bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 211: Racial Gaps in Percutaneous Coronary Intervention in Patients with End-stage Renal Disease
Authors: Sergeev Alexander V
Published: July 2021

Background:
End-stage renal disease (ESRD) increases risk of coronary artery disease (CAD) and also worsens prognosis in CAD patients. Percutaneous coronary intervention (PCI) with stenting is an effective treatment procedure for certain categories of CAD patients. It remains unclear whether post-procedure mortality in ESRD patients is associated with patients’ race and a type of stent [[Unable to Display Character: –]] a drug-eluting stent (DES) or a bare-metal stent (BMS).

Hypothesis:
We hypothesized that disparities in utilization of DES and BMS stents and post-procedure mortality would exist in CAD patients with ESRD (CAD-ESRD).

Methods:
We conducted a retrospective cohort study of in-hospital mortality in 12,289 CAD-ESRD patients [mean
+
SD age: 65.4
+
11.9 years; 60.3% (7,414 of 12,289) males] after PCI with DES and BMS during 2007-2011. Patients’ race was defined as white, black, or other (Asian, Pacific Islander, Native American). Due to short length of stay, in-hospital death was defined as a binary variable (discharged alive or deceased). Multivariable logistic regression was used to obtain adjusted odds ratios (OR) for in-hospital death after DES and BMS PCI in relation to patients’ race, adjusting for clinical and demographic characteristics, including age, gender, number of stents inserted, number of vessels treated, socio-economic status, emergency department (ED) admission, rural/urban area status.

Results:
Crude (unadjusted) post-PCI mortality was 4.4%, with crude post-DES mortality being 3.4% and post-BMS mortality being 6.7% (
P
<0.001). In the adjusted multivariable analysis, DES stents were also associated with lower mortality as compared to BMS (adjusted OR, 0.49; 95% confidence interval (CI), 0.42-0.57;
P
<0.001). DES stents were received by the majority of patients in all racial groups: 68.3% black, 68.9% white, and 76.9% other patients received DES. In the adjusted multivariable analysis, black patients had a borderline lower risk of post-procedure death than white patients (adjusted OR, 0.70; 95% CI, 0.49-0.99;
P
=0.046), while in white and other patients the risk of post-procedure death was similar (adjusted OR, 0.70; 95% CI, 0.48-1.03;
P
=0.072).

Conclusions:
Our results are indicative of the persistence of racial differences in post-PCI mortality in CAD-ESRD patients still exist, regardless of the improvements in the technique. Further studies investigating the mechanisms responsible for these disparities are warranted.
Abstract 224: No Difference in Complications or Mortality by Implanted Cardioverter Defibrillator Type in Veterans Enrolled in The Outcomes Among Veterans with Implantable Devices (OVID) Registry
Authors: Schneider Preston M , Pellegrini Cara N , Heidenreich Paul , Keung Edmund , Massie Barry M , Aleong Ryan G , Peterson Pamela N , Varosy Paul D
Published: July 2021

Introduction:
Dual chamber ICD implantation has been associated with higher complication rates than single chamber ICD implantation without associated decrease in morbidity or mortality in prior reports. If this association is present using validated long term outcomes or whether the same is true for cardiac resynchronization therapy defibrillator (CRT-D) devices is not well described.

Methods:
The OVID registry enrolled 3,918 veterans between 2003 and 2009. Retrospective chart abstraction from enrollment to implant date captured pre- and peri-procedural data. Patients were then followed prospectively until death or study conclusion. Abstraction was done by trained abstractors. Clinical outcomes and mortality were abstracted and validated. Mortality was cross referenced with the social security death index. Association of ICD type (single chamber, dual chamber, CRT-D) with mortality, non-fatal major events (major adverse cardiac events, TIA, stroke, cardiogenic syncope, cardiac hospitalization, device complication or infection, procedural complications), and the composite of mortality and non-fatal events was examined using Cox proportional hazards regression, adjusting for baseline clinical characteristics and comorbidities.

Results:
There were 786 deaths and 1143 non-fatal major events over 11,290 person years of follow up. In unadjusted analyses, CRT-D was associated with non-fatal major events (HR 1.26, 95% CI 1.09-1.45; p<0.05) and the composite outcome (HR 1.12, 95% CI 1.06-1.35; p<0.05) as was Dual chamber ICD (non-fatal major-HR 1.19, 95% CI 1.03-1.37; p<0.05, composite-HR 1.17, 95% CI 1.04-1.31; p<0.05). No significant difference existed in risk between ICD types in the unadjusted analysis of mortality or for any outcome when adjusted for clinical covariates.

