bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 313: Risk Factors for Mortality in Patients with Severe Aortic Stenosis Referred for Transcatheter Aortic Valve Implantation Who Remain Untreated
Authors: Kang Donna , Bach David S , Chetcuti Stanley , Grossman Paul M , Deeb George M , Patel Himanshu , Booher Anna , LaBounty Troy M
Published: March 2022

Background:
The availability of transcatheter aortic valve replacement (TAVR) has expanded the proportion of patients with severe aortic stenosis (AS) who are candidates for valve replacement. Nevertheless, many patients decline or are not candidates for TAVR or surgical replacement, and their prognosis and risk factors for mortality are incompletely understood.

Methods:
We examined 148 patients with severe AS referred for TAVR, but not treated with an aortic valve procedure, and with complete echocardiography and at least 3 months of follow-up. We determined all-cause mortality using the social security death index, and compared patient characteristics and echocardiography findings between survivors and non-survivors.

Results:
Mean age was 78.9±10.4 years, and 53.4% were male. Mean follow-up was 10.3±8.7 months, and death occurred in 63 (42.6%) of patients. Mean follow-up for survivors was 14.4±8.6 months, and mean time to death was 4.7±5.2 months. Cumulative survival was 55.7% and 47.2% at 1 and 2 years, respectively. Table 1 provides unadjusted and adjusted variables associated with all-cause mortality.

Conclusions:
Patients with severe AS referred for TAVR but remaining untreated experience a mortality rate of nearly 50% at one year. While comorbidities were not associated with mortality, presenting clinical variables and echocardiography findings can identify patients at increased risk of death.
Abstract 332: Association of Body Mass Index with Health Status Outcomes in Patients Undergoing Percutaneous Coronary Intervention
Authors: Sharma Praneet K , Merrill Eric D , Kureshi Faraz , Buchanan Donna M , Jayaram Natalie , Grodzinsky Anna , Salisbury Adam , Fendler Timothy , Tang Fengming , Ting Henry H , Spertus John A
Published: March 2022

Background:
An obesity paradox, with better long-term survival in obese patients undergoing percutaneous coronary intervention (PCI), has been well described. The association between obesity and health status outcomes after PCI is unknown.

Methods:
We prospectively enrolled 3,281 PCI patients in a 10-center observational cohort study and categorized their body mass index (BMI) into normal (18.5 to <25), overweight (25 to <30), obese (30 to <35) and morbidly obese (≥ 35).Generalized linear models were used to describe the association between BMI and health status measures at 6 & 12 months, after adjusting for baseline characteristics and health status scores. Health status outcomes included; Seattle Angina Questionnaire [SAQ] Angina Frequency (AF), and Quality of Life (QL) scores, as well as the EQ-5D visual analogue scale (EQ-5D VAS). Interaction with time was not significant, so an estimate of the average benefit over time was generated.

Results:
The distribution of patients’ BMI revealed that 17% were normal, 35% overweight, 28% obese and 20% morbidly obese. Compared with normal weight patients, morbidly obese individuals were younger (mean 60.8 yr vs. 67.9 yr) and had a higher prevalence of diabetes, hypertension and heart failure. They underwent radial artery access (12.0% vs. 7.0%) and drug eluting stent implantation (80.4% vs. 76.0%) more frequently. Unadjusted changes in scores were lower (worse) among morbidly obese as compared with normal weight patients for SAQ AF (mean difference [MD] -1.52; 95% Confidence Interval [CI] -3.05, -0.02), SAQ QL (MD -2.51; CI -4.48, -0.54), and EQ-5D VAS (MD -5.74;CI -7.52, -3.96). After adjustment, these differences were no longer significantly different for SAQ AF and SAQ QL (figure), although EQ-5D VAS scores remained lower among obese and morbidly obese patients.

Conclusion:
The overall health status was mildly worse among obese and morbidly obese individuals after PCI, but the benefits of PCI on patients’ disease-specific health status were similar across weight categories. This suggests that PCI is equally effective in improving angina and disease-specific quality of life, independent of patients’ weight.
Abstract 353: Physicians Do Not Accurately Predict Length of Stay of Patients Admitted with Heart Failure
Authors: Durstenfeld Matthew S , Saybolt Matthew D , Praestgaard Amy , Kimmel Stephen E
Published: March 2022

Objective:
Determine the accuracy of physicians’ predictions of length of stay of inpatients with heart failure and compare those predictions based on physician experience.

Background:
Discharging a medical inpatient is a complex process often dependent upon a multidisciplinary team. Discharge planning begins with the physician who must anticipate patients’ lengths of stay, response to acute therapy, complications, and post-hospitalization needs. Increasing focus on patient safety emphasizes eliminating preventable harm including 30-day re-admissions, medication errors, and insufficient post-discharge care. To achieve these goals, early discharge planning is critical and is contingent upon an accurate estimate of length of stay at the time of admission. However, the accuracy of physician predictions of length of stay has not previously been studied.

Methods:
In this prospective, single-center, observational study we measured physicians' predictions of length of stay of patients admitted to an academic referral hospital’s heart failure teaching service. We compared admitting interns’ (PGY1, less than 6 months experience), supervising residents’ (PGY2-4, 1-3 years experience), and attending cardiologists’ (mean 19±9.7 years experience) predictions at admission with actual length of stay. The primary outcome was accuracy of physician predictions stratified by experience. Secondary outcomes included comparisons among predictions made by interns, residents, and cardiologists.

