bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 137: A Community Initiative to Reduce Blood Pressure in Latinos: The San Antonio AHA Check.Change.Control Initiative
Authors: Langabeer James R , Champagne-Langabeer Tiffany , DaLuna Lariss , Silva Nora , Meraz Leah T , Perry Samaniego Laura
Published: March 2022

Background:
Hypertension remains one of the most important, modifiable cardiovascular risk factors. Yet, the largest minority ethnic group (Hispanics/Latinos) often have different health outcomes and behavior, making hypertension management more difficult. In this study, we explore the effects of one large community-based intervention.

Methods and Results:
The American Heart Association sponsored an initiative targeted towards Hispanics called the Check.Change.Control program in San Antonio Texas (7
th
largest city in the U.S.; nearly 56% Hispanic population). The initiative was funded by a gift from the Max and Minnie Tomerlin Voelcker Fund. There have been 5,800 patients enrolled to-date, and 4,598 have completed the intervention from July 2016 to December 2017. Three ambulatory clinics provided geographic distribution across the region (Figure 1). Patient navigators helped to enroll and follow-up with hypertensive patients (>130 mmHg) over a 90-day period. The first and final BP readings were performed in the physician’s office, and 4 interim measurements were recorded telephonically by provided cuffs for a total of 6 BP readings. The intervention consisted of self-engagement in home BP monitoring, fitness and nutritional counseling sessions, and provider coaching and follow-up. Primary outcomes included BP systolic change between first and last reading, and health-related quality of life assessment. Average patient age was 57 years (±11.7) and 59% were female. Using univariate paired samples pre-post design, we found an average of 6 mmHg reduction in systolic BP across the sample (139 vs. 133, t=10.32, p<.001). Quality of life (EQ- 5D VAS) indicated a mean change after intervention from .80 to .82 (t=31.03, p<.001).

Conclusions:
Community-based interventions which extends hypertension management outside of the provider’s office can be effective at patient self-engagement and BP reductions for Latino populations.

Figure 1: Geospatial Analysis of Study Participants
Abstract 142: Engaging Patients Throughout the Health System: A Landscape Analysis of Top Research Institutions and Cold Call Policies
Authors: McHugh Kelly R , Swamy Geeta K , Hernandez Adrian F
Published: March 2022

Background:
Healthcare institutions may often prohibit “cold-calling,” or direct contact with a potential research participant when the person initiating contact is unknown to the patient. This policy aims to maintain patient privacy, but may lead to unintended consequences such as physician gatekeeping or increase concerns for coercion if treating physicians are the sole contact allowed. Patients may also be denied full knowledge and benefit of research opportunities, and clinical studies may suffer from selection bias and under enrollment. Differences in cold call policies across institutions have yet to be explored.

Objectives:
To review the current landscape of cold call policies among top academic institutions in order to inform guidance about future policy change.

Methods:
Sixteen institutions with the highest NIH grant funding were classified as providing guidance about cold-calling, prohibiting cold-calling, and/or allowing exceptions to the cold call policy, based on publically available data.

Results:
Among the top 16 research intensive institutions, 5 institutions have no cold-call policy. There are 7 institutions that prohibit cold-calling with exceptions, including when provider contact is impractical. There are 2 that do not have a cold call policy, but provide guidance such as taking extra care to respect patient privacy and inform patients of how they were identified. Finally, 2 prohibit cold-calling without exceptions. For patients not receiving care within the hospital’s health system, some institutions require that the PCP make first contact (Table).

Conclusion:
The approach to engaging patients in large, research intensive health systems varies significantly. As healthcare has evolved with more virtual visits, team-based care or system-based care, the engagement of potential research participants should similarly evolve while preserving patient privacy and autonomy. Potential solutions include opt-in or opt-out approaches for future contact, replacement of cold call policies with best practices, or a team based collaborative approach between physicians and researchers to guide recruitment decisions.
Abstract 144: Nuclear Stress Testing- Exercise vs. Chemical
Authors: Sharma Prerna , Kochar Tanureet , Memon Adil , Bhagat Abhishek , Whelan Meg E , Kemper Suzanne , Carter William
Published: March 2022

Background:
The incidence of coronary artery disease is increasing, resulting in a concurrent rise in cardiac stress testing which usually includes an exercise (ETT) or chemical stress test (CST) with nuclear imaging (SPECT). CST with imaging is recommended for those with the inability to exercise, a left bundle branch block (LBBB) or a paced rhythm at baseline. However, the proportionate use of CST with SPECT appears to be on the rise. The purpose of our study is to assess the frequency of ETT vs. CST with SPECT over the last 10 years.

Methods:
This is a retrospective chart review of 854 adult patients at Charleston Area Medical Center (CAMC) who had a CST or ETT with SPECT from January 1, 2007 - April 30, 2016. The frequency of both stress tests, along with patient demographics, physical capabilities, the reason for performing the test, test results and 6 month outcomes were recorded.