Conclusions:
Unadjusted analyses showed an association between dual chamber ICD and CRT-D devices and risk of non-fatal major events and the composite outcome versus single chamber ICD implantation. This did not persist when adjusted for clinical characteristics and comorbidities, though we are underpowered for small differences. Further study is needed as prior reports may not have adjusted adequately for clinical covariates and lacked validated outcomes.
Abstract 239: Impact of Nurse Practitioner Directed Comprehensive Heart Failure Program in the Clinical Decision Unit
Authors: Onwuanyi Anekwe , Axiyan Maihemuti , Edwards Michele , Rhoads Barbara , Johnson Jasmine , Knauss Michael , Fouts Florence , Wirth Diane , Ede Victor , Wheatley Mathew
Published: July 2021

Background:
Hospitalization due to acute heart failure (HF) is a leading cause for admission and a major source for healthcare dollar expenditure. Clinical decision units (CDU) in the emergency department (ED) have been increasingly utilized by hospitals to prevent unnecessary HF admissions. If post CDU discharge and follow up care is suboptimal, there is increased likelihood for repeat ED visit and/or admission.We conducted this study to prove that a nurse practitioner (NP) directed intervention consisting of HF specific education coupled with timely outpatient clinic follow up will reduce repeat ED visit and/or 30 days readmissions.

Methods:
A retrospective chart review of HF patients admitted to the CDU using a prespecified protocol from 1/2013-12/2013 was performed. The patients were divided into two groups, those seen by the HFNP in the CDU (intervention group) vs. those not seen by HFNP (the control group). The intervention consisted of face-to-face heart failure education, medication optimization, symptom management; follow up phone call within 24-48 hours and heart failure clinic follow up 1-3 days post CDU discharge. Outcomes variable were repeat ED visits and/or readmissions within 30 days. Descriptive statistics and Chi-square were used for data analysis.

Results:
160 patients were admitted to the CDU using the heart failure protocol. 15 patients were found not to have heart failure and excluded from the study. Of the 145 heart failure CDU patients, 33 required admission and were not included in further analysis. The final study population was 112 patients, with 85 patients receiving the intervention. The mean ages for the intervention and control groups were 57.2 vs 55.9. There were 11 admissions (13% all cause) in the intervention group within 30 days following CDU discharge and 5 (6%) were HF related after adjudication. For the control group, there were 7 admissions (26% all cause) and 6 (22%) heart failure related. The difference in all cause 30 day admissions was statistically significant (p = 0.035).

Conclusion:
NP directed intervention in the CDU significantly reduced ED visit and 30 days readmission. Further studies are required to fully investigate this findings and potential impact on health care expenditure.
Abstract 244: Association of Chest Pain versus Dyspnea as Presenting Symptom for Coronary Angiography with Demographics, Coronary Anatomy, and 2-Year Mortality
Authors: Paudel Rajiv , Beridze Natalia , Aronow Wilbert , Ahn Chul , Sanaani Abdallah , Agarwal Pallak , Farell Kim , Jain Diwakar , Timmermans Robert , Cooper Howard , Panza Julio
Published: July 2021

Background:
The two most common conditions leading to an indication for coronary angiography are known or suspected coronary artery disease (CAD) and heart failure. However, whether the clinical presentation of chest pain (CP) versus dyspnea impacts on the demographics, coronary anatomy findings and outcomes of patients undergoing coronary angiography is unknown.

Methods:
We studied 1,053 patients (63% men, mean age 64 years), who underwent coronary angiography during 2012 at Westchester Medical Center and determined their most relevant clinical presentation from their medical records through the admission note. 2-years mortality was obtained from social security death index.

