bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 145: Risk Stratification and Assessment for future Cardiac Events in Patients admitted with ACS Using a Novel Critical Pathway and its ` Validation by Framingham Risk Score, an ACAP-PAIN Database Analysis
Authors: Pamidimukala Chaithanya K , Aziz Emad F , Bastawrose Joseph H , Mohamed Shuaib , Pai Urvi , Usmani Rishad , Kumar Shashi , Pratap Balaji , Benjo Alexandre M , Herzog Eyal
Published: March 2022

Background:
We developed a novel pathway for management of patients with Acute Coronary Syndrome (ACS), designed with the acronym of PAIN (P) Priority Risk, (A) Advanced Risk, (I) Intermediate Risk, and (N) Negative Risk that reflects patients most immediate risk stratification upon admission. Our objective was to compare the patient risk stratification upon admission using the PAIN pathway to the Framingham Risk Score (FRS).

Methods:
A total of 6911 ACS patients admitted to a NYC hospital from Sept., 2004, to Dec., 2010, were enrolled in our prospective ACAP-ACS registry. Patients were stratified and treated according to the PAIN pathway. Mean risk factors for patients in the PAIN pathway were compared with the FRS.

Results:
The study population consisted of 3761 men (54%) with a mean age 60 ± 14 years and 3150 women (46%) with mean age 66 ± 15 years. On initial stratification P patients had 3.01 traditional risk factors, A patient had 3.50, I patients with 4.3 risk factors, and N patient had 1.9, P<0.001. Using the Framingham risk score model, P patients had a score of 10.6 while I patients had a score of 10.9, P<0.01. Also Hispanic (H) patients had the highest risk score when compared to African-American and Caucasian (3.4 ± 2.4, 3.3 ± 2.1, 3.1 ± 2.1), P<0.001.

Conclusion:
I patients according to our PAIN pathway had more risk factors which correlate with a higher risk for future cardiac events as calculated from the Framingham Risk Score. H population would benefit the most from a more aggressive intervention compared to others.
Abstract 154: Type of Beta Blocker Use Among Patients with Versus without Diabetes after Myocardial Infarction
Authors: Arnold Suzanne V , McGuire Darren K , Lipska Kasia J , Tang Fengming , Spertus John A , Goyal Abhinav , Gore M O , Lanfear David E , Maddox Thomas M , Kosiborod Mikhail
Published: March 2022

Background:
Discharge beta blocker (BB) prescription after myocardial infarction (MI) is guideline recommended for all eligible patients and is a core quality measure. Numerous BB choices are presently available that vary with regard to their glycometabolic effects, a potentially important consideration in patients with diabetes mellitus (DM). We studied whether clinicians preferentially select BBs with favorable metabolic effects in patients with DM.

Methods:
Among 4316 MI patients from 24 US hospitals enrolled in the TRIUMPH registry (2005-08), we investigated the frequency of “DM-friendly” BB use at discharge by DM status. BB were classified as potentially favorable (e.g., carvedilol, labetalol), or potentially adverse (e.g., metoprolol, atenolol) with regards to their effects on glycemic control. Hierarchical logistic regression examined the association of DM with favorable BB use, adjusting for LV dysfunction to examine whether the favorable BB were being selected primarily for their metabolic effects or for their heart failure indication.

Results:
Mean age was 59, 33% were women, 30% nonwhite, and 31% (n=1331) had DM. BB were prescribed at discharge in 90.4% of patients without DM and in 91.4% of those with DM (Figure). Only a small fraction of DM patients received a favorable BB (13.7%), but this proportion was modestly higher than in patients without DM (10.3%; p=0.001; unadjusted OR for DM vs non-DM 1.52, 95% CI 1.24-1.87). After adjusting for LV dysfunction (which was more common in DM patients and strongly associated with greater use of favorable BB; OR 4.57, 95% CI 3.69-5.65), the association of DM with use of favorable BB was attenuated but remained significant (OR 1.44, 95% CI 1.16-1.78).

Discussion:
In a large, multicenter MI registry, DM was associated with increased discharge prescription of BBs with potentially favorable effects on glycemic control. However, the vast majority of DM patients were still prescribed BB with potentially adverse metabolic effects. Continued efforts to discern the clinical relevance of the metabolic effects of BBs are needed, and if clinical differences are demonstrated, significant opportunities exist to improve current practices of BB use in diabetic patients.
Abstract 156: Body Mass Index and Outcomes among Patients with Atrial Fibrillation from the ATRIA2-CVRN Study
Authors: Black Mary Helen , Wu Jun , Singer Daniel E , Udaltsova Natalia , Harrison Teresa N , Shen Albert Yuh-Jer , Fang Margaret C , Go Alan S , Reynolds Kristi
Published: March 2022