Results:
Predictions were made on 166 consecutively admitted patients within 24 hours of admission. Of those 166 patients, 98 (59%) had predictions by physicians at all three levels, with predictions made by 21 interns, 24 residents, and 8 cardiologists. Patients had a mean age of 56±14 years old and were 62% male (61 of 98). Median length of stay was 7.5 days (interquartile range 4-13). Mean difference between predicted and actual length of stay was statistically significant for all groups: for interns, -5.8 days (95% CI -8.2 to -3.4, p<0.0001), residents, -4.6 days (95% CI -7.1 to -2.0, p=0.0001), and cardiologists, -4.3 days (95% CI -6.5 to -2.1, p=0.0003). There were no statistically significant differences among intern, resident, and attending predictions, as determined by GEE modeling (p=0.61).

Conclusion:
Physicians, regardless of experience level, systematically underestimate length of stay of patients admitted with heart failure. Prediction models could assist with improved discharge planning.
Abstract 355: Are Left Ventricular Assist Devices (LVAD) Underutilized in Heart Failure? A Pilot Survey of Provider Assessment of LVAD Candidacy and Referral
Authors: Foxen Jilian L , Wagner Jean , Gatzke Janet , Nagel Jill , Prinsen Jenny , Freund Monique , Blank Teresa , Houlihan Robert , Monnahan-Chicos Randi , Birchem Sandra , Kushwaha Sudhir , Joyce Lyle , Redfield Margaret
Published: March 2022

Background:
Left ventricular assist device (LVAD) implantation is a new therapy for advanced heart failure (HF). The number of HF patients eligible for LVAD and the cardiology providers’ comfort level with referral for LVAD remains unclear.

Objective:
To assess provider perception of LVAD candidacy and LVAD referral patterns in consecutive HF patients.

Methods:
Providers completed a survey for each HF patient seen between March 1, 2013 and April 26, 2013. The survey listed standard LVAD candidacy criteria and asked 1) if a patient was an LVAD candidate (yes, no, unsure); 2) reasons patients were not LVAD candidates (check list, table); and 3) whether the patient had been referred for LVAD evaluation (yes, no, unsure).

Results:
Patients (n=522) were seen in a tertiary HF outpatient clinic (n=357; 68%), a tertiary HF inpatient service (n=36; 7%), a tertiary general cardiology service (n=45; 9%) or a community based outpatient cardiac clinic (n=84; 16%) Median age of patients was 73 years and 65% were male. Provider assessment of LVAD candidacy was “no” in 443 (85%), “yes” in 35 (7%) and “unsure” in 43 (8%) with ineligibility for LVAD attributed to multiple concerns (Table). Ninety percent of patients considered “too old” for LVAD were over 78 years of age. Provider designation of LVAD candidacy as yes or unsure varied across practice setting: tertiary HF outpatient clinic, 12%; tertiary HF inpatient service, 42%; tertiary general cardiology service, 22%; and community based outpatient cardiac clinic, 13%. In patients with a provider designation of LVAD candidacy as yes or unsure (n=78), only 21 (27%) patients had been referred for LVAD evaluation.

Conclusion:
When provided with LVAD candidacy criteria, providers indicated 15% of HF patients were (7%) or were possibly (8%) LVAD candidates but indicated that few patients had undergone a formal LVAD evaluation. These data suggest that measures to improve evaluation of HF patients for LVAD are needed.
Abstract 360: Hypovitaminosis D and the Risk of Obstructive Sleep Apnea
Authors: Janneck Jessica , Iyengar Rupa L , Maceda Cynara , Beebe Heather N , Yakunina Yuliya , Sawit Simonette T , Crowley Laura , Woodward Mark , McLaughlin Mary Ann
Published: March 2022

Background:
The prevalence of hypovitaminosis D has greatly increased in the American population, and is now estimated at 45%. There is increasing evidence that vitamin D is not only important for bone health but vitamin D deficiency is linked to chronic disease such as cardiovascular disease (CVD), diabetes, and cancers. The American obesity epidemic has increased the prevalence of Obstructive Sleep Apnea (OSA) in the American population. Patients with OSA are not just at risk for increased fatigue and daytime drowsiness but when untreated, OSA can increase the risk for a broad range of cardiovascular morbidities, such as hypertension, coronary artery, disease, and heart failure. Since vitamin D deficiency and OSA have independently been associated with CVD it is crucial to assess their relationship to each other. Few studies to date have examined the relationship between low levels of serum 25 hydroxyvitamin D (Vit-D) and risk for OSA. We aim to show a relationship between hypovitaminosis D and OSA in a large population.

Methodology:
We evaluated 813 participants in the World Trade Center-CHEST Program from January 2011 to September 2013. After excluding those taking vitamin D supplementation, analysis was performed on 624. Blood samples were analyzed for various laboratory parameters including Vit-D and hs-CRP. Vit-D insufficiency was defined as Vit-D < 30 ng/ml. Using the Berlin Questionnaire, a validated questionnaire to evaluate OSA risk, subjects were classified as low risk or high risk. In addition, those with self-reported physician diagnosis of OSA were classified separately. Independent t-test, ANOVA, and chi-squared analyses were performed.

