bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 20: The Effect of Resistance Training on Survival and Cardiovascular Outcomes: A Systematic Review and Meta-Analysis
Authors: Saeidifard Farzane , Medina Inojosa Jose R , West Colin P , Olson Thomas P , Somers Virend K , Prokop Larry J , Lopez-Jimenez Francisco
Published: July 2021

Background:
This is the first systematic review and meta-analysis to investigate the effect of resistance training (RT) on survival and other cardiovascular outcomes including ischemic heart disease events and stroke.

Methods:
An experienced librarian searched databases up to September 25
th
, 2017, for randomized trials and cohort studies that evaluated the effect of RT on survival and cardiovascular events in the general population. The databases included Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. Two investigators conducted the screening process independently and in duplicate. Cochrane tools were used to assess the risk of bias in clinical trials and observational studies. We calculated hazard ratios and 95% confidence intervals using RevMan and fixed and random effect models and had a subgroup analysis based on doses of RT and for the combination of RT and aerobic exercise (AE) vs no exercise.

Results:
The search identified 1429 studies from which 10 (one randomized trial) met the inclusion criteria, including 338,254 participants with a mean follow up of 8.14 years. The meta-analysis showed that RT, in comparison with no exercises, is associated with 24% lower all-cause mortality and 48% lower mortality when combined with AE. Based on subgroup analysis, performing 1-2 sessions of RT/week is associated with lower all-cause mortality by 28% (HR 0.72, 95% CI 0.66-0.78) whereas > 5 sessions of RT/week has no association with all-cause mortality (HR 0.99, 95% CI 0.76-1.31). Further, RT alone or combined with AE is associated with lower CV mortality compared to no exercise (Figures). Finally, RT alone also showed a borderline association with lower all-cancer mortality. Heterogeneity was present for several comparisons, and subsequent analysis will explore sources of this variability. Using study design-specific Cochrane risk of bias tools, no major sources of bias were identified in the included studies. One cohort study looked at the effect of RT on coronary heart disease events and found 23% risk reduction in men, while no study specifically assessed the effect of RT on cerebrovascular outcomes.

Conclusion:
RT is associated with lower all-cause, CV and all-cancer mortality. RT appears to have an additive effect when combined with AE.
Abstract 204: Cardiovascular Mortality and Non-fatal Cardiovascular Events After Diagnosis of Acute Aortic Syndrome
Authors: Weiss Salome , Sen Indrani , Huang Ying , Killian Jill M , Harmsen W. Scott , Mandrekar Jay , Chamberlain Alanna M , Goodney Philip P , Roger Veronique L , DeMartino Randall R
Published: July 2021

Background:
Acute aortic syndrome (AAS) includes aortic dissection (AD), intramural hematoma (IMH) and penetrating aortic ulcer (PAU) and confers high rates of aortic related events. However, the risk of cardiovascular (CV) events in this patient group is unknown. The aim of this study was to define the rates of CV events in an incident cohort of AAS patients.

Methods:
Medical records and death certificates of all Olmsted County, MN residents with a diagnosis of AAS from 1995-2015 were reviewed and compared to age- and sex- matched population controls. Primary outcome was non-aortic CV mortality. Secondary outcome was overall mortality and first time non-fatal CV event (myocardial infarction (MI), heart failure (HF) or stroke). Events were analyzed using Cox proportional hazards regression adjusting for comorbidities.

Results:
Of 133 patients with AAS (77 AD, 21 IMH, 35 PAU) 57% were male, median age was 72 (SD 14) and median follow-up was 10 years. Overall survival in AAS cases and controls was 62% versus 83% at 5 years and 44% versus 60% at 10 years (adj HR 1.8, p<.001, 95% CI 1.3-2.4). CV death occurred in 21 (29%) of 73 AAS decedents due to HF (9), MI (5), other cardiac causes (5), stroke (1) and peripheral vascular disease (1). CV-related survival at 5 and 10 years after AAS diagnosis (91% and 81%) was not significantly different from controls (95% and 86%) after adjustment for comorbidities (adj HR 1.8, p=.1, 95% CI 0.9-3.6). AAS was associated with an increased risk of any first time CV event (adj HR 2.6, p<.001, 95% CI 1.6-4.4; Figure), first time diagnosis of MI (adj HR 2.8, p<.001, 95% CI 1.7-4.7) and HF (adj HR 3.2, p<.001, 95% CI 1.6-6.2) but not stroke. When excluding acute events within 14 days of diagnosis, AAS was still associated with a significantly higher mortality (adj HR 1.6, p=.011, 95% CI 1.1-2.4) and an increased risk of any first time CV event (adj HR 2.2, p=.018, 95% CI 1.1-4.1), first time MI (adj HR 2.2, p=.012, 95% CI 1.2-4.1) and HF (adj HR 2.9, p=.006, 95% CI 1.4-6.2) but not stroke.

Conclusions:
AAS is associated with a higher overall mortality and an increased risk of any first time CV event, first time MI and HF that persists beyond the acute phase. These data highlight the risk of CV events among those with AAS and implicate the need for long-term cardiovascular management in these patients.
Abstract 209: Education Level and Long-Term Outcomes After Acute Myocardial Infarction: The China PEACE Prospective AMI Study
Authors: Huo Xiqian , Khera Rohan , Zhang Lihua , Wang Qianying , Herrin Jeph , Lu Yuan , Nasir Khurram , Hu Shuang , Li Jing , Li Xi , Zheng Xin , Masoudi Frederick A , Spertus John A , Krumholz Harlan M , Jiang Lixin
Published: July 2021

Background:
China has a growing burden of acute myocardial infarction (AMI) and wide variation in educational attainment. Less education is associated with worse cardiovascular outcomes in Western populations; whether this relationship exists in China is unclear. We assessed the association between educational attainment and AMI outcomes in China to inform future healthcare interventions.