Atrial fibrillation (AF) is a strong, independent risk factor for stroke, CVD-related mortality, and other cardiovascular complications. While studies have reported associations between higher BMI and AF incidence, few have examined the risk of thromboembolic and bleeding outcomes attributable to overweight or obesity in AF patients. We examined the longitudinal effect of BMI on all-cause mortality, as well as thromboembolic and major bleeding events, in a large cohort of incident AF patients from Kaiser Permanente Northern and Southern California. Outcomes include stroke (STR), STR and/or any other thromboembolic event (OTE), STR and/or intracranial hemorrhage (ICH), ICH and/or any other bleed (OBL). BMI (kg/m
2
) measured nearest AF diagnosis, and demographic and clinical covariates were extracted from electronic health records and administrative databases. BMI was categorized as underweight (BMI < 18.5), normal weight (18.5
<
BMI < 25), overweight (25
<
BMI < 30), moderately obese (30
<
BMI < 40) or extremely obese (BMI
>
40). Multivariable Cox proportional hazard models were used to estimate the effect of BMI on time to event, during off-warfarin periods, adjusted for age, sex, race/ethnicity, and history of hypertension, diabetes and coronary artery disease. Among 22,487 AF patients (46% female; 6% Black, 12% Hispanic, 7% API) with off-warfarin time during follow-up, 34% were overweight, 29% obese and 6% extremely obese. Mean age ± SD was 72 ± 13 years. Median (IQR) length of off-warfarin follow-up was 1.38 (1.57) years. Crude all-cause mortality and incident thromboembolic and bleeding rates were highest among underweight or normal weight patients and gradually declined with increasing BMI (Table; all P-trend < 0.002). The unadjusted relative risks for all outcomes were substantially and significantly lower with increasing BMI (Table). However, after adjustment for demographic and clinical confounders, only risk of all-cause mortality was significantly lower for overweight and moderately obese compared to normal weight patients (Table). In conclusion, overweight and moderate obesity appear protective for all-cause mortality in at-risk AF patients during off-warfarin periods, but these effects do not appear to be mediated by reduced risk of thromboembolism or major bleeding.
Abstract 163: Decreasing Adverse Drug Events Through a "Simple Intervention"
Authors: Joy Brian F , Harrison Sheilah , Teske Douglas W , Simsic Janet
Published: March 2022

BACKGROUND:
Patients in the cardiac intensive care unit (CICU) are at risk for adverse drug events (ADE). CICU ADEs may result in life-threatening consequences and have been shown to be associated with polypharmacy, severity of illness, and intensity of treatment. The purpose of this review was to highlight the significance of a multidisciplinary huddle following each ADE in reducing future events.

METHODS:
All patients admitted to the CICU at Nationwide Children’s Hospital from 2010 to 2012 were retrospectively reviewed. ADE reporting is voluntary via an electronic Event Reporting System. ADEs are placed on a 9 point clinical severity scale based on the seriousness of the error. Huddles, defined as an in depth multidisciplinary discussions revolving around causative factors and potential interventions, were instituted following harm-causing ADEs (clinical severity 4-9) and select high risk non-harming ADEs (clinical severity 1-3). ADEs were tracked, and the resultant huddles were reviewed. Huddle contributors included physicians, nurses, nurse practitioners, and pharmacists. Huddle process included chart review of events leading to the ADE, caregiver input about contributing clinical or situational factors, root cause identification, and prevention strategies.

RESULTS:
There were 238 ADEs (clinical severity 1-9); 60 huddles were conducted on ADEs of all severities. Causative factors identified were errors in drug administration (N=40), nursing stressors (N=21), nursing double check (N=17), human factors (N=16), handoffs (N=13), staffing (N=9), equipment (N=5), verbal orders (N=3), pharmacy (N=2), and medication reconciliation (N=1). Action plans initiated included extending the “distraction free zone”, improving nursing handoffs, implementing a hands-free communication system, improving the electronic medical record, educating and reinforcing unit policies, and eliminating verbal orders. Harm-causing ADEs were reduced from 0.43 to 0.06 per 1000 doses administered (p<0.0001).

CONCLUSION:
Multidisciplinary huddles are one effective tool utilized to spearhead a quality improvement initiative to reduce ADEs in a CICU. Huddles are analogous to a small-scale root cause analysis with the goal to determine causative factors and develop interventions to prevent future events.
Abstract 166: Chasing the 90-Minute Target for First Medical Contact to Balloon (FMC2B) Time in EMS-Transported STEMI Patients at Two Teaching Hospitals
Authors: Goyal Abhinav , Stigaard Leslie , Jeter Muna , Casey Mary , Vanairsdale Sharon , Wilson Jane , Rab Syed Tanveer , Keadey Matthew , Osborne Anwar , Morris Douglas , Capes James , Liberman Henry , Ross Michael A
Published: March 2022

Background:
AHA Guidelines establish a 90-minute target for First Medical Contact to Balloon (FMC2B) time in STEMI patients transported by emergency medical services (EMS) to STEMI-receiving centers. We describe the measures implemented and progress to date in achieving this new standard of care in two STEMI-receiving hospitals within one health system.

Quality Improvement Goal and Data Sources:
In Quarter 3 (Q3) 2011, our hospitals began participating in the AHA Mission: Lifeline program to build regional STEMI systems of care. We established a goal for each hospital to achieve the 90-minute FMC2B target in 75% or more of EMS-transported STEMI patients within at least one quarter in 2012. We used our AHA Mission: Lifeline reports (derived from our submitted ACTION-Registry GWTG data) to track our FMC2B times quarterly across five quarters (Q3 2011 through Q3 2012), and internal hospital data to determine the relationship between pre-hospital cath lab activation and achieving FMC2B targets.

Interventions and Results:
There were 36 and 43 STEMI patients respectively at each hospital who were eligible for FMC2B reporting over five quarters. Rates of achieving the 90-minute FMC2B target are shown before, during, and after implementation of seven hospital-wide interventions (Figure). Success rates were initially variable but improved in the last three quarters at both hospitals. One hospital reached the 75% consistency threshold for achieving the FMC2B target in Q1 2012, and both hospitals achieved a ≥70% success rate in the final reported quarter (Q3 2012). In both hospitals combined, 71.4% of patients with pre-hospital cath lab activation achieved the 90-minute FMC2B target, compared with only 50.0% when the cath lab was activated after hospital arrival (p=0.033). Equipment breakdown during attempted transmission of the pre-hospital ECG was a common reason for failure to activate the cath lab from the field.

