA electronic health record. This application was created to support quality improvement, but the validity, completeness, and timeliness of these data, relative to a standard medical record are unknown.

Methods:
In a random sample of 10 VA catheterization labs, we abstracted a standardized set of key data elements (based on the National Cardiovascular Data Repository mortality model) from the reports of catheterization procedures. At each site, we selected 10 procedures performed before CART-CL adoption and 10 after adoption for comparison. Notes from procedures performed before CART-CL adoption were entered directly into VISTA/CPRS, VA’s electronic health record. Validity was assessed by comparing data elements recorded in notes generated by CART-CL versus VISTA/CPRS. Completeness was assessed using a standardized list of data elements. Timeliness was defined as the percentage of catheterization reports available to the treating provider on the day of the procedure.

Results:
The 200 cases selected were evenly distributed between elective and ACS indications. Of the 1690 observations abstracted from CART-CL-generated notes and analyzed for validity, 1664 (98.5%) were valid. Only 7 data elements had less than 100% validity with lowest validity found in diabetes medications (94%) and statin dose (84%). Two thousand five hundred eighty-one of 3276 (79%) data elements in CART-CL were complete, as compared with 2098 of 3323 (63.1%) data elements in CPRS charts before CART-CL implementation (p-value < 0.0001). The number of data elements analyzed for validity and completeness differed due to varying prevalence of conditions and procedures within the study population. Seventy-one percent of CART-CL catheterization reports were available to treating providers the day of the procedure, as compared with 58.0% of VISTA/CPRS catheterization notes before CART-CL adoption (p-value = 0.055). Among those reports not available on the day of the procedure, the median time-to-availability was not significantly shorter after adoption of CART-CL than before (3.0 vs. 5.0 days, p-value = 0.887).

Conclusions:
CART-CL is an electronic, point-of-care clinical application that collects VA cath lab patient and procedural information in a standardized fashion. Compared to the previous method of medical charting, it has high validity, and superior completeness and timeliness. Accordingly, it can serve as an effective quality assessment tool for cath labs.
Abstract 277: Quality Initiative to Reduce Radiation Exposure and Detect Radiation Injury in the Congenital Cardiac Catheterization Lab
Authors: Simsic Janet , Swinning Jason , Harrison Sheilah , Kempton Tanya Maria , Cheatham John P , Teske Douglas W , Holzer Ralf J
Published: March 2022

Background:
The frequency and duration of cardiac catheterization for patients with complex congenital heart disease have increased as a result of the advances in technique and devices available. Increasing catheter interventions require efforts to reduce patient radiation exposure and improve detection of radiation burns. Follow-up protocols based on fluoroscopy time alone are often inadequate as surveillance measures to identify patients that develop radiation burns.

Objective:
The objective of this study was (1) to reduce the radiation exposure during cardiac catheterization and (2) to improve the quality of post cardiac catheterization radiation surveillance by the development of standardized dose dependent follow-up protocols.

Methods:
Quality initiatives introduced to reduce radiation exposure from July 2008 - July 2010 included (1) fluoroscopy frame rate reduction from 30 to 15 fps; (2) digital acquisition frame rate reduction from 30 to 15 fps for pts > 65kg; (3) Toshiba system upgrade superior noise reduction filter with high-quality fluoro-record capabilities. Quality initiatives for follow-up surveillance based on radiation exposure included (1) all patients exposed to a dose of ≥ 3000mGy received a letter explaining radiation risks and possible signs of radiation burns, as well as a phone call 1 week post procedure inquiring about possible signs of radiation burns or other skin changes; (2) all patients exposed to a dose of ≥ 6000mGy received 2 additional phone calls at 3 and 6 weeks post procedure; and (3) all patients exposed to a dose of > 9000mGy had a follow-up appointment with a cardiologist 4-6 weeks post procedure with skin assessment for radiation injury.