Results:
Insufficient Vit D was noted in 74.5% (468) of the participants. Subjects who screened positive for high risk of having OSA had lower mean Vit-D levels compared with those with low risk for OSA. Those with the lowest mean Vit-D level were most likely to have a verified diagnosis fsleep apnea (p=0.015).

Conclusion:
A significant association was found between hypovitaminosis D and OSA in this study population. Those with high risk for OSA and diagnosed OSA have significantly decreased Vit D levels. It is imperative to evaluate Vitamin D levels and OSA risk in order to achieve optimal management of CVD.
Abstract 376: African-American Patients Presenting with Unexplained Syncope Have Significantly Worse Outcome Compared to Other Races: An ACAP-SELF Dataset Analysis
Authors: Pratap Balaji , Bastawrose Joseph , Pamidimukala Chaithanya , Patel Dipen , Kalamkar Prachi , Lingannan Archana , Panneerselvam Narmadha , Gurram Adilaxmi , Umali Tad , Shahanoor Ziasmin , Verzosa Joanna , Herzog Eyal , Aziz Emad F
Published: March 2022

Background:
In the US, 2 million people are evaluated for syncope annually. Published literature shows that of all ethnicities, African Americans (AA) are more likely to have comorbidities like hypertension, diabetes & lifestyle risk factors that translate to poorer outcome. Having published short-term outcomes showing worse outcome for AA with syncope, we followed up these patients over 5 years to evaluate long-term outcomes.

Methods:
3044 patients were prospectively followed after presenting with syncope. Patients were separated into five ethnic groups: Caucasians(30%), AA(30%), Hispanics(20%), Asians(3%) and others(17%). Patients or relatives were interviewed at least yearly during the follow-up period of 5 years. The primary endpoint was a composite of readmission for syncope, myocardial infarction, stroke or death.

Results:
AA were older with mean age of 68±20 years, had hypertension (72% vs. 60%, p<0.001), higher creatinine levels (1.5mg/dl vs. 1.2mg/dl, p< 0.001), diabetes (28% vs. 23%, p<0.001), heart failure (12% vs. 9%, p=0.04), and smoking (26% vs. 10%; p=0.003). Compared to all other races, AA had significantly worse outcome as seen by the KM curve in the primary endpoint (33% vs. 25%; HR 1.5; 95% CI: 1.25-1.75; p<0.0001).

Conclusions:
AA who are admitted with unexplained syncope are identified according to the SELF pathway as high risk group that can likely be attributed to the presence of comorbidities and warrants hospitalization for further work-up and optimizing medical management.
Abstract 384: Monitoring of Preoperative Anticoagulation Status in Post-PCI Patients on Warfarin Undergoing Non-Cardiac Surgery: Risk of Major Adverse Cardiac Events and Transfusion
Authors: Valle Javier A , Graham Laura , Derussy Aerin , Itani Kamal , Hawn Mary T , Maddox Thomas M
Published: March 2022

Background:
There is limited data on an optimal approach to preoperative INR screening in patients prescribed warfarin, with current guidelines lacking definitive recommendations on timing or need of INR assessment. Outcomes for these patients are largely unknown. Accordingly, we describe rates of pre-operative INR testing rates and its association with postoperative major adverse cardiac events (MACE) and transfusions among post-PCI patients on warfarin undergoing non-cardiac surgery (NCS).

Methods:
We identified all post-PCI VA patients undergoing NCS from 2004-2011 who were prescribed warfarin. Among these, we assessed rates and results of INR assessment (>1.5, ≤ 1.5, or unknown) within 5 days of NCS. We measured the association of INR status with 30d MACE and post-operative RBC transfusions, using multivariable regression analysis to adjust for cardiovascular and operative risk factors. We also adjusted for the use of perioperative bridging therapy with heparin products.

Results:
Among 1,357 post-PCI patients on warfarin undergoing NCS, 534 (39.3%) had an INR drawn within 5 days of surgery. INR was high (>1.5) in 166 (31.1%) and low (≤ 1.5) in 368 (68.9%). Unadjusted MACE rates were similar between those without an INR (5.3%), with a low INR (8.2%), and with a high INR (6.0%) (p-value = 0.17). PRBC transfusion was higher in those with a high INR (17.5%) compared to low (12.5%) or no INR (9.5%) (p-value=0.008). After adjustment, MACE was significantly associated with ESRD, prior MI, use of bridging therapy, and inpatient surgery status, but not INR status (Table). PRBC transfusion was associated with a high INR (OR 3.95, CI 1.91-8.17) and use of bridging therapy with heparin (OR 1.81, CI 1.07-3.05).

Conclusions:
Strategies for monitoring and managing cardiac patients on warfarin are heterogeneous in the pre-operative period, with nearly half of patients undergoing NCS without pre-operative INR evaluation. The presence of a high INR value predicted pRBC transfusion, but not MACE. Our study suggests a role for pre-operative screening of INR in patients on warfarin to assess risk for post-operative bleeding.
Abstract 132: Transvenous Lead Extraction: One Center Experience
Authors: Yager Neil , Balulad Sujata , Hosannah Hilton , Venditti Ferdinand J , Tan Henry
Published: March 2022

Introduction:
Indications for cardiovascular implantable electronic devices (CIED) and implant procedures for the management of arrhythmia and heart failure continue to grow. Transvenous lead extraction (TLE) is the gold standard for treatment of CIED-related infection and lead malfunction. Operator experience and pathological issues, such as lead adhesions, can affect results and complications rates of TLE. Comparative safety and efficacy associated with TLE of implantable cardioverter-defibrillator (ICD), bi ventricular ICD (BIVICD or ICD+ LV lead) and pacemaker (PPM) leads for our center have not been characterized.

