bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 14775: Barriers to Anticoagulation Treatment in Atrial Fibrillation: A Survey of Providers in a Large Rural Healthcare System
Authors: Rudeck Macaela N , Benziger Catherine P
Published: May 2021

Introduction:
Atrial fibrillation (AF) is common and oral anticoagulants are recommended to reduce risk of thromboembolism for patients with elevated risk. Barriers to anticoagulation are not well described.

Objectives:
We aim to evaluate gaps in provider knowledge and barriers to anticoagulation management in AF.

Methods:
A REDCap survey was sent to providers at Essentia Health (N=894), a large rural healthcare system in MN, WI, and ND. Providers were grouped into 3 categories: cardiology, primary care, and other. Providers were asked how they would manage a hypothetical patient with AF: 67-year-old female with hypertension, recurrent episodes of paroxysmal AF, no other medical history. Answer options included aspirin, warfarin, or novel oral anticoagulant (NOAC). Demographic data were obtained along with answers to questions assessing barriers to anticoagulation use and patient education. Providers who reported they do not see AF patients were excluded (N=23).

Results:
A total of 220 providers started the survey (75.5% completion rate). Of 157 providers who completed the case study, 74.5% correctly recommended treatment with a NOAC. Providers in cardiology were more likely than those in primary care and other specialties to select NOAC (96.4% vs. 68.5% vs. 76.2%, respectively; p=0.01). Most (92%) providers stated they personally discuss the need for anticoagulation with their patients. Providers noted the primary barrier to educating patients about their increased risk of stroke was: “They have trouble understanding what I am trying to explain to them” (24%), “They think that once their symptoms are being treated, the risk of AF-related stroke goes away” (17%), and “They don't really believe their condition is serious” (13%). Providers cited the top barrier to patient compliance with anticoagulation was patients concern of cost with no difference between specialty (cardiology 40.7% vs. primary care 46.7% vs. other 34.8%; p=0.53).

Conclusion:
Cardiology providers are more likely to correctly recommend a NOAC, compared to primary care or other specialties, for AF. Primary barriers to patient education and compliance include inadequate patient understanding and medication cost.
Abstract 14788: African Americans and Hispanics Are Disproportionately Impacted by Obesity: National Health and Nutrition Examination Surveys (NHANES) 2003-2018
Authors: palmer michael K , Toth Peter P
Published: May 2021

Introduction:
There are numerous health disparities impacting African Americans and Hispanics compared to other racial and ethnic groups in the US leading to poorer clinical outcomes. Obesity is an important risk factor predisposing to cardiac and renal diseases and it is important to quantify differences in obesity in greater detail.

Hypothesis:
African Americans and Hispanics may be disproportionately and adversely impacted by obesity.

Methods:
From 77007 participants in 8 NHANES surveys (between 2003-2004 and 2017-2018), we included 39952 aged 20-79 years. Participants with BMI data (n = 39440, 98.7%) were categorized as being underweight (BMI < 18.5), normal (BMI 18.5 - <25), overweight (BMI 25 - <30), obese (BMI 30 - <40) or morbidly obese (BMI 40+). Results were extrapolated to the entire US population (50 states plus the District of Columbia) using the direct method to the US Census 2000 population. The R language was used to perform statistical analyses.

Results:
Morbid obesity is as more common in black women (16%) compared with white or Hispanic women (both 8%). Black women are more overweight, obese, or morbidly obese compared with black men (80% vs 71%). Black men (7%) have a higher prevalence of morbid obesity compared to white (5%), Hispanic (5%), or “other” (race other than Hispanic, black, Asian, or white) racial/ethnic groups (4%). Hispanic men (80%) and African American women (80%) have the highest prevalence of overweight/obesity/morbid obesity. Normal weight is more common among race/ethnicity ‘other’ in both men and women. White women have a higher prevalence of normal weight compared to white men (34% vs 25%).

Conclusion:
There are important differences in the prevalence of obesity and morbid obesity between racial and ethnic groups in US adults. More emphasis needs to be placed on preventing/treating morbid obesity, particularly in Hispanic men and African American women, to reduce CV risk and correct disparities in health outcomes.
Abstract 14797: Pediatric Arrhythmogenic Ventricular Cardiomyopathy Often Misclassified in End Stage Heart Failure Patients - A 30 Year Tertiary Care Center Experience
Authors: Choudhry Swati , Kearney Debra L , Hope Kyle D , Tunuguntla Hari P , Spinner Joseph , Price Jack F , Dreyer William , Denfield Susan W
Published: May 2021

Introduction and Background:
Arrhythmogenic ventricular cardiomyopathy (AVC) is a hereditable disorder characterized by fibro-fatty infiltration of the right ventricular myocardial wall. The purpose of this study was to describe the clinicopathologic phenotype of AVC in pediatric end-stage heart failure patients who underwent heart transplantation (HTx).

Hypothesis:
We hypothesized that AVC is misclassified in the young population who require heart transplant.

Methods:
We investigated 371 consecutive cases of primary pediatric (≤21 years) heart transplantation performed at Texas Children’s hospital between 1989 and 2018. Heart re-transplants were excluded from the study. Explanted hearts and tissue blocks were examined by a cardiac pathologist after HTx. Histological Diagnosis of AVC was based on the presence of major and minor diagnostic criteria according to the 2010 Revised Task Force Criteria.

Results:
Over half of the patients who underwent HTx had cardiomyopathy (212/371=57%) as the underlying primary diagnosis. After comprehensive histological evaluation of explanted hearts, 8 cases (8/212=3.8%) were diagnosed with AVC. Predominantly right ventricular disease was seen in 2/8 (25%), and biventricular involvement in 6/8 (75%) patients on pathological examination. Six out of 8 patients (6/8=75%) were misclassified, 4 as dilated cardiomyopathy, 1 as viral myocarditis, and 1 as restrictive cardiomyopathy. The median age at heart transplant (AVC cohort) was 11 years. Four of 8 (50%) were males. Six of 8 (75%) had a significant ventricular arrhythmia burden manifesting as non-sustained ventricular tachycardia requiring antiarrhythmic therapy. Genetic testing was undertaken in 3 of 8 (37.5%); all three were found to have pathogenic mutations in the PKP2 gene.