Results:
The proportion of ETT with SPECT between 2007-2008 was 70.4% (138 of 196) which decreased to 37.7% (75 of 199) between 2015-2016. However, within the same time frame the proportion of CST with SPECT increased from 29.6% (58 of 196) to 62.3% (124 of 199). In patients who had CST, 4.2% (14 of 311)had a LBBB, 9.7% (32 of 331) had a paced rhythm, 13.0% (43 of 331) had reported inability to exercise and 76.3% (171 of 331) had reported ability to ambulate without assistance. For 70.7% (234 of 331) patients, there was no reported reason for choosing CST over ETT with SPECT. Regadenoson was the vasodilator used most frequently for CST. When comparing outcomes in patients who had stress tests with SPECT, 8.8% (29 of 331) of patients who had CST versus 6.3% (33 of 523) who had ETT needed cardiac catheterization (p = 0.18) within 6 months, while 2.4% (8 of 331) of the CST patients versus 1.9% (10 of 523) of ETT patients (p=0.62) required revascularization within 6 months. In patients who had ETT, 81.8% (421 of 523) achieved greater than 85% maximum heart rate for age and 90.4% (473 of 523) achieved greater than 80% maximum heart rate for age.

Conclusion:
There has been a marked increase in CST with SPECT performed at CAMC between 2007-2016. While most patients may have the physical capacity and baseline EKG characteristics to qualify for an ETT with SPECT, a clear explanation for this pattern remains unknown. A possible analysis of changes in patient characteristics over this time may provide some insight into this trend.
Abstract 145: Illinois Acute Stroke Ready Hospital Designation is Associated With Improved Door-to-Needle Best Practices
Authors: Richards Christopher T , Jones Peggy , Sednew Renee M , Mirostaw Julie , O’Neill Kathleen , Prabhakaran Shyam
Published: March 2022

Background:
National guidelines recommend door-to-needle (DTN) time ≤ 60 minutes for patients with acute ischemic stroke (AIS). American Heart Association’s Target: Stroke initiative has identified several evidence-based best practices associated with optimal DTN times. In 2009, the state of Illinois passed legislation to establish a statewide stroke system of care, and updated it in 2014 to recognize three tiers of stroke designations - Acute Stroke Ready Hospital (ASRH), Primary Stroke Center (PSC), and Comprehensive Stroke Center (CSC) - to promote equitable access to these evidence-based stroke practices for all residents of Illinois. The ASRH designation ensures that patients with acute stroke receive essential recommended care at the entry point of care. As part of formal designation, ASRHs are required to submit stroke quality outcomes to the state demonstrating adherence to recommended guidelines for acute stroke care at the entry point of care. Prior to legislation, these hospitals were not required to submit data. The impact of ASRH designation on DTN best practice implementation has not been well studied.

Methods:
We performed a retrospective study of a state-wide stroke quality improvement database, the Get With the Guidelines (GWTG)-Stroke registry for Illinois Critical Access Hospital Network participating hospitals from 2009-2017. De-identified records for patients with confirmed stroke from 2009-2017 presenting to Illinois-designated ASRH were included for analysis. Excel was used for analysis, and descriptive statistics are presented.

Results:
A total of 33 ASRH-designated hospitals in Illinois participated in the GWTG Illinois Critical Access Hospital benchmark during the study period. Included patients and treatment characteristics are listed in the Table along with performance in key best practice areas: Median DTN Times and Door to CT < 25 minutes.

Conclusions:
Since Illinois introduced ASRH designation in 2009, a steady improvement in meeting acute stroke benchmarks has been observed for hospitals providing care at the entry point of care. Statewide stroke legislation should be considered as a strategy for supporting system-wide implementation of acute stroke best practices.
Abstract 166: End-of-Life Situations in Cardiology: A Qualitative Study of Physicians and Nurses’ Experience in a Large University Hospital in France
Authors: Ecarnot Fiona , Chopard Romain , Seronde Marie-France , Schiele Francois , Meneveau Nicolas
Published: March 2022

Introduction:
With advances in medication and device therapy for heart failure pts, the number of end-of-life situations encountered in cardiology is rising. We aimed to understand perceptions and attitudes of medical and paramedical staff regarding end-of-life situations using a qualitative approach.

Methods:
Single-centre, qualitative study using semi-directive interviews with physicians, nurses and nurses’ aides in a university hospital cardiology unit. Participants were invited to describe experiences and feelings about end-of-life situations. Interviews were transcribed in full and analyzed using thematic analysis.

Results:
13 physicians, 16 nurses and 5 nurses’ aides were interviewed. The main themes that arose in the discourse were the frequency, the type of death (emergency vs chronic disease), the value of the pt’s life, the positive effect of communication, and the rarity of advance directives (AD). The majority felt that end-of-life situations are increasingly frequent, and their management has improved. Cardiology was felt to be a highly technical discipline where death is generally rapid; otherwise, for pts with end-stage heart failure, the course of disease allows time to anticipate end of life issues. Nurses tend to engage in a degree of “coaxing” to persuade physicians to move from a curative to a palliative frame of mind, particularly in the cardiac intensive care unit. The perceived value of the pt’s life plays a role in the level of therapeutic engagement, with younger patients receiving more intensive resuscitation manoeuvers, whereas oldest-old patients are more rapidly labelled as “end of life” cases. Communication was felt to be key to ensuring that pt, family and healthcare workers (HCW) are all in agreement regarding clinical status and likely outcome. Nurses in particular can suffer considerable distress when their opinions regarding the pt’s status or wishes are not taken into account by the physicians, or when they are asked to continue invasive therapies for a pt they consider to be at the end-of-life. Poor communication was felt to engender suffering both among HCW and families; and lack of time was cited as a frequent cause. AD were not unanimously considered useful; some felt that discussing end-of-life may be more harmful than helpful, and overall, AD remain infrequent in our unit. The pt’s wishes are taken into account if possible, but some believe the pt is not qualified to know what can be done, and in such cases, their wishes may be disregarded as inappropriate to the clinical situation.