Conclusions and Next Steps:
Consistent achievement of the 90-minute FMC2B target in STEMI patients requires unprecedented team-building and trust between EMS, ED, and cardiology personnel. A particular focus in 2013 will be increasing the rate of pre-hospital cath lab activations through EMS-to-ED phone calls when EMS is unable to transmit the field ECG to our hospitals.
Abstract 173: Tailoring Follow-Up Methods for Hard-to-Reach Participants in Outcomes Research: An Example from TRACE-CORE
Authors: McManus Richard H , Person Sharina , Barysauskas Constance , Ash Arlene , Kiefe Catarina I
Published: March 2022

Aims:
Telephone follow-up for longitudinal outcomes research is common, with widely variable response rates. Non-respondents are often different from respondents and come from vulnerable groups, including racial and ethnic minorities, elders, or those with multiple co-morbidities. We aimed to create a comprehensive follow-up strategy to target follow-up resources to the hardest-to-reach participants. These methods could help outcomes researchers retain hard-to-reach patients in longitudinal studies.

Methods:
Using interview completion data from the first 614 patients hospitalized with an acute coronary syndrome and enrolled in the Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE) cohort at our largest enrollment site, we fit a logistic regression model that used socio-demographic characteristics and difficulties with hearing and vision to predict likelihood of non-completion of a 1-month post-hospitalization telephone interview. Patients whose predicted probability of non-completion exceeded a threshold were triaged to a new follow-up protocol with more intensive calling by site-specific staff with access to medical records and follow-up appointment schedules. We compared the post-implementation follow-up completion rates to the expected completion rates based on the model.

Results:
The model predicted a completion rate of 69.8% (56 of 80) among the hard-to-reach group; our intervention achieved a 85.0% (68 of 80) completion rate (p=0.002). Increases in response rates were observed across most subgroups, although not all improvements reached statistical significance (Table). Improvements in completion rates were less pronounced for vulnerable groups.

Conclusions:
We used a statistical model to prospectively identify a “hard-to-reach” group for more intensive follow-up efforts. The statistical model provided an expected completion rate for patients receiving the new protocol against which the observed rate could be tested, allowing us to conclude that the enhanced protocol worked to improve follow-up in these typically hard-to-reach populations.
Abstract 178: Developing a Real-Time Event Monitoring System for Congenital Cardiothoracic Surgery
Authors: Phillips Alistair , Olshove Vincent
Published: March 2022

Background:
The Institute of Medicine in December 2006 set out on a campaign to save 5 million lives. During this effort they set out to score medical events using the Adverse Drug Events scoring system, which scores events from A to I, with I being a lethal event. We have adapted the scoring system to monitor events that occur in post-operative pediatric cardiothoracic patients. There are 3750 events that are contained in our database.

Methods:
In January 2007 we began tracking all events that occurred in our post-operative patients. Four nurse specialists who have been trained in the scoring system track these events. All events are reviewed and audited by the same person.

Results:
From 1/2007 through 12/2008, 430 patients underwent pediatric cardiac surgery requiring cardiopulmonary bypass. The mean age was 6±10.4 years with median age of 1.2 years, median weight was 8.6 Kg. Median length of stay was 6 days. The hospital discharge mortality rate was 2.6%, comprehensive complexity score of 3.8±1.1, 60.2% of the patients were extubated in the operating room, and 30.9% of patients received no blood products. Total events were 747 with 666 events reported A through D, and 81 events greater than E.

Conclusions:
Developing a comprehensive, standardized event monitoring system will be important to help define quality measures. Most importantly, this event monitoring system is robust and will give real-time feed back on how the patients are doing.
Abstract 19: U.S. Trends in Left Ventricular Assist Device Use and Outcomes: An Analysis of Medicare Administrative Data
Authors: Okrah Kingston , Cram Peter
Published: March 2022

BACKGROUND:
Left Ventricular Assist Devices (LVAD) have become the treatment of choice for many patients with advanced symptomatic heart failure who are not candidates for heart transplant (destination therapy) or who are waiting for a donor heart (bridge therapy). Little is however known about contemporary trends in LVAD volume, per-capita utilization and mortality especially among older patients. We examined trends related to LVAD implantation among the U.S. Medicare population.

METHODS:
Using Medicare inpatient data (MedPAR), we identified all fee-for-service beneficiaries age 65 and older who received LVADs between 2006 and 2010 using ICD-9 code 37.66. We examined the number of LVADs implanted each year and per-capita utilization (LVADs per 100,000 Medicare enrollees per-year) for every year during our study period. We also examined mortality rates during the index admission and within 90-days and 365-days from the index admission for each year. Trends over time were compared using Mantel-Haenszel test for trend.

RESULTS:
The number of LVADs implanted in fee-for-service Medicare beneficiaries age 65 and older increased from 145 in 2006 to 547 in 2010 (an increase of 277%). Among the 1,549 patients who received LVADs, mean age was 70.5 years (84% male, 85% white). Per-capita LVAD utilization increased by 245% from 1.1 per 100,000 patients in 2006, to 3.8 per 100,000 patients in 2010. In-hospital mortality decreased over the study period (40.7% in 2006 to 19.6% in 2010; P<0.0001) while 90-day mortality increased (82.8% in 2006 to 89.8% in 2010; P=0.02) as did one-year mortality (97.2% in 2006 to 100% in 2010; P=0.002). CONCLUSION: The utilization rate of LVADs in the Medicare population increased significantly between 2006 and 2010 and was accompanied by an increase in 90-day and one-year mortality despite a decrease in in-hospital mortality. These results and the trend towards increasing mortality warrant careful attention and consideration by physicians, patients, and policy makers.
Abstract 196: Heart and Lung Transplant Center Policies on Recreational and Medical Marijuana Use
Authors: Page Robert L , Keller Karin E , Ambardekar Amrut V , Lindenfeld JoAnn
Published: March 2022

Introduction:
As of January 2013, medical marijuana (MM) is currently legal in 18 states across the United States. In thoracic transplantation, standardized polices do not exist regarding MM use. We surveyed 317 US thoracic transplant medical directors regarding their center’s policies surrounding both MM and recreational marijuana (RM) use.