Methods:
We used data from the prospective China PEACE-Prospective AMI study of 3369 consecutive patients hospitalized with AMI from 53 hospitals across all 21 provinces between 2012 and 2015. We collected detailed information from abstraction of hospital records, supplemented with patient interviews. Educational attainment was categorized into: high (high school, college or postgraduate degree), intermediate (junior high school), or low (primary school or illiterate). We used survival models to assess the relationship between education and 1-year all-cause mortality and major adverse cardiovascular events (MACE: all-cause death, nonfatal myocardial infarction, nonfatal stroke, heart failure), both unadjusted and after adjustment for demographic characteristics and cardiovascular risk factors.

Results:
The mean participant age was 60.7±11.9 years, 23.2% (781 of 3369) were women, and 33.3% (1123 of 3369) had high, 32.4% (1092 of 3369) intermediate, and 34.3% (1154 of 3369) low educational attainment. In unadjusted analysis, compared with high educational attainment, low educational attainment was associated with a higher 1-year risk of death (HR for low vs high education 3.09, 95% CI 1.69-5.65) and MACE (HR 2.41, 95% CI 1.72-3.37)(Figure). In risk-adjusted analyses, the association between education and mortality was attenuated and no longer statistically significant (adjusted HR 1.68, 95%CI 0.89-3.19,
P
= .11). However, the risk of MACE at one year remained significantly greater (adjusted HR 1.81, 95%CI 1.27-2.58,
P
= .001).

Conclusions:
In a national Chinese cohort of patients hospitalized with AMI, lower educational attainment was associated with a higher risk of adverse events in the year following discharge. This association highlights the need to explore mechanisms underlying this relationship, and to consider interventions for adults with lower levels of education.
Abstract 210: Coronary Artery Luminal Diameter, False Positive Stress Myocardial Perfusion Imaging and Body Mass Index: Is There an Association?
Authors: Sitwala Puja , Abusara Ashraf , Ladia Vatsal , Lopez Pablo , Paul Timir
Published: July 2021

Background:
Single Photon Emission Computerized Tomography Myocardial Perfusion Imaging (MPI) stress test is a widely used test to evaluate patients with suspected CAD with relatively higher false positive rate. There is a paucity of data on the association of false positive MPI, coronary artery diameter particularly focusing on left anterior descending artery (LAD) and body mass index (BMI).

Methods:
An institutional review board approved, retrospective study included female patients with abnormal MPI stress tests showing reversible ischemia in the anterior walls but without any disease in LAD arteries as assessed by coronary angiography within 3 months of the stress tests. Two qualified physicians reviewed the cine-angiograms and LAD diameter was categorized into two groups 3 mm and 3 mm. Categorical and continuous variables were analyzed using chi -square test and analysis of variance test respectively with a p value for significance as < 0.05.

Results:
A total of 251 female patients who had both false positive MPI stress test and normal coronary angiograms were analyzed. The mean (±SD) age, BMI and left ventricular ejection fraction (LVEF) was 59.9±12.3 years, 34.1±9.5 kg/m
2
and 59.4±7.2 % respectively. There was 76% of the patients had LAD diameter of ≥3 mm and 24% had < 3 mm. There was no statistically significant difference in mean age, BMI and LVEF between the two groups of the vessel sizes. The mean age was 60.5±12.5 vs 58.1±11.7 years (p = 0.20) and mean BMI was 33.5±9.3 vs 35.7±10.2 kg/m2 (p = 0.12) in ≥3 mm vs < 3 mm vessels. There was no statistically significant association noted between BMI categories and vessel diameters. When BMI was categorized as < 24.9, 25-29.9, 30-39.9 and > 40, there was 17.6% vs 15.5 %; 22.5% vs 17.2%; 36.4% vs 39.7% and 23.5% vs 27.6% patients had ≥ 3 vs < 3 mm vessels respectively (Chi-square p value = 0.77).

Conclusion:
There is no association between the luminal diameter of LAD and false positive MPI. Additionally, vessel diameter does not depend upon BMI. Further studies are needed to assess these observations.
Abstract 22: Association of Hospital Race and Payer Mix With Inpatient Mortality Among Patients Admitted for Acute Coronary Syndrome, Heart Failure and Arrhythmia
Authors: Srivastava Pratyaksh K , Fonarow Gregg C , Bahiru Ehete , Ziaeian Boback
Published: July 2021

Background:
Patient characteristics insufficiently explain observed disparities in cardiovascular outcomes among hospitalized patients, suggesting a role for community or hospital-level factors. Here, we evaluate the association of hospital segregation by black race and payer mix with inpatient mortality using a nationally representative sample of hospitalizations.

Methods:
Using the National Inpatient Sample (NIS), we identified adult hospitalizations with a primary diagnosis of acute coronary syndrome (n=550,005), heart failure (n=863,870) and atrial/ventricular arrhythmia (n=656,070). We divided NIS hospitals in to quartiles based on percent of hospital black and low payer (Medicaid or uninsured) admissions. We utilized logistic regression to determine whether hospital race or low payer quartile was associated with inpatient mortality among those admitted for acute coronary syndrome (ACS), heart failure (HF) and atrial/ventricular arrhythmia. Models were adjusted for age, sex, patient comorbidities, and hospital characteristics.