Conclusions:
Most participants felt that management of end-of-life has greatly improved in terms of pain relief and communication. Poor communication remains prevalent and can be a source of suffering for patients, families and caregivers, especially nurses.
Abstract 168: Engaging Patients to Inform Hypertension Management in a Safety-Net Outpatient Setting
Authors: Alikhan Muhammed , Johnston Ethan , Venkitachalam Lakshmi , Pauly Rebecca
Published: March 2022

Hypertension is one of the most common diagnoses carried by adults yet is often difficult to manage. A combination of medical therapy, patient engagement, and self-care is required to achieve blood pressure control. We, therefore, sought to elicit patient views on lifestyle factors that are known to influence optimal management of hypertension.

From outpatient clinics, we identified patients with documented hypertension and taking at least one antihypertensive medication. Patients with secondary causes of hypertension or end-organ damage were excluded. Following informed consent, patient views were elicited using the Kear Hypertension Management Instrument (KHMI), the Motivators of and Barriers to Health-Smart Behaviors Inventory (MB-HSBI), and the Stages of Change questionnaire (SOC). Participants were also provided with a 10-point Likert scale (10-very highly motivated/confident) to rate their level of motivation and confidence to maintain heart-healthy behaviors. Data are summarized using descriptive statistics for continuous and categorical variables.

Between 12/02/17 and 01/16/18, 19 eligible individuals of at least age 18 provided data; 95% (n=18) were African-American and 68% (n=13) were female. On the KHMI, 63% (n=12) reported either seldom or never forgetting to take medication. 84% (n=16) reported following a low salt diet a good bit of the time or more frequently. Only 32% (n=6) reported exercising as prescribed and 47% (n=9) reported participating in stress-reducing activities with similar frequency. 58% (n=11), reported never experiencing medication side effects. Only 1 in 3 patients reported financial barriers in obtaining medication. Interestingly, the relationship between motivators and barriers to adopt a healthy lifestyle varied by type of behavior. On the MB-HSBI, 53% (n=10) patients shared being highly motivated to eat a healthy breakfast while only 21% (n=4) reported having the least barriers to do so. However, only 26% (n=5) reported being highly motivated to increase physical activity and 37% (n=7) reported having the least barriers to do so. The SOC revealed 74% (n=14) of patients saying they have been maintaining heart-healthy behaviors for 6+ months. When asked to rate motivation to maintain behaviors on the 10-point scale, the median=8 and IQR=5. For confidence in maintaining these behaviors, the median=8 and IQR=4.

In our setting of safety-net outpatient care, patients with documented hypertension were highly motivated to pursue healthy lifestyle behaviors with a low prevalence of financial barriers to medication access. However, self-reported access to and awareness of physical activity and stress management options is less encouraging and warrant attention. Further analyses are planned to continue study and elucidate the relationship of these patient reported outcomes with temporal change in clinical outcomes including blood pressure.
Abstract 173: Reducing the Burden of Low Risk Chest Pain Admissions; Role of the Expedited Outpatient Stress Testing Quality Improvement Initiative
Authors: Almufleh Aws S. , Harnett David T. , Ritcey Brandon , Chow Benjamin
Published: March 2022

Background:
Chest pain is a frequent cause for emergency department (ED) presentation and is associated with significant costs. A pathway for expedited outpatient stress testing and follow-up for low risk chest pain patients in the ED was established in our institution. We present patients’ demographics and evaluate the efficacy, safety and overall performance of this quality improvement (QI) initiative.

Methods:
All patients referred to the program were retrospectively identified from the first year of experience. Rates of MACE and readmissions were determined at both 30 and 60 days of follow-up. Average time to testing and clinic assessment were measured. Rates of Cardiology consultations and admissions for chest pain were determined before and after program implementation.

Results and discussion:
A total of 425 patients were identified who were referred to the program. Forty patients were excluded from analysis as they failed to attend or declined testing, were inappropriately referred, or were lost to follow-up. Patient characteristics, outcome data, and adverse events are shown in table 1. A rate of over 75% stress testing within 5 days of ED visit and 68% of clinic visit within 6 weeks of a positive test was observed. Trends towards a reduction in admissions and consultations occurred in the year following program implementation(Figure 1).

Conclusion:
This local program for rapid out-patient testing for low risk chest pain patients in the ED is feasible, safe, and effective. Lack of patient adherence to follow-up is a concern with this out-patient approach. Improving time to stress testing and clinic waiting times have been identified as institutional priorities on the basis of this QI project.
Abstract 178: A
Shocking
Inefficiency: Unexpected Cancellations of Elective Cardioversions at a High Volume Electrophysiology Lab
Authors: Lambert Cameron T , Toro Saleem , Bumgarner Joseph M , Tarakji Khaldoun G
Published: March 2022

Background:
Despite advances in pharmacologic therapies and ablation techniques, elective cardioversions (CV) remain integral to the care of patients with atrial fibrillation (AF). These outpatient procedures require appropriate patient preparation to maintain patient safety and maximize success rates. These preparations include confirming adequate anticoagulation and pre-CV heart rhythm recording. Despite these preparations, unexpected cancellations of CV occur and lead to patient dissatisfaction and lost productivity. The objective of this study was to examine the frequency and cause of unexpected CV cancellations in a large volume center and to assess how novel technologies may improve efficiency in the future.