Results:
In 2008, there were 519 patients; median radiation exposure was 544 mGy (range 10-31519); median fluoroscopy time was 23 min (range 1-335); radiation burns N=4. In 2009, there were 495 patients; median radiation exposure was 439 mGy (range 0.4-15955); median fluoroscopy time was 24 min (range 0.1-192); radiation burns N=7. In 2010, there were 519 patients; median radiation exposure was 322 mGy (range 1.6-19196); median fluoroscopy time was 24 min (range 0.5-386); radiation burns N=4. In 2011, there were 572 patients; median radiation exposure was 220 mGy (range 1-11108); median fluoroscopy time was 23 min (range 0.3-201); radiation burns N=3. The median patient radiation exposure decreased by over 50% from 2008 to 2011 (p<0.001 ). Fluoroscopy times did not change significantly during the study period (p=0.9).

Conclusions:
Quality improvement initiatives aimed at reduction of cardiac catheterization radiation exposure and dose dependent follow-up protocols have been effective in reducing the radiation exposure and improving detection of radiation burns in patients with congenital heart disease undergoing cardiac catheterization.
Abstract 286: Can the Functional Capacity Measured by Duke Activity Status Index Increase the Value of Imaging during Stress Testing?
Authors: Prabhakar Sourabh , Poornima Indu , Sodagam Archana , Vido Diane
Published: March 2022

Background:
The incidence of abnormal myocardial perfusion imaging (MPI) has been reported to be very low in patients exercising >10 metabolic equivalents (METs) without ST depression on EKG. We sought to determine if the Duke Activity Status Index (DASI), which predicts functional capacity(FC), can determine who benefits the most from exercise stress testing (EST) with MPI. We hypothesized that DASI-predicted FC of <10 METs will identify patients with a higher likelihood of abnormal MPI.

Methods:
DASI questionnaire was prospectively administered to 163 patients without prior history of coronary artery disease (CAD) referred for EST with MPI. DASI was used to predict METs by dividing the total score by 3.5. The study population was divided based on DASI score>35 (corresponding to METs>10) to determine the relationship with abnormal MPI. Abnormal MPI was defined as a summed stress score (SSS) >0 or left ventricular ejection fraction (LVEF) <45%. These cutoffs were used to identify
any
abnormalities that may occur in this population without prior diagnosis of CAD.

Results:
Among the 163 patients, 52% were males, mean age was 53±10 years, 14% were diabetic, 93% had atypical symptoms and 74% had normal baseline EKG's. Mean DASI-predicted METS was 13.3±3.5 and mean measured METS was 10.4±3.0. There was a strong correlation between DASI-METS and measured METS (Spearman's rho=0.47; p<0.001). DASI was >35 in 128 (79%) and ≤35 in 35 (21%) patients, respectively. Abnormal MPI was noted in 8 patients (7 abnormal SSS, 1 abnormal EF). SSS was>0 in 3 out of 128 (2%) in the DASI >35 group compared to 4 of 35 (11%) in the DASI≤35 group (p<0.05). LVEF<45% was noted as an isolated abnormality in 1 patient with DASI>35. All patients with DASI>35 had a low-risk scan. High-risk scan (SSS>8 and LVEF<45%) was noted in 3 patients with DASI≤35.

Conclusions:
In patients without prior CAD referred for EST with MPI, DASI can help increase the value of MPI by identifying a subset that will benefit more from MPI. Patients with a DASI≤35 have a significantly higher likelihood of having both abnormal MPI and severely abnormal MPI. Functional capacity should be considered in addition to pretest probability of CAD and baseline EKG in evaluating the appropriateness of stress testing with imaging. Studies with larger sample sizes are warranted to validate this approach.
Abstract 289: Peripheral Arterial Disease and Vulnerability to Cardiovascular Events: Data from the Heart and Soul Study
Authors: Grenon S. Marlene , Owens Christopher D , Conte Michael S , Vittinghoff Eric , Whooley Mary , Cohen Beth
Published: March 2022

Objectives:
Among patients with coronary artery disease (CAD), those with comorbid peripheral arterial disease (PAD) have a greater vulnerability to cardiovascular (CV) events than those with CAD alone. It is unclear why the presence of PAD predisposes patients with CAD to adverse CV outcomes. In a prospective cohort study of patients with CAD, we evaluated potential mechanisms that might explain the adverse CV outcomes associated with PAD.