Results:
The mean age (95% CI) of the ACS, HF, and arrhythmia cohorts was 66.8 (66.7-67.0), 71.7 (71.5-71.9) and 70.0 (69.8-70.1) years, respectively. In adjusted models, ACS patients admitted to hospitals with >18.7-25.7% (Q2), >25.7%-34.0% (Q3), and >34.0% (Q4) low payer admissions experienced a 12% (OR 1.12, 1.03-1.20), 10% (OR 1.10, 1.01-1.19), and 12% (OR 1.12, 1.02-1.23) increased odds of inpatient mortality, respectively, when compared to hospitals with ≤18.7% low payer admissions (Q1). In the arrhythmia cohort, patients admitted to hospitals with >34.0% (Q4) low payer admissions experienced a 25% increased odds of inpatient mortality compared to those admitted to hospitals with ≤18.7% (Q1) low payer admissions (OR 1.25, 1.11-1.41). Among heart failure patients, those admitted to hospitals with >20.5% (Q4) black patients experienced a 17% (OR 0.83, 0.74-0.93) decreased odds of inpatient mortality compared to those admitted to hospitals with ≤4% (Q1) black admissions.

Conclusion:
Hospital low payer makeup positively associates with odds of inpatient mortality among patients admitted for acute coronary syndrome and arrhythmia. Hospital black makeup inversely associates with odds of inpatient mortality among patients admitted for heart failure.
Abstract 237: Patient and Center Level Characteristics for Critically Ill Cardiac Encounters Across 2 Care Settings
Authors: Galiatsatos Panagis , Powell-Wiley Tiffany , Li Xiaobai , Kadri Sameer , McAreavey Dorothea , Solomon Michael
Published: July 2021

Introduction:
Cardiac intensive care involves delivery of comprehensive critical care using advanced therapies for high-risk conditions. It is unclear if the outcomes such patients experience are evenly distributed throughout all care settings and what patient- and hospital-level factors impact these health outcomes. We evaluated the distribution of case-mix, acuity and processes of care from a nationally reflective convenience sample of intensive care units (ICUs).

Methods:
The Cerner Healthfacts Database was used to identify critically ill cardiac encounters (CICE). The sample consisted of inpatients hospitalized between January 2009 and December 2014 coded with a cardiac principal diagnosis and requiring direct admission or transfer to an ICU within 48 hours of hospital admission. Hospitals were dichotomized into those with a single undifferentiated ICU (Group 1) and those with a multidisciplinary ICU framework (≥1 ICU including at least 1 cardiac type; Group 2).

Results:
There were a total of 44012 individual hospital encounters in 68 hospitals, including 18001 patients in Group 1 and 26011 in Group 2. The majority of hospitals in Group 2 were teaching. There were no difference in admission SOFA score for cardiac patients admitted to the ICU, and no difference in the unadjusted in-hospital death rates. Further hospital-level factors are in Table 1. Acute myocardial infarction was the leading diagnosis in Group 1 (6429 encounters; 35.7% of total encounters) and Group 2 (11394 encounters; 43.8% of total encounters).

Conclusion:
Critically ill patients with cardiac diagnoses demonstrated equivalent baseline severity of illness, in-hospital mortality and lengths of stay when admitted to hospitals with single of multiple ICU care settings. However, hospitals with a multi-ICU setting tended to be teaching hospitals.
Abstract 261: Global Patterns of Comprehensive Cardiovascular Risk Factor Control in Patients With Type 2 Diabetes Mellitus: Insights From the Global DISCOVER Registry
Authors: Patel Krishna K , Charbonnel Bernard , Chen Hungta , Cid-Rufaza Javier , Fenici Peter , Hammar Niklas , Ji Linong , Kennedy Kevin F , Khunti Kamlesh , Kosiborod Mikhail , Pocock Stuart , Shestakova Marina , Shimomura Iichiro , Surmont Filip , Watada Hirotaka , Gomes Marilia B
Published: July 2021

Background:
Guidelines recommend optimal control of cardiovascular risk factors such as blood pressure, lipids and smoking in addition to glycemic control to reduce the risk of micro and macro-vascular complications in patients with type 2 diabetes mellitus (T2D). However, the extent of comprehensive cardiovascular risk factor control in T2D internationally is not well-known.

Methods:
A total of 14,169 T2D patients initiating second-line therapy across 37 countries were enrolled in the DISCOVER registry. Optimal cardiovascular risk factor management at study baseline was defined as control of the following risk factors among eligible patients: 1) Systolic BP <140mmHg for all T2D patients; 2) statin prescription in all T2D patients ≥ 40 years, high-intensity statin for those with T2D and ASCVD; 3) non-smoking status for all T2D patients; 4) treatment with ACE-Inhibitor/Angiotensin Receptor Blocker (ACEI/ARB) in patients with T2D and 5) hypertension (HTN)/albuminuria and secondary ASCVD prevention with low-dose aspirin (ASA) in those with T2D and ASCVD. Global and country specific rates of individual and combined risk factor control were calculated. Inter-country variability was estimated using median odds ratios (MOR).

Results:
Mean age of the DISCOVER cohort was 56.6 (SD= 11.7) years; 7534 (53.2%) were male, mean BMI was 29.6 (SD= 5.9) kg/m
2
, median duration of T2D was 4.1 (IQR 2.0, 7.8) years. A total of 1643 (11.9%) patients had ASCVD, 7221 (51.0%) had HTN and 606 (4.3%) had albuminuria. Overall, among eligible patients, BP was controlled in 67.2% (9043/13457); statin treatment was prescribed in 38.3% (4977/12987); 85.2% (12,075/14169) were not smoking; ACEI/ARB treatment was prescribed in 53.7% (4917/9151), and ASA for secondary prevention was prescribed in 51.6% (847/1643) patients with ASCVD. Of 13,118 patients with 3 or more risk factors, 5312 (40.5%) had optimal control of at least 3 risk factors with wide inter-country variability.