Methods:
Patients with AF who presented for scheduled elective CV were screened consecutively for enrollment. All patients were contacted the day before CV to confirm adequate anticoagulation and to provide instructions regarding fasting and the use of medications the morning of the planned CV. Information regarding the patients’ anticoagulation strategies and history were recorded at the time of enrollment. INR levels were obtained using routine serum and point of care testing. Statistical analysis was performed to evaluate trends in cancelled CV, potential impacts on the EP lab and to assess the ability of mobile technology to improve the CV process.

Results:
Two hundred patients were enrolled (Age 68 ± 12). Anticoagulation strategies varied in this group and included apixaban (N=90), warfarin (N=73), rivaroxaban (N=35) and dabigatran (N=2). Three patients required unplanned transesophageal echocardiogram. Thirty-two patients presented for CV but had their procedure cancelled due to a subtherapeutic INR (N=5), supratherapeutic INR (N=2), being in normal sinus rhythm (N=14), thrombus present on TEE (N=5) and intolerance of the TEE (N=2). CV was successful in 96% of patients (N=192). Point of care testing (POCT) and standard serum measurements were strongly correlated (r=0.961, p<0.001) although POCT INR testing results were, on average, 0.2 higher than standard serum measurements (95% CI [0.15-0.25]).

Conclusions:
A shocking percentage of CV are cancelled unexpectedly highlighting an opportunity to improve efficiency and productivity in the EP lab. The cancellations appear to be driven by inadequate anticoagulation and patients unexpectedly arriving in normal sinus rhythm. Technology providing remote assessment of both of these clinical variables is already commercially available. This remote monitoring of heart rhythm and INR may provide opportunities to reduce cancellations, improve patient satisfaction and boost EP lab productivity.
Abstract 19: Physical Activity After Chronic Total Occlusion PCI and Its Association With Health Status
Authors: Peri-Okonny Poghni A , Spertus John , Grantham J. Aaron , Kirtane Ajay J , Sapontis James , Lombardi William , Karmpaliotis Dimitri , Moses Jeffrey , Nicholson William J
Published: March 2022

Introduction:
Regular exercise provides multiple benefits to patients with coronary artery disease, but patients with chronic total occlusions (CTOs) may not participate in regular exercise due to refractory angina. There are few data to describe exercise participation after CTO PCI and the association of exercise patterns with health status after CTO PCI.

Methods:
We studied 1000 consecutive patients enrolled in OPEN CTO, a prospective 12 US center registry of CTO PCI. Participants were asked about participation in regular exercise (yes/no) at baseline and 12 months after CTO PCI, and the frequency of exercise (<1x/wk, 1-2x/wk, >=3x/wk) was collected among exercisers. Regular exercise included participation in any amount of exercise on a regular basis. Multivariable regression was used to compare 12-month health status change across 4 groups defined by exercise frequency at baseline and 12 months after CTO PCI [no regular exercise at baseline and 12 months, and reduced, increased, and consistent exercise at 12-months], adjusting for patient characteristics, technical success of the CTO PCI and completeness of revascularization. Health status was assessed using the Seattle Angina Questionnaire (SAQ) Angina Frequency (AF), Physical limitations (PL), Quality of life (QoL) and Summary Score (OS) domains.

Results:
A total of 869 patients with complete exercise data were included in the analysis. The proportion exercising regularly increased from 33.5% at baseline to 56.6% 12 months after CTO PCI (p < 0.01). Predictors of regular exercise at 12 months included baseline exercise, smoking, change in SAQ OS and baseline SAQ OS (Fig 1a). After multivariable adjustment, consistent or increased exercise frequency was associated with significantly greater improvement in SAQ PL, AF, Qol and OS scores ( p<0.01 for all, Fig 1b).

Conclusion:
Participation in regular exercise significantly increased 12 months after CTO PCI, and patients who had greater health status benefit after PCI were more likely to exercise regularly at 12 months. CTO PCI may enable CAD patients with limiting symptoms to engage in regular exercise. Further study of the association between health status improvement and exercise after CTO PCI is needed.
Abstract 192: Trends in Carotid Imaging in the VA Health System Following Choosing Wisely: An Interrupted Time Series Analysis
Authors: Anderson Timothy , Madden Erin , Zhang Sandy J , Mowery Danielle , Chapman Wendy , Keyhani Salomeh
Published: March 2022

Background:
The majority of carotid imaging is performed on asymptomatic patients, those without stroke or transient ischemic attack, for whom the evidence for carotid revascularization is limited. In 2013, three
Choosing Wisely
campaigns identified carotid imaging for syncope (American Academy of Neurology), screening (American Academy of Family Physicians) and preoperatively before cardiac surgery (Society of Thoracic Surgeons) as low-value. The impact of these recommendations is unknown.

Methods:
We compared annual rates of carotid imaging in the VA Health System between 2007 and 2016. As administrative carotid imaging codes are non-specific, we used natural language processing to identify carotid imaging, including ultrasound, computed tomography angiography (CTA) and magnetic resonance angiography (MRA). We reviewed the study reason listed in radiology records to develop a lexicon of test indications for identifying imaging for syncope, preoperative testing and carotid bruits. We conducted an interrupted time series analysis to determine whether trends in overall and indication-specific asymptomatic carotid imaging changed, comparing imaging rates prior to the recommendations (2007-2012) and following their release (2014-2016).

