bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 51: Neutrophil to Lymphocyte Ratio Predicts Mortality in Stage D Heart Failure Patients
Authors: Nagarajan Vijaiganesh , Cauthen Clay A , Tang WH Wilson
Published: March 2022

Background
Neutrophil to lymphocyte ratio (NLR) has shown to be a predictor of prognosis in acute heart failure and other disorders like pancreatitis and hepatocellular carcinoma, but utility of NLR in chronic heart failure has not been evaluated before. Our hypothesis is that NLR is an independent predictor of prognosis in advanced (“stage D”) chronic heart failure.

Methods
We reviewed 537 consecutive patients with stage D heart failure who underwent evaluation for advanced heart failure therapies from 2007 to 2010. Patients were divided into tertiles based on NLR. Predictors of NLR and mortality were determined. Survival was determined by chart review and confirmed by Social Security Death Index.

Results
In our study cohort (mean age 53.6 ± 12.8 years, 73% male, mean LVEF 21.6 ± 14.2%), higher NLR was associated with lower albumin (OR, 0.23, 95% CI, 0.16-0.34) and higher blood urea nitrogen (OR, 1.03, 95% CI, 1.01, 1.04). Death rates increased with NLR by tertiles (7.3%, 31.6%, and 41.8%). NLR (HR, 1.02, 95% CI, 1.01, 1.05) proved to be an independent predictor of mortality in a multivariate model including albumin and blood urea nitrogen.

Conclusion
In patients with advanced Stage D chronic heart failure, NLR is an independent predictor of mortality.

Figure 1:
Survival Analysis showing increasing mortality with increasing NLR by tertiles.
Abstract 54: An Assessment of Hypertension Care and Consistency of Blood Pressure Control in a General Medical Clinic
Authors: Katsouli Anthi , Pandey Tanu , Goldberg David
Published: March 2022

Introduction:
Nationally, in 2007-8, 69% of people with treated hypertension have blood pressure at target for control. African Americans and persons of lower socioeconomic status are disproportionately affected by hypertension and have lower rates of controlled BP. Although economic, social and behavioral risk factors partially explain these differences in health status, the quality of healthcare may also contribute to poor outcomes among ethnic minorities. We conducted a study to assess the quality and consistency of hypertension care in a general medical clinic (GMC) of a safety net hospital that serves a vulnerable population.

Methods:
A retrospective chart review of established patients with hypertension was conducted in GMC at John Stroger Hospital of Cook County. Patients were selected using a random sampling method over two weeks. BP control was defined as <140/90 mmHg. Consistent control was defined as BP<140/90 on 4 or more visits. Stage 2 HTN was defined as BP>160/100. The primary outcome measure was proportion with controlled and consistent BP.

Results:
Of the 200 charts, 108 met inclusion criteria. The mean age was 63 (23-90 years); 56% (60 of 108) were women, 68% (73 of 108) were African American. Dyslipidemia was the most common co-morbidity (82 of 108), followed by diabetes mellitus (59 of 108). The sample had BMI of 32 and 52% ( 56 of 108) had controlled BP and 12% (13 of 108) had stage 2 HTN at the index visit. Only 8% (9 of 108) never had controlled blood pressure across the five visits and 27% (29 of 108) ever had stage 2 HTN. In the overall sample, 42% ( 46 of 108) had consistent control of BP. Among those with controlled BP at the index visit, 73% ( 41 of 56) had consistent control. Among those with elevated BP at the index visit, only 7% (6 of 52) had consistent control.The consistency was not predicted by age, gender, ethnicity, diabetes or number of medications.

Conclusion:
Among a largely minority population of hypertensive patients and multiple co-morbidities we found deficits in control of BP. Just over half had controlled BP at the index visit, less than half have consistent control of their BP. To approach national rates of control of blood pressure and improve the consistency of control, we recommend a clinic based quality improvement effort
Abstract 57: Reduction Of Cardiovascular Admissions From The Emergency Department: A Coordination Of Care Model Using Early Access To Specialists After Normal Working Hours
Authors: Gavin Michael C , Lu Jonathan C , Ho Kalon K , Ullman Edward , Nathanson Larry A , O'Halloran Thomas D , Pinto Duane S , Zimetbaum Peter J
Published: March 2022

BACKGROUND:
Despite the implementation of diagnostic and treatment algorithms for many common cardiovascular (CV) complaints, identifying low- and intermediate-risk patients presenting to the emergency department (ED) who could be managed without hospital admission remains difficult. We hypothesized that the presence of an attending cardiologist in the ED after normal working hours can help reduce the number of avoidable CV admissions by providing ED physicians with the support needed to identify, manage, and safely transition patients to the outpatient setting.

METHODS:
Beginning 08/22/2011, an attending cardiologist was available to consult on ED patients on weekdays between 6PM and midnight. The study population included all patients seen in the ED of an academic medical center on weekdays from 08/22/2011 to 11/30/2011 presenting in the afternoon/evening with a primary diagnosis of chest pain, atrial fibrillation (Afib), congestive heart failure (CHF), and syncope (based on ICD-9 diagnostic coding). Consultations were requested by the ED attending for patients where the intention was for inpatient admission, or where the disposition decision was complex. Rates of inpatient admission and 30-day return visit to the ED were compared to the same time period in the previous year using the Fisher’s exact test.