Conclusion:
In a global registry of individuals with T2D from 37 countries, comprehensive control of ASCVD risk factors was not achieved in most patients, with wide variability among countries. Better strategies are needed to consistently provide comprehensive cardiovascular risk factor control in patients with T2D to improve long term outcomes.
Abstract 32: Have
Choosing Wisely
Recommendations Changed Diagnostic Testing Patterns for Patients With Syncope?
Authors: Anderson Timothy , Thombley Robert L , Lin Grace A
Published: July 2021

Background:
Syncope is a common reason for emergency department visits. Guidelines suggest minimal initial workup, including history, physical exam, and ECG testing. Additional cardiac testing is recommended in only high risk patients and neuroimaging is rarely indicated. Because of the low yield of neuroimaging, in 2012, the
Choosing Wisely
campaign recommended against its use for syncope. Our objective was to examine trends in cardiac testing and neuroimaging of patients presenting to the ED with syncope, before and after the
Choosing Wisely
recommendations and to describe hospital variation in testing rates.

Methods:
We linked State Inpatient and Emergency Department Databases to conduct a retrospective study of all ED visits in 2009 and 2013 for 8 states reporting procedure utilization. We calculated rates of ECG, advanced cardiac testing (echocardiogram, stress testing, diagnostic catheterization) and neuroimaging (head CT, brain MRI, carotid ultrasound) for all adults with a discharge diagnosis of syncope. Differences between years were estimated using mixed effect regression modeling adjusted for patient characteristics, comorbidities, and hospital random effects.

Results:
We identified 287,261 ED visits for syncope in 2009 and 315,221 ED visits in 2013 from 676 hospitals. Between 2009 and 2013, adjusted rates of ECG testing increased from 81.1% of discharges to 84.3% (p<.0001). Rates of advanced cardiac testing increased from 10.3% to 12.4% (p<.0001), driven primarily by a substantial increase in the use of echocardiograms (8.3% vs 11.3%, p<.0001). Rates of neuroimaging increased from 36.0% to 42.0% (p<.0001) with increased utilization of all tests. Rates of ECG, advanced cardiac testing and neuroimaging varied significantly between hospitals in both years (Figure). The median hospital-level change in testing between years was 1.6% (IQR -3.5 to 11.2) for ECG, 1.2% (IQR -1.8 to 5.9) for advanced cardiac imaging and 4.2% (IQR -5.3 to 18.4) for neuroimaging.

Conclusions:
Among patients presenting to the ED with syncope, rates of both high- and low-value diagnostic testing increased between 2009 and 2013, with substantial variation between hospitals. Thus, the 2012
Choosing Wisely
recommendations do not appear to have had a significant effect on testing for patients presenting with syncope.
Abstract 15: Temporal Trends of Drug Eluting Stent Use After Myocardial Infarction: Does More Selective Utilization Impact Health Status Outcomes?
Authors: Stolker Joshua M , Patil Harshal , Chhatriwalla Adnan K , Venkitachalam Lakshmi , Kennedy Kevin F , Jones Philip G , Nallamothu Brahmajee K , Srinivas V.S. , Bach Richard G , Cohen David J , Spertus John A
Published: July 2021

BACKGROUND
Despite widespread acceptance of drug eluting stents (DES), concerns about cost and safety contributed to lower DES use by late 2006, particularly in off-label scenarios such as acute MI. The population-level impact of this trend on health status is unknown.

METHODS
We evaluated Seattle Angina Questionnaire (SAQ) scores among patients (pts) undergoing in-hospital PCI in TRIUMPH, a 24-center registry of acute MI. For each 3-month period of enrollment, we calculated the frequency of DES use and the mean 6-month Angina Frequency (SAQ-AF) score for pts treated that quarter. We then constructed a linear regression model to evaluate whether DES use, or time periods of high vs. low DES use, were independently associated with 6-month SAQ-AF scores.

RESULTS
Among 1744 MI pts undergoing PCI with complete health status assessments, 1033 were treated with DES (59%). DES use decreased significantly in late 2006, but overall 6-month angina burden remained stable (
Figure
). After adjusting for multiple clinical factors, SAQ-AF scores exhibited a borderline association with DES use (ß-coefficient 1.86 ± 1.0, p=0.06). When dichotomizing pts into years with high (2005-06) and low (2007-08) DES use, there was no relationship between high vs. low DES use on SAQ-AF in the multivariable model (ß=0.01 ± 1.0, p=0.99).

CONCLUSION
More selective use of DES after 2006 has not impacted population-level angina control at 6 months among MI pts treated with PCI. This suggests that clinicians were able to reduce DES use through better selection of those pts most likely to benefit from DES therapy, but further research is needed to better understand the processes of care associated with these findings.
Abstract 7: Increasing Use of Cardiovascular Devices and Rising Health Care Costs
Authors: Groeneveld Peter W , Epstein Andrew J , Yang Feifei , Yang Lin , Polsky Daniel
Published: July 2021

Background:
Drug-eluting stents (DES) and implantable cardioverter-defibrillators (ICDs) are among the most common, and most costly, interventional therapies used in patients with cardiovascular disease. Medicare coverage decisions for DES and ICDs in 2003-2005 portended a large growth in health care costs for patients with coronary artery disease (CAD) and chronic heart failure (CHF). However, the actual fiscal impact of DES and ICDs is uncertain.