Results:
We identified 773,044 carotid images for asymptomatic indications (mean age, 69.9 years; 96.5% men) including 720,961 ultrasounds, 28,979 CTAs, and 24,539 MRAs. From 2007 to 2016 the annual rate of asymptomatic imaging decreased from 10.79 to 10.35 images per 1,000 veterans (rate ratio 0.96; P<0.001). Annual rates of imaging for bruits also decreased while imaging for syncope and preoperative evaluation increased (rate ratios: 0.62, 1.08 and 1.59, all P<.0001) (Figure). Rates of asymptomatic imaging declined by 1.01% annually (95% CI -1.18% to -0.84%) prior to Choosing Wisely, with a change to a flat rate in the post-period (0.12%; 95% CI -0.37% to 0.62%). Trends in annual rates of imaging for syncope and preoperative evaluation increased following Choosing Wisely, while the rate of decrease of imaging for bruits diminished.

Conclusions:
The release of 3 Choosing Wisely guidelines targeting carotid imaging did not reduce overall or indication specific rates of asymptomatic carotid imaging in the VA Health System.
Abstract 2: Financial Toxicity From Out-of-pocket Annual Health Expenditures in Low-income Adults With Atherosclerotic Cardiovascular Disease in the United States
Authors: Khera Rohan , Valero-Elizondo Javier , Okunrintemi Victor , Saxena Anshul , de Lemos James A , Krumholz Harlan M , Nasir Khurram
Published: March 2022

Background:
Health insurance is effective in preventing financial hardship from unexpected major healthcare events. However, to determine whether vulnerable patients are adequately protected from longitudinal health care costs, it is also essential to assess the financial impact of cumulative out of-pocket (OOP) healthcare expenses for common chronic conditions like ASCVD, particularly for low-income families.

Methods:
Using the Medical Expenditure Panel Survey (2006-2015), we assessed the annual inflation-adjusted OOP expenses, inclusive of insurance premiums, for all patients with ASCVD (coronary, cerebral, or peripheral vascular disease). We assessed these expenses at a family-level, i.e. for families with ≥1 members with ASCVD, and compared against annual family incomes. Low-income families were defined by an income <200% of the federal poverty limit. OOP expenses of >20% and >40% of family income defined high, and catastrophic health expenses, respectively. Survey methods were used to obtain national estimates.

Results:
We identified 22521 adults (≥18y) with ASCVD, represented in 20600 families in MEPS. They correspond to an annual estimated 23 million or 9.9% of US adults, and 21 million or 15% of all US families. Of these, 39% were low-income. The median annual family OOP expenses were $2450 (IQR 725, 5343), and income was $39765 (IQR 19080, 77635). Overall, OOP expenses represented a median 6.4% (IQR: 1.3, 19.1) of income in low-income, and 5.5% (IQR 2.6, 10.4) in mid/high income families. Low-income families had over 3-fold and 9-fold higher odds than mid/high income families of expenses of >20% of income (24.1% vs 8.1%, OR 3.6 [3.2, 4.1]), and >40% of income (11.2% vs 1.4%, OR 9.2 [7.5, 11.2]) (Fig A). While more low-income families gained insurance coverage (90% in 2006 to 93% in 2015), those with insurance had higher rates of OOP expenses than those without insurance (Fig B/C) or any mid/high income insurance subgroups.

Conclusion:
1 in 4 low-income families with a member with ASCVD experience a high financial burden, and 1 in 10 experience a catastrophic healthcare expense, even with insurance coverage. Underinsurance of low-income families has improved minimally. To alleviate economic disparities, policy interventions must extend focus to improving the quality of coverage for low-income families.
Abstract 202: Outcomes of Region-Wide Cardiac Rehabilitation
Authors: Suskin Neville , Frisbee Stephanie , Stranges Saverio , Pierce Adam , Ricci Joseph
Published: March 2022

Background:
Cardiac rehabilitation (CR) is recommended for patients with cardiovascular disease, however the impact of a region-wide, centrally managed CR model with local non-medical community-based delivery of CR is unknown in a universal health care system setting.

Objectives:
To determine the impact of a regional 6-month, once per week supervised exercise session CR model on mortality and re-hospitalization compared to a matched control within a regional health care system.

Methods:
The regional CR service comprised: a standardized regional referral strategy for patients with established cardiac disease including stable heart failure, local (within a 30-minute drive time from place of residence) CR service delivery by trained CR professionals. Patient data that was prospectively entered into a regional CR database for patients referred to CR from 2012 through 2014, was linked to government mandated administrative databases and all-cause mortality and hospitalization rates were compared between patients who were referred to CR vs. a matched cohort who were not. Matching included age, sex, year of referral, socioeconomic status, and cardiac condition at hospital discharge. Mortality and re-hospitalization were assessed at 1-yr post index cardiac event excluding the initial 6-month period to account for immortal time bias.