RESULTS:
Among patients presenting to the ED with one of the diagnoses of interest during the study period, there was a significant decrease in the inpatient admission rate compared to the same period in 2010 (52.0% vs. 38.6%; p<0.001, see Figure). Baseline clinical characteristics of the 2 cohorts were similar. During the study period, 174 consults were performed by the evening attending cardiologist with the diagnoses of interest accounting for 53% (n=93) of these. The decrease in admission rate was largely driven by an increase in the proportion of patients with chest pain being managed with observation in the ED (36.9% vs. 51.1%; p<0.001), and a decrease in the percentage of patients with Afib being admitted (61.1% vs. 45.0%; p=0.02). The incidence of return visits to the ED within 30-days following discharge did not increase (13.0%, 46/353 vs. 8.8%, 35/399; p=0.08).

CONCLUSION:
A program involving cardiology staff in the coordination of disposition decisions in the ED after normal working hours resulted in a reduction in the number of inpatient admissions for common CV conditions without increasing the incidence of return visits to the ED within 30 days.
Abstract 61: Are Door to Balloon Times An Adequate Measure of STEMI Acute Care?
Authors: Lawson William E , Wilbert Lisa , Chung William , Mygland Kari , Sokoloff Lisa , Greene William
Published: March 2022

Background:
Early reperfusion of patients with STEMI, with a target door to balloon (D2B) time < 90 min, is a core measure of acute myocardial infarction treatment. However, it only applies to patients going to the lab emergently. Patients with STEMI may undergo catheterization outside this initial window or may be unrecognized and not undergo catheterization at all. This study was performed to identify patients with an ECG consistent with an acute MI and clarify the reasons they did not undergo catheterization during their admission.

Methods:
During the period of January- July 2011 all patients with an ECG consistent with STEMI were identified by interrogation of the MUSE computerized ECG system. This list of patients was compared to the list of patients undergoing cardiac catheterization to identify those patients with ECG evidence of STEMI that did not undergo catheterization. This list was analyzed for common factors and to clarify whether care was appropriate and timely.

Results:
During the observed time period there were 217 patients with STEMI by ECG. Emergency revascularization was requested in 88, with 8 subsequently cancelled. The median D2B time was 60.5 minutes [D2B time from our ED was 62.5 minutes, 43 minutes for transfer patients from arrival time at Stony Brook]. During their admissions 148 of the patients underwent cardiac catheterization; 62 did not undergo catheterization. The single largest (25 patients) subgroup ruled out for myocardial injury; ECGs reflected early repolarization, prior infarction. The 2
nd
largest subgroup (15 patients) had serious comorbidities (active GI bleeding 2, intracerebral bleeding/acute CVA 7, sepsis/DIC 3, multiple comorbidities 3). A subgroup of 10 patients refused cardiac catheterization or were DNR/DNI. Myocarditis was diagnosed in 3 patients. The work-up to rule out MI was incomplete in 7 patients. Two patients died in the ED prior to reaching the cath lab. Overall 11 of the 62 patients not undergoing catheterization died.

Conclusions:
The D2B time is an important quality measure STEMI treatment. However, it is important to ensure that STEMI patients are not being missed and that treatment is not delayed. Comparing all patients with an ECG consistent with STEMI with those undergoing emergent catheterization for STEMI allows opportunities for improvement in the system to be identified and modified and should be a part of the ongoing quality assurance monitoring system.
Abstract 63: Hospital Length of Stay after Percutaneous Coronary Intervention among Acute Coronary Syndrome Patients Treated with Clopidogrel or Prasugrel in a United States Hospital Database
Authors: Bae Jay , Ernst Frank , Lipkin Craig , Faries Douglas , Zhao Zhenxiang , Moretz Chad
Published: March 2022

Background:
Research on the use of newer antiplatelet agents and their outcomes from a real-world setting is scarce. Hospital length of stay (LOS) has been used as a measure for resource use and as a proxy for patient outcomes. We analyzed a large geographically diverse database from the US and compared LOS between patients on clopidogrel or prasugrel. Patients were hospitalized for acute coronary syndrome (ACS) and had undergone percutaneous coronary intervention (PCI).

Methods:
Using a large database maintained by PREMIER, Inc., we analyzed patient characteristics and LOS during the index (first) hospitalization among ACS-PCI patients treated with clopidogrel or prasugrel between July 2009 and June 2011. Observed LOS was analyzed with t-tests. A multivariate regression model with a negative binomial distribution was used to evaluate differences in LOS, adjusting for the following covariates: age, ACS type (non-ST-elevation myocardial infarction [NSTEMI], STEMI, Unstable Angina [UA]), gender, race, renal insufficiency, diabetes, anemia, heart failure, number of vessels, bleeding events, and comorbidities based on the Charlson-Deyo weighting of disease states.

Results:
Data were available for 75,315 patients who received clopidogrel and 9,483 patients with prasugrel. For clopidogrel and prasugrel, respectively, the observed mean LOS (SD) was 3.5 (4.4) days and 2.9 (2.4) days (P<0.0001) for the overall study population, and 4.0 (5.2) days and 3.3 (2.4) days for STEMI (P<0.0001), 3.9 (4.6) days and 2.9 (2.5) days for NSTEMI (P<0.0001), and 2.5 (2.4) days and 2.1 (1.8) days for UA (P<0.0001). The overall adjusted LOS results similarly showed statistically significantly shorter LOS for prasugrel-treated patients than clopidogrel-treated patients.

Conclusion:
In this study, prasugrel- treated patients had a shorter average LOS compared to clopidogrel-treated patients. After adjusting for patient demographics and clinical characteristics, the results still held. The unobserved confounder bias, however, may exist in this real-world observational database research.
Abstract 64: High Adherence to Colesevelam HCI Associated with Lower Risk of Major Cardiovascular Events
Authors: Ye Xin , Qian Chunlin , Li Tracy
Published: March 2022

Introduction:
Medication adherence is a challenge in chronic disease management. Poor medication adherence may lead to suboptimal health outcomes for patients and negative economic impact on healthcare resources.