Methods:
We evaluated 1020 patients with stable CAD who were recruited from 2000-2002 and followed for an average of 7.2 ± 2.6 years. Incident PAD events were adjudicated based on physician diagnosis, radiological imaging and/or need for PAD surgery. We used Cox proportional hazards models to evaluate the association between development of PAD events (entered as a time-dependent covariate) and subsequent risk of cardiovascular (CV) events (myocardial infarction, congestive heart failure, cerebrovascular event, revascularization) or death based on detailed review of medical records. Models were adjusted for traditional cardiovascular risk factors (age, race, sex, diabetes, hypertension, hypercholesterolemia, kidney function, inflammation) and self-reported history of PAD at baseline.

Results:
Among the 1020 patients, 67 patients developed incident PAD events during the follow-up period. Patients who developed PAD events had a higher risk of subsequent CV events and death compared to those who did not develop PAD (Figure). After adjustment for traditional cardiovascular risk factors and self-reported history of PAD, development of PAD events remained associated with an 84% increased risk of subsequent cardiovascular events [adjusted HR 1.84, 95% CI 1.15, 2.96, p=0.01] and an 89% increased risk of death [adjusted HR 1.89, 95% CI 1.30-2.74, p=0.0009]. Only a small portion of this association was explained by baseline differences in levels of IL-6, TNF-alpha and fibrinogen.

Conclusions:
In a contemporary cohort of patients with CAD, development of incident PAD was associated with adverse CV outcomes. The increased risk of CV events was not explained by shared risk factors or inflammation. Further research is necessary to understand how the presence of PAD increases risk of subsequent CV events.
Abstract 301: Therapeutic Hypothermia Induced Change in Electrocardiographic Parameters and In-Hospital Mortality
Authors: Lam David H , Dhingra Ravi , Catino Anna B , Grigel Cynthia L , Kono Alan T
Published: March 2022

Introduction:
Therapeutic hypothermia (TH) is recommended by the American Heart Association for selected patients over the age of 18 who remain comatose after a cardiac arrest. Hypothermia triggers changes in electrocardiogram (ECG) parameters, but the association of these changes to in-hospital mortality remains unclear.

Hypothesis:
We hypothesized that TH would decrease heart rate (HR) and increase QTc interval without change in mortality.

Methods:
We retrospectively compared the ECG parameters from the pre-cooling phase to the ECG performed during the hypothermic phase (target temperature 33° Celsius) on all consecutive patients who received TH between 12/2006 and 2/2011 at our institution (n=58). Paired 2-sample t-test was used to compare ECG parameters and hospital outcomes. In-hospital mortality related to QTc interval change was compared using Pearson’s chi-squared test.

Results:
Compared to the pre-cooling ECG parameters, TH resulted in significant increases in PR and QTc intervals and decrease in HR (
Table
). During hospitalization, 27 of the 58 patients who received TH died. Patients who survived versus patients who died did not differ in HR change (-20.2 vs -25.4, p=0.58), change in PR interval (+11.7 vs +2.6, p=0.33), or change in QTc interval (+51.0 vs +27.8, p=0.22). Patients who survived had a longer QRS increase with TH than those who died (+5.6 vs -22.5, p=0.006). Eleven patients presented with right bundle branch block (RBBB) morphology on their pre-cooling ECG, but only 1 continued to have RBBB during cooling. Three patients presented with left bundle branch block (LBBB), but only 2 remained in LBBB with cooling. None developed new bundle branch block during TH. Comparing patients who had decreased QTc intervals with TH to those with prolonged QTc intervals, 9 out of 16 died in the former group whereas 16 out of 39 died in the latter group (p=0.0001).

Conclusion:
Therapeutic hypothermia in comatose patients with cardiac arrest led to a significant decrease in heart rate and prolongation of QTc interval with no association to mortality. Further research is needed to examine whether prolongation of QTc and/or QRS with hypothermia reflects improved outcomes.
Abstract 308: Incidence of Non-Cardiac Chest Pain in Follow-up After Acute Myocardial Infarction and Association with Clinical Outcomes
Authors: Salisbury Adam C , Amin Amit P , Li Yan , Chan Paul S , Spertus John A
Published: March 2022

Background:
Non-cardiac chest pain is common in the general population, but its incidence after acute myocardial infarction (AMI) is unknown. Moreover, whether patients with non-cardiac chest pain after AMI experience poorer outcomes than patients without these symptoms is unclear.