Conclusion:
Arrhythmogenic ventricular cardiomyopathy is often misclassified in the young population who require heart transplant. Pediatric dilated and restrictive cardiomyopathy phenotypes with end-stage heart failure waitlisted for a heart transplant (HT) who have a significant ventricular arrhythmia burden should be investigated for AVC.
Abstract 14799: Cardiovascular Risk Stratification and Efficacy of Dapagliflozin on Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus in the DECLARE-TIMI 58 Trial
Authors: Oyama Kazuma , Wiviott Stephen D , RAZ Itamar , Cahn Avivit , Goodrich Erica , Bhatt Deepak L , Leiter Lawrence , McGuire Darren K , WILDING JOHN , Gause-nilsson Ingrid A , Mosenzon ofri , Sabatine Marc S , Bohula Erin A
Published: May 2021

Introduction:
In DECLARE-TIMI 58, the SGLT-2 inhibitor, dapagliflozin reduced the risk of the composite of cardiovascular death (CVD) or hospitalization for heart failure (HHF), and renal-specific outcomes in a broad range of patients with type 2 diabetes mellitus (T2DM). The TIMI Risk Score for Secondary Prevention (TRS 2°P) is a clinical risk score developed in patients with atherosclerotic cardiovascular disease (ASCVD) that provides risk stratification.

Hypothesis:
We hypothesized that the TRS 2°P would provide risk stratification in this population and that dapagliflozin would provide cardiovascular protection regardless of risk.

Methods:
DECLARE-TIMI 58 included patients with T2DM and either multiple risk factors or established ASCVD. Patients were stratified into 3 risk categories based on the 10-point TRS 2°P (see
Figure
, low: 1 or 2 points, intermediate: 3 points, or high: ≥4 points). Outcomes were major adverse cardiovascular events (MACE) (CVD, myocardial infarction, or ischemic stroke), CVD/HHF, components for MACE, and renal-specific composite outcomes.

Results:
Low, intermediate, or high risk, comprised respectively 49.8%, 31.2%, and 19.0% of the total of 17159 patients. In the placebo arm, increasing risk category was associated with a higher risk of all the outcomes of interest across risk categories (P-trend<0.001 for each) (
Figure
). The C-statistics were 0.67 for MACE and 0.72 for CVD/HHF in the placebo arm. Relative risk reductions in CVD/HHF and renal-specific composite outcomes with dapagliflozin were consistent for patients across the spectrum of TRS 2°P (P>0.05 for each interaction).

Conclusions:
Cardiovascular risk stratification using TRS 2°P identifies high-risk patients with T2DM for MACE, CVD/HHF, individual components for MACE, and renal-specific outcomes. Reductions in CVD/HHF and renal-specific outcomes with dapagliflozin versus placebo were consistent across the range of TRS 2°P.
Abstract 14804: Complications and Mortality Following CRT-D versus ICD Implants in Older Medicare Beneficiaries
Authors: Zeitler Emily P , Austin Andrea , Friedman Daniel J , Leggett Christopher G , Gilstrap Lauren , Skinner Jonathan , Al-khatib Sana M
Published: May 2021

Introduction:
Despite growing numbers of older HF patients, clinical trials of implantable defibrillators (ICDs) and cardiac resynchronization therapy (CRT) rarely include older patients (≥75 yrs).

Hypotheses:
(1) Among Medicare beneficiaries, older CRT-D patients have a higher risk of procedure-related complications than older ICD patients. (2) Compared with older ICD patients, older CRT-D patients have lower risk of death.

Methods:
We identified Medicare beneficiaries with HF and reduced LVEF who underwent ICD or CRT-D implant based on CPT codes (1/2008-8/2015) by age group (65-74, 75-84, and 85+). After matching device groups with inverse probability weighting (IPW), we estimated the comparative hazard ratio (HR) of death by age group and device type using a Cox proportional hazards model.

Results:
Compared with the ICD group, the CRT-D group was older and more likely to be white and female and have atrial fibrillation; CRT-D patients were less likely to have ischemic heart disease. Use of guideline directed medical therapy was similar between groups. In all age groups, complications were more common in the CRT-D group. IPW was successful, and after matching, the HR for death was lower in the CRT-D versus the ICD group; this finding was most pronounced in the 85+ age group in which the HR for death in the CRT-D versus ICD group was 0.76 (95% CI 0.64-0.88). (Table)

Conclusions:
Procedure-related complications in older HF patients were higher in CRT-D versus ICD patients and generally increased with age. Overall high post-implant mortality in ICD patients (± CRT) highlights the difficulty in assessing competing mortality risk when considering patients for an ICD especially in the oldest patients in whom clinical trial data are absent. However, in matched Medicare beneficiaries, CRT-D was associated with a lower risk of mortality in all age groups compared with ICD alone. These findings support the use of CRT in eligible older patients undergoing ICD implantation.
Abstract 14827: Risk of Venous Thromboembolism in Hospitalized COVID-19 Patients Undergoing Thromboprophylaxis: Meta-analysis of Cohort Studies
Authors: Jamil Adeel , Jamil Umer , Dahal Suraj , Gunnam Vamsikrishna , Najafi Homa , Memar Montazerin Sahar , Shojaei Fahimehalsadat , Kahe Farima , Marszalek Jolanta , Lee Jane , Chi Gerald
Published: May 2021

Introduction:
Preliminary evidence indicates that prophylactic-dosing thromboprophylaxis may be inadequate to control the increased risk of venous thromboembolism (VTE) in coronavirus disease 2019 (COVID-19) patients, and the usefulness of D-dimer measurement as a biomarker for VTE risk classification in this setting remains unclear. The study aimed to estimate the incidence of VTE and examine the difference in D-dimer levels among anticoagulated COVID-19 patients with and without VTE incident.