Hypothesis:
High adherence to colesevelam is associated with lower risk of major cardiovascular events of acute myocardial infarction (AMI) and stroke, among hyperlipidemia and/or type 2 diabetes mellitus (T2DM) patients newly treated with colesevelam.

Methods:
Thomson Reuters Marketscan 2007-2010 Commercial and Medicare databases including inpatient, outpatient and pharmacy claims were utilized for this study. The first colesevelam prescription fill date during this period was identified as the index date. The study sample consisted of hyperlipidemia and/or T2DM patients initiating colesevelam, with at least 6 months continuous enrollment before and after the index date. Adherence to colesevelam was measured as Medication Possession Ratio (MPR), calculated as total days of supply during one-year period after the index date (adherence cohort assignment period (ACAP)) divided by 365. Patients were assigned to one of three adherence cohorts (High: MPR≥0.8, medium: 0.5≤MPR<0.8, low: MPR<0.5.). The outcome was the time to the first hospitalization with a primary diagnosis for AMI or stroke during the follow up period, which began at the end of ACAP and continued to the end of the enrollment period or December 31, 2010, whichever occurred first. Association of colesevelam adherence and the outcome was examined by multivariate Cox regression, adjusting for patient demographics, baseline comorbidities, concomitant medications, and AMI or stroke during ACAP.

Results:
A total of 31,017 patients met the inclusion criteria and were included in the analysis, of which 5,696 (18.4%), 4,643 (15.0%), 20,678 (66.7%) were high, medium and low adherence, respectively. As compared to the low adherence group, the high adherence group was older, had more males, had more baseline cardiovascular risk factors, and had greater use of concomitant medications. Compared to patients with low adherence, high adherence patients were about 41% less likely to experience AMI or stroke hospitalization during the follow up period (Hazard Ratio: 0.59; 95% CI, 0.41 - 0.84, P=0.004). Other factors associated with significantly lower risk of AMI or stroke hospitalization included female gender, younger age, absence of baseline transient ischemic attack or coronary heart disease, absence of concomitant use of aliskiren, insulin or metformin, and absence of AMI or stroke during ACAP.

Conclusions:
High adherence to colesevelam was significantly associated with lower risk of major CV events (AMI and stroke) among hyperlipidemia and/or T2DM patients. The finding suggests that interventions to improve adherence to colesevelam in these patients may have long-term cardiovascular benefits.
Abstract 68: Gender Differences In Functional Status Following Myocardial Infarction. A Systematic Review Of The Literature.
Authors: Kucharska-Newton Anna , Jones Sara , Handler Lara , Kalbaugh Corey , O'Brien Emily , Patel Mehul , Fares Wassim , Platts-Mills Timothy , Rosamond Wayne
Published: March 2022

Background:
Evaluation of functional status following myocardial infarction (MI) is essential for long-term prognosis and treatment. We hypothesized that functional status following hospitalized MI is lower among women as compared to men.

Methods:
Peer-reviewed articles that presented functional status stratified by gender were identified from MEDLINE, PsycInfo, CINAHL, Embase, and the Cochrane Database of Systematic Reviews (Jan. 1, 1991-May 20, 2011) using the terms: myocardial infarction, acute coronary syndrome, functional status, and quality of life. A priori exclusion criteria included: non-English language, review papers, expert opinions or discussions, case reports, studies without original data, samples without MI patients or measures of physical functioning; studies not on adults or studies restricted to all men or all women; and studies with outcomes not stratified by gender or MI status. Initial search identified 2102 articles/abstracts. Based on eligibility criteria, we excluded from initial review 1537 articles. Title and/or abstract review of remaining 565 studies led to further exclusion of 491, leaving 74 articles. A full-text review narrowed this to 30 articles which were then abstracted.

Results:
Average follow-up time after MI was 11.8 months (range: 0-89 months) with average number of study participants 879 (range: 60-2950). Majority of the studies (n=23, 77%) used generic, rather than disease-specific, health-related quality of life questionnaires (e.g. SF-36) to assess functional status. Of the 30 articles abstracted, 26 (87%) reported better functional status in men with MI as compared to women with MI. Effect of age, comorbidities, and clinical variables on association of gender with functional status following MI was assessed in 5 studies and found to attenuate gender differences to non-significant level in 2 studies. Increase in gender-related differences in functional status after MI was reported in 2 of 5 studies that evaluated change in functional status over time.

Conclusions:
Functional status of women with MI is on average worse than functional status of men with MI. Differences in clinical variables, age, and comorbidities may partly explain gender differences in post-MI functional status.
Abstract 72: Increased Risk Of Reinfarction And Death In Patients Using Sedatives After First-time Myocardial Infarction - A Nationwide Propensity Score Matched Study
Authors: Gislason Gunnar H , Fosbol Emil L , Schjerning Olsen Anne-Marie , Kober Lars , Torp-Pedersen Christian
Published: March 2022

Background:
Anxiety and sleep deprivation is associated with higher levels of circulating catecholamines and adrenergic stress, which may increase cardiovascular risk. We examined risk of recurrent myocardial infarction and death related to use of sedatives as a proxy for anxiety and sleeplessness in patients after first-time myocardial infarction.