Methods/Results:
Retrospective chart analysis was done of 75 patients (63 males; mean age 65
+
14.8 years) using ICD-9 codes for TLE indications, techniques, results and associated complications (April 2006 to July 2013).

TLE was done for ICDs 41%, BIVICD 32% and PPM 27% of the time. The most common cause (88%) of extraction was device related infection. Other causes were lead fracture, malfunction and patient request (12%). Primary prevention ICD (+/- LV lead) was the most commonly extracted device (56%) TLE due to infection was seen in patients with diabetes (DM 30%), chronic renal insufficiency (CRI 11%), end stage renal disease on hemodialysis (ESRD on HD 11%) and in patients with device and nondevice related procedures in the year prior to TLE (38%). Methicillin sensitive staphylococcus aureus was the most common organism (29%).

Laser assisted TLE (31%) was required in superior vena cava (SVC) coil extraction at the SVC/atrial (70%) scar site and in lead extraction at subclavian vein (26%) scar for both right atrial and ventricular (RA/RV) leads. RA tip fragment was abandoned in scar tissue in 4 patients. Interventional radiology assisted atrial tip retrieval was done in one patient. One TLE related atrial tear was repaired by cardiac surgery. There were 5 deaths unrelated to the TLE procedure.

Conclusion:
Of the total 75 patients with TLE, infection was more common in patients with DM, CRI, ESRD on HD and in males. Our experience showed that primary prevention ICD (+/- LV lead) was the most commonly extracted device. In our center, TLE success rate was independent of the cause of TLE, age of the patient, and may be related to operator experience and technique.
Abstract 145: REcovery after in HoSpital Cardiac Arrest: Late Outcomes and Utilization (ResCU) - Study Overview and Recruitment Process
Authors: Hanisko Kaitlyn , Bucy Rachel , Ewing Lee , Davis Jennifer , Youles Bradley , Kepreos Kyle , Lehrich Jessica , Guyer Heidi , Chan Paul , Iwashyna Theodore J , Nallamothu Brahmajee K
Published: March 2022

Background:
In-hospital cardiac arrest (IHCA) is common and associated with considerable morbidity, mortality, and resource costs. Understanding patterns of long-term outcomes is essential in those who survive IHCA. However, there has been limited data on patient-reported outcomes among survivors, in part because they are believed to be difficult to access.

Objective:
To assess the feasibility and acceptability of a centralized phone-based survey of patient-reported outcomes among Veteran survivors of IHCA 1 year post-discharge.

Methods:
Veteran survivors of IHCA (ICD-9-CM codes 99.60, 99.63 or 427.5) who were discharged from a VA Medical Center from September 1, 2013 to October 31, 2013 were identified. After confirmation of eligibility by medical record review, they were sent a research information packet. Those who did not opt-out were contacted by phone 2 weeks later. Research Assistants (RAs) were trained to address any study related concerns and complete IRB-approved informed consent. Veterans who consented were surveyed by phone or mail. If a Veteran was not reached at first contact, RAs followed a call back procedure of attempting subsequent calls at different times of the day and alternate contacts. A $10 gift card was offered to participants for their time completing the survey.

Results:
The recruitment and enrollment process is detailed in Figure 1. In this pilot study, we achieved a 74% (37 of 50) survey completion rate in a national cohort of 1-year survivors of IHCA. This required 323 call attempts, of which 70 calls reached patients. The remaining calls included voicemails (n=61), speaking to an informant (n=19), call-backs (n=18), and other (e.g. busy signal, no answer (n=155)). RAs completed 35 phone surveys and 2 mailed surveys; 1 Veteran died between consent and survey. The median respondent required 4 calls to complete the survey, interquartile range 2-6. The mean total call length (including consent and survey) was 22.9 minutes (median 20 minutes, interquartile range 17-26), with mean total survey length of 16.6 minutes.

Conclusion:
High recruitment and survey completion rates are feasible among survivors of IHCA without prior contact, 1 year post-discharge. This process will be applied to ResCU’s prospective cohort and adapted to ensure continued participation at 3, 6, 9 and 12 months post-discharge.
Abstract 151: Guideline Concordance of New Statin Prescriptions (Who got a Statin?)
Authors: Cascino Thomas , Vali Marzieh , Bravata Dawn , Redberg Rita , Keyhani Salomeh
Published: March 2022

Background:
Statins are recommended for the treatment of cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD). The 2013 ACC-AHA guidelines for the management of cholesterol was the first major update in the management of cholesterol since the 2004 guideline (ATP III). The new guidelines expand the number of patients recommended to receive statin therapy compared to ATP III with the greatest increase among patients taking statins for primary prevention. Despite the prevalence of statin use, little has been published about the indications for new prescriptions and the concordance of statin prescriptions to guidelines.

Objective:
To assess the concordance of new statin prescriptions in the Veterans Health Administration (VA) compared with the ATP-III (the guidelines in force in 2012) and the ACC-AHA guidelines.