Results:
Fewer patients who completed CR compared to matched controls died (14/1,318 or 1.1% vs. 31/1,318 or 2.4%, p=0.011), or were readmitted to hospital (128 or 9.7% vs. 190 or 14.4%, p<0.001). Fewer patients who started but did not complete CR (CR non-completers) died compared to matched controls (10/639 or 1.6% vs. 21/639 or 3.3%, p=0.045), however there was no difference in hospital readmission rates between CR non-completers compared to matched controls (18.0% vs. 14.9%, p=0.13). More patients who were referred to CR but did not enroll in CR, died compared to matched controls (241/3,933 or 6.1% vs. 196/3,933 or 5.0%, p=0.027), or were readmitted to hospital (932 or 23.7% vs. 643 or 16.3%, p<0.001).

Conclusions:
In a universal health-care system, patients who completed a regionally coordinated, locally delivered, standardized CR program close to home, experienced lower mortality or re-hospitalization rates compared to matched patients not referred to CR. This association was not likely due to a referral bias as patients who were referred to CR but did not enroll in CR faired worse, not better, compared to matched non-CR referred patients. Health care system decision makers (e.g. provincial governments in Canada) should strongly consider funding regional CR strategies.
Abstract 205: Stroke Risk and Symptom Recognition Post Cardiac Catheterization
Authors: Rivet Cindy , Schaefer Karen , Strom Carmelia
Published: March 2022

Over 1.4 million cardiac catheterization procedures (CCPs) take place yearly. CPP related stroke incidence in 1973 was reported as 0.23%. CCPs are invasive in nature with complications occurring due to unintentional trauma to preexisting atherosclerotic aortic plaques or thrombus formation at catheter/guidewire tips. Less common causes of ischemic stroke are air, left ventricular clot, hypotension, arterial dissection, fractured guidewire. Transient neurological deficits have been reported following high-osmolar contrast injection into carotid/vertebral arteries. With improved practice, current stroke incidence is 0.06%. Performing >4000 procedures in FY 2017, our facility sought to compare our statistics vs. current literature.

Cardiovascular disease was the leading cause of global death in 2013 (17.3 million); stroke close behind at 11.8 million. Ninety-two million Americans live with cardiovascular disease/stroke after effects accruing $316 billion in indirect costs: health expenditures/lost productivity. Seventeen percent of strokes occur in the hospital; with stroke suffered post CCPs having morbidity/mortality rates of 19-37%.Time to recognition/treatment of stroke symptoms is vital to provide best outcomes.

Increase in visual symptoms post CCPs was noted by Procedural Care Unit staff with questionable correlation to radial access usage. Staff education on atypical stroke symptom recognition/empowerment and comfort to initiate Code Stroke protocol was conducted. There was variability in practitioner approach to calling Code Strokes vs. observing patients post symptom recognition. Meetings were held with Cardiology, Neurology, Hospital Administration, Departmental Leadership, Stroke Manager to come to consensus on patient management. There should be a low threshold for performing screening neurologic exams: alertness, speech, visual, sensory, motor symptoms and for calling Code Strokes. With more sensitive diagnostic tools, the process of diagnosis should be streamlined. Real time Code Stroke data was collected from December 2015-November 2017;with final analysis completed in November 2017.The research team consisted of PCU Clinical Manager, PCU Clinical Lead, Stroke Manager.

Data analysis showed 48 Code Strokes called; 30 being confirmed as strokes. Of confirmed cases 67% were male, 63% were radial, 57% had interventional procedures. Presenting symptoms of stroke, in order of frequency, were vision, arm drift/weakness, then facial droop and speech. The typical act FAST stroke assessment tool would not be helpful in the majority of these patients.

Literature shows women have higher stroke risk after CCPs. Our analysis showed higher prevalence in men and with radial access. The most common symptom of visual changes, results in NIHSS scores of 0, which may impact practitioners ordering stroke work-ups; when focus should be on patient disability.
Abstract 208: A Large, Retrospective Cohort Study Comparing Cardiovascular Outcomes With β-blocker Combination Treatment in Patients With Hypertension
Authors: Punzi Henry , Ali Sanjida , Li Qian , Patel Mehul , Neutel Joel
Published: March 2022

Objectives:
Hypertension is a major risk factor for cardiovascular (CV) events. While β-blockers (BBs) lower blood pressure and reduce CV event risk, the comparative CV event risk and rate of hospitalization due to CV events between hypertensive patients treated with vasodilatory β
1
-selective antagonist/β
3
agonist, nebivolol (NEB), and non-vasodilatory β
1
-selective BBs, atenolol (ATN) and metoprolol (MET), is unknown.

Methods:
Incident users of NEB, ATN or MET receiving ≥1 additional antihypertensive were identified from US claims data (2007-2014). First BB claim on/after 1/1/2008 defined index drug and date. Follow-up lasted ≥6 months, until index drug cessation or other BB use. Treatment cohorts (N=16,787 each) were matched by the number of antihypertensive drug classes used in follow-up and on propensity score (1:1) to balance confounders (follow-up duration, baseline demographics and clinical characteristics). Clinical outcomes based on matched cohorts were: hospitalization risk for composite CV outcome (myocardial infarction [MI], congestive heart failure, stroke, and angina; assessed by Cox proportional hazards regression) and event rate ratio for CV-related hospitalizations (assessed by count regression with negative binomial distribution) comparing ATN and MET with NEB. Both regressions were adjusted for concomitant antihypertension medication possession ratios (≥75%) and baseline confounders balanced in matching.