Methods and population:
Patients, without prior psychiatric disease, surviving 30 days after discharge from first-time MI 1997-2009 and their subsequent drug use was identified by individual-level-linkage of nationwide registers hospitalization and drug dispensing from pharmacies in Denmark. Propensity scores for use of sedatives within the first year were calculated by logistic regression analysis conditional on baseline characteristics. Patients using sedatives were matched on propensity scores with 1 control not receiving sedatives and risk of recurrent myocardial infarction and death within the first-year after discharge was compared using cumulative incidence curves and Cox proportional-hazard models.

Results:
A total of 24,217 patients using sedatives after discharge and 24,217 matched controls, who were balanced in baseline characteristics, were included. The mean age was 71 years (SD 12.5 years) and 55% were males. Recurrent myocardial infarction by 1 year was observed in 2,411 (10%) patients using sedatives and 1,928 (8%) controls (Fig.); adjusted hazard Ratio (HR) 1.26 (1.18-1.36). In a separate analysis, dividing sedatives into anxiolytics and hypnotics yielded a HR of 1.18 (1.10-1.26) and 1.21 (1.14-1.29), respectively. Patients using sedatives had increased 1 year mortality relative to controls, HR 1.15 (1.09-1.21), but mortality was higher in patients using anxiolytics compared to hypnotics, HR 1.24 (1.16-1.33).

Conclusion:
Patients using sedatives after MI are at increased risk of recurrent myocardial infarction and death and may be targets for more aggressive approach to secondary preventive interventions.
Abstract 73: Effect Of A Lifestyle Improvement Program Using Cardiac Rehabilitation Resources On Metabolic Syndrome Components
Authors: Rodriguez-Escudero Juan P , Somers Virends , Heath Amy , Thomas Randal , Squires Ray , Lezlie Johnson , Lopez-Jimenez Francisco
Published: March 2022

Objective
We studied the effect of a lifestyle therapy program using the resources already available in a cardiac rehabilitation setting for patients at risk for metabolic syndrome (MetS).

Methods
We created a six-week cardiometabolic program (CMP) using facilities and resources of a cardiac rehabilitation setting. The CMP included a minimum of 6 once-a-week 60 min sessions consisting of exercise training and nutrition instruction, in addition to 6 once-a-week 60 min group behavioral modification classes following the LEARN program. We also assessed the outcomes in 239 patients (pts) who had at either obesity or hyperglycemia: 58 pts had enrolled and completed the CMP, 58 pts had signed up for the CMP but either never attended or dropped out early (Control 1) and had follow-up data, and 123 pts had not signed up for the CMP but had been seen in the outpatient preventive cardiology practice at the Mayo Clinic (Control 2). We compared changes in components of the MetS from baseline to six weeks (for the CMP group) and at 6 months for all pts.

Results
Of 187 people who signed up for the CMP, only 62 completed the program and from those, 58 gave authorization to use their clinical data in research. Of the 125 that never attended or dropped out early, 58 had follow-up data. Clinical characteristics of the CMP, Control 1, and Control 2 groups and improvement in each of the outcome measures are shown in the Table. In the CMP group, there was a significant improvement at 6 weeks in waist circumference, weight, diastolic blood pressure and total cholesterol. At 6 months the fasting glucose had also significantly improved. In contrast, improvements in Control 1 and Control 2 were modest at best. See Table. When comparing the 6 month changes in the CMP and Control 1, those in the CMP had more pronounced weight loss (-4.5±5 kg vs -0.14±6 kg, p<0.001); decrease in systolic blood pressure (-1.1±17 mmHg vs +9.6±20 mmHg, p=0.004); and decrease in diastolic blood pressure (-4.6±11 mmHg vs +3.4±15 mmHg, p=0.0017). Similarly, comparing CMP vs Control 2, a significantly greater drop in body weight (-4.5±5 kg vs -0.9±3 kg, p<0.001) and in diastolic blood pressure (-4.6±11 mmHg vs -0.7±9 mmHg, p=0.0202) was noted in the CMP. The change in the number of MetS components per patient dropped significantly, favoring the CMP group compared with the control groups.

Conclusion
A lifestyle therapy program for patients at risk for MetS can be implemented using existing resources of a cardiac rehabilitation program, although enrollment and completion rates are low. Such a program, however, is effective at improving cardiometabolic outcomes in individuals at risk for MetS.
Abstract 78: Reperfusion therapy and door-to-balloon time among ST-elevation Myocardial Infarction patients in Northern Italy.
Authors: Veronesi Giovanni , Borsani Andrea , Marzegalli Maurizio , Merlino Luca , Cesana Giancarlo , Ferrario Marco M
Published: March 2022

Aim
. Guidelines recommend early reperfusion therapy for patients with ST-elevation Myocardial Infarction (ST-e MI). We aim to evaluate the adherence to guidelines in Northern Italy in 2007-2008.

Methods
. The study population comprises the 35-79 years old residents in the Varese Province. From the regional Hospital Discharge Record database we identified n=1229 hospitalizations with a main discharge code ICD-IX 410.xx not 410.7x occurring in the 17 surveyed hospitals. Clinical information was available for n=1221 events; particular attention was dedicated to the time of symptoms onset, ER arrival, first ECG, fibrinolytic therapy and Percutaneous Coronary Intervention (PCI) execution. Finally, n=49 non acute events were excluded, leaving a final number of n=1172 hospitalizations. The main performance measure is the proportion of patients receiving reperfusion therapy (either fibrinolysis or PCI) among those without documented contraindications to therapy. We further considered a sex- and age at admission-adjusted analysis, through a logistic model. The median door-to-balloon time (time between ER arrival and PCI) was computed among nontransfer patients admitted to a ST-e MI receiving facility who did not receive fibrinolysis (n=488).