Methods:
Using national data, we identified every patient who had received a new statin prescription (no statin use in the prior year) in the VA in 2012. Patients were excluded if they had less than 2 primary care visits or if they had incomplete data. Data on age, risk factors, and clinical conditions were extracted. Framingham and ACC-AHA 2013 cardiovascular risk calculator scores were calculated to determine estimates of 10-year risk for ASCVD for all patients. Statin use was compared with the recommendations of ATP III and the ACC-AHA guidelines. We considered all age ranges to be concordant with the guideline.

Results:
We identified 266,008 new statin prescriptions in 2012 in the VA, of which, 156,756 patients had complete data. Among statin prescriptions, 85% (133,434 of 156,756) were prescribed for primary prevention and 15% (23,322 of 156,756) were prescribed for secondary prevention. Mean age was 62 and 68 among patients receiving statins for primary and secondary prevention, respectively. The respective median Framingham risk score and ACC-AHA scores were 16 (IQR 10 to 20), and 19.26 (IQR 11to 32) among patients receiving statins for primary prevention. Among patients receiving statins for primary prevention, 23% (31,085 of 133,434) did not have an indication supported by the ATP III guidelines and 20% (26,413 of 133,434) did not have an indication supported by the ACC/AHA guideline. Within patients who received a statin for primary prevention, 9% (11,716 of 133,434) were less than 45 years old, 14% (18,210 of 133,434) were greater than 75 years old, 0.28% (373 of 133,434) were receiving dialysis, 2% (2,702 of 133,434) had evidence of terminal cancer or were receiving end of life care, and 0.06% (83 of 133,434) had evidence of severe congestive heart failure or severe chronic obstructive pulmonary disease.

Conclusions:
Among veterans, the majority of statins are prescribed for primary prevention. One in 5 veterans received a statin for an indication not supported by either guideline. These findings present an opportunity to reduce inefficient care.
Abstract 177: Residual Angina Following Elective PCI in Patients with Diabetes
Authors: Grodzinsky Anna , Arnold Suzanne V , Tang Fengming , Jones Philip G , McGuire Darren K , Goyal Abhinav , Spertus John A , Jang Jae-Sik , Beltrame John , Kosiborod Mikhail
Published: March 2022

Background:
While patients with diabetes (DM) have more diffuse coronary artery disease (CAD), the data on whether they experience more (or less) angina than patients without DM are conflicting. Although older studies suggested that patients with DM have less angina (due to silent ischemia), this has been contradicted by more recent work among patients after myocardial infarction. However, the prevalence of angina after PCI in patients with DM and stable CAD has not been examined.

Methods:
In a 10-site US PCI registry, we assessed angina in patients before elective PCI and at 1, 6, and 12 months after PCI with the Seattle Angina Questionnaire (SAQ) angina frequency (AF) score (range 0-100, higher=better). We also examined the rates of antianginal medication prescription at discharge. A multivariable, repeated measures Poisson model including demographic and clinical variables such as multivessel coronary disease was used to examine the association of diabetes with angina.

Results:
Among 1080 elective PCI patients (mean age 65, 74.7% male), 34.0% had DM. At baseline, 1, 6, and 12 months, patients with DM had similar angina prevalence as those without DM (Figure). In addition, when assessed as a continuous variable, SAQ AF scores were also similar at baseline and each follow-up for patients with DM vs. without DM (Figure). Patients with DM were more commonly prescribed calcium channel blockers and nitrates at discharge (DM vs. not: 27.9% vs 20.9% [p=0.01] and 32.8% vs. 25.5%, [p=0.01], respectively), while beta-blockers and ranolazine were prescribed at similar rates. In the multivariable, repeated measures model, the risk of angina remained similar at 1 and 12 months, and was slightly higher at 6 months in patients with vs. without diabetes (1 month: RR 1.10, 95% CI 0.84-1.44; 6 month: RR 1.24, 1.06-1.44; 12 months RR 1.04, 0.80-1.36).

Conclusions:
Patients with stable coronary artery disease and diabetes exhibit a burden of angina that is at least as high as those without diabetes, despite more aggressive antianginal prescription at discharge. These findings contradict the prevailing “conventional wisdom” which dictates that patients with diabetes experience less angina due to silent ischemia.
Abstract 181: Exploring Symptom Clusters in People with Heart Failure: A Latent Profile Analysis
Authors: Park Jumin , Johantgen Meg
Published: March 2022

Background:
A symptom cluster is a group of two or more symptoms that occur together and are related to each other. It is important to explore symptom clusters in heart failure (HF) because patients with HF generally experience multiple symptoms that often occur simultaneously in groups or clusters rather than in isolation. The purposes of this study are to identify symptom clusters in patients with HF and to determine socio-demographic and clinical characteristics influencing symptom cluster membership.

Methods:
The study used existing data in a cross-sectional design. The data were obtained from 4,076 HF patients recruited from in- and out-patients settings from the United States. Symptoms were identified from the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Five physical symptoms and three psychological symptoms were examined: edema, shortness of breath, fatigue/increased need to rest, fatigue/low energy, sleep difficulties, worrying, feeling depressed, and cognitive problems. Latent profile analysis was used to identify symptom clusters.

Results:
Four relatively distinct classes were identified: all mild symptoms (28%), moderate physical symptoms (26%), moderate psychological symptoms (14%), and all severe symptoms (33%). Significant differences among the four latent classes were found for several characteristics including age, gender, ethnicity, educational level, body mass index (BMI), and New York Heart Association (NYHA) functional classification.