Results:
Of 1,053 patients, 654 (62%) had CP, 229 (22%) had dyspnea, 117 (11%) had CP and dyspnea, and 53 (5%) had an abnormal stress test with no symptoms. Patients with dyspnea were older (67 years vs. 63 years, p<0001), had a higher serum creatinine (1.3 mg/dL vs. 1.1 mg/dL, p = 0.0011), lower left ventricular ejection fraction (LVEF) (47% vs. 54%, p <0. 0001), more frequently had cardiogenic shock (5% vs. 1%, p =0.0004), less obstructive coronary artery disease (CAD) (45% vs. 63%, p < 0.0001) and less percutaneous coronary intervention (31% versus 10%, p< 0.0001), and similar 2-year mortality (4% vs. 7%, p=0.75). Log-rank test showed no difference in time to death between CP and dyspnea (p=0.104). Stepwise Cox regression analysis showed no significant difference in mortality rates between CP and dyspnea (p=0.11). Significant risk factors for time to death were age (HR 1.07, p <0.0001), serum creatinine (HR 1.5, P<0.0001), body mass index (HR 0.93, p = 0.005), and obstructive CAD (HR 3.2, p = 0.011).

Conclusions:
Patients undergoing coronary angiography who presented with dyspnea were older, had a higher serum creatinine, lower LVEF, more frequent cardiogenic shock, less obstructive CAD, and less percutaneous coronary intervention compared to patients presenting with CP. However, the difference in clinical presentation was not associated with a higher 2-year mortality.
Abstract 267: Case-Based CME Improves on Clinical Decision-Making in Non-ST Elevation Myocardial Infarction
Authors: Larkin Amy , LaCouture Michael , Padbury Caroline
Published: July 2021

Introduction:
Evolving therapies and guideline recommendations to treat non-ST elevation myocardial infarction (NSTEMI) create clinical confusion. The educational and practice impact of a case-based design of CME were measured on clinical decision-making related to NSTEMI treatment.

Methods:
The continuing medical education (CME) activity was developed as an online case-based text activity modeled after the interactive grand rounds approach where clinicians make clinical decisions about treatment for a given patient. The activity targeted primary care physicians (PCPs) and cardiologists who manage patients experiencing a NSTEMI and focused on application of guideline recommendations. The effects of education were assessed using a linked pre-assessment/post-assessment study design that separated learners into 3 categories: improved (incorrect pre, correct post), reinforced (correct pre and post), and unaffected (incorrect post). For all questions combined, the McNemar’s chi-squared test was used to assess whether the mean post[[Unable to Display Character: ‐]]assessment score differed from the mean pre[[Unable to Display Character: ‐]]assessment score. P values are shown as a measure of significance; P values <.05 are statistically significant. Cohen’s D was used to calculate the effect size. The activity launched online on April 16, 2014 and data were collected through July 24, 2014.

Results:
533 PCPs and 531 cardiologist completed both the pre- and post-assessment survey with a large overall effect size of 1.836 (
P
<0.05) and 1.799 (
P<0
.05), respectively. PCPs Correct responses on post-assessment questions ranged between 62% and 292% higher after CME completion. While only 8 (2%) participants answered all 4 questions correctly on the pre-assessment, 296 (56%) answered them all correctly on the post-assessment. Between 33% and 63% of participants showed improvement post-educational intervention. Cardiologists Correct responses on post-assessment questions ranged between 34% and 249% higher after CME completion. While only 28 (5%) participants answered all 4 questions correctly on the pre-assessment, 430 (81%) answered them all correctly on the post-assessment. Between 26% and 65% of participants showed improvement after the educational intervention.

Conclusion:
Online case-based CME activities modeled after the interactive grand rounds approach prompted changes in clinical knowledge, showing that when effectively constructed, this methodology is an effective tool to improve clinical application of guidelines and clinical decision-making in NSTEMI. This interactive educational format should be applied to CME for future activities.
Abstract 270: Reduction in 30-day Heart Failure Readmissions
Authors: Kravitz Kathleen A , Khot Umesh N
Published: July 2021

Heart failure (HF) 30-day readmission after hospitalization continues to have a significant clinical and economic burden and hospitals are seeking methods to prevent these readmissions.

We tried many projects to reduce heart failure readmissions without much success. After much analysis we found that preventable readmissions occur early. Our hypothesis was that the “defect” is in-hospital or in transition at discharge. This idea led to a pilot study to reduce HF readmissions.

A paper based checklist was created, utilizing a patient-centered approach to the delivery of care to optimize clinical outcomes. This checklist included in-hospital care metrics which were reinforced at various times throughout the patient’s hospital stay to ensure discharge readiness. A multi-disciplinary team: nursing, physician/LIP, pharmacy, nutrition and care management were responsible to address the following measures:

Medication reconciliation

Diet compliance

Importance of follow up care

Standard physician care

Addressing quality metrics

We implemented this pilot study on one nursing unit and limited the use of the checklist to two physician/LIP service groups. We used an intention-to-treat analysis approach and included concurrent and historical data to determine effectiveness of the HF discharge checklist.