Results
. Mean age at admission was 63.8±10.7 years, 74.5% were men. A documented contraindication to therapy was present in 1.4% of the records. Reperfusion treatment (either fibrinolysis or PCI) was administered to 74.7% of eligible patients. Treatment prevalence differed by gender (p-value: 0.04) and age (p-value: <.0001), being lower for women and the elderly (75-79 years old). The time of PCI execution was available on 74% of records. The overall median door-to-balloon time was 123 minutes. Considering primary PCIs (within 6 hours from ER arrival; n=227, 63%), the median time reduced to 74 minutes, and 65% of procedures fulfilled the recommended 90 minutes. This proportion decreased with age (p<0.05) but did not differ by gender.

Conclusions.
More efforts are needed to raise the prevalence of reperfusion treatment and to shorten the door-to-balloon time for primary PCI, especially among women and the elderly. To improve data completeness, a better standardization of clinical records is desirable.
Abstract 85: Target Heart Rate Determinants, ECG and Echocardiographic Responses to Supine Bicycle Dobutamine Testing in Chest Pain Evaluation
Authors: Yager Neil , Bindra Amarinder , Rastogi Ashish , Fein Steven A , Torosoff Mikhail
Published: March 2022

Background:
We investigated the impact of the addition of supine bicycle exercise to standard dobutamine stress echocardiography in patients referred for evaluation of chest pain.

Material and Methods:
Results of 210 consecutive dobutamine stress echocardiographic tests with (SBDT group: 93 patients, 43% females, 61+/-12 years old) or without (DT group: 117 patients, 49% females, 57+/-12 years old) supine bicycle were reviewed. One patient was unable to perform supine bicycling and in one patient test was stopped due to hypertensive response. Analysis of variance (ANOVA), chi-square, and logistic regression analyses were used.

Results:
Supine bicycling was associated with increased double product (24838+/-5291 vs. 21936+/-5522 in DT, p<0.001), while test time (12+/-4 vs 14+/- 4 min in DT, p=0.008) and maximum dobutamine dose were decreased (30+/-11 vs. 35+/-11 mcg/kg/min in DT, p=0.004). Abnormal, ischemic ECG (17% vs. 8% in DT, p=0.035) and ECHO responses (19 vs. 14% in DT, p=0.267) were more common in SBDT. When ECG and echo results were compared, false-positive ECG response was significantly more common in SBD (10% vs. 1%, p=0.01), likely due to augmented venous return or LVEDP rise. Target heart rate (THR) was achieved in 90% of tests with supine bicycle vs. 80% in DT, p=0.046. Supine bicycle retained THR predictive significance (5.5, 95%CI 1.9-15, p<0.002) after adjustment for history of CHF (0.04, 95%CI 0-0.6, p=0.021), smoking (20, 95%CI 1-425, p=0.06), diabetes (0.01, 95%CI 0-0.4, p=0.004), and baseline diastolic DP (1.05, 95%CI 1-1.1, p=0.038). Age, gender, history of hypertension, coronary artery disease, baseline systolic BP and heart rate were not predictive of whether patient has achieved THR.

Conclusion:
Addition of supine bicycle exercise to standard dobutamine testing is well tolerated and results in more patients achieving THR. Supine bicycle exercise with dobutamine testing should be strongly considered in patients with history of heart failure, smoking, diabetes, or diastolic hypertension. Using combined stress test is associated with better resource utilization (shorter test time and lower peak dobutamine dose) and increased test sensitivity (higher double product).
Abstract 9: Effectiveness of Bleeding Avoidance Strategies in Women and Men Following Percutaneous Coronary Interventions: A Report from the NCDR®
Authors: Thompson Lauren E , Masoudi Frederick A , Kim Sunghee , Rao Sunil , Subherwal Sumeet , Tsai Thomas T , Messenger John , Daugherty Stacie L
Published: March 2022

Background:
Following percutaneous coronary intervention (PCI) women have more bleeding and whether these gender differences are related to differences in the effectiveness of bleeding avoidance strategies (BAS) is unknown.

Methods:
Among 570,777 patients (68% men, 32% women) in the CathPCI Registry
®
between 2/28/2008 and 3/31/2011, the absolute difference and relative risk of bleeding for BAS (vascular closure devices, bivalirudin, radial approach and their combinations) compared with no BAS was determined. Using multivariable logistic regressions adjusted for the propensity for getting BAS, bleeding rates for men and women were compared.

Results:
Women had higher rates of bleeding following PCI regardless of BAS strategy. After adjustment, both genders had significantly lower risks of bleeding with each BAS strategy compared with no BAS. All BAS were associated with a similarly lower relative risk of bleeding compared with no BAS, except for a greater benefit of radial approach + bivalirudin in women (interaction p=0.02). The absolute reductions in bleeding associated with each BAS were greater in women compared to men (bilvalirudin: 5.8% women vs. 2.9% men). (Table)

Conclusion:
Following PCI, the use of BAS was associated with similar relative risk reductions in bleeding risk for men and women; however, the absolute differences were approximately twice as high in women. These data underscore the importance of using BAS, especially in women, who are at particularly high risk for bleeding after PCI.