Conclusion:
Identification of four clusters of HF symptoms may be useful in helping patients and clinicians recognize symptoms as a group versus individual and unrelated symptoms. These clinical insights may lead to the development and testing of novel symptom management interventions. The study also suggested that socio-demographic and clinical characteristics are important considerations when assessing the clusters.
Abstract 21: Stroke Physician Report Cards Improve Physician Response Times for Thrombolytic Treatment
Authors: Yanase Lisa , Corless Leslie , Stuchiner Tamela , Baraban Elizabeth
Published: March 2022

To assess whether direct comparative feedback changes stroke physician behavior to improve Emergency Department (ED) page-to-stroke physician arrival, ED page-to-needle and door-to-needle (DTN) times in thrombolytic therapy for acute ischemic stroke.

Background:
Rapid thrombolytic therapy improves stroke outcomes. Interplay between ED processes and stroke physician behavior influences treatment times. We noted a broad range of intervals between times the physician was paged, to arrival and treatment among 4 Board-certified Vascular Neurologists at two affiliated Primary Stroke Centers.

Method:
In January 2013 a physician report card was implemented, comparing each physician to the group’s mean and median time points for all 2012 stroke treatment cases. Report cards were then provided quarterly. The pre-implementation (2012) and post-implementation (2013) intervals for overall and individual median page-to- physician arrival, page-to-needle and DTN times were compared using a Mann-Whitney U test. Included in this analysis were all treatment cases that did not have a documented reason for delay (per Target Stroke criteria).

Results:
Between the pre and post implementation period, the overall median physician page-to-response time decreased by 8.0 minutes (p=0.001). The range of median difference for individual physician page-to-response time was 3-11 minutes. The overall median physician page-to-needle time decreased by 8.0 minutes (p=0.004). The range for the median difference for individual physician page-to-needle time was 5.5-11 minutes. The overall median door-to-needle time decreased by 5 minutes (p=0.104), however, this was not significant. The range for change in individual physician median door-to-needle times was -1 to 9 minutes.

Conclusion:
The results show that direct, personal and comparative feedback to stroke physicians influences their page-to-response, page-to-needle times and may affect DTN times. There was a clear trend overall, and the page-to-response and page-to-needle times showed significant improvement. Though our numbers were too small to detect statistical significance for individuals, the benefit of improved treatment times is likely clinically significant.
Abstract 218: Impact of Electronic Health Record Components on Hospitals’ Performance in Heart Failure and Myocardial Infarction Mortality and Readmission Rates
Authors: Saunders Victor F , Panjwani Anita A , Allen Norrina B
Published: March 2022

Background:
Cross-sectional studies have identified an association between the use of electronic health records (EHRs) and the quality of cardiovascular care; however, there is little longitudinal data to support this association. The objective of this study was to assess the impact of EHR implementation on heart failure (HF) and myocardial infarction (MI) 30-day mortality and 30-day readmission rates in the following two years.

Methods:
To measure hospitals’ implementation of EHR and its specific components, we used national data from the American Hospital Association (AHA) Health IT survey representing data for years 2009 and 2010. Hospitals which did not use EHRs in 2009 but did in 2010 were considered newly implemented. Hospitals which did not use an EHR system in either 2009 or 2010 were considered as not yet implemented and hospitals which were using EHRs in both 2009 and 2010 had already implemented EHRs. We examined the use of specific EHR components including clinical decision support tools, electronic clinical documentation, computerized provider order entry, the ability to generate quality data and the ability to electronically share patient data with outside hospitals. To assess hospital performance in HF and MI 30-day mortality/readmission rates, we used data from CMS Hospital Quality Initiative, Hospital Compare. We used baseline performance in 2010 and tracked change to 2012. We used a difference-of-difference statistical analysis to compare the change over time between hospitals with EHR components newly implemented to ones who had not yet implemented EHRs. We adjusted for hospital characteristics including bed size, region, profit-status and their baseline performance.

Results:
This study included 3300 hospitals that responded to both 2009 and 2010 surveys. In general, large, not-for-profit, and southern hospitals were significantly more likely to have implemented the different EHR components. For HF, implementation of two EHR components, ‘Clinical Discharge Summaries’ and ‘Electronic Exchange of Patient Data’ were significantly associated with slower increase in 30-day mortality as compared to hospitals who had not yet implemented them (p=0.01 and 0.002 respectively). Only the EHR component ‘Computerized Provider Order Entry of Lab Tests’ was significantly associated with a faster decrease in HF readmissions (p=0.03). For MI, none of the EHR components’ implementation was associated with changes in 30-day mortality. ‘Clinical Provider Order Entry for Radiology and Lab Tests’ were significantly associated with a slower increase in 30-day MI readmissions (p=0.03).

Conclusion:
Select components of EHRs have positive impact on heart failure 30-day mortality and myocardial infarction 30-day readmission rates. As hospitals and physician practices continue to adopt and expand their EHR systems these components and their potential benefits should be considered.
Abstract 229: Training Cardiovascular Outcomes Researchers: A Survey of Mentees and Mentors
Authors: Khazanie Prateeti , O’Brien Sean M , Al-Khatib Sana M , Crowley Matthew J , Wang Tracy Y , Peterson Eric D , Sanders Gillian D
Published: March 2022

Background:
Although many young investigators are interested in cardiovascular (CV) outcomes research, recent funding cutbacks may threaten the development of future leaders in this field.