Methods:
We examined Medicare claims from 2003-2006 and separately identified cohorts of patients between ages 65-84 in each year diagnosed with CAD and CHF. Patients were assigned to one of 306 contiguous geographic localities (i.e., Dartmouth Atlas Hospital Referral Regions [HRRs]). For each disease group in each locality in each year, we calculated the average cost of care (including Medicare payments, supplemental insurance, and patient payments) as well as the average use rate of DES (for CAD) and ICDs (for CHF). We estimated time-series HRR-fixed-effects regression models predicting average costs, with % technology use as an independent variable. We included a measure of the annual change in costs of care for non-cardiovascular disease in each HRR to control for annual cost increases unrelated to ICDs/DES.

Results:
Average inflation-adjusted costs for CAD patients increased from $13,558 in 2003 to $14,215 in 2006 (p<0.001), while average costs for CHF patients increased from $18,930 in 2003 to $20,235 in 2006 (p<0.001). Time-series regressions indicated that a 1% increase in DES use among the CAD population resulted in $394 in higher mean costs (p<0.001), and 1% increased ICD use in the CHF population resulted in $627 in higher mean costs (p<0.001). In aggregate, between 2003-2006 the cost increase attributable to DES in the Medicare CAD population ages 65-84 was $4.97 billion (89% of total growth), and the cost increase in the Medicare CHF population attributable to ICDs was $893 million (29% of total growth).

Conclusions:
Rising use of DES and ICDs between 2003-2006 was associated with significantly higher costs for patients with CAD and CHF, respectively. Increased use of these technologies explained substantial fractions of the growth in health care costs for CAD and CHF patients during these years.
Abstract 8: Door-to-Imaging Times in Patients Presenting With Acute Stroke
Authors: Kelly Adam G , Hellkamp Anne S , Olson DaiWai , Smith Eric E , Schwamm Lee H
Published: July 2021

Objectives:
National guidelines recommend that patients presenting with acute stroke undergo brain imaging within 25 minutes of emergency department arrival. Delays in brain imaging may prevent or reduce effective stroke treatments such as thrombolysis.

Methods:
Data from the
Get With the Guidelines-Stroke
program from 2003 through 2009 were analyzed to determine overall imaging rates, temporal trends, and predictive variables associated with door-to-imaging times in patients who presented to an emergency department within 2 hours of stroke symptom onset and did not have clear contraindications to thrombolytic treatment. Multivariable logistic regression adjusting for within-hospital clustering was performed to identify the independent predictors of brain imaging within 25 minutes of emergency department arrival.

Results:
The study population consisted of 221,538 patients. Brain imaging was performed within 25 minutes in only 21.6% of patients. Rates of brain imaging <25 minutes were low among all stroke subtypes (ischemic stroke 22.1%, subarachnoid hemorrhage 18.7%, intracerebral hemorrhage 28.3%) and remained low but increased slightly from 2003 to 2009 (18.8% to 21.7%). In the multivariable model, the following variables were associated with less likelihood of brain imaging being completed within 25 minutes of arrival: age > 70 years; female gender; African American race; history of diabetes, carotid stenosis, peripheral vascular disease, or smoking; use of antihypertensive or diabetic medications; symptom onset in another acute care or chronic care facility; transportation to hospital other than ambulance; and hospital location in the Northeast region. History of atrial fibrillation/flutter and use of cholesterol-reducing medications were associated with a higher likelihood of brain imaging completed within 25 minutes.

Conclusions:
In most patients with acute stroke symptoms, brain imaging is not performed within the recommended 25 minutes. Future quality improvement initiatives should focus on reducing door-to-imaging times, with a specific emphasis on the predictive variables identified in this analysis.
Abstract P110: Patterns and Intensity of Medical Therapy in Patients Undergoing Percutaneous Coronary Intervention
Authors: Borden William B , Redberg Rita F , Mushlin Alvin I , Spertus John
Published: July 2021

Background
The COURAGE study compared the effectiveness of optimal medical therapy (OMT) with, or without, percutaneous coronary intervention (PCI), in stable coronary artery disease (CAD). Understanding the translation of the COURAGE findings into practice could inform other contemporary comparative effectiveness studies.

Methods
We compared use of OMT both pre-PCI and at the time of discharge from the procedure before, and after, COURAGE's publication. The analysis was restricted to stable CAD patients undergoing PCI in the ACC-NCDR database from 9/05 - 12/08. Pre-PCI OMT was calculated as being on all of the following: aspirin, beta blocker and statin. Post-PCI OMT required all of the following: aspirin or thienopyridine, beta blocker, statin, and angiotensin converting enzyme inhibitor or angiotensin receptor blocker, if applicable.

Results
There were 383,444 patients who met study criteria. Aggressive OMT was used pre-PCI in 43.5% of patients (n = 75,529) before COURAGE was published and in 44.3% (n = 92,878) afterwards (p<0.0001; Figure). The use of aggressive OMT at discharge after PCI before, and after, COURAGE publication was 39.1% (n = 67,853) and 41.8% (n=87,524) (p<0.0001).

Conclusion
Minimal increases (<3%) in the aggressive use of OMT after the release of COURAGE suggest that 1) the benefits of PCI, which in COURAGE were coupled with the aggressive use of life-prolonging medications, may not be observed in routine clinical care, and 2) that there was little impact of the COURAGE results on clinical practice. Important opportunities exist to improve the clinical care of stable CAD patients and to increase the adoption of comparative effectiveness research.
Abstract P111: Revascularization in Perioperative Myocardial Infarction After High Risk Surgery is Associated With Reduced Mortality
Authors: Cohen Joshua , Kao John , Vidovich Mladen I
Published: July 2021

Background:
The incidence of perioperative myocardial infarction (PMI) is 5-35% after high-risk vascular surgeries, and increases mortality. We sought to determine the incidence of PMI after abdominal aortic aneurysm (AAA) and lower extremity revascularization (LE) procedures in current practice and describe the potential benefit of coronary revascularization.