Table:
Gender stratified in-hospital risk of bleeding according to bleeding avoidance strategy (BAS).
Abstract 92: One-Year Health Status Benefits Following Invasive Treatment for Lower-Extremity Peripheral Arterial Disease: The Importance of Patients' Baseline Health Status
Authors: van Zitteren Moniek , Denollet Johan , Heyligers Jan M , Elshof Jan-Willem , Nooren Maria J , Burger Desiree H , de Fijter W M , Dinkelman Maarten K , Vriens Patrick W , Smolderen Kim G
Published: March 2022

Introduction:
The decision-making process for invasive treatment in lower-extremity peripheral arterial disease (PAD) is ambiguous. There is a lack of appropriateness criteria and limited information available on health status gains to be expected following invasive treatment. We compared 1-year health status outcomes by the receipt of invasive treatment among patients with PAD and evaluated whether baseline health status was indicative of the 1-year health status gains, assuming that patients with lower baseline health status scores would receive the highest benefit.

Methods:
Baseline and 1-year health status (SF-12, Physical Component Score [PCS]) was assessed in 380 patients with newly diagnosed PAD (Rutherford 1-3) enrolled from 2 Dutch vascular clinics (March ‘06-November ’10). The 1-year treatment strategy (invasive [endovascular, surgery] vs. non-invasive [exercise therapy]) and clinical information was abstracted. Mean 1-year health status scores were compared by invasive treatment. Propensity weights were calculated for the receipt of invasive treatment using baseline characteristics and included in a linear regression analysis to predict 1-year PCS scores, with 1-year treatment strategy, baseline PCS scores, and the interaction between 1-year treatment strategy and PCS scores as predictors, while adjusting for demographics, lesion location, clinical risk factors, and depression.

Results:
Invasive treatment was performed in 38% (192 of 380). Patients with baseline health status scores in the lowest quartile undergoing invasive treatment had the greatest health status improvement (11.6±10.5 vs. 4.2±8.1, P<.0001), whereas those in the highest quartile did not improve significantly, regardless of the treatment strategy (0.1±6.3 vs. -2.5±8.4, P=.17) (Figure). One-year invasive treatment (B=5.51; 95%CI 0.55;10.48; P=.03) and lower baseline health status scores (B=-.44; 95%CI -.57;-.33; P<.0001) were independently associated with greater 1-year health status gains. The interaction with baseline health status and treatment strategy failed to reach significance (P=.36).

Conclusions:
Although invasive treatment in lower-extremity PAD is associated with clinically relevant 1-year health status benefits, we found that patients with lower starting levels of their health status had more to gain. Whether or not this will imply that only patients below a certain health status threshold should be offered invasive treatment needs to be subject of further research.
Abstract 94: Brief Discontinuation of Proton Pump Inhibitor Therapy Enhances Anti-Platelet Effects of Clopidogrel
Authors: Alimohammad Rizwan , Bagenski Amy , Torosoff Mikhail , Fein Steven
Published: March 2022

Background:
It has been suggested that proton pump inhibitor (PPI) administration may decrease clinical efficacy of clopidogrel. We have studied changes in platelet reactivity during brief discontinuation of chronic PPI administration in patients on clopidogrel maintenance therapy.

Methods:
Study was approved by institutional IRB and informed consent was obtained in all patients. Study population consisted of 9 outpatients (6 females, 68+/-6 years old) on chronic clopidogrel and PPI therapy. VerifyNow P2Y12 point of care assay was used to measure P2Y12 platelet reactivity unit (PRU) and percent platelet inhibition. Platelet reactivity was measured on PPI therapy, 10 days after stopping PPI, and 10 days after re-starting PPI. Control baseline platelet reactivity testing was conducted on each occasion and remained unchanged (on enrollment 321+/-44 PRU vs. off clopidogrel 327+/-33 PRU vs. on clopidogrel 342+/-36, p=0.159). Repeated measurements ANOVA analysis was used to study overall changes in platelet reactivity. Fisher’s protected least significance difference intervals test was used to compare individual groups. All tests were 2-tailed, p<0.05 was considered significant.

Results:
We observed a significant reduction in platelet reactivity after PPI discontinuation (baseline PRU 205+/-111 vs. PRU 159+/-116 on day 10 post last PPI dose, p=0.028). Resuming PPI resulted in increased platelet reactivity (228+/-94 PRU after 10 days of PPI, p=0.002). Accordingly, PPI discontinuation was associated with significantly enhanced platelet inhibition (baseline percent inhibition 38+/-31 vs. 52+/-33% on day 10 after stopping PPI, p=0.029). Re-starting PPI resulted in significantly less effective platelet inhibition (percent inhibition 34+/-23% 10 days after PPI resumption, p=0.009). There were no significant differences in platelet reactivity (p=0.243) and percent inhibition (p=0.596) when baseline values were compared with ones obtained after 10 days of PPI treatment.

Conclusions:
We have documented dynamic changes in clopidogrel induced platelet inhibition associated with discontinuation and resumption of PPI therapy. Clopidogrel appears to provide significantly less effective platelet inhibition when PPI is administered simultaneously.
Abstract 97: Hypertension Gap Analysis. Population Level Perspectives from Lake County, IL
Authors: Rasty Sam , Dubois Marty , Soliman William
Published: March 2022

Background:
In our analysis we have attempted to perform uncontrolled hypertension gap analysis for the residents of Lake county, IL based on the hospital discharge data for residents of lake County, IL collected between 2001- 2009.

Methods:
The hospital discharge data between 2001-2009 for primary diagnosis of HTN was screened and analyzed. All patients (< 4 yr to > 85yr ) were categorized in 10 age groups for both males and females and comparative analysis were performed. Patient cases for essential hypertension were identified using ICD-9 code for essential hypertension code=401 ( including malignant(code 401.0), benign(code401.1) and non-specified (code 401.9).