Methods & Results:
From April-Nov 2014, we surveyed mentees and mentors to determine current training experiences of early CV outcomes investigators across the U.S. We contacted successful grantees of government agencies, members of professional organizations, and trainees within cardiovascular outcomes training programs by e-mail. There were 185/662 mentee and 76/541 mentor responses. Mentees were equally split by sex; most had completed training >3 yrs ago and were clinicians. Mentors were more likely female, mostly ≥20 yrs post-training, associate/ full professors, clinical, and mentoring 2-4 people. Over 80% mentees entered into training to be academicians and left with the same goal. Over 70% of mentees wanted to have >50% time for research in the future. Over 80% of mentors believed that future investigators would need >50% of their time dedicated to research efforts in order to be successful; 22% of mentors thought that future researchers needed more time than the mentors themselves had in their early careers. Most mentees (80%) reported that they were satisfied with their relationship with their mentor and had been given opportunities to develop independently. Mentors were more likely than mentees to report that funding cutbacks had negatively affected the ability to succeed (58% mentees vs. 84% mentors). Across funding mechanisms, mentees were more optimistic than mentors about securing funding (Figure). Both mentees and mentors reported greatest preparedness for job/career satisfaction (79% for both) and publications (84% vs. 92%) and least preparedness for financial futures (48% vs. 46%) and work-life balance (47% vs. 42%).

Conclusions:
Both mentees and mentors were optimistic about the future of cardiovascular outcomes research; however, they expressed pessimism regarding funding. Future studies should characterize the types of research that are currently being submitted and funded at different agencies to identify critical gaps and needs and to improve young investigators’ chances of obtaining independent funding.
Abstract 232: Cost-effectiveness Analysis of Lipoprotein Subfraction Testing in Patients at Intermediate Risk of Cardiovascular Events
Authors: Shiffman Dov , Arellano Andre R , Caulfield Michael P , Bare Lance A , Melander Olle , Devlin James J
Published: March 2022

Background:
The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease (CVD) in Adults defined 4 patient groups who would benefit from statin therapy. For patients who are not classified into a statin benefit group, and have an estimated 10-year CVD risk between 5% and 7.5%, the guidelines suggest that additional risk factors may be considered to inform moderate-intensity statin treatment decisions. Low density lipoprotein concentration (LDL-P) has been shown to be associated with incident CVD events among patients with <7.5% 10-year risk after adjusting for established risk factors.

Objectives:
To assess the cost-effectiveness of using LDL-P for risk assessment as an aid in making statin treatment decisions in patients with an estimated 10-year CVD risk of 5% to 7.5%.

Methods:
We conducted a cost-effectiveness analysis using a Markov model that assessed patient healthcare costs and outcomes from a payer perspective over a 5 year time horizon. A usual care strategy was compared with an LDL-P test-and-treat strategy in a hypothetical intermediate risk population_those with an estimated 10-year CVD risk of 5% to 7.5%. The test-and-treat strategy entailed testing LDL-P levels in 10,000 patients and treating only those in the top decile of LDL-P _those who would be reclassified above estimated 7.5% 10-year risk_with a moderate-dose statin therapy. Future cost and utilities were derived from published literature and were discounted at 3% annually. Single- and multi-variable sensitivity analyses were conducted to investigate the effect of the base-case assumptions on the difference in costs and quality-adjusted life years (QALYs) between the two strategies.

Results:
Compared with a usual care strategy, LDL-P testing of 10,000 patients followed by moderate-intensity statin therapy of patients in the top decile of LDL-P resulted in 17 fewer patients with CVD events, cost savings of more than $300,000, and about 13 additional QALYs over a 5 year horizon.

Conclusions:
CVD risk assessment by LDL-P testing of patients with estimated 10-year CVD risk of 5% to 7.5%, who were not classified into a statin benefit group, may be an event-reducing and a cost-saving strategy compared with usual care.
Abstract 237: Protocol-guided Weaning From Mechanical Ventilation in The Cardiac Intensive Care Unit
Authors: Konerman Matthew C , Grafton Gillian , Sinha Shashank S , Haas Carl F , Eakin Richard M , Leggett Scherolyn , Taylor Nikki , Nallamothu Brahmajee K , Gurm Hitinder S
Published: March 2022

Background:
Rates of prolonged mechanical ventilation (MV) in cardiac intensive care units (CICU) have significantly increased over the past few decades. MV is associated with numerous complications including prolonged ICU length of stay as well as increased mortality. The most effective method of liberation from MV includes a daily assessment of weaning readiness, interruption of sedation, and spontaneous breathing trials (SBTs). Effective weaning protocols require multidisciplinary collaboration between physicians, nurses, and respiratory therapists.

Methods:
We identified and implemented several quality improvement interventions to improve weaning from MV in the University of Michigan Health System (UMHS) CICU. We specifically changed the time of SBTs from 4-5 AM to 8-9 AM to promote physician involvement in weaning and improve physician-nursing-respiratory therapist communication. By performing SBTs during morning rounds, we intended to optimize physician communication with nursing and respiratory therapy regarding selection of patients for SBT, evaluation of SBT success, identification of barriers to weaning, and selection of patients for extubation. We hypothesized that these interventions would decrease MV time to initial SBT, duration of MV, and ICU length of stay.