Data for the pilot study was from the index discharge date starting April 1, 2013 to June 22, 2013. The HF readmissions for 2013 were compared to the heart failure readmissions for 2012, using the same time period April 1 to June 22. We also filtered to the physician service group in the previous year (2012) for comparison.

Heart failure readmission rates in all primary and secondary HF diagnosis patient population using the checklist were very positive with results at 14.6% (12 of 82). This was compared to the previous year (2012) using the selected physician group and found the readmission rate was 26.5% (18 of 68). Heart failure readmission rates for the hospital population were 18.7% (67 of 358) in 2013, compared to 24.5% (83 of 339) in 2012. Heart failure readmission rates on the selected nursing unit, including both patient populations with and without the checklist, were 20% (29 of 145) in 2013 vs. 25.2%927 of 107) in 2012.

The use of the paper based checklist was a success to reduce heart failure 30 day readmissions.
Abstract 332: Toward Big Data: Integrating Cardiovascular Registry and Claims Data to Create a Clinical Practice-based Analytical Platform
Authors: Hess Gregory P , Fonseca Eileen , Beachy James , Masoudi Frederick A , Rumsfeld John S
Published: July 2021

Background:
There is great promise in ‘big data’ analytics that leverage multiple data sources including clinical registries and claims data, creating large, broadly distributed, and clinically detailed analytical platforms to study a range of cardiovascular topics, including practice patterns associated with optimal clinical outcomes.

Objective:
Describe a newly created integrated analytical platform utilizing U.S. cardiovascular registry records and healthcare claims data from real-world clinical practices.

Methods:
The analytical platform includes records from five American College of Cardiology (ACC) National Cardiovascular Data Registry programs and pharmacy, private practitioner and hospital claims data from Symphony Health Solutions (SHS). The NCDR registries include ≈ 650,000 patients in ACTION Registry-GWTG (acute coronary syndrome), 6.7m in CathPCI (diagnostic cardiac catheterizations and PCI), 660,000 in ICD (implantable cardioverter defibrillators), 33,000 in IMPACT (pediatric and adult congenital treatment) and 3.4m in PINNACLE (ambulatory CAD, HTN, HF and AFib). With history as early as 2003, SHS currently receives one or more pharmacy, practitioner or hospital claims annually for ≈274m patients in the U.S. All payer types are represented, including self-pay pharmacy patients.

Patient inclusion criteria: 1) Data within 2006 [[Unable to Display Character: –]] 2014, 2) one or more records in ≥ 1 of 5 NCDR registries, 3) one or more claims observed in ≥ 1 of 3 SHS datasets: pharmacy, private practitioner or hospital claims, 4) populated data fields enabling generation of a unique, patient-level, synthetic identifier (ID) for matching and longitudinal linkage across the registry(s) and the dataset(s). The analytical platform has been developed using a HIPAA and HITECH compliant, certified approach.

Results:
Over 8.7 million patients have been successfully linked between the NCDR registries and the SHS claims data. On average, 95% of patients in the registry(s) sample was also observed and matched in the SHS datasets.

Conclusion:
High match rates were observed between the ACC and SHS data, identifying large populations of patients with cardiovascular disease. Clinical registry data combined with longitudinal claims data will generate a ‘broad’ and ‘deep’ data platform for analytics of quality of care and outcomes.
Abstract 334: Confusion: Bereaved Caregiver Perspectives on the End-of-Life Experience with a Left Ventricular Assist Device
Authors: McIlvennan Colleen K , Jones Jacqueline , Allen Larry A , Swetz Keith M , Nowels Carolyn , Matlock Daniel D
Published: July 2021

Background:
For patients and their loved ones, decisions at the end-of-life in the setting of chronic progressive illness are among the most complex in medicine. Complicating these decisions are increasingly available, invasive, and potentially life-prolonging technologies. One such technology is the left ventricular assist device (LVAD). Understanding the experience of dying with an LVAD can guide efforts to minimize distress for patients and their caregivers.

Objective:
To synthesize caregivers’ perspectives about the caregiver and patient experience with care transitions at end-of-life with LVAD.

Methods:
We conducted semi-structured, in-depth interviews with bereaved caregivers of patients with LVADs previously cared for at the University of Colorado. We excluded caregivers if the patient’s death had occurred greater than 3 years prior to the interview date. Data were analyzed using a mixed inductive and deductive approach.