Results:
N= 827,355 discharge records were screened. Overall there were N=1959 cases ( malignant= 393; benign=17 and non-specific = 1549 ) that were discharged with the primary diagnosis of hypertension reflecting a crude rate of 0.236 % or 236 per 100,000 patients. This rate is consistent with a previous report by the state of IL in 2004. There were N=1249 female and N=710 male cases. Using the US population in year 2000 as the standard , the age adjusted rate per 100,000 patients were 196.85 +/- 7.37 for females (crude rate of 248.77) and 236.41 +/- 10.92 cases in men ( crude rate of 218.27). For majority of patients the length of stay were either 1 day (n=744), 2 days (n=567) or 3 days (n=318). This compares to formerly reported data in IL for an average of 2.6 days. Analysis of data based on the zip codes indicates 3 suburbs with a high density of hispanics and blacks with the highest reported cases ( Waukegan= 243 cases , Zion= 102 cases, North Chicago=99 cases). In Case of Waukegan the current village composition consists of more than 50% hispanics with over 70%of population of Mexican heritage. The overall age adjusted HTN rate in Waukegan is 279.2 +/- 19.11 cases per 100,000 which is greater than the average calculated rate for either males or females in the lake county (table 1).

Conclusion:
Our current data suggest a high rate of age adjusted discharge rate for HTN in parts of Lake county. The top three villages contributing to admissions for uncontrolled hypertension are composed of a large number of hispanic and black population. Compared to 2006 AHQR national report of age adjusted rates of 61 and 161 cases per 100,000 in overall US hispanic and black population, and also the analysis of overall rates in males and females at the lake county , uncontrolled HTN is Waukegan is much higher than previously reported data.
Table 1 : Age -adjusted rates for essential hypertension
Rate for Lake CTY -Females = 196.85 +/- 7.37* Rate for Lake CTY-Males = 236.4 +/- 10.92
#
Rate for Waukegan males and females combined = 279.2 +/- 19.11 *OR=1.42 (.64-.81), P<.0001 Waukegan compare to Lake-females
#
OR=1.18 (.73-.98), P=0.022 Waukegan compare to Lake-males
Abstract 1: The Association Between Patient Selection for Diagnostic Coronary Angiography and Hospital-Level PCI Appropriateness: Insights from the NCDR
Authors: Bradley Steven M , Spertus John A , Nallamothu Brahmajee K , Chan Paul S , Kennedy Kevin F , Patel Manesh R , Bryson Chris L , Malenka David J , Rumsfeld John S
Published: March 2022

Background.
It is unknown if patient selection for diagnostic coronary angiography is associated with PCI quality as assessed by the Appropriate Use Criteria (AUC). We sought to determine if hospitals that frequently perform coronary angiography in asymptomatic patients, a clinical scenario where the benefit of angiography is less clear, are more likely to perform inappropriate PCI.

Methods.
We restricted our analyses to patients without known heart disease undergoing elective (non-acute) angiography or PCI at NCDR hospitals reporting at least 50 PCI procedures annually. As not all NCDR participating hospitals report diagnostic angiograms, we excluded hospitals reporting fewer diagnostic coronary angiograms than PCI. We identified 521,125 patients who underwent elective coronary angiography and 155,220 patients who underwent elective PCI at 553 hospitals reporting to the NCDR CathPCI Registry between July 2009 and June 2012. The association between hospital quartiles of the proportion of asymptomatic patients at angiography and the proportion of inappropriate PCI, per the 2012 AUC, was evaluated by Mantel-Haenszel trend test.

Results.
Overall, 132,613 patients (25.5%) who underwent coronary angiography were asymptomatic. The hospital proportion of asymptomatic patients at angiography ranged from 0.2% to 87.7%. Categorized as hospital quartiles, the median proportion of asymptomatic patients was 7.9% in hospitals of the lowest-quartile, 15.6% in the second lowest-quartile, 23.7% in the second highest-quartile and 35.5% in the highest-quartile. By hospital quartiles, the proportion of asymptomatic patients at angiography was significantly associated with the proportion of inappropriate PCI (median hospital proportion of inappropriate PCI; 17.7% vs. 22.6% vs. 26.5% vs. 28.9% from lowest to highest quartile, p<0.001 for trend; Figure 1).

Conclusions.
In a national sample of hospitals performing invasive coronary procedures, the proportion of coronary angiograms performed in asymptomatic patients was associated with the proportion of inappropriate PCI. Further study to clarify factors related to practice variability in processes of patient selection prior to the cardiac catheterization laboratory may optimize the use of both diagnostic angiography and PCI.
Abstract 113: Regional Variation In The Receipt Of Coronary Revascularization Following Diagnostic Catheterization In British Columbia
Authors: Ng Carmen H , Pu Aihua , Ding Lillian , Zhang Ruth , Kmetic Andrew
Published: March 2022

Background:
Differences in the management of coronary artery disease have previously been found to be partly attributable to non-clinical factors, but there have been few studies examining this issue in Canada. Variation in revascularization rates across regions of the province of British Columbia (BC) has been previously observed but not studied. The BC Cardiac Registry allows a unique opportunity to explore the factors that contribute to this variation and the associated clinical outcomes.

Methods:
All BC residents aged 20 years and older who received a diagnostic catheterization between 2008/09 and 2010/11 in one of five hospitals in the province with a catheterization laboratory were identified from the BC Cardiac Registry, a longitudinal clinical registry of all cardiac procedures performed in the province. Patients were followed to determine hospital level rates of revascularization (PCI or CABG) within 90 days of the diagnostic catheterization. Risk-adjustment was performed with a logistic regression model to determine whether the cathing hospital was an independent predictor of revascularization rates. All cause mortality rates following diagnostic catheterization were calculated and Cox regression was used to determine the effect of the cathing hospital on 1-year mortality.