Methods:
This study was conducted in accordance with the PRISMA guidelines, and the protocol was registered in PROSPERO (Registration Number: CRD42020189192). A comprehensive literature search of PubMed from inception to May 2020 was performed to harvest original studies that reported the frequency of VTE and death among COVID-19 patients who received thromboprophylaxis on hospitalization. The endpoints included VTE (a composite of pulmonary embolism [PE] or deep vein thrombosis [DVT]), PE, DVT, and mortality.

Results:
A total of 11 cohort studies were included. Among hospitalized COVID-19 patients, 23.9% (95% confidence interval [CI], 16.2% to 33.7%) developed VTE despite anticoagulation. PE and DVT were detected in 11.6% (95% CI, 7.5% to 17.5%) and 11.9% (95% CI, 6.3% to 21.3%) of patients, respectively. Patients in the intensive care unit had a higher risk for VTE (30.4% [95% CI, 19.6% to 43.9%]) than those in the ward (13.0% [95% CI, 5.9% to 26.3%]). The mortality was estimated at 21.3% (95% CI, 17.0% to 26.4%). COVID-19 patients who developed VTE had higher D-dimer levels than those who did not develop VTE (mean difference, 2.05 μg/mL; 95% CI, 0.30 to 3.80 μg/mL; P=0.02).

Conclusions:
Heightened risk of VTE in COVID-19 despite prophylactic anticoagulation calls into research on optimal thromboprophylaxis and risk stratification. Prominent elevation of D-dimer may be associated with VTE development and can be used to identify high-risk subsets.
Abstract 14831: Racial Disparities and Modifiable Cardiovascular Risk Factors in Black Patients With Familial Hypercholesterolemia
Authors: Agarwala Anandita P , Deych Elena , Hussain Aliza , Jones Laney , Sturm Amy C , Aspry Karen E , Ahmad Zahid , Ballantyne Christie M , Goldberg Anne C
Published: May 2021

Introduction:
Black men and women are at higher risk for atherosclerotic cardiovascular disease (ASCVD) and when diagnosed, have greater morbidity and mortality as compared to individuals from European ancestry (EA). In patients with familial hypercholesterolemia (FH), it remains unknown whether Black patients have similarly increased risk for ASCVD.

Hypothesis:
To characterize the prevalence of ASCVD and to determine the strongest predictors of ASCVD in Black FH patients compared to EAs.

Methods:
The prevalence of ASCVD in 173 Black adult patients with FH followed in US-based lipid clinics was assessed retrospectively through a multicenter. A multivariate logistic regression model was used to determine the strongest predictors of ASCVD. Covariates included age, sex, diabetes mellitus, hypertension, and current smoking. ASCVD was defined as coronary, peripheral, and cerebrovascular events including angina, myocardial infarction, coronary angioplasty, peripheral arterial surgery, claudication, peripheral angioplasty, transient ischemic attack, stroke, and carotid endarterectomy.

Results:
Baseline characteristics of the 173 Black adult patients compared to EAs are shown in table 1. Black patients with FH were more likely to have higher BMI, hypertension, diabetes and to be current smokers. The prevalence of ASCVD in Black patients with FH was 38% compared to 30% in EAs, an absolute difference of 8% (p=0.047). The strongest predictors of ASCVD in Black patients with FH were hypertension and current smoking (table 2).

Conclusions:
Black patients with FH have a significantly higher prevalence of ASCVD when compared to EAs with FH. The strongest predictors of ASCVD in Black patients with FH were hypertension and current smoking. Aggressive primary prevention strategies specifically focused on the management of hypertension and smoking cessation should be tested for impact on the cardiovascular risk profile of Black patients with FH.
Abstract 14843: Electrocardiographic Manifestations of Immune Checkpoint Inhibitor Associated Myocarditis
Authors: Power John R , Alexandre Joachim , Choudhary Arrush , ozbay benay , Palaskas Nicolas L , Lehmann Lorenz H , Finke Daniel , Cautela Jennifer , Thuny Franck , Tamura Yuichi , Hayek Salim S , Azam Tariq U , Asnani Aarti , Mehegan Tyler , Aras Mandar A , Baik Alan H , Gilstrap Lauren , Laufer-Perl Michal , Arangalage Dimitri , Ewer Steven , Martini Matthew , Nowatzke Joseph , Orimoloye Olusola A , Brinkley Douglas M , Meijers Wouter C , Fenioux Charlotte , EDERHY Stephane , Moslehi Javid J , Salem Joe-elie
Published: May 2021

Introduction:
Immune checkpoint inhibitor (ICI)-myocarditis is a new syndrome with estimated 50% mortality. Similar to acute cellular rejection (ACR), it is pathologically characterized by lymphocytic infiltration. We aimed to characterize the electrocardiograph features of ICI-myocarditis, compare them to ACR, and evaluate their association with adverse outcome.

Methods:
Presenting ECG of 130 cases of ICI-myocarditis were collected from a multicenter network spanning 12 countries and compared to 50 cases of ACR. ECG were quantified and interpreted by two blinded cardiologists. 53 patients with ICI-myocarditis had baseline ECG available for comparison via paired univariate analysis. Cox models correcting for age and sex determined association with a composite outcome of life-threatening arrhythmia or myocarditis-related death.

Results:
ICI-myocarditis patients had average age of 68(58-76), were 61.2% male, and 64.8% had prior cardiovascular disease. QRS prolongation (26% vs 13%, p=0.008), conduction disorders (67% vs 44%, p=0.007) such as left bundle branch block (LBBB) (18% vs 4% p=0.008), ST/T wave changes (50% vs 24%, p=0.004), and PVCs (16% vs 6%, p=0.020) were more prevalent on presenting ECG compared to baseline. ICI-myocarditis showed more PVCs (16% vs 2%, p=0.011) and less ST/T wave changes (41% vs 66%, p=0.002) when compared to ACR. On multivariate analysis, the combined outcome of life-threatening arrhythmia or myocarditis-related death was associated with pathological Q waves (HR=3.60 (1.78-7.27) p<0.001), QRS prolongation (HR=3.35 [1.00-11.21] p=0.05), LBBB (HR=2.24 [1.13-4.45] p=0.021), and supraventricular arrhythmia (HR=2.03 [1.05-3.91] p=0.035) on presenting EKG.