Results:
Between September and November 2014, 8 bereaved caregivers were interviewed. Interview durations ranged from 31-65 minutes (mean=40). The majority (n=5) were widows of the patients; other caregivers included 2 friends and a mother. Caregivers described three main themes that coalesced around feelings of confusion in those final days and weeks with their loved ones: 1) confusion about the process of death with an LVAD: “[my daughter] said ‘You know Mom, he probably can't die. Even though he wants to. Because everything is keeping him going’”; 2) confusion about the legal and ethically permissible care of patients approaching death with an LVAD: “They don't actually turn it off until certain signs aren't there, ‘cause as long as there’s a chance you know? It would be considered murder.”; 3) confusion about the fragmented integration of palliative and hospice care: “He was bleeding again. And I didn't know what to do. I didn't know if we could take him to the ER? And I really didn't understand palliative care, in its entirety.”

Conclusions:
Despite increasing use of LVADs in patients with advanced heart failure, bereaved caregivers of LVAD patients describe a high level of confusion at the end of life: about the nature of the death, about the medical decisions to be made, and about the support services provided. There remains a need to develop LVAD-specific support for caregivers, as well as hospice and palliative care programs, to manage complex patient care needs at the end-of-life.
Abstract 346: The Lived Experience of Patients with Fibromuscular Dysplasia
Authors: Kuck Christa , Bluhm Minnie , Heidt Steven T , Mace Pamela D , Kline-Rogers Eva , Bumpus Sherry
Published: July 2021

Background:
Fibromuscular dysplasia (FMD) is a non-atherosclerotic, non-inflammatory vascular disorder that may lead to stenosis, beading, aneurysm, and dissection of affected arteries. Although considered a rare disease, recent studies suggest that FMD may be more prevalent than once thought. Common clinical presentations include hypertension, headache, fatigue, and pulsatile tinnitus. Understanding what it is like to have FMD and the unique concerns and challenges of FMD patients is crucial to providing quality care, yet little work has been done to address these issues. The purpose of this study is to illuminate the lived experience of being diagnosed and living with FMD.

Methods:
A qualitative approach was used to conduct in-depth interviews with a convenience sample of 21 individuals with FMD. Interviews were conducted using a semi-structured interview guide with open-ended questions and audio-recorded. Recordings were transcribed verbatim. Transcripts were coded and analyzed using conventional content analysis to identify patterns and themes within and across interviews. Participants were further categorized as High, Medium or Low Functioning based on their reported level of disability and capacity to work and perform daily activities.

Results:
The average age of participants was 53.7 years. All were Caucasian, one was male, and more than 90% were married (Table 1). Equal numbers of patients were represented in each level of functioning, but this occurred by chance. Participants report a complex array of physical (fatigue, pain, pulsatile tinnitus), psychological (anxiety, depression), and social (intimacy, disability) challenges that impact their quality of life. At times, they experience healthcare providers as dismissive and having insufficient knowledge about FMD. Patient-identified opportunities to improve FMD care include increasing providers’ knowledge of FMD, and incorporating holistic care (for body, mind, emotions) into treatment plans.

Conclusion:
Using a qualitative approach to study the lived experiences of patients with FMD resulted in a more thorough understanding of the concerns and challenges they face. Results may prompt discussion about assisting providers in becoming more knowledgeable about FMD and opportunities to include holistic care in the treatment of FMD.
Abstract 7: Patient and Physician Discordance in Reporting Symptoms of Angina: Insights from the Angina Prevalence and Provider Evaluation of Angina Relief (APPEAR) Study
Authors: Shafiq Ali , Kureshi Faraz , Arnold Suzanne V , Gosch Kensey , Breeding Tracie , Jones Philip , Spertus John
Published: July 2021

Background:
Eradication/minimization of angina is a primary therapeutic goal in the management of stable coronary artery disease (CAD). However, eliciting the presence/frequency of patients’ angina can be challenging, particularly in a busy outpatient clinic. We independently measured and compared patients’ and physicians’ assessments of the frequency of angina in US outpatient cardiology practices.

Methods:
From the ACC NCDR PINNACLE registry, we identified 23 practices and conducted a cross-sectional study of patients with stable CAD. Using the SAQ Angina Frequency (AF) scale, patients’ angina was categorized as daily/weekly (SAQ AF Score <60), monthly (SAQ AF Score=60-99) and none (SAQ AF Score=100). Kappa statistics were used to assess agreement between physicians’ and patients’ reported angina.