Methods:
We obtained names of the medical directors for US heart and lung transplant centers through the United Network for Organ Sharing (UNOS). A survey regarding MM and RM policies was developed, approved by the Colorado Multiple Institutional Review Board, and emailed through SurveyMonkey from April 2012-October 2012. Descriptive statistics were used to determine overall percentage of responses.

Results:
The survey was sent to 317 directors; 82 surveys were returned (25.8% overall response). 67.1%, 28.0%, and 4.9% were from heart, lung, and heart-lung programs, respectively. 80.5% of respondents were directors of adult programs, while 12.2% were from pediatric programs and 7.3% were affiliated with both adult and pediatric programs. Table 1 summarizes center policies on contraindications. During the study period, MM was state legalized for 32.9% of the directors. 2.5% of programs allowed their patients to drive while using MM, 21.0% did not, and 33.3% had no policy regarding this subject. Only 5.0% of respondents believed that a drug-drug interaction existed between marijuana and a patient’s immunosuppressive medications, while 78.8% were unsure of an drug-drug interactions.

Conclusions:
There is substantial heterogeneity among thoracic transplant programs about the acceptability of both MM and RM as a contraindication for transplantation. Additional data about drug-drug interactions with marijuana and the influence of MM and RM on transplant outcomes is warranted; harmonization of state and federal laws would advance this agenda.
Abstract 197: Multilevel Analysis Of Clinical Trial Data: Is It Necessary?
Authors: Kolm Paul , Zhang Zugui , Spertus John , Weintraub William S
Published: March 2022

Introduction:
Major clinical trials involve any number of sites in order to enroll enough patients to adequately power the study. In addition, sites enrolling patients in a trial may belong to different health systems (e.g., countries). Differences among patients and practices of these systems/sites potentially introduces a component of variation that may affect the results of the statistical analysis of the data, and thus the conclusions of the study. In this study, we examined the impact of the multilevel nature of the COURAGE Trial on the analysis of patients’ quality of life data.

Methods:
The aim of the COURAGE Trial was to determine whether the addition of PCI to optimal medical therapy, when used as an initial management strategy, reduces the risk of death or nonfatal MI in patients with stable CAD, compared with optimal medical therapy alone. A total of 2,287 CAD patients were enrolled from 3 health care systems: Canadian (16), VA (15) and US non-VA (19) hospitals. A 3-level mixed effects model was used to analyze differences in change is Seattle Angina Questionnaire (SAQ) scores from baseline to 3 years follow-up. Health care system and hospital were treated as random effects, repeated measurements of patient SAQ scores was a fixed effect. Within-patient variability, as in any analysis, was considered a random effect. The intra-class correlation (ICC) coefficient was calculated as an index of the random effects on the analysis.

Results:
The results of the COURAGE quality of life study have been previously published. The multilevel analysis indicated that health care system and hospitals had little impact on the results. The ICC including health care system and hospital as random effects was 0.35 compared to 0.34 when not included in the analysis.

Conclusions:
In the COURAGE Trial, multiple health care systems and hospitals had virtually no effect on the statistical results. However, this may not necessarily be the case for all studies in which there is a multilevel component. Multilevel effects should always be assessed in these types of studies.
Abstract 201: Predictors of Stroke in Hospitalized Patients with Thrombotic Thrombocytopenic Purpura
Authors: Subramanian Kathir S , Kolte Dhaval , Syed Rashid Z , Balasubramaniyam Nivas , Palaniswamy Chandrasekar , Aronow Wilbert S , Harikrishnan Prakash , Sule Sachin , Peterson Stephen J
Published: March 2022

Background:
Stroke may be the presenting symptom of thrombotic thrombocytopenic purpura (TTP), but the predictors of stroke in patients with TTP are unknown. We sought to seek the differences in characteristics in TTP patients presenting with and without stroke.

Methods:
The study examined data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality for the years 2001 to 2010. Patients aged ≥ 18 years with the diagnosis of TTP (ICD-9 code 446.6) who received therapeutic plasmapheresis (ICD-9 code 99.71) were included for analysis. Patients with stroke among the group were identified using the HCUP clinical classification Software code (109 for stroke). Data on baseline characteristics and mortality were analyzed.

Results:
A total of 4032 patients were identified to have TTP. Among these patients, 329 (8.16%) had the diagnosis of stroke. The independent predictors of stroke in this population by logistic regression analysis were age (OR 1.017; 95% CI 1.008 -1.026 p<0.001), white race (OR 0.704; 95% CI 0.536-0.926 p=0.012), dyslipidemia (OR 1.876; 95% CI 1.309-2.689 p= 0.001) and acute myocardial infarction (AMI) (OR 3.108; 95% CI 2.090-4.621 p<0.001). Independent predictors of in-hospital mortality in patients with TTP who developed stroke were hypertension (OR 0.399; 95% CI 0.190-0.839 p= 0.015), acute renal failure (OR 2.178; 95% CI 1.063-4.461 p=0.033), atrial fibrillation (OR 17.170; 95% CI 3.349-88.030 p=0.001), and ventricular tachycardia/ ventricular fibrillation/cardiac arrest (OR 12.748; 95% CI 1.982-81.979 p=0.007).