Conclusions:
ICI-myocarditis manifests as new conduction delays, ST/T-wave changes, and PVCs. QRS prolongation, LBBB, pathological Q waves, and supraventricular arrhythmias were associated with subsequent adverse outcomes.
Abstract 14864: Parental Obesity Leads to Mild Diastolic Dysfunction and Impaired Exercise Tolerance, but Not Hypertension, in Female Offspring
Authors: da Silva Alexandre A , Gava Fabio , Omoto Ana C , Moak Sydney P , Dai Xuemei , Hall John E , do Carmo Jussara M
Published: May 2021

We found that parental obesity leads to high blood pressure (BP) and diastolic dysfunction in male offspring. Here, we examined the impact of parental obesity on BP regulation, systolic and diastolic function, and exercise tolerance in female offspring. The following groups were studied: 1) offspring fed normal diet (N) born from N lean parents (N-F1-N, n=5); 2) offspring fed high fat diet (H) born from N parents (N-F1-H, n=6); 3) offspring fed N born from H obese parents (H-F1-N, n=7); and 4) offspring fed H born from H obese parents (H-F1-H, n=7). Parents were fed H or N from weaning until the end of lactation, while offspring were placed on N or H diet from weaning until 22 weeks of age. Body weight, fat and lean mass were measured weekly (EchoMRI4-in-1 System). Cardiac function including ejection fraction (EF), isovolumetric relaxation time (IVRT), early (E’) and late (A’) mitral annular diastolic velocities were measured by echocardiography (VisualSonics VEVO-3100) using left ventricle long and short axes, pulse wave and tissue Doppler. BP, measured by telemetry, was similar among all groups. Compared to lean N-F1-N control mice, H-F1-N mice had similar body weight (23.7±0.1 vs. 25.2±1.8 g), fat mass (3.4±0.1 vs. 4.4±1.6 g) and lean mass (22.9±0.4 vs. 24.6±0.3 g). Both offspring groups fed H after weaning were heavier than offspring fed normal diet, however, H-F1-H mice were significantly heavier than N-F1-H mice (41.2±1.6 vs. 37.4±1.0 g) due to greater fat mass (16.2±1.1 vs. 13.2±1.0 g) and lean mass (25.1±1.7 vs. 22.9 vs. 0.3 g). Despite no major differences in EF among all 4 groups, mice born from obese H parents exhibited signs of diastolic dysfunction, irrespective of their own diet, as indicated by reduced E’/A’ ratio (0.8±0.1 and 1.2±0.2 vs. 1.6±0.1 and 1.5±0.2, for H-F1-H and H-F1-N vs. N-F1-N and H-F1-H, respectively), reduced exercise capacity (4.2±0.7 and 4.7±0.5 vs. 5.9±0.7 and 7.4±0.3 m.kg), and increased IVRT in obese H-F1-H compared to obese N-F1-H (28.4±2.3 vs. 22.2±0.8 ms). These results indicate that despite no alterations in BP diet-induced parental obesity is associated with signs of diastolic dysfunction and impaired fitness in female offspring, which is exacerbated by continuing to feed the offspring with H diet.
Abstract 14866: Plasma B-type Natriuretic Peptide Levels Are Associated With Future Cardiovascular Events in Patients With Type 2 Diabetes Mellitus Without Known Cardiovascular Disease
Authors: Ikeda Shota , Shinohara Keisuke , Enzan Nobuyuki , Matsushima Shouji , Tohyama Takeshi , Funakoshi Kouta , Kishimoto Junji , Itoh Hiroshi , Komuro Issei , Tsutsui Hiroyuki
Published: May 2021

Introduction:
B-type natriuretic peptide (BNP) is known to predict future cardiovascular (CV) events in patients with known CV disease. However, these associations have not been investigated in patients with type 2 diabetes mellitus (T2DM) without known CV disease. We investigated whether BNP levels are associated with CV events among T2DM patients without known CV disease using the dataset of EMPATHY study.

Methods and Results:
The EMPATHY was a randomized controlled trial of intensive statin therapy in T2DM patients without known CV disease. CV events were defined as composite of cardiac (acute coronary syndrome and coronary revascularization [excluding heart failure]), cerebral, and vascular events. A total of 4704 patients without CV events or death during the first 12 months were included and 114 CV events occurred during a median follow-up of 37.8 months. The patients were divided based on quartile of baseline BNP levels (Q1: <7.4, Q2: 7.4-14.8, Q3: 14.8-28.7, Q4: ≥28.7 [pg/mL]). Compared to the lowest quartile of BNP, only the highest quartile was associated with increased risk for CV events after adjustment (HR 2.96, 95% CI 1.29-6.79, p=0.010). Using this highest quartile cutoff, we categorized BNP <28.7 pg/mL as low BNP and BNP ≥28.7 pg/mL as high BNP. Compared to patients with low BNP, the adjusted HRs for CV events were 2.12 (95% CI 1.35-3.34, p=0.001) in patients with high BNP at baseline and 2.64 (95% CI 1.67-4.17, p<0.001) in those with high BNP at 12 months. In analysis using serial measurement, patients who had repeatedly high BNP or had low BNP at baseline and high BNP at 12 months were in significantly higher risk for CV events compared to those who had repeatedly low BNP (HR 3.28, 95% CI 1.90-5.66, p<0.001 or HR 2.65, 95% CI 1.44-4.87, p=0.002, respectively), whereas those who had high BNP at baseline and low BNP at 12 months were not (HR 1.99, 95% CI 0.90-4.39, p=0.089).