Methods:
We analyzed the Nationwide Inpatient Sample from 1998 - 2006. Adult records were selected for indicating AAA and LE procedures. This group was queried for acute myocardial infarction and either percutaneous coronary intervention or coronary artery bypass grafting. In-hospital mortality was determined. We compared categorical data using the Chi-square test.

Results:
The incidence of PMI was 2.4% (6755/269100) overall, in-hospital mortality increased with PMI. Revascularization was associated with decreased mortality.

Conclusion:
In contemporary US practice, PMI appears to be under-diagnosed in this sample compared to previous prospective studies, and continues to be associated with increased in-hospital mortality. The utilization of coronary revascularization was associated with decreased mortality. Due to the retrospective nature of this study, causation cannot be determined.
Abstract P131: Utilization of a Clinical Registry to Drive Practice-Based Learning and Improvement Among Cardiology Fellows in Training: Observations From the American College of Cardiology's PINNACLE Registry™
Authors: Frederick Melissa , Pai Ramamanohara , Guduguntla Vamshidhar , Rosman Howard , Kehoe Katie , Mitchell Kristi , Fiocchi Fran , Oetgen William , Wright Janet
Published: July 2021

Background:
The Accreditation Council for Graduate Medical Education (ACGME) has defined six core competencies that reflect changing needs of health care delivery. One of these competencies, practice-based learning and improvement (PBLI), is essential for improving processes and outcomes of care. As an initial step, incorporating a standardized method for data collection is required and helps physicians monitor the quality of their work, identify learning and QI needs and positively change practice behavior.

Methods:
The PINNACLE Registry is an outpatient practice-based QI program designed to optimize quality of care through the standardized collection and reporting of clinical data on CAD, atrial fibrillation, heart failure and hypertension. Twelve cardiac fellows participate in the PINNACLE Registry at St. John Hospital and Medical Center in Detroit. At each clinic encounter, a data collection form (DCF) which captures patient demographics, history/risk factors, and current therapies were recorded and transmitted to the ACC to generate comparative feedback reports about the quality of care delivered to patients. Use of the DCF was piloted from September 2009 through November 2009 and expanded to all patient encounters from December 1, 2009 through January 31, 2010. Impressions from the first 60 encounters are reported.

Results:
Fellows reported that the DCF improved their knowledge, though the initial process of collecting data impacted clinic workflow. Utilization of the DCF initially resulted in longer patient visits which decreased over time (average 7 minutes reduced to 4 minutes per patient). As a checklist connecting patient workflow to best cardiology evidence, residents reported that diagnostic and therapeutic decisions were not simply monitored, but guided by the DCF.

Conclusions:
The DCF was found be a useful tool for data collection and clinical decision support. Participation in the PINNACLE Registry has provided the opportunity to further the ACGME core competencies of patient care and practice-based learning and improvement in a cardiology fellow outpatient clinic.
Abstract P136: Identifying Opportunities to Further Improve Outcomes for Patients With Coronary Artery Disease and Heart Failure in a Managed Care Organization
Authors: Jordan Courtney O , Kottke Thomas E
Published: July 2021

Background:
We have created and evaluated a decision support tool to identify opportunities to improve outcomes for patients with coronary heart disease and heart failure (CAD/HF). Applying national data, we concluded that improving care for patients with chronic disease would generate the greatest improvement in outcomes. The purpose of this analysis is two-fold: 1) to determine whether the decision support tool can be applied to data available from a “real” medical group, and 2) to determine whether the conclusions generated from analysis of the medical group data are similar to the conclusions generated from U.S. data.

Methods:
We created the tool to calculate the number of deaths that might be prevented or postponed if care for heart disease prevention and treatment were improved from current levels to optimal care_that is, the elimination of risk factors and the prescription of all effective medications before and between acute events, and the delivery of all effective therapies to individuals during an acute event. In this analysis we focus on calculating the impact of optimizing care for 40-74 year old patients treated for CAD/HF in a HealthPartners Medical Group (HPMG) clinic or at Regions Hospital between August 8, 2007 and July 31, 2008.

Results:

Condition or Event
Deaths Prevented or Postponed by Optimizing Care

Chronic heart disease with EF >35%
39

Chronic heart disease with EF <=35%
20

Myocardial infarction with ST elevation
1

Myocardial infarction without ST elevation
1

Unstable angina/other acute heart disease
3

Acute heart failure with EF <35%
10

New ambulatory or incidental diagnosis
10

Conclusions:
This study demonstrates that 1) it is feasible to use our decision support tool to identify opportunities to improve outcomes for patients of a medical group, and that 2) as we concluded from the analysis of national data, the greatest opportunities to improve outcomes for patients with CAD/HF treated by this medical group lie with patients who are between acute events.
Abstract P137: Recognition of Cardiovascular Risk Factors and Implementation of Primary Prevention Interventions with Utilization of an On-Line Form
Authors: Khambatta Sherezade , Bjerke Mary C , Kopecky Stephen L , Thomas Randal J , Allison Thomas G , Lopez-Jiminez Francisco
Published: July 2021

Purpose:
Awareness, documentation and management of Cardiovascular Risk Factors (CVRF) are measures of quality of care in primary and secondary prevention of Cardiovascular Disease (CVD). We measured the recognition, documentation and management of CVRF in patients at a preventive cardiology clinic with the use of a standardized on-line form.