Conclusion:
Stroke develops in 8.16% of patients admitted with TTP. The independent predictors of stroke in this group of patients are age, white race, dyslipidemia, and AMI.
Abstract 209: Analysis of the Costs and Payments of a Coordinated Stroke Center and Regional Stroke Network
Authors: Rymer Marilyn M , Armstrong Edward P , Meredith Neil R , Pham Sissi V , Thorpe Kevin , Kruzikas Denise T
Published: March 2022

Objective:
A comprehensive regional stroke program implemented at Saint Luke’s Neuroscience Institute (SLNI) was recently shown to generate increased access to advanced stroke care and improved patient management and treatment per guidelines. The purpose of this current study was to evaluate the costs associated with implementing a progressive, comprehensive stroke program at SLNI.

Methods:
This was a retrospective analysis of total hospital costs and payments received from all payers for treating ischemic stroke patients at SLNI as program enhancement evolved over time (2005, 2007, 2010). Results from SLNI were compared with previously published national benchmarks. The analyses were stratified by patient demographic characteristics, patient outcomes, treatments, time, and comorbidities.

Results:
Financial and clinical registry data were available for 1,570 SLNI patients with an acute ischemic stroke. The median total cost (direct + indirect costs) per patient was $12,812. Controlling for inflation, there was no difference in SLNI total costs between 2005 and either 2007 or 2010. However, after controlling for inflation, SLNI median costs were lower in some subgroups compared to national estimates including discharged to home/home health care ($14,247 versus $16,613), females ($15,907 versus $19,826), and patients with an intracranial hemorrhage ($20,339 versus $26,470). Within SLNI patients, those discharged to home or home healthcare were -$1,712 less costly than patients discharged to other locations. In addition, patients who were 65 years of age and older were less costly (-$1,852) than younger patients. Patients receiving intra-arterial tPA or an embolectomy were associated with a $7,568 higher cost than patients who did not receive these treatments. Longer stays were associated with an increased cost of $2,246 per day. The median financial data indicated that the SLNI profit margin was negative for managing patients diagnosed with acute ischemic stroke across the study population. Multivariate analysis revealed lower payments of -$5,575 were associated with each patient age 65 years or older, while longer lengths of stay increased payment by $1,283 per day.

Conclusions:
This analysis indicates that SLNI has successfully implemented a comprehensive program with coordinated regional care, dedicated high-level staffing, state-of-the-art technology, and process efficiencies that results in better access and care while overall total hospital costs remained unchanged. However, SLNI total operating costs continue to outweigh payments, similar to that observed in previous studies, indicating the need for further reimbursement consideration. Despite such reimbursement challenges, this study suggests a comprehensive stroke care program with improved access and treatment may be financially feasible for other hospitals to implement.
Abstract 212: Estimation Of Long-term Care Needs For Stroke By Integrating Functional Disability And Survival
Authors: Hung Mei-Chuan , Hsieh Ching-Lin , Hwang Jing-Shiang , Jeng Jiann-Shing , Wang Jung-Der
Published: March 2022

Background and Purpose:
This study aimed to estimate the dynamic changes of different physical functional disability states and life-time care needs for subjects with different subtypes of stroke.

Methods:
We examined a hospital-based cohort including 16,043 subjects who had their first stroke during 1995-2010. The Barthel Index (BI) was used to measure physical functional disability levels in 1,111 consecutive subjects at the stroke clinic and the rehabilitation ward. A total BI score below 60 was considered as severe level of disability. Kernel-smoothing method was used to estimate the dynamic changes of different physical functional disability. The survival function was extrapolated to lifetime by a semi-parametric method and then multiplied with proportions of different kinds of disabilities over time to obtain the long-term care needs for different subtypes of stroke.

Results:
On average, stroke subjects had 8.30 (± 0.36) years without disability, 0.85 (± 0.14) years with mild disability, 1.23(± 0.18) years with moderate disability and 1.38 (± 0.19) years with severe disability as measured by BI. Assistance in bathing appears the most common need for care. Subjects with a cardio-embolic infarct suffered the longest period of severe disability (2.34 years), followed by those with intracerebral hemorrhage and large artery atherothrombotic infarct.

Conclusions:
Among different subtypes of stroke, cardio-embolic infarct suffered the longest duration of physical functional disability related to self-care. The method can also be employed to other chronic diseases with different types of functional disabilities.
Abstract 213: The Smoking Paradox in Acute Ischemic Stroke: Findings from Get With The Guidelines - Stroke
Authors: Ali Syed F , Smith Eric E , Bhatt Deepak L , Pan Wenqin , Fonarow Gregg C , Schwamm Lee H
Published: March 2022

Introduction:
Smoking doubles the risk of acute ischemic stroke (AIS) and has been associated with lower in-hospital mortality in patients with myocardial infarction and heart failure. We investigated the association of smoking and mortality in AIS patients in Get With The Guidelines (GWTG)-Stroke.

Methods:
We analyzed all AIS patients (n=899,295) without a prior history of CAD from 04/2003-10/2012 in GWTG-Stroke. Categorical data were analyzed by Pearson Chi-square and continuous data by Wilcoxon test. Multivariable models with generalized estimating equations for in-hospital clustering were used to estimate odds ratios of in-hospital mortality. All significant predictors on univariate analysis were included in the multivariable model.