Conclusion:
Increased BNP levels were associated with higher risk of CV events (excluding heart failure) in T2DM patients without known CV disease. HR for CV events was greater in patients with repeatedly high BNP than in those with high BNP at only one of the two measurements, suggesting that serial BNP measurement may be more useful for predicting future CV events in T2DM patients.
Abstract 14877: A Never Ending Tale of Pericarditis
Authors: Ibrahim Michel , Fattouh Michael , Siddiqi Omar , Jacobs Alice K
Published: May 2021

Background:
The evidence on recurrent pregnancy-related pericarditis is limited, and management strategies are based mainly on case reports and expert opinion.

Case:
A 25-year-old G2P1, 28-week pregnant female, with a history of presumed viral pericarditis complicated by pericardial tamponade and recurrent colchicine resistant pericarditis which was successfully treated with a prolonged steroid taper in the postpartum period, now 1 year in remission presents with shortness of breath and pleuritic chest pain with elevated inflammatory consistent with prior presentation of myo-pericarditis. A trans-thoracic echocardiogram (TTE) revealed a mild pericardial effusion without evidence of systolic dysfunction, and pericardial tamponade.

Decision-Making:
Given prior history of pregnancy related colchicine resistant pericarditis which was complicated by pericardial tamponade around her prior delivery time, it was decided by an interdisciplinary team involving rheumatology, cardiology and obstetrics, to initiate prednisone 10 mg daily. Symptoms subsequently subsided with a down trend of cardiac and inflammatory biomarkers. Daily 10 mg prednisone was to be continued up through delivery but within 2 months she presented yet again with a similar clinical picture and was diagnosed with recurrence of disease. Her prednisone was increased to 20 mg daily with symptom resolution. Two weeks later, she went into labor and received stress dose steroids. She had a normal spontaneous vaginal delivery without any complications. She continued the same dose of 20 mg of prednisone until her follow-up with rheumatology when the decision was made to initiate azathioprine and slowly titrate off the steroids.

Conclusion:
The case highlights not only the rare association between pregnancy and recurrent pericarditis but also the complexity of its management. The case of our patient underscores the importance of family planning, shared-decision making, and management by an interdisciplinary team comprised of rheumatology, obstetrics/gynecology, and cardiology. There are currently no known well controlled trials of therapy for pregnancy related idiopathic recurrent acute pericarditis.
Abstract 14884: Invasive Hemodynamic Remote Monitoring for Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Authors: Hajduczok Alexander G , Muallem Samer N , Nudy Matthew S , DeWaters Ami L , Boehmer John P
Published: May 2021

Background:
In heart failure (HF) patients, remote monitoring of hemodynamics using implantable devices may be used to predict and reduce HF exacerbations.

Methods:
A meta-analysis of randomized controlled trials (RCTs) testing remote monitoring versus standard of care for management of HF patients was performed. Endpoints included all-cause mortality and Cardiovascular (CV)/HF hospitalizations. Risk Ratios (RR) and 95% confidence intervals (CI) were calculated for each endpoint. A secondary analysis tested for heterogeneity of treatment effect (HTE) using Chi
2
and I
2
tests comparing implanted right ventricular/pulmonary pressure monitoring versus impedance-based monitoring on HF hospitalization.

Results:
10 RCTs (n=6,020) were identified with a mean follow-up of 1.74 years. The mean age and reported ejection fraction were 64.1 and 27.1%, respectively. Remote monitoring did not reduce mortality (RR 0.88, [95% CI 0.76, 1.03]) or CV/HF hospitalizations (RR 0.99, [0.81, 1.20]) (Figure 1). When performing the test of subgroup differences, there was significant HTE for HF hospitalization between those studies that used implanted right ventricular/pulmonary pressure monitoring versus impedance-based monitoring (Chi
2
= 7.92, p = 0.005, I
2
= 87.4%).

Conclusions:
Compared to standard of care, remote monitoring of physiologic markers of HF did not reduce mortality and CV or HF hospitalization. However, right ventricular/pulmonary pressure monitoring may reduce HF hospitalization compared to impendence-based monitoring. Further studies are necessary to evaluate the role of remote monitoring in patients with heart failure.
Abstract 14895: Shear Stress-induced Endothelial Inflammatory Response and EndMT Promote Adverse Remodeling in a Microengineered Coronary-artery-on-a-chip
Authors: Zhao Peng , Yao Qingzhou , Ao Lihua , Jarrett Michael , Zhang Peijian , The Erlinda , Zhai Yufeng , Fullerton David , Meng Xianzhong
Published: May 2021

Background:
Atherosclerotic lesions preferentially occur at bifurcations and branching points where blood flow exerts low and bidirectional oscillatory shear stress (OSS) to the vascular walls. This study aims to determine the role of OSS in the induction of inflammatory activation and phenotypic transition in coronary artery endothelial cells and investigate the interaction between endothelial cells and smooth muscle cells in a coronary-artery-on-a-chip.

Methods and Results:
A three-dimensional microengineered human coronary-artery-on-a-chip was developed and incorporated with OSS to mimic the flow patterns within the microenvironment of coronary artery in atheroprone regions. Human coronary artery endothelial cells (HCAECs) were cultured on the upper surface of a collagen I-coated membrane, and human coronary artery smooth muscle cells (HCASMCs) were seeded on the opposite side of the membrane. Single-cell RNA sequencing analysis revealed that HCAECs were segregated into four subgroups after being exposed to OSS for 24 h, and inflammatory response and EndMT-related genes were enriched simultaneously in most HCAECs. OSS-induced inflammatory response and EndMT in HCAECs were confirmed by immunoblotting and immunofluorescence, and these changes were mediated by the Notch1/p38 MAPK-NF-κB signaling pathways. Moreover, HCAECs exposed to OSS induced extracellular matrix (ECM) protein remodeling and proliferation in HCASMCs through a paracrine mechanism. Multiplex ELISA analysis identified that RANTES exhibited the greatest increase after OSS in HCAEC culture and played a major role in modulation of ECM protein remodeling in HCASMCs. Further, IL-37 was able to prevent OSS-induced inflammatory response and EndMT in HCAECs and thereby abrogated ECM protein remodeling and proliferation in HCASMCs.