Methods:
Within the 24-US center TRIUMPH registry, we classified patients as having or not having a physician-adjudicated readmission with non-cardiac chest pain and assessed patients' health status and 2-year mortality. Patients' health status was evaluated using the quality of life domain of the disease-specific Seattle Angina Questionnaire (SAQ QoL) and the physical and mental component summary scores of the generic Short Form 12 (SF-12) at 1, 6, and 12 months after AMI. The associations between non-cardiac chest pain hospitalization and 2-year mortality and patients' health status were assessed using hierarchical, multivariable logistic regression and repeated measures linear regression, respectively, adjusting for potential confounders.

Results:
Of 3127 AMI patients, 130 (4.2%) were hospitalized with non-cardiac chest pain over the follow-up period. Two-year mortality was similar between patients with (3.8%) and without non-cardiac chest pain (6.8%, p=0.19). In contrast, patients hospitalized with non-cardiac chest pain had worse adjusted disease-specific health status (SAQ-QoL: -10.61 points [95% CI -13.48, -7.74])) and generic health status (SF-12 physical component summary: -2.78 points [95% CI -4.24, -1.32]); SF-12 mental component summary (-3.51 points [95% CI -4.88, -2.14]). Married patients were independently less likely to be hospitalized (OR 0.6, 95% CI 0.4-0.9) while those with a history of chronic heart failure were more likely to be admitted with non-cardiac chest pain (OR 2.2, 95% CI 1.2-3.9).

Conclusions:
Patients hospitalized with non-cardiac chest pain experienced worse health status in the first year after AMI than patients without these symptoms, suggesting these patients experience ongoing, rather than transient, poor health status post-AMI. Further research is needed to elucidate the etiology of poor health status in these patients and develop novel treatment strategies for improving their physical functioning and quality of life.
Abstract 310: Are Patients with Ischemic Heart Disease Living Long Enough to Die of Other Causes? Results from the Heart and Soul Study
Authors: Dixson Jeffrey A , Welles Christine , Regan Mathilda C , Whooley Mary A
Published: March 2022

Background:
Cardiovascular disease is the leading cause of death in the world and has always been considered the leading cause of death in patients with chronic ischemic heart disease (IHD). However, cardiovascular mortality has fallen markedly due to recent therapeutic advances. Whether patients with IHD may be living long enough to die of other causes has not been evaluated.

Methods:
We determined causes of death in a contemporary cohort of 927 patients with chronic IHD. Participants with stable IHD enrolled in the Heart and Soul Study in 2000-02 and were followed for an average of 7.12 (SD ± 2.67) years, with <1% loss to follow-up per year. Causes of death were determined based on detailed review of medical records, death certificates and coroner reports by two blinded adjudicators. In the event of disagreement, a third blinded adjudicator was consulted.

Results:
During 6587 ± 81 person years of follow-up, a total of 297 participants (32%) died. Of the 297 deaths, 124 (42%) were due to cardiovascular causes, and 173 (58%) were attributable to non-cardiovascular causes (Table). Myocardial infarction, stroke, and sudden death accounted for 73% of the cardiovascular deaths. Cancer, pneumonia, and sepsis accounted for 71% of the non-cardiovascular deaths.

Conclusions:
In a contemporary cohort of 927 patients with chronic IHD, the majority died from non-cardiovascular causes. These findings suggest that IHD therapies have improved to the point where patients with IHD may be living long enough to die of other causes.
Abstract 319: Are Young Women At Higher Risk For Events After Acute Coronary Syndromes?
Authors: Davis Melinda , Krishnan Sangeetha , Diamond Jamie , Jackson Elizabeth A
Published: March 2022

Background:
Prior studies suggest increased mortality among young women experiencing acute coronary syndromes (ACS); however, data on characteristics which place younger women at risk is limited.

Methods:
We examined data from 979 men and women under the age of 55 admitted to the University of Michigan Health System with an ACS event from January 1999 to December 2006. Demographics, medications on admission, in-hospital management and outcomes at six month were included in the analysis. The primary outcomes of interest were changes in rates of cardiac related rehospitalization, revascularization, recurrent myocardial infarction (MI), and death over time.