Results:
Among all AIS patients, 20% were current smokers, defined as any cigarette use in the past year. Smokers were substantially younger (13 years), more often male, with fewer vascular risk factors and comorbid conditions. When recorded, median NIHSS was lower. Smokers were more likely to be admitted to large, academic hospitals, and more often in the South and Midwest. Both groups received a similar frequency of evidence based in-hospital interventions. In-hospital mortality was lower amongst smokers (Table 1). The significant univariate mortality difference attenuated dramatically after adjusting for age and other covariates in the multivariable model, OR increased from 0.56 (0.54, 0.58) on univariate analysis to 0.87 (0.84, 0.91) on multivariable model. Other independent predictors of mortality were increasing age [1.10 (1.08, 1.11) per 10 yr], male gender [1.17 (1.14 - 1.20)], white race [1.18 (1.14 - 1.23)], higher initial NIHSS [1.13 (1.12 - 1.13) per point], atrial fibrillation [1.29 (1.25 - 1.33)], PVD [1.15 (1.08 - 1.23)] and DM [1.12 (1.09 - 1.16)].

Conclusion:
Smoking continues to be a major risk factor for presenting with acute ischemic stroke at a much younger age and with fewer vascular risk factors. The association with lower in-hospital mortality, even after covariate adjustment, may represent residual confounding due to the marked age differences and unmeasured confounding or it may reflect a protective association. Further research is warranted.
Abstract 216: Identification of Secondary Cardiovascular Risk in Patients with Familial Hypercholesterolemia after Coronary Artery Disease from a US Database
Authors: Salimi Tehseen , Wang Hongwei , Zhang Quanwu
Published: March 2022

Background:
Despite extensive research on health impact of hypercholesterolemia (HC), the cardiovascular (CV) risk in pts with familial hypercholesterolemia (FH) is not well understood. This study was performed to identify the secondary CV risk in pts with FH after coronary artery disease (CAD).

Methods:
Statin users between Jan 2004 and Jun 2010 were identified from the US IMPACT health insurance claims database. Two groups of FH pts with CAD were identified according to Simon Broome criteria: High-LDL FH (HFH) LDL-C ≥200 mg/dL; Moderate-LDL FH (MFH) 190≤ LDL-C <200 mg/dL. A non-FH cohort was identified as HC+ CAD, with 100< LDL-C <190 mg/dL. Secondary CV event rates (including stoke, myocardial infarction, unstable angina) were assessed in the 3 cohorts against the most recent LDL-C value prior to the CV event.

Results:
Secondary CV event rate was 7.5/100 pt-yrs in HFH (n=1277, age 59 yrs, 49% male, mean baseline LDL-C 189 mg/dL), 6.1/100 pt-yrs in MFH (n=549, 59 yrs, 48% male, LDL-C 149 mg/dL) and 4.6/100 pt-yrs in Non-FH (n=4484, 61 yrs, 60% male, LDL-C 126 mg/dL). CV event rate increased 63% in HFH (rate ratio (RR)=1.63, p<0.01) and 33% in MFH (RR=1.33, p=0.02) compared to the Non-FH cohort. Furthermore, CV risk continued to rise with LDL-C across all 3 cohorts (8% per every additional 20 mg/dL LDL-C, p<0.01), even in the HFH cohort that had the highest base CV event rate (5% per 20 mg/dL LDL-C, p=0.02). Older age, male gender and more comorbidities were associated with increased CV risk, while ezetimibe+statin and atorvastatin were associated with a lower CV risk compared to simvastatin.

Conclusions:
Secondary CV event risk increased with LDL-C levels across the FH and non-FH cohorts identified from the US managed care insurance claims database. Compared with non-FH, FH pts are at a significantly higher CV risk. CV risk continues to rise with LDL-C levels even within the high LDL FH cohort. These findings suggest a prominent clinical gap especially in the high LDL FH pts that require appropriate identification for effective therapy.
Abstract 221: National and Regional Trends in Hospitalizations for Ischemic Stroke after Acute Myocardial Infarction in the United States: 1999-2010
Authors: Shi Ruizhi , Wang Yun , Lichtman Judith H , Krumholz Harlan M , Dharmarajan Kumar , Masoudi Frederick A , Dodson John A , Chen Jersey , Chaudhry Sarwat I , Spertus John A , Nallamothu Brahmajee K
Published: March 2022

Background:
Elderly survivors of acute myocardial infarction (AMI) are at elevated risk for ischemic stroke. Changes in treatment for AMI and proportions of NSTEMI combined with an increasing aging population may have influenced the risk of post-AMI strokes. We sought to characterize temporal trends in the risk for post-AMI strokes older patients and assess whether patterns differed by age, sex, race, revascularization status, and region within the US.

Methods:
We used 100% of Medicare inpatient claims data to identify fee-for-service (FFS) patients aged >64 years hospitalized for AMI in 1999-2010. We excluded patients who died during AMI hospitalization or were transferred. Revascularization status was identified during the index admission. We used a Cox proportional hazards regression model to estimate risk-adjusted annual changes in one-year ischemic stroke hospitalization after AMI, overall and by subgroups. Changes were adjusted by age, gender, race, medical history and comorbidities. We calculated the 30-day post-stroke mortality. Stroke belt regions were defined as the states with high stroke hospitalization rates in the southeast United States and were compared with non-stroke belt regions.