Background and Methods:
An on-line “Risk Profile Form” was created by the Cardiovascular Health Clinic at the Mayo Clinic. The form automatically populates height, weight, laboratory values including lipids, fasting blood glucose, novel risk factors, and results of cardiac stress testing. Clinicians enter information on hypertension, diabetes, smoking, family history, depression, self-reported stress level, quality of life, diet and physical activity. The form uses computerized algorithms to calculate BMI, identify metabolic syndrome, calculate Framingham Risk Score, and generate recommendations for exercise, diet, and other aspects of CV prevention. The form is reviewed with the patient and added to the medical record in addition to the consultation note. We assessed a random sample of 210 preventive cardiology consultations for 2007, 2008 and 2009 and compared the recognition, documentation and management of CVRF in patients in whom the form was and was not used.

Results:
The “Risk Profile Form” was used for 92 of the 210 patient encounters reviewed. Detailed results are reported in
Table 1
.

Conclusions:
Use of a simple, standardized on-line form with incorporated computerized algorithms improves identification, documentation and management of CVRF and total CVD risk.

Table 1:

Comparison of Risk Factor Management With and Without Use of Risk Profile Form

Risk Factor
Form Used
Form Not Used
P-Value

Smoking history assessed
79 of 92 (86%)
80 of 118 (68%)
0.002

BMI documented
92 of 92 (100%)
104 of 118 (88%)
0.001

Intake of fruits, vegetables and saturated fat evaluated
91of 92 (99%)
64 of 118 (54%)
0.001

Assessment of vigorous, moderate and mild exercise
92 of 92 (100%)
107 of 118 (90%)
0.002

Metabolic syndrome assessed
82 of 92 (89%)
12 of 118 (10%)
0.001

Framingham risk score documented
86 of 92 (93%)
7 of 118 (6%)
0.001

Weight management recommendations made
88 of 92 (96%)
72 of 118 (61%)
0.001

Hypertension management discussed
17 of 18 (94%)
25 of 35 (71%)
0.06

Dyslipidemia management discussed
62 of 63 (98%)
60 of 63 (95%)
0.40
Abstract P143: Connecting Quality to Outpatient Practice: Implementing Office-Guideline Applied in Practice Program in Cardiac Care in a Federally Qualified Community Health Center
Authors: Olomu Adesuwa B , Sokolnicki Annette , Bevilacqua Maria , Pandya Naziri , Eagle Kim , Holmes-Rovner Margaret
Published: July 2021

Background:
Much work has been done to improve the quality of care delivered to hospitalized patients with coronary artery disease (CAD). However, innovative approaches to quality improvement in office settings are less advanced. To address this challenge, we adapted the Michigan in-hospital ACC Guideline Applied in Practice (ACC GAP) AMI initiative to office practice. In this study we sought to 1) Adapt the ACC GAP tools to develop patient-centered secondary prevention tools in outpatient setting 2) Demonstrate the feasibility and effectiveness of the Office-GAP Program in a Federally Qualified Community Health Center (FQCHC) in Ingham County in Michigan.

Method:
The study design was a process evaluation to test the feasibility of provider training, patient group visit, and use of GAP tools during office visits. A pre and post design assessed use of aspirin, Beta-blockers, ACE-inhibitors, lipid lowering agents, cholesterol assessment, and smoking cessation. Two doctors, 1 nurse-practitioner (NP), 8 staff, and 139 patients with a diagnosis of CAD or diabetes mellitus in one FQCHC participated in this pilot study. Evaluation used participant observation, GAP tools use evaluation and patient and physicians surveys to test each component.

Results:
All providers and staff attended the 90-minute physician training, while 60/139(43.2%) patients; 25 (41.7%) males, 30 (50%) whites' attended 90-minute group visits. Preliminary results demonstrate the feasibility of an Office-GAP program. Patients with good or complete perceived understanding of CAD increased, 11/58 (19%) Vs 42/58 (72.4%) and patients with little or no understanding of CAD decreased from 45/58 (77.6%) to 13/58 (22.4%) after the group visit. All patients (35) that completed their first follow up with their physician used the GAP tool with their physicians. Preliminary analysis shows an increase in evidence-based medication use; full results will evaluate impact.

Conclusion:
Implementation of the ACC GAP decision support tools is feasible within the FQCHC and has the potential to improve patient knowledge, and evidence-based medication use for patients with heart disease and diabetes. Further evaluation is needed to establish reach, effectiveness and cost-effectiveness of this approach.
Abstract P158: Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting
Authors: Dacey Lawrence , Braxton John , Kramer Robert , Schmoker Joseph , Charlesworth David , Helm Robert , Frumiento Carmine , Sardella Gerald , Clough Robert , Jones Stephan , Malenka David , Olmstead Elaine , Ross Cathy , O'Connor Gerald , Likosky Donald
Published: July 2021

Introduction:
Endoscopic saphenous vein harvesting has developed into a standard of care at many cardiothoracic surgical centers. The association between this technique and long-term morbidity and mortality has recently been called into question. We describe the association between use of open versus endoscopic vein harvesting and the risk of mortality and repeat revascularization within northern New England during a time period (2001-2004) in which both techniques were being performed.

Methods:
Prospective cohort study. From 2001-2004, 52.5% (4,485 of 8,542) of patients undergoing isolated coronary artery bypass grafting surgery had their saphenous vein harvested endoscopically. Surgical discretion dictated the vein harvest approach.