Results:
Among 1153 outpatients with stable CAD from 23 cardiology clinics, 8% reported daily/weekly, 24% monthly and 68% no angina. When patients reported daily/weekly, monthly or no angina symptoms, physicians agreed 70%, 16% and 94% of the time respectively, with physicians reporting no angina a quarter of the time in patients with weekly or greater angina (Figure). Agreement between patients and physician reports, as determined with a Kappa Statistic, was 0.41 (95% CI=0.36, 0.44)

Conclusion:
There was discordance between patient and physician reports of angina, especially among patients who reported having infrequent angina over the past 4 weeks. Moreover, physicians reported no angina among 1 of 4 patients having daily/weekly symptoms. Improving the communication between patients and physicians about the presence of angina may improve patients’ treatment and outcomes. These results support recent proposals to include patient-reported outcomes measures in routine clinical care, which may support better recognition, by physicians, of patients’ symptoms and improve treatment.
Abstract 130: Clinically Important Difference in the Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) Score: Results from the ORBIT-AF Registry
Authors: Simon DaJuanicia N , Thomas Laine E , O’Brien Emily C , Fonarow Gregg C , Gersh Bernard J , Kowey Peter R , Reiffel James A , Naccarelli Gerald V , Spertus John A , Peterson Eric D , Piccini Jonathan P
Published: July 2021

Background:
The Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) survey has recently been validated to measure the impact of atrial fibrillation on patients’ quality of life, but a clinically important difference (CID) in AFEQT score has not been defined. Knowing the CID is needed to interpret the meaningfulness of differences between treatments in clinical trials; or patient populations for quality assessment.

Objectives:
To calculate CID values in AFEQT in the ORBIT registry.

Methods:
ORBIT-AF is a US-based outpatient AF registry that measured disease-specific QoL with the AFEQT tool (score range= 0 (worst) to 100) at baseline and at 1 year follow-up. Two anchor-based methods were used to relate changes in AFEQT to clinically important differences in the more established European Heart Rhythm Association (EHRA) measure of functional status. Ranging from 1 (no symptoms) to 4 (disabling), a change of 1 EHRA class was defined as an important change in the anchor. Both the mean change and receiver operating characteristics (ROC) methods were then used to identify CIDs in AFEQT at 1 year follow-up. This was done for both improvement and worsening on the anchor. The mean change method defines a CID as the mean change in AFEQT score among patients with a 1 EHRA class change. The ROC method identifies a CID as the point on the ROC curve that best discriminates patients who experienced an important change in the anchor (≥ 1 EHRA class change) from those who experienced no change.

Results:
AFEQT was assessed in 2008 AF patients at baseline and 1347 patients at 1 year from 99 US sites participating in ORBIT-AF. CIDs and 95% confidence intervals (CI) corresponding to an improvement in EHRA for the mean change method were 5.4 (3.6, 7.2) AFEQT points and 1.9 (0.4, 9.3) AFEQT points for the ROC method. CIDs corresponding to worsening in EHRA for the mean change method were -4.2 (-6.9,-1.5) AFEQT points and -7.4 (-13.9,-4.6) AFEQT points for the ROC method.

Conclusions:
Changes in AFEQT as small as 2 points may be clinically relevant, although CIDs vary depending on the method of calculation. The variability suggests identifying a single universal CID to assess improvement in quality of life in AF patients may not be ideal and improvement may relate to the nature of a patient’s symptoms and their baseline level of activity.
Abstract 152: Enterprise Data Warehouse-Supported Early Identification of Acute Decompensated Heart Failure Admissions for Efficient and Multidisciplinary Transitional Care Team Interventions
Authors: Mutharasan R. Kannan , Kansal Preeti , Benacka Corrine , Navarro Daniel , Abecassis Michael M , Alphs Jackson Hannah , Anderson Allen S , Berry Jaeker Jillian A , Davidson Charles , Gurvich Itai , Noskin Gary , Schaeffer-Pettigrew Christine , Soulakis Nicholas D , Van Mieghem Jan , Yancy Clyde W
Published: July 2021

Background:
Multidisciplinary transitional care teams represent a model for reducing heart failure readmissions. Within this context, early identification of patients hospitalized with acute decompensated heart failure (ADHF) permits meaningful transitional care plan development. Improving the efficiency of early identification of the higher risk ADHF patient represents an area not well studied in hospitalized heart failure (HF).