Results:
We reviewed the clinical data and outcomes of 172 mechanically ventilated patients in the UMHS CICU (83 prior to and 89 following our intervention). Our intervention was associated with a trend toward decreased duration of MV (mean duration 4.95 vs. 3.66 days, p=0.13) and a trend toward a shorter ICU length of stay (mean duration 9.91 vs. 8.10 days, p=0.22) (Figure). Nonsignificant reductions in MV time to initial SBT (2.31 vs. 2.09 days, p not significant) and time from initial SBT to end of MV (2.40 vs. 1.82 days, p not significant) were also observed.

Conclusions:
These results suggest that a collaborative, multidisciplinary effort including physicians, nurses, and respiratory therapists may be effective in improving the care of mechanically ventilated patients in the CICU. Larger, multicenter studies further evaluating our protocol-guided weaning strategy are warranted to establish its efficacy in the management of these patients.
Abstract 243: A Novel Cost Effectiveness Model of Eicosapentaenoic Acid (EPA) for Secondary Prevention in the United States
Authors: Schmier Jordana K , Hulme-Lowe Carolyn , Nelson John R , Chowdhury Sumita , Everett P. Benjamin , Philip Sephy
Published: March 2022

Background:
Cardiovascular disease (CVD) is responsible for one in every four deaths in the United States as well as direct and indirect costs exceeding $100 billion. Each year in the US, 210,000 heart attacks and 185,000 strokes occur among patients who have previously experienced one. Given the substantial burden of CVD, a novel model was developed to explore the cost-effectiveness of a prescription EPA only omega-3 intervention among secondary prevention populations in the US.

Methods:
The framework and initial clinical data source for model input was the published Japanese EPA Lipid Intervention Study (JELIS) secondary prevention strata, which included major coronary and stroke endpoints. Two US-focused base case scenarios were developed based on published data: a standard and an aggressive scenario, with the aggressive scenario assuming a highly effective intervention. Costs and utilities were derived from published studies in the US, or the wholesale acquisition cost (WAC), in the case of prescription costs. The initial utility value assigned to this secondary prevention population was 0.78, with unique decrements for each event. Expert opinion was used when clinical assumptions were required for unreported data points. The model takes the perspective of a US, commercial, third-party payer. Costs are presented in 2014 US$. The model extends for 5 years and applies a discount rate of 3% to costs and benefits. Sensitivity analyses are presented to understand the influence of various parameters on outcomes.

Results:
Under the base case assumptions for the standard US scenario, EPA plus statins compared to statins alone was associated with cost savings (average 5-year costs $29,393 vs. $30,587 per person for EPA plus statins vs statins monotherapy, respectively) and improved utilities (average 3.61 vs. 3.56 respectively), denoting that the strategy of combining EPA with statin therapy exceeds accepted thresholds for cost-effectiveness when compared to statin monotherapy. The aggressive scenario was even more favorable for the combined strategy; being more cost-effective than statin monotherapy, with five-year savings ($29,707 vs. $38,793) and more utilities accrued (3.61 vs 3.50). The results of this model were found to be robust during sensitivity analyses exploring alternative scenarios, with consistent findings of cost-effectiveness or cost savings in the standard and aggressive US scenarios.

Conclusions:
This novel model suggests that combining EPA with statin therapy for secondary prevention of cardiovascular disease in the United States may be cost-saving and appears to be a more compelling intervention than statin monotherapy. The framework of this model provides a starting point for development of microsimulation models as more data become available.
Abstract 246: Potential for Healthy Survivor Bias Among Symptomatic Peripheral Artery Disease Patients with Long Follow-up: Comparing 1 Year Versus 3 Year Post-Index Outcomes
Authors: Chase Monica , Friedman Howard , Navaratnam Prakash , Heithoff Kim , Simpson Ross J.
Published: March 2022

Background:
A symptomatic peripheral artery disease (SPAD) study using a 1 year pre- and 3 year post-index window and an analysis that restricted observations to a 1 year pre-and post-index period were compared to determine if the longer length of follow-up in the first study impacted study outcomes due to a ‘healthy survivor’ bias.

Methods:
Patient records from Jan 1, 2006 through June 30, 2010 were extracted from the MarketScan Commercial and Encounters database (MCED). The earliest date of a record of SPAD was the index date. Patients with stroke/TIA, and contraindications to anti-platelet therapy were excluded in both analyses. Since mortality attrition is not captured in the MCED, comparative descriptive and univariate statistics comparing pre- and post-index demographics, comorbidities, concomitant medication use, CV and PAD related events and procedures, annualized resource utilization and costs between these two studies were generated and compared.

Results:
A total of 16,663 and 28,987 eligible SPAD patients were identified for the 3 year and the 1 year post-index populations. Baseline patient demographics, rates of comorbid illness and rates of concomitant medication use were similar between these populations. 1 year post-index SPAD patients had a higher annualized rate of inpatient, and outpatient service utilization. Both all-cause and PAD related annualized costs were higher in the 1 year post-index population when compared to the comparator 3 year post-index population (see Figure 1). It is possible that there is a ‘healthy survivor’ bias associated with the 1-year pre-/3-year post-index since resource use and costs are much higher in the study with shorter follow-up, indicating that attrition due to mortality may be driving outcomes in the original study.

Conclusions:
A comparative review of findings from these SPAD studies has revealed that the ‘healthy survivor’ bias may have led to an under-estimation of SPAD outcomes in the 1-year pre-/3-year post-index. A replication of the 1-year pre-/3-year post-index using a data source with mortality data is warranted.