Results:
Use of endoscopic vein harvesting increased from 34% (781 of 2,291) in 2001 to 75% (1,341 of 1,792) in 2004. Patients undergoing endoscopic vein harvesting had greater disease burden. Endoscopic vein harvesting was associated with a significant reduction in long-term mortality [adjHR: 0.79, (CI 95% 0.68, 0.91)] and risk of repeat revascularization or mortality [adjHR: 0.87, (CI 95% 0.78, 0.98), Figure]. Endoscopic vein harvesting was associated with a non-significant increased risk of repeat revascularization [adjHR: 1.08, (CI 95% 0.89, 1.31)]. Similar results were obtained in a propensity-matched analysis.

Conclusion:
The use of endoscopic vein harvesting was associated with a reduced risk of mortality as well as a composite endpoint of mortality or repeat revascularization four years after the index admission. This practice insignificantly increased the risk of repeat revascularization.
Abstract P172: Prevalence and Predictors of CRP Elevation in a Secondary Prevention Sample With Well-Controlled Traditional Lipid Values
Authors: Ward Sarah , Nelson David R , McCollam Patrick , Sarsour Khaled , Johnston Joseph A
Published: July 2021

Background
The Emerging Risk Factors Collaboration and JUPITER trial suggest elevated C-reactive protein (CRP) has an association with cardiovascular risk factors and outcomes in primary prevention populations. Less is known about CRP elevation frequency in subjects with known cardiovascular disease (CVD), particularly those with well-controlled traditional lipids (LDL, HDL, triglycerides). Our study objective was to quantify prevalence of and examine predictors of CRP elevation in a nationally representative secondary prevention sample meeting NCEP lipid targets.

Methods:
We identified adults (≥18) with self-reported CVD, complete fasting lipid profile and CRP data from NHANES 2005-06 (n=228). Those with “optimal” control of lipids (NCEP: LDL <100 mg/dL, HDL >40/50 mg/dL for men/women, triglycerides <150 mg/dL) were included (n=61, 26.8%). Logistic regression models utilizing strata and weighting information were used to examine association between multiple subject characteristics and elevated CRP (>2.0 mg/L), with and without adjustment for age, gender, race/ethnicity.

Results:
Of 61 secondary prevention subjects with well-controlled traditional lipids, 73.3% had elevated CRP, and 62.8% reported current use of lipid lowering medications. Subjects with elevated CRP were older (mean age 66.3 vs. 58.7), and more were of non-Hispanic white race/ethnicity (81.3% vs. 67.0%). Adjusting for demographics, subjects with elevated CRP were more likely to have smoking history (65.5% vs. 38.5%, OR [95% CI] 4.64 [1.70-12.73]) but not current smokers (16.4% vs. 20.4%), less likely to report recent moderate physical activity (48.2% vs. 92.2%, OR [95% CI] 0.08 [0.02-0.33]), and more likely to be obese (BMI≥30 kg/m
2
) (62.7% vs. 4.8%, OR [95% CI] 320.6 [48.2->999]). Neither diabetes nor current anti-dyslipidemic treatment were significantly associated with elevated CRP.

Conclusion:
CRP elevation is very common in subjects with known CVD, even with optimal control of traditional lipids and despite anti-dyslipidemic treatment. Subjects with smoking history, less physical activity, and obesity appear to be at greatest risk. Correlation with outcomes through longitudinal analysis is needed to establish clinical significance of the findings.
Abstract P178: Echocardiographic Correlates of Persistent Q-Waves in Patients With ST-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention
Authors: Kirnus Mikhail , Iyanoye Adeyemi , Hubbard Elizabeth , Torosoff Mikhail
Published: July 2021

Background
Historic data suggests 65-70% prevalence of Q-waves and concurrent wall motion abnormalities in patients with ST-elevation myocardial infarction (STEMI) treated with thrombolytics. We investigated prevalence of post-MI Q-waves and correlation between Q-waves and left ventricular wall motion abnormalities in STEMI patients treated with primary percutaneous coronary intervention (PCI).

Study Design
A retrospective study cohort included 145 patients (24% females, 57+/-13 years old) without prior Q-wave MI who underwent successful primary PCI for STEMI at a single academic tertiary center. New York State Angioplasty Registry endpoints were utilized. Echocardiograms and ECGs (median 53 days post STEMI) were reviewed for presence or absence of segmental wall motion abnormalities (WMAs) and Q-waves. ANOVA and chi-square analyses were performed.

Results
Prevalence of post PCI Q-waves in STEMI patients was 69%, similar to historic 64% in TIMI 14 trial patients (p=0.258). Timing of PCI was not a significant predictor of Q-waves, but there was a trend towards higher pre- and post-PCI creatine kinase and troponin levels in patients with Q-waves. Patients with history of hypertension were less likely to develop Q-waves (62% vs. 77%, p=0.048), while age, gender, history of CHF, COPD, diabetes, renal failure, smoking, and admission hemodynamic status were not predictive of post-PCI Q-waves. WMAs were present in 38% of patients with Q-waves vs. 9% in the rest of the cohort (p=0.0003). Q-waves were equally likely to develop regardless of location of ST elevations at presentation; however, WMAs were more likely in patients with Q-waves in leads II-III-AVF (p=0.008) and V1-2-3 (p<0.0001), V4-5-6 (p=0.008), but not I-AVL (p=0.07). Positive predictive value for WMAs in patients with Q waves was 38%, while negative predictive value for lack of WMAs in patients without Q waves was 91%.

Conclusions
Prevalence of Q waves, reflective of myocardial damage, in STEMI patients treated with primary coronary intervention is similar to such observed in thrombolysis trials. Positive predictive value of Q-waves for WMAs is low. In CAD patients without Q-waves segmental WMAs are unlikely.