Conclusion:
OSS provokes inflammatory response and EndMT in HCAECs through activating the Notch1/p38 MAPK-NF-κB signaling pathways. The novel findings demonstrate that OSS-induced endothelial inflammatory response and associated EndMT promote vascular adverse remodeling and that anti-inflammatory cytokine IL-37 may have therapeutic potential for suppressing endothelial changes and resultant vascular adverse remodeling.
Abstract 14897: Activation Dyssynchrony Between Contact Multielectrode Mapping and Subsurface Near-Infrared Optical Mapping During Human Atrial Fibrillation
Authors: Mikhailov Aleksei , Hansen Brian , Fazio Matthew , Zakharkin Stanislav , Zhao Jichao , Nalar Aaqel , Kennelly James , Subr Megan , Rodrigo Miguel , LI Ning , Uma Mylavarapu , Kalyanasundaram Anuradha , Buck Benjamin , Mohler Peter J , Whitson Bryan , Mokadam Nahush , Hummel John , Fedorov Vadim V
Published: May 2021

Due to complex 3D human atrial structure, atrial fibrillation (AF) mapping with multielectrode arrays (MEA) mostly represents surface activation. Therefore, MEA may not properly visualize patient specific AF mechanisms, which impairs ablation outcomes. Conversely, near-infrared optical mapping (NIOM) visualizes subsurface intramural activation and can efficiently reveal reentrant drivers responsible for AF maintenance. Delay between surface activation seen by MEA electrograms (EGMs) vs subsurface activation seen by NIOM optical action potentials (OAPs) occurs due to dyssynchrony between myocardium layers, especially during AF. Coronary perfused explanted human atria (n=7) were mapped with NIOM (0.3-0.9mm
2
resolution) and 64-electrode MEA (3mm
2
resolution). Unipolar EGMs were analyzed for the steepest negative deflection. The delay between [-dV/dtmax] of unipolar EGMs and corresponding optical action potentials (OAPs) was compared in 500ms and 300ms pacing and AF. Subsequent structural analysis was done by 9.4T MRI (154-180μm
3
resolution) with gadolinium enhancement and histology. Delay between EGM and OAP local activation times rate-dependently and heterogeneously increased from 6±3 ms and 10±4 ms during 500ms and 300ms pacing to 15±11 ms (with maximum delay 47±18 ms) during pacing induced AF (average cycle length 124±65ms). Large local OAP-EGM delay, seen during AF, correlates with higher fibrosis percentage and fiber twist (p<0.05). NIOM identified reentrant drivers maintaining AF, which were incorrectly visualized as multiple breakthroughs in 68% of MEA maps (n=22). Higher frequency leads to an increased activation discrepancy between EGM and NIOM caused by increased dyssynchrony in regions of higher fibrosis percentage and fiber twist, which may prevent MEA from proper identification of AF drivers in diseased fibrotic human atria. Reannotation of EGM activation based on NIOM may be required for correct AF mechanisms visualization.
Abstract 14899: Personalized Computational Modeling Identifies Embolic Stroke of Undetermined Source Patients With Potential Arrhythmic Substrate
Authors: Bifulco Savannah , Scott Griffin D , Sarairah Sakher , Birjandian Zeinab , Roney Caroline , Niederer Steven A , Mahnkopf Christian , Kuhnlein Peter , Mitlacher Marcel , Tirschwell David , Akoum Nazem W , Boyle Patrick M
Published: May 2021

Introduction:
Late-gadolinium enhanced (LGE)-MRI has revealed atrial fibrotic remodeling in embolic stroke of undetermined source (ESUS) patients. Curiously, fibrosis levels in ESUS patients are the same as those observed in AF. A potential explanation is that ESUS patients have pre-clinical arrhythmic substrate, but lack the triggers needed to initiate AF.

Hypothesis:
Simulations in computational models reconstructed from LGE-MRI scans can determine if the fibrotic substrate of a particular ESUS patient has the capacity to sustain reentry.

Methods:
ESUS (per standard criteria) was verified by a neurologist. 45 ablation-naïve AF patients and 45 ESUS patients within three months of stroke underwent LGE-MRI for fibrosis assessment. Left atrial (LA) models were built from LGE-MRI scans. Fiber orientations were mapped into each LA model using universal atrial coordinates. Burst pacing from 15 sites was used to test inducibility of arrhythmia sustained by reentry (Fig A).

Results:
In 23/45 (51%) ESUS and 29/45 (64%) AF models, we observed sustained reentry. Fibrosis burden was significantly higher for patients in whom simulations suggested the existence of pre-clinical arrhythmic substrate; however, within the inducible and non-inducible sub-groups, there was no significant difference in fibrosis burden for ESUS vs. AF patients (Fig B). This suggests that the presence of pre-clinical substrate in ESUS is correlated with fibrosis burden, although exceptions to this supposition were not uncommon (i.e., inducible low-fibrosis and non-inducible high-fibrosis models; Fig C).

Conclusions:
In this modeling study, pro-arrhythmic properties of fibrosis in ESUS and AF are indistinguishable. This suggests that some ESUS patients have pre-clinical fibrotic substrate, but do not have AF due to a lack of suitable triggers. Ongoing clinical follow-up will test whether abundance of pre-clinical substrate is predictive of incident AF.
Abstract 15071: Effect of Percutaneous Coronary Intervention on Death and Myocardial Infarction in Patients Withstable Coronary Artery Disease and Inducible Ischemia
Authors: Radaideh Qais , Osman Mohammed , Kheiri Babikir , Al-Abdouh Ahmad , Barbarawi mahmoud , Bachuwa Ghassan , Tamis-Holland Jacqueline E , Shammas Nicolas W , Boden William E
Published: May 2021

Introduction:
There has been a continuous debate about the survival benefit of percutaneous coronary intervention (PCI) for the management of patients with stable coronary artery disease (CAD) and moderate to severe ischemia. To address this, we performed a meta-analysis of RCTs comparing PCI plus MT vs. MT alone in stable CAD patients to evaluate endpoints of all-cause mortality, cardiovascular (CV) mortality, and MI in a larger cohort of patients with objective evidence of myocardial ischemia.