Objective:
To validate the sensitivity and specificity of an enterprise data warehouse (EDW)-based strategy for early identification of patients with ADHF.

Methods:
An EDW query was constructed to identify patients with ADHF based on clinical and diagnosis-related parameters, including BNP level and administration of intravenous diuretics. The EDW query was run daily; expert clinicians verified the diagnosis of ADHF based on comprehensive chart review. This classification was used to determine specificity of the query for ADHF. We computed the sensitivity of the EDW-based approach by matching query results to heart failure diagnosis related group (DRG) data and primary discharge diagnosis data from separate hospital systems.

Results:
During the study period of 70 days, a total of 2354 charts were screened (33.6 charts per day). A total of 410 patients were identified by chart review as having heart failure requiring active management, for a specificity of 17.4%. Sensitivity was computed using both heart failure DRG data and primary discharge diagnosis data. Of the 114 patients discharged with a heart failure DRG (291, 292, or 293), all 114 were detected a priori by the admission EDW screen, for a sensitivity of 100%. A similar analysis conducted using HF principal diagnoses, which includes cardiac surgery-related admissions, yielded a sensitivity of 97.2%.

Conclusions:
EDW-based screening of patients based on simple clinical parameters early in the hospitalization is highly sensitive for detection of ADHF hospitalizations, but specificity is low. Brief chart review by expert clinicians is rapid, and identifies a specific cohort of patients that can be targeted for multidisciplinary HF transitional care. A better delineation of risk has broad outpatient workflow implications. Ongoing process improvements will demonstrate if early identification of at-risk patients yields significant reduction in HF readmissions.
Abstract 154: Estimating Treatment Effects in More Than Two Treatment Groups via Propensity Score Weighting: Practical Guidance and Application from Anticoagulant Therapy in Atrial Fibrillation Study
Authors: Adeboyeje Gboyega , Sylwestrzak Gosia , Barron John
Published: July 2021

Background:
The methods for estimating and assessing propensity scores in the analysis of treatment effects between two treatment arms in observational studies have been well described in the outcomes research methodology literature. However, in practice, the decision makers may need information on the comparative effectiveness of more than two treatment strategies. There’s little guidance on the estimation of treatment effects using inverse probability of treatment weights (IPTW) in studies where more than two treatment arms are to be compared.

Methods:
Data from an observational cohort study on anticoagulant therapy in atrial fibrillation is used to illustrate the practical steps involved in estimating the IPTW from multiple propensity scores and assessing the balance achieved under certain assumptions. For all patients in the study, we estimated the propensity score for the treatment each patient received using a multinomial logistic regression. We used the inverse of the propensity scores as weights in Cox proportional hazards to compare study outcomes for each treatment group

Results:
Before IPTW adjustment, there were large and statistically significant baseline differences between treatment groups in terms of demographic, plan type, and clinical characteristics including validated stroke and bleeding risk scores. After IPTW, there were no significant differences in all measured baseline risk factors. In unadjusted estimates of stroke outcome, there were large differences between dabigatran [Hazard ratio, HR, 0.59 (95% CI: 0.53 - 0.66)], apixaban [HR, 0.69 (CI: 0.57, 0.83)], rivaroxaban [HR, 0.60 (CI: 0.53 0.68)] and warfarin users. After IPTW, estimated stroke risk differences were significantly reduced or eliminated between dabigatran [HR, 0.89 (CI: 0.80, 0.98)], apixaban [HR, 0.92 (0.76, 1.10)], rivaroxaban [HR, 0.84 (CI: 0.75, 0.95)] and warfarin users.

Conclusions:
Our results showed IPTW methods, correctly employed under certain assumptions, are practical and relatively simple tools to control for selection bias and other baseline differences in observational studies evaluating the comparative treatment effects of more than two treatment arms. When preserving sample size is important and in the presence of time-varying confounders, IPTW methods have distinct advantages over propensity matching or adjustment.
Abstract 20: Dying With a Left Ventricular Assist Device as Destination Therapy
Authors: Dunlay Shannon M , Strand Jacob J , Wordingham Sara E , Stulak John M , Kushwaha Sudhir S , Luckhardt Angela , Swetz Keith M
Published: July 2021

Background:
Left ventricular assist devices as destination therapy (DT-LVAD) have been shown to decrease mortality compared with medical management, and can improve quality of life for many patients with advanced heart failure. However, while most patients live longer with DT-LVAD than they would have with medical therapy, deaths still occur. We sought to systematically examine the end-of-life care of patients who died with a DT-LVAD at a single center.