Results:
Women <55 years old represented 25.9% of the ACS cohort. Compared to young men, young women were more likely to have a prior history of heart failure (11.4% vs. 6.5% p=0.024) and diabetes mellitus (33.1% vs. 21.7%, p< 0.001) and hypertension (33.1% vs. 21.7%, p< 0.001). Young women were less likely to present with ST elevation MI (22.4% vs. 31.2%, p=0.008) and more likely to present with unstable angina (33.1% vs. 22.9%, p=0.001.) compared to younger men. Younger women were less likely to receive percutaneous coronary interventions and lyctics. Upon discharge, among patients without contraindications, younger women were less likely to receive aspirin (85.1% vs. 93.9%, p<0.001), beta blockers (77.2% vs. 87.3%, p< 0.001), ace-inhibitors/ angiotensin receptor blockers (52.4% vs. 65%, p=0.0208) and lipid lowering agents (68.9% vs. 81%, p<0.001), as compared to young men. During hospitalization young women were more likely to experience a major bleeding event (5.5% vs 2.2%, p=0.022) compared to young men patients; while rates of recurrent ischemia/MI or renal failure were similar between the two groups. At six months, young women experienced higher rates of rehospitalization compared to young men (37.4% vs. 25.5%, p<0.001). No statistically significant differences were observed in the mortality rates or recurrent MI between young men and women. The rates of discharge medications have improved over time in both groups.

Conclusion:
Compared to men under the age of 55 years, young women have similar rates of mortality or recurrent MI, but higher rates of in-patients bleeding events and higher rates of cardiac-related hospitalization at 6-months. Of concern were the observed gender-differences in preventive medications at time of discharge, which may impact on rehospitalization rates.
Abstract 4: The Impact of an Emergency Medical Services Hospital Bypass Protocol on Reperfusion Time for Patients with ST-elevation Myocardial Infarction (STEMI)
Authors: Fosbol Emil L , Granger Christopher , Jollis James , Monk Lisa , Lin Li , Lytle Barbara , Xian Ying , Garvey Lee , Mears Greg , Corbett Claire M , Peterson Eric D , Glickman Seth
Published: March 2022

Background:
As part of a statewide STEMI regionalization program, North Carolina implemented statewide emergency medical service protocols, which encouraged that STEMI patients should be sent directly to a PCI-capable hospital, potentially bypassing hospitals without PCI capacities. We assessed EMS adherence to this protocol, predictors of bypass, and subsequent association of this with patient treatment times and outcomes.

Methods:
We linked data from the ACTION-GWTG registry and the EMS Pre-hospital Medical Information System (PreMIS) from 06/2008 to 09/2010. Using a Google map application, we selected EMS transported patients that either 1) bypassed a closer non-PCI hospital and went directly to a PCI center, or 2) were first taken to a non-PCI center and subsequently transferred for PCI.’ We determined predictors of bypass using multivariable logistic regression modeling accounting for clustering within hospital referral regions. Time from first-medical-contact (FMC) to PCI/reperfusion and in-hospital mortality were compared between groups.

Results:
Among 1224 eligible STEMI patients, 765 (63%) underwent bypass to a PCI facility while 479 (37%) were first treated at a non-PCI hospital and then transferred for PCI. Adjusted predictors of undergoing bypass were white race (OR 1.37, 95% CI 1.02-1.84), chief complaint of chest pain (OR 2.08, 95%CI 1.46-2.95), having received a pre-hospital 12-lead electrocardiogram (OR 2.14, 95%CI 1.10-4.15), cardiogenic shock (OR 1.82, 95% CI 1.22-2.72), and a prior history of PCI (OR 1.66, 95% 1.11-2.50). Time from FMC to PCI was 95 min (IQR 77-117) in the bypass group vs 179 min (IQR 138-288) in the non-bypass group, p-value for difference <0.0001. Time from FMC to initial reperfusion therapy (PCI or fibrinolysis) was 94 min (IQR, 76-116) in the bypass group vs. 124 (IQR, 67-179) in the non-bypass group, p for difference <0.0001. Crude inhospital mortality was lower in the bypass group vs. the non-bypass group (6.3% vs. 9.4%, p-value for difference = 0.046).