Results:
Compared with NEB, hospitalization risk due to composite CV events, MI, and angina was significantly higher with ATN and MET (Table). The unadjusted rate of all hospitalizations due to composite CV events per 1,000 persons per year was significantly greater in ATN and MET users compared with NEB users, while the adjusted ratio of composite CV event rate was significantly greater with MET, but not ATN (Table).

Conclusions:
In adults receiving combination antihypertension therapy, NEB treatment was associated with a lower risk for CV-related hospitalization than either ATN or MET. Lower risk of hospitalization was supported by event rate data, as patients receiving NEB combined with other antihypertensives were hospitalized less frequently than patients receiving combination therapy with either ATN or MET.
Abstract 217: Smoking Cessation and Patient Outcomes in the BRIDGE Clinic Population
Authors: Brown Kiera , Krallman Rachel , Montgomery Daniel , Morgan Spencer , Fried Sarah , Kline-Rogers Eva , Eagle Kim A , Bumpus Sherry M
Published: March 2022

Background:
Cigarette smoking is associated with significant morbidity and mortality among patients with cardiovascular disease. Yet, nearly 1 in 6 people in the US continue to smoke. This study sought to determine the prevalence of smoking and smoking cessation education in the BRIDGE post-discharge cardiac transitional care clinic and associated outcomes.

Methods:
Chart review was conducted of 133 randomly selected patients who attended their BRIDGE appointment between 2011-2015 and were current smokers. Demographics and outcomes were compared between patients who did and did not have documentation of smoking cessation education at their BRIDGE clinic visit and between those who did and did not quit smoking at 30 and 180 days post-discharge.

Results:
At 30 days post-discharge, 32 (24.1%) patients had quit smoking. At 180 days, 8 patients (6.0%) had resumed smoking, but an additional 10 (7.5%) had quit. There were no demographic differences between those who did and did not quit at 30 or 180 days. Further, there were no differences in readmission (21.9% v. 12.9%, p=0.214) or death (0.0% v. 1.0%, p=1.000) rates between patients who did and did not quit at 30 days post-discharge. However, patients who had quit at 180 days were more often readmitted compared to those who had not quit (55.9% v. 25.3%, p=0.001). Of 133 patients, smoking cessation was discussed with 55 (41.4%). Smoking cessation education was provided at similar rates to patients who did and did not quit smoking at 30 and 180 days (30 day, 28.1% v. 45.5%, p=0.081; 180 day, 32.4% v. 44.4%, p=0.217), and there were no demographic differences between these groups. However, those who discussed smoking cessation were more likely to visit the ED within 180 days post-discharge (50.9% v. 26.9%, p=0.005).

Conclusions:
A quarter of patients who quit smoking at 30 days post-discharge had resumed smoking at 180 days. Surprisingly, patients who quit smoking had higher readmission rates at 180 days. This study should be repeated with a larger sample size and explore other potential factors influencing these outcomes. For example, documentation of smoking cessation education was far lower than anticipated and may not be representative of actual discussion frequency. Efforts to design better strategies to encourage smoking cessation and reduce relapse are critical.
Abstract 218: Effectiveness of Telehealth on Hypertension Management and Control Among Disparate Populations - A Systematic Review and Meta-analysis
Authors: Chowdhury Farah M , Ayala Carma , Chang Tiffany , Dalmat Deborah , Shantharam Sharada , Zhang Xuanping
Published: March 2022

Introduction:
Telehealth (TH) that uses telecommunications (e.g. Internet, landline, or mobile phone) as a method to provide healthcare remotely is used to improve hypertension (HTN) control. However, the effectiveness of TH on HTN control among disparate populations is unclear.

Methods:
We conducted a systematic review and meta-analyses using the Cochrane methodology. The Healthy People 2020 social determinants of health were used to define disparate populations. Multiple databases were searched for publications from January 2000-July 2017. Inclusion criteria noted disparate populations, telehealth, and hypertension. No restrictions were made for sample size, location, or language due to lack of available data on disparate populations. Non-English studies were translated in English. Outcomes were: 1) systolic blood pressure (SBP) or diastolic blood pressure (DBP) change, 2) goal blood pressure (BP), 3) medication adherence, and 4) continuity of care (CoC) by same healthcare provider or team. Descriptive analysis and subgroup meta-analyses were conducted as appropriate.

Results:
After screening 1997 items, 22 primary studies were included (14 RCTs, 3 non-RCTs, and 5 pre-post studies). Sample size at baseline was 22,372 (range: 12-5,851). Studies reported disparate populations by social and community context (100.0%), health and health care (52.4%), economic stability (42.9%), and education (23.8%). Interventions included telemonitoring (90.5%), and/or self-management education (76.2%). In six months or less the pooled effect of five studies demonstrated a significantly larger SBP and DBP reduction in the TH group with CoC compared to usual care (UC) [mean difference in mmHg (95% confidence interval (CI)): SBP: -8.02 (-15.34 to -0.69); DBP: -4.32 ( -8.29 to -0.35)]. Also, the pooled effect of four studies for SBP and three studies for DBP in 6.1-24 months showed a significantly larger reduction of BP in the TH group compared to usual care (UC) [mean difference in mmHg (95% CI): SBP: -2.70 (-3.37 to -2.03); DBP: -2.01 (-2.43 to -1.59)]. Nine of the 22 studies reported goal BP as an outcome. Four of five RCTs were among those nine studies that reported improvement in the TH group achieving goal BP compared to UC. Seven studies reported medication adherence as an outcome, including four RCTs. Only one RCT reported significant medication adherence improvement in the TH group compared to UC (p<0.05).