Methods:
All patients undergoing DT-LVAD at the Mayo Clinic in Rochester, Minnesota from January 1, 2007 through September 30, 2014 who subsequently died prior to July 1, 2015 were included. The cause of death was determined based on review of documentation in the electronic medical record, including autopsy reports, death certificates and clinical notes. Details about palliative care consultations, hospice enrollment, hospitalizations, and device deactivation at the end-of-life were obtained from the electronic medical record.

Results:
Of 89 patients that died with a DT-LVAD (84 HeartMate II, 3 HeartWare, 2 Heartmate XVE, mean age at death 66.1 years), the mean (standard deviation) time from LVAD implantation to death was 2.0 (1.9) years. The most common causes of death were multiorgan failure (25.9%), hemorrhagic stroke (24.7%), and progressive heart failure (20.0%). Nearly half (45.6%) of patients saw palliative care in consultation within a month prior to death. However, only 13 (15.5%) patients enrolled in hospice a median of 11 (range 1-315) days prior to death, including 4 patients with concurrent cancer, 2 with stroke, and 7 with multiorgan failure. The vast majority of patients (78.6%) died in the hospital, and of those hospitalized at death, 87.7% died in the intensive care unit. Most patients hospitalized at death transitioned to a comfort-directed approach to care within 24 hours of dying. In total, 43 (48.3%) patients had their LVAD deactivated prior to death, with all but 3 undergoing deactivation in the hospital. The vast majority of patients died within an hour of LVAD deactivation, and all within 26 hours.

Conclusions:
In contrast to the general heart failure population, most patients with DT-LVAD die in the hospital and very few enroll in hospice. A significant body of research has demonstrated that patients who die in the intensive care unit and the hospital, as opposed to home or with hospice assistance, experience worse quality of life, quality of death and caregiver outcomes. Potential reasons that patients with DT-LVAD may experience different end-of-life care than other patients with heart failure exist, including that they often experience sudden changes in health status prior to death from acute events such as hemorrhagic stroke. However, further work is needed to understand these differences and to determine whether patients with DT-LVAD are receiving optimal end-of-life care.
Abstract 204: Echocardiographic Evidence for Systemic Atherosclerosis, Atrial Fibrillation, and Long-Term Prognosis in Stroke Patients
Authors: Pieper Justin , Ashamalla Michael , Yager Neil , Sedhom Daniel , Gate Khetan , Nguyen Veronica , Shkolnik Boris , Torosoff Mikhael
Published: July 2021

Background:
Echocardiography is routinely performed for evaluation of cardiac embolic causes in stroke patients. We sought to examine the association of echocardiographic evidence of atherosclerosis with atrial fibrillation and long-term outcomes.

Materials and methods:
Retrospective chart review was performed in 756 consecutive patients treated for non-hemorrhagic stroke at a single academic medical center. Transthoracic echocardiograms were reviewed for presence of mitral annular calcifications, aortic valve sclerosis, or aortic atherosclerosis. Admission ECG and telemetry recordings were evaluated for documented dysrhythmias. Mean follow up length was 46+/- 20 months.

Results:
A significant number (57.7%) of patients with non-hemorrhagic stroke diagnosed with atrial fibrillation had evidence of cardiac and systemic atherosclerosis on transthoracic echocardiogram, which was less likely in patients with normal sinus rhythm (35.4%) or non-sinus non-atrial fibrillation rhythms (37.1%, p<0.05).

Findings of cardiac and systemic atherosclerosis were more common in older patients (75+/- 11 vs 60+/- 16 years old, p<.001), with lower BMI (27.4+/- 6.0 vs. 29+/- 6.5, p<.001), and hypertension (71.9% vs. 59.2 %, p=.002).

Patients with findings of cardiac and systemic atherosclerosis were more likely to die during follow-up (56.1% vs. 43.9%, p<.001).

Conclusion:
In patients with non-hemorrhagic stroke, cardiac and systemic evidence of atherosclerosis was strongly associated with atrial fibrillation and portended poor long-term prognosis. In stroke patients with cardiac and systemic evidence of atherosclerosis and rhythms other than atrial fibrillation, extended ECG monitoring may