Methods:
An electronic database search was conducted for RCTs that compared PCI on top of MT versus MT alone. A random effects model was used to calculate relative risk (RR) and 95% confidence intervals (CIs).

Results:
A total of 7 RCTs with 10,043 patients with a mean age of 62.54 ± 1.56 years and a median follow up of 3.9 years were identified. Among patients with (CAD) and moderate to severe ischemia by stress testing, PCI didn’t show any benefit for the primary outcome of all-cause mortality compared to MT(RR = 0.85; 95% CI 0.646-1.12; p= 0.639). There was also no benefit in cardiovascular (CV) death (RR = 0.88 ; 95% CI 0.71-1.09; p =0.18) or myocardial infarction (MI) (RR = 0.271 ; 95% CI 0.782-1.087;
P
=0.327) in the PCI group as compared to MT.

Conclusions:
Among patients with (CAD) and evidence of moderate to severe ischemia by stress testing, PCI on top of MT appears to add no mortality benefit as compared to with MT alone.
Abstract 15072: Thirty Day Episode of Care Spending Following Heart Failure Hospitalization Among Medicare Beneficiaries With Heart Failure
Authors: Desai Nihar R , Parzynski Craig , Riello Ralph J , Sarocco Phil , Ahmad Tariq
Published: May 2021

Background:
Heart failure (HF) is one of the costliest conditions in the US with immense public health interest to examine and improve the value of care. We sought to characterize current payments spanning the index hospitalization through 30-days post-discharge for Medicare beneficiaries with HF.

Methods:
Using Medicare fee-for-service administrative claims data, we identified patients hospitalized with HF from 2016-2018 with the following primary discharge diagnoses (ICD-10 codes): systolic HF (50.2 and 50.4), diastolic HF (50.3), hypertensive heart disease (HHD) with HF (I11), and HHD with HF and chronic kidney disease (CKD) (I13). Coding patterns over time across these four groups, mean 30-day episode of care spending overall, and proportion of total costs allocated to the index hospitalization and post-acute care were analyzed.

Results:
The study sample included 174,539 patients hospitalized with systolic HF; 163,071 diastolic HF; 221,820 HHD with HF; and 359,950 HHD with HF and CKD. Over time, there was a substantial increase in the use of the HHD with HF +/- CKD codes, accounting for 52% of HF hospitalizations in 2018 (Figure). We found substantial spending on 30-day episode for HF with nearly 2-fold variation across mean spending. Overall, 30-day episode spending was significantly higher for HHD with HF and CKD as compared to other diagnoses. Across all codes, the index hospitalization accounts for 70% of total episode spending while 30% is accounted for by post-acute care spending (Table).

Conclusions:
This patient episode-level analysis of contemporary Medicare beneficiaries suggests several areas to improve the value of HF care. The 30-day episode of care spending for heart failure hospitalizations is substantial with more than 2-fold variation. The impact of alternative payment models on HF outcomes and spending remains an important area for ongoing investigation.
Abstract 15073: Best Anticoagulation Strategy for Stroke Prophylaxis in Atrial Fibrillation Patients With Amyloidosis
Authors: Mohanty Sanghamitra , TRIVEDI CHINTAN G , Gallinghouse Joseph , Della Rocca Domenico G , Gianni Carola , MacDonald Bryan , Mayedo Angel , Bassiouny Mohamed , Gallinghouse G , Burkhardt John , Horton Rodney , Al-ahmad Amin , Natale Andrea
Published: May 2021

Background:
A considerable proportion of elderly patients are known to have coexistent atrial fibrillation (AF) and amyloidosis. Both conditions increase stroke risk.

Objective:
We evaluated the best anticoagulation strategy in a series of AF patients with amyloidosis.

Methods:
Consecutive AF patients with coexistent amyloidosis undergoing catheter ablation at our center were included in the analysis. Based on the stroke-prophylaxis approach they were divided into 2 groups;
group 1: left atrial appendage occlusion (LAAO) with Watchman and group 2: oral anticoagulation.
Following LAAO, all patients remained on full dose non-vitamin K oral anticoagulants (NOAC) for 45 days. Transesophageal echocardiogram (TEE) was performed at 45 days to assess completeness of closure. If the occlusion was complete, patients were kept on aspirin, 81 mg/day for long-term. In case of leak or dense ‘smoke’ in the left atrium (LA) or enlarged LA, they were prescribed half-dose NOAC. NOACs included dabigatran, apixaban, endoxaban and rivaroxaban. Group 2 patients remained on full-dose NOAC during the whole study period (1 year). All patients were prospectively followed up for 1 year.

Results:
A total of 87 patients were included in the analysis;
group 1: 56 and group 2: 31
. CHA
2
DS
2
-VASc score was comparable between the groups (gr. 1: 3.7±1.6 and gr. 2: 3.2±1.7, p=0.18). The most commonly used NOACs were apixaban (45, 51.7%) and rivaroxaban (34, 39%). After the 45-day TEE, 34 patients from group 1 remained on baby-aspirin and 22 on half-dose NOAC. Of the 22, 12 patients had leaks <5 mm, 6 had large LA (mean diameter 5.2±1.4 cm) and 4 patients had dense LA smoke. At 1-year follow-up, 3 stroke and 1 transient ischemic attack were reported in group 1 on baby-aspirin (4/34, 11.8%). No stroke or bleeding complications occurred in the 22 patients on half-dose NOAC. In group 2 patients on full-dose OAC, a total of 5 (5/31, 16.1%) bleeding events (1 subdural hematoma and 4 GI bleedings) were recorded. Additionally, a stroke was reported that happened during brief discontinuation of OAC for another medical procedure.