Results:
Among 2,433,036 AMI hospitalizations and 58,009 ischemic stroke readmissions, the risk-adjusted one-year readmission rates for ischemic stroke after AMI decreased from 3.3% (95% CI 3.2%-3.4%) in 1999 to 2.6% (95% CI 2.6%-2.7%) in 2010, a relative 21.2% decline. Overall risk-adjusted relative annual decline was 2.6% (95% CI 2.3%-2.9%). Post-AMI stroke rates declined across all age-sex-race groups and most treatment groups (Figure). Thirty-day mortality rates after stroke decreased a relative 8.6% (1999, 21.0% 95% CI 19.7%-22.5%; 2010, 19.2%, 95% CI 18.0%-20.5%). Post-AMI stroke rates were 6% higher in stroke belt regions, but both stroke belt regions and all other regions showed declines over time.

Conclusions:
From 1999 to 2010, the hospitalization rates of ischemic stroke after AMI decreased overall and for demographic subgroups and those undergoing PCI, CABG, or no revascularization. Declines were seen for all regions, but were consistently higher for stroke belt states. Post-AMI strokes 30-day mortality rates decreased over time.
Abstract 233: Trends in Referral to Post-Acute Care Services after an Acute Stroke Hospitalization in the U.S.: Findings from the Get With The Guidelines-Stroke Program
Authors: Prvu Bettger Janet , McCoy Lisa , Smith Eric E , Fonarow Gregg C , Schwamm Lee H , Peterson Eric D
Published: March 2022

Background:
Despite proven benefits of post-acute rehabilitation care, prior studies had suggested overall use of stroke rehabilitation was declining, largely in response to payment reform. We examined more contemporary trends in discharge to stroke inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), or home with home health referral (HH) over the last decade of Medicare prospective payment reform.

Methods:
We examined trends in discharge destinations (IRF, SNF, HH, or home without services) for 849,780 patients age >18 years with acute ischemic or hemorrhagic stroke at 1,687 hospitals participating in the Get With The Guidelines-Stroke (GWTG-Stroke) program. Multivariable analysis was used to identify factors associated with discharge to any post-acute care (IRF, SNF or HH) vs. discharge home without services.

Results:
Between 2003 and 2011, 43.7% of acute stroke patients were discharged home without services, 25.4% to IRF, 19.5% to SNF, and 11.5% to HH. Discharge to post-acute care increased by 2.1% (p=0.001) for all patients over the period. This included an increase for IRF (by 6.9%, p<0.0001) and HH (by 3.6%, p<0.0001) while discharge to SNF decreased 8.3% (p<0.0001). Discharge disposition and trends varied both by age and stroke severity. In a multivariable-adjusted model we found that older patients (≥65 vs. <65) were more likely to be discharged to post-care care every calendar year with similar ORs, ranging from 2.6 to 2.8. Other factors independently associated with discharge to any post-acute services versus none are shown in Table 1.

Conclusions:
Since 2003 there was a slight increase in the proportion of stroke patients discharged to post-acute care among hospitals participating in GWTG-Stroke. However, 4 in 10 patients are discharged home without services. Over the last decade of payment reform, there has been modest change in types but not the overall referral to post-acute services for stroke patients.
Abstract 248: The KCCQ-12: A Short Version of the Kansas City Cardiomyopathy Questionnaire
Authors: Jones Philip , Gosch Kensey , Li Yan , Reid Kimberly , Tang Fengming , Chan Paul , Spertus John
Published: March 2022

Background:
The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a well-validated and widely used 23-item instrument that measures patient-reported symptoms, function and quality of life for patients with heart failure. We sought to develop a shortened version to reduce response burden and facilitate greater use within busy clinical environments.

Methods:
We used data from 2 multicenter randomized trials (EVEREST: n=2,005; EPHESUS: n=1,616) and one multicenter outpatient cohort study (n=547) to develop and validate a short version of the KCCQ. We included items from the Physical Limitation, Symptoms, Quality of Life and Social Limitation scales, which directly measure patients’ current health status. In development cohorts, we used equidistant item-total correlation methods to identify items that best correlated with their respective full-version score across the entire range of scores. We considered item response variability and missingness in choosing between similarly performing items. Using the selected items, we calculated summary scores for each of the 4 scales, and an overall summary score as the average of the 4 scale scores. (As in the full KCCQ, scores were rescaled so that 0 denotes the worst and 100 the best possible health status.) Finally, in independent validation cohorts, we conducted a range of analyses to investigate the validity, reproducibility, and responsiveness of the short-version scores.

Results:
We identified 12 items that tracked strongly with their corresponding full-version scores (3 of 6 Physical Limitation items; 4 of 8 Symptom items; 2 of 3 Quality of Life items; 2 of 3 Social Limitation items). Correlations between the resulting short-version and full-version scores was excellent (r=0.92 to 0.99), and missing rates were the same or lower for all scores. In validation studies, the KCCQ-12 demonstrated strong performance comparable to the full KCCQ (Table).

Conclusions:
The KCCQ-12 is a valid, reproducible, responsive instrument for assessing disease-specific health status among patients with heart failure, with properties and performance similar to the full KCCQ but with a substantially reduced response burden.
Abstract 25: Predicting Outcomes among Patients with Heart Failure Receiving Anticoagulation with Warfarin
Authors: Kim Eun-Jeong , Rose Adam
Published: March 2022

Background:
Many patients receiving oral anticoagulation for atrial fibrillation (AF) have heart failure (CHF). CHF predicts a greater risk of stroke and relatively poor anticoagulation control. However, it is not known which patients with CHF are at greatest risk of poor anticoagulation control or bleeding complications. Therefore, we risk-stratified the patients with CHF who are receiving warfarin for AF according to their risk of experiencing poor anticoagulation control and major hemorrhage using data available in the Veterans Health Administration (VA) Clinical Data Warehouse.