Results:
The cohort included 32,585 diagnostic catheterization cases, of which 73.9% (24,076) received revascularization within 90 days. Unadjusted hospital rates ranged from 64.6% (2,730 of 4,224) to 83.8% (5,135 of 6,130). Among cases who received revascularization, the PCI:CABG ratios ranged from 3.1 to 4.7. The logistic regression model measuring the association between cathing hospital and the receipt of revascularization demonstrated significant hospital differences, despite controlling for demographic and clinical risk factors. The OR of receiving revascularization at hospital B compared to hospital A was nearly 3-fold (OR=2.8, 95% CI 2.6 - 3.1). There were also significant hospital differences after risk-adjustment in the receipt of PCI vs. CABG. Hospital C was more likely to treat patients with PCI (OR=1.3, 95% CI 1.2-1.5) compared to hospital A. Exploration of interaction terms found that hospital differences were significant among STEMI patients. The probability of mortality at 1 year following diagnostic catheterization ranged from 0.035 to 0.067 among hospitals, based on Kaplan-Meier estimation. Cox regression modeling revealed that there were significant hospital differences in 1-year mortality after adjusting for patient characteristics.

Conclusions:
There was substantial regional variation in revascularization practice among hospitals in the province of British Columbia, Canada. Identification of subgroups where variation in practices were significant, such as use of PCI vs. CABG among STEMI patients, offer opportunities for follow-up and quality improvement.
Abstract 132: Utilization of Cardiac Rehabilitation Programs Among Veterans
Authors: Schopfer David W , Takemoto Steven , Allsup Kelly , Forman Daniel E , Whooley Mary A
Published: March 2022

Background:
Exercise-based cardiac rehabilitation (CR) programs reduce morbidity and mortality in patients with ischemic heart disease (IHD), but they are vastly underutilized. Although numerous barriers for both providers and patients exist, geographic distance has been highlighted as a major factor affecting utilization of CR programs. However, the extent to which patient participation is associated with availability of nearby CR programs is unknown. We sought to determine whether the presence of an on-site CR program was associated with greater utilization of CR in Veterans with IHD.

Methods:
We categorized VA medical centers based on the presence or absence of an onsite CR program. Eligible patients were defined as patients hospitalized for acute myocardial infarction (MI), percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) at any VA facility between 2008 and 2011. We calculated the proportion of eligible patients who participated in CR using CPT codes for VA and/or non-VA (fee basis) care using VA administrative data. We then compared the proportion of eligible patients who participated in CR at facilities with vs. without onsite CR programs.

Results:
Of the 123 VA facilities that provide inpatient cardiac care, 35 (28%) have on-site CR programs. Between 2008-2011, 20837 Veterans were hospitalized with acute MI, 25214 underwent PCI, and 10989 had CABG. The proportion of eligible patients participating in any (VA or non-VA) CR program ranged from 5.7% (782/13626) to 6.8% (1000/14722). The presence of an onsite CR program was associated with greater likelihood of participating (8.9% vs. 5.1%, p=0.02).

Conclusions:
Presence of an on-site CR program was associated with greater utilization of CR. However, the proportion of eligible patients who participated in CR was extremely low (<10%) regardless of the presence or absence of an on-site program. These findings suggest that disseminating existing models of onsite CR programs may not substantially improve utilization of this evidence-based program. Alternative strategies must be evaluated to facilitate participation in CR.
Abstract 142: Patterns and Predictors of Intensive Statin Therapy among Patients with Type 2 Diabetes Mellitus after an Acute Myocardial Infarction
Authors: Abdallah Mouin S , Kosiborod Mikhail , Tang Fengming , Karrowni Wassef Y , Maddox Thomas M , McGuire Darren K , Spertus John A , Arnold Suzanne V
Published: March 2022

Background:
Patients with diabetes mellitus (DM) and acute myocardial infarction (AMI) are at increased risk for death and recurrent AMIs. Intensive statin therapy, a key component of aggressive risk factor management, has been shown to improve AMI outcomes especially in such a high risk population. However the frequency and predictors of intensive statin therapy among patients with DM after an AMI has not yet been described.

Methods:
We examined patterns of intensive statin therapy at discharge among AMI patients with prevalent DM enrolled in a 24-site US registry (TRIUMPH). Intensive statin therapy was defined as discharge on a statin with an expected LDL lowering of >50% (i.e., 80mg of atorvastatin or ≥20mg of rosuvastatin). We investigated the association of patient characteristics (including DM duration, DM treatment type and HbA1c levels) with intensive statin therapy at discharge using hierarchical modified Poisson models.

Results:
The analysis cohort was comprised of 1,319 patients with DM who were discharged alive after an AMI; mean age was 60 years, 41% women, 42% nonwhite and mean HbA1c of 8.3. At hospital discharge, only 21% were prescribed intensive statin therapy. In the multivariable model, ST-elevations on arrival, statin use on admission and higher LDL levels were independent predictors of intensive statin therapy. DM duration, HbA1C, and DM treatment type were not associated with intensive statin therapy (Figure).

Conclusion:
In a large, multicenter registry, only 1 in 5 patients with DM were prescribed intensive statin therapy at discharge after an AMI. While type of AMI, and LDL levels did correlate with intensive statin therapy upon discharge, neither DM duration nor severity was significantly associated with intensive statin therapy. These observations suggest an under-recognition of the high-risk nature of these patients and represent an opportunity for systems improvement to optimize prescription of high-intensity statins, in accordance with evidence-base.