Conclusion:
Telehealth shows promise to improve HTN control in disparate populations. Continuity of care with TH reduced SBP and DBP and thus may prevent associated serious complications. These results may inform healthcare providers, health plans, and decision makers about the benefit of using TH to improve HTN control among disparate populations.
Abstract 226: Effect of Ezetimibe Added to High-intensity Statin Therapy in Patients With Hypercholesterolemia: A Meta-Analysis
Authors: Ling Hua , Lee Jiehyun , Cooley Michael , Ayoung-Chee Ricky , Hernandez James
Published: March 2022

Background:
In the IMPROVE-IT trial, adding ezetimibe to simvastatin resulted in a 24% further lowering of low-density lipoprotein cholesterol (LDL-C) levels and modest benefit on cardiovascular outcomes compared to simvastatin only. However, whether the conclusion can be extrapolated into patients taking high-intensity statin plus ezetimibe is not known. Therefore, a meta-analysis was performed to evaluate the impact of ezetimibe added to high-intensity statin on LDL-C levels in patients with hypercholesterolemia.

Methods:
A systematic literature search was performed through Dec 2017 using PubMed and EMBASE with the following key terms: atorvastatin, rosuvastatin, ezetimibe, LDL-C and “low-density lipoprotein”. The analysis was restricted to randomized controlled trials in patients with hypercholesterolemia at high cardiovascular risk. The outcome of this analysis was mean difference in LDL-C reduction in patients treated with high-intensity statin plus ezetimibe compared to corresponding high-intensity statin monotherapy. The analysis was performed using RevMan 5.3 and MIX 2.0 Pro.

Results:
Of the initial 404 citations, six randomized controlled trials involving 714 patients were included in this analysis. Compared to the high-intensity statin monotherapy group, overall the mean difference in LDL-C reduction with high-intensity statin plus ezetimibe was -12.07% (95% CI: -2.16 to -21.97; p = 0.02). The results were associated with substantial heterogeneity (I
2
= 84%, p < 0.00001). Assessment of publication bias using Egger’s and Begg’s tests showed that no potential publication bias existed among the included trials (Egger’s test: p = 0.573; Begg’s test: p = 0.299). Notably, the mean difference in LDL-C reduction was decreased to -8.6% (95% CI: -4.22 to -12.98; p = 0.0001) with non-significant heterogeneity (p = 0.27, I
2
= 22%) when the study by Robinson 2014 was omitted in sensitivity analysis.

Conclusion:
Among patients with hypercholesterolemia, adding ezetimibe to high-intensity statin led to a mild but significant additional reduction in LDL-C levels compared to high-intensity statin monotherapy. Whether this mild further lowering of LDL-C levels achieved with the addition of ezetimibe to high-intensity statin would lead to a benefit in clinical outcomes needs further investigation.
Abstract 231: Does the Implementation of Pneumonia Prevention Practices Reduce Risk of Pneumonia Following Cardiac Surgery?
Authors: Strobel Raymond J , Harrington Steven D , Hill Chris , Thompson Michael P , Cabrera Lourdes , Wilton Penny , Gandhi Divyakant , DeLucia Alphonse , Paone Gaetano , Zhang Min , Prager Richard L , Likosky Donald S
Published: March 2022

Purpose:
Pneumonia is the most prevalent healthcare-associated infection following isolated coronary artery bypass surgery (CABG) and is associated with increased length of stay and mortality. Bundled infection prevention practices have been proposed as a tool for quality improvement, however the extent to which their adoption is associated with reducing risk of pneumonia is unknown.

Method:
We undertook a cohort study of 2,482 patients undergoing CABG from 2016 to 2017 across 18 centers participating in a statewide collaborative. Three pneumonia prevention practices were identified via structured literature review and benchmarking site visits: 1) preoperative nasal and oral antibiotic prophylaxis, 2) lung protective ventilation, and 3) goal-directed postoperative ambulation. These practices were implemented as a bundle, with a composite (bundle) score calculated as the total number of practices received by each patient. We estimated the association between composite score and development of pneumonia using logistic regression, adjusting for baseline risk (using a published risk model). Sensitivity analyses were conducted by age, sex, chronic lung disease, and operative status.

Results:
Pneumonia occurred in 2.4% (n/N = 60/2482) of patients. Bundle scores ranged from 0 to 3, with 75% of patients receiving a score of 1 or 2, and 22% having a score of 3. Crude and adjusted rates of pneumonia were lower in patients with higher scores (p-trend < 0.01; Figure); this finding was consistent across clinically important subgroups. Lung protective ventilation (OR
adj
: 0.42) and goal-directed postoperative ambulation (OR
adj
: 0.11) were significantly associated with lower odds of pneumonia (both p < 0.01); preoperative nasal and oral antibiotic prophylaxis was non-significantly protective of pneumonia (OR
adj
: 0.63, p = 0.11). Each 1-unit increase in bundle score was associated with a 57% decrease in operative mortality, and a more than 1 day reduction in (i.e., -27 hours) ICU length of stay (both p < 0.01).

Conclusion:
In this statewide study, we identified components of a bundle associated with reduced odds of pneumonia. Broader adoption of this bundle may serve as an effective strategy for improving value for cardiac surgical patients.