Methods and results:
We examined 66,099 subjects who had been anticoagulated for stroke prevention in AF for at least 6 months between 10/1/06-9/30/08. Based on ICD-9 codes, patients were divided between those who carried a diagnosis of CHF and those who did not. Among patients with CHF, we examined various predictors of percent time in therapeutic range (TTR), a measure of anticoagulation control. The predictors were chosen by the principle that more severe CHF would cause hepatic congestion, leading to a greater variability of anticoagulation control and greater risk of adverse events. We identified ten severity markers which predicted worse anticoagulation control (i.e. lower TTR) and chose the variables with the largest adverse impact on TTR such as aspartate transaminase (AST) >80 IU/L, alkaline phosphatase >150 IU/L, sodium <130 mEq/L, any receipt of metolazone, and any inpatient admissions for CHF exacerbation. We then developed a composite score of heart failure severity with CHF with no criteria, CHF with 1 criterion, CHF with 2 criteria, and CHF with 3 or more criteria. This composite score performed well to predict TTR; patients without CHF (referent) had a mean TTR of 65%, while groups of CHF patients with increasing severity had a mean TTR of 62%, 57%, 53%, and 50%, respectively (p < 0.001 for difference among groups). In addition, the composite CHF severity score also predicted the age-adjusted hazard of major hemorrhage. Compared to patients without CHF, patients with CHF of increasing severity had hazard ratios of 1.84, 3.04, 3.65, and 5.13 respectively (all p < 0.001 compared to no CHF).

Conclusion:
We developed a composite score for CHF severity which predicted both anticoagulation control and the rate of major hemorrhage among patients anticoagulated with warfarin. This study suggests that relatively easily observable characteristics can be used to risk-stratify patients with CHF who are receiving anticoagulation for AF.
Abstract 251: Risk Factors for Recurrence of Cardiovascular Events Following Acute Coronary Syndrome: Longitudinal Analysis from 2006-2011
Authors: Reddy Vanessa S , Luthra Rakesh , Xu Yaping , Wilhelm Kenneth , Power Thomas P , Fisher Maxine D , Cziraky Mark J
Published: March 2022

Background:
Cardiovascular (CV) disease is the leading cause of mortality in the US and worldwide; thus, it is important to understand the disease sequelae and prognostic predictors to help improve patient outcomes and reduce healthcare costs.

Methods:
Patients with an ICD-9 code for acute myocardial infarction (MI) or unstable angina (UA) during acute coronary syndrome (ACS) hospitalization were identified from the HealthCore Integrated Research Database (HIRD
SM
) between Jan 2006 and Sep 2011. A multivariable Cox proportional hazards model was used to evaluate the effect of risk factors on time to first subsequent CV event (defined as stroke, MI or CHD-related mortality), adjusting for baseline demographic characteristics, comorbidities, treatment utilization and index ACS characteristics.

Results:
Of 140,903 ACS patients identified, mean age was 66.8 years, 58.6% were male, and mean follow-up was 1.9 years. Baseline comorbidities include 41.9% with type 1 or 2 diabetes mellitus (DM), 60.4% hypertension (HTN), 10.7% renal dysfunction and 3.3% prior CABG/PCI. During the index ACS hospitalization, 42.7% had UA, 40.3% CABG and/or PCI and 3.6% of patients died. A total of 22.0% of patients had a recurrent CV event following index ACS, with an increased adjusted hazard of a recurrent event if the patient was older (hazard ratio=1.48 in
>
65 vs <65 years), had a history of heart failure (HR=1.41), renal dysfunction (HR=1.36), HTN (HR= 1.14) or DM (HR=1.10), all P < 0.001. Additionally, patients had a decreased adjusted hazard of a recurrent CV event with pre-admission single or fixed-dose combination statin use (HR=0.96 and 0.87, respectively) or a CABG prior to admission (HR=0.89), all P <0.001.

Conclusion:
Following an ACS event, patients with pre-admission statin use or a prior CABG had decreased risk, while older patients or those with baseline comorbidities had increased risk of an adverse CV event occurring sooner. Ultimately, identifying high-risk ACS subgroups may facilitate tailored and more aggressive treatment to improve outcomes.
Abstract 255: Neutrophil-to-Eosinophil Ratio Predicts Mortality in Patients with Advanced Heart Failure
Authors: Nagarajan Vijaiganesh , Cauthen Clay , Tang WH Wilson
Published: March 2022

Background:
Higher neutrophil count has been associated with poor prognosis in patients with heart failure. Also, eosinopenia has been recently described in some studies as a prognostic marker. The prognostic value of neutrophil-to-eosinophil ratio (NER) in advanced heart failure patients has not been explored.

Methods:
We reviewed 491 consecutive patients with stage D heart failure who underwent transplant evaluation from 2007 to 2010. NER = absolute neutrophil count
/
absolute eosinophil count. Based on NER, patients were divided into tertiles. Survival (death or heart transplant) analysis was analayzed by Kaplan-Meier curves in different tertiles.

Results:
Mean NER was 62.8 ± 111.3. Mortality/transplant rates increased with increasing NER tertiles (43.6%, 50.6%, and 54.9%). Kaplan-Meier survival analysis showed statistically significant prognostic importance with increasing NER tertiles. (log rank, p = 0.03, Figure.1). NER (HR, 1.24, 95% CI, 1.05, 1.46, p = 0.009) proved to be an independent predictor of mortality in a multivariate model including age, gender, diabetes, albumin, sodium, creatinine, etc.

Conclusion:
Neutrophil-to-Eosinophil ratio may provide independent prediction of adverse outcomes in patients with advanced heart failure.