Conclusions:
After implementation of a statewide STEMI regionalization program, 2/3 of EMS transported patients bypassed a closer non-PCI center and went directly to a PCI-capable center. Patients who bypassed and went directly to PCI capable centers had significantly more rapid reperfusion times and lower mortality compared with patients not undergoing EMS.
Abstract 43: Use Of The Meld Score To Predict Adverse Outcomes Among Patients With End Stage Liver Disease Undergoing Cardiac Catheterization
Authors: Lulla Sanya , Kattaa Sindura , Berkes Jaime , Kerbow David , Dickens Carolyn , Shroff Adhir
Published: March 2022

Introduction
Patients awaiting liver transplantation often have other comorbidities including coronary artery disease (CAD). Many patients undergo cardiac catheterization to diagnose and potentially treat CAD. However, patient with end stage liver disease (ESLD) are at risk for a host of complications and revascularization procedures are not commonly performed given this concern. The ability to predict which patient will experience a complication is not clearly defined. The MELD score is a composite measure used commonly in the hepatology community to quantify the severity of liver dysfunction.

Methods
We reviewed the medical records of all patients under consideration for liver transplantation between March 2006 and December 2010. We recorded demographic and laboratory data, cardiac risk factors and adverse events up to 1 year following cardiac catheterization. Adverse events included: all-cause death, myocardial infarction, stroke, repeat revascularization, cardiac re-hospitalization and periprocedural bleeding. Only patients with complete follow-up records were included. The MELD score, a common measurement of liver disease severity, was calculated at the time of initial referral. MELD scores were divided into tertiles.

Results
Among the 440 patients referred to the cath lab, 78 (18%) underwent coronary angiography. The mean age was 56 and 35% of the cohort were women. Minorities accounted for 49% of the population. The mean MELD score was 17. Nearly 51% of patients experienced at least one adverse event and 30% had multiple events. There was a non-significant trend towards an increased adverse event rate from the lowest to highest MELD score group. (42%, 46%, 70%, p=0.1) The overall mortality rate was 28%.

Conclusion
Patients with combined ESLD and coronary artery disease have an extremely high rate of adverse events following cardiac catheterization. Over half of the patients experienced an adverse event and nearly a third were dead at one year. The MELD score may be useful as a tool to predict the risk of having an adverse event in this complex patient population.
Abstract 48: Diabetic Patients with Acute Coronary Syndrome Have Better 6 Month and 2 Year Outcomes with Revascularization Compared to Medical Therapy Alone
Authors: Olomu Ikponmwosa O , Montgomery Daniel G , Krishnan Sangeetha M , Kline-Rogers Eva , Cheng Alex , Olomu Adesuwa B , Froehlich James B , Jackson Elizabeth , Eagle Kim A
Published: March 2022

Background:
Recent trials suggest patients with diabetes may do better with coronary-artery bypass graft (CABG); however long-term trends in the rates of CABG and percutaneous coronary intervention (PCI) compared to medical therapy from a real-world population are not well known.

Methods:
We analyzed 1003 DM patients admitted with acute coronary syndrome (ACS) from 1999 to 2008 at a tertiary care center. Rates of revascularization were examined by study year. In addition in-hospital, 6mo and 2yr outcomes were obtained by phone interview and medical chart review. Multiple logistic regression models were created for 6mo and 2yr outcomes, adjusting for variables known to be associated with mortality.

Results:
Of 1003 DM/ACS patients, 505 were medically managed, 399 received percutaneous coronary intervention (PCI) and 99 received a coronary-artery bypass graft (CABG). At baseline, the medical group was the oldest and sickest. Rates of CABG increased particularly in the years between 2001 and 2003, and rates of PCI increased from 2003 to 2006. Both types of revascularization procedures have declined in recent years and medical management accounts for over 50% of diabetic ACS patients. (Figure 1) At 6mo, both CABG (p=0.02, OR 0.17, 95%CI 0.04-0.74) and PCI (p=0.03, OR 0.46, 95%CI 0.23-0.92) reduced mortality among DM patients after controlling for the GRACE risk score. A similar reduction in mortality was noted at 2yr for CABG (p=0.01, OR 0.35, 95%CI 0.16-0.77) and PCI (p=0.03, OR 0.62, 95%CI 0.40-0.95) compared to medical therapy alone.

Conclusions:
Rates of revascularization among

DM/ACS patients have declined in recent years, particularly for CABG. Both types of revascularization are associated with significant survival benefit, suggesting improving access to these procedures among DM/ACS patients is warranted.