Conclusion:
In our series of patients with coexistent AF and amyloidosis, half-dose NOAC following LAA occlusion procedure was observed to be the safest stroke-prophylaxis strategy.
Abstract 15076: County-level Subgroups With Unique Cardiovascular Outcomes: An Unsupervised Clustering Analysis
Authors: Segar Matthew W , Rao Shreya , Hughes Amy E , Pandey Ambarish
Published: May 2021

Introduction:
Regional heterogeneity in cardiovascular disease (CVD) risk has been demonstrated in the United States (US), however associations between county-level social and demographic risk factors and CVD mortality have not previously been described. To address this, we evaluated whether unsupervised machine learning-based clustering could identify distinct US county subgroups with unique CVD outcomes.

Methods:
The study included 2,676 counties from the 2020 County Health Rankings program. Unsupervised hierarchical clustering of 46 candidate variables encompassing demographic, health behaviors, socioeconomic factors, and healthcare access domains was used to derive phenogroups. The association of phenogroups and age-adjusted CVD mortality was assessed by linear regression.

Results:
Clustering identified 4 phenogroups based on within-cluster inertia. Cluster 1 (N=924; 24.5%) counties were largely white, suburban households with high income and access to healthcare. Cluster 2 counties (N=451; 16.9%) were large with predominantly Hispanic residents and below average prevalence of CVD risk factors. Cluster 3 (N=951; 35.5%) counties included rural, white residents with the lowest levels of healthcare access. Cluster 4 (350; 13.1%) counties were comprised of predominantly black residents with substantial cardiovascular comorbidities and physical and socioeconomic burdens. Age-adjusted cardiovascular mortality increased in a stepwise fashion from 247 in cluster 1 to 349 per 100,000 residents in cluster 4 (FigA) with the phenogroups demonstrating regionality across the US (FigB). Addition of phenogroup in linear regression improved model performance with a
R

2

of 0.70.

Conclusions:
Unsupervised machine learning clustering based on demographic and behavior data can identify unique county phenogroups with differential risk of CVD mortality and may aid in identifying communities at highest risk for CVD-related adverse events.
Abstract 15108: Phenotypic Associations and Clinical Outcomes of Genetically Predicted Left Ventricular End Systolic Diameter in Prevalent Heart Failure
Authors: Ramsey Jacob , Farber-Eger Eric , Lowery Brandon , Mosley Jonathan , Wells Quinn
Published: May 2021

Introduction:
Varying degrees of systolic dysfunction after myocardial injury suggest a genetic basis for cardiac contractile reserve. Left ventricular end systolic dimension (LVESD), acquired by transthoracic echocardiography (TTE), is a proxy for cardiac contractility, and common variation underlying LVESD may offer insight into the underlying biology and clinical manifestations of heart failure (HF) and related phenotypes.

Hypothesis:
We hypothesized that elevations in genetically predicted LVESD would be associated with prevalent HF with reduced ejection fraction (HFrEF), but not HF with preserved ejection fraction (HFpEF), and with mortality among those with established HF.

Methods:
LVESD measurements (n = 7,630) were extracted for adults of European ancestry with available genome-wide genotyping who had also undergone clinically indicated TTE at Vanderbilt University Medical Center (VUMC). A polygenic risk score (PRS) for LVESD was created and validated in a separate cohort. HF status was defined using a validated algorithm. Logistic regressions were used to test for association of the PRS with prevalent HFrEF and HFpEF. Cox proportional hazards was used to test for association between PRS and incident death among (2,672) subjects with HF. All models were conducted in R and adjusted for age and sex.

Results:
A linear model of measured LVESD was significant for PRS (R^2 = 0.092, p < 0.001). The PRS was significantly associated with prevalent HFrEF (OR 1.15 per SD, p < 0.003) but not HFpEF. Genetically predicted LVSD was not associated with mortality among patients with HF (OR 1.01, p = 0.83).

Conclusions:
Genetically predicted LVESD, assessed by PRS, was associated with risk of prevalent HFrEF but not HFpEF. LVESD PRS was not associated with incident death in subjects with overall HF. These results suggest a potential role of LVSD PRS in HFrEF risk stratification, and further research should explore the relationship between LVESD PRS and incident HF.
Abstract 15120: Mechanistic Determinants of Atrial Functional Mitral Regurgitation
Authors: Matta Milad , Abou Hassan Ossama K. , Ayoub Chadi , Harb Serge C.
Published: May 2021

Introduction:
Atrial functional mitral regurgitation (AFMR) is an increasingly recognized entity that is defined as MR in the absence of primary leaflet pathology and left ventricular dysfunction.

Objectives:
Identify the mechanistic determinants of AFMR by cardiac computed tomography (CT).

Methods:
We reviewed all consecutive CTs performed in atrial fibrillation (Afib) patients pre/post-ablation and appendage occlusion procedures starting in February 2017. We identified the first 50 patients with significant MR (≥2+) then 50 controls without MR that were age and gender-matched. Clinical and echo data were collected. A dedicated CT software (Aquarius, TeraRecon) was used to perform detailed annular measurements

Results;
The median age was 70.7 years, and 39% were females. There were no significant differences in baseline clinical comorbidities, including type and duration of Afib, and medication use, including rate control agents and antiarrhythmics (Table 1). On echo, patients with significant MR had larger LA volumes (mean +/- SD, 47.63 ml/m2 +/- 17.21 vs. 35.53 +/- 14.22, p<0.001) higher estimated RVSP (40.77 +/- 13.88 mmHg vs. 33.54 +/-6.92, p 0.004), and more frequent concomitant significant TR (32% vs 8%, p=0.006). On CT analysis, there were significant differences (all p<0.001) in the mitral annular measurements, including larger area, perimeter, and septo-lateral and inter-commissural distances in the MR group (Figure 1).

Conclusion:
Patients with Afib who develop significant AFMR have significantly larger annular and atrial sizes, higher RVSP, and more concomitant significant TR. The type and duration of Afib do not appear to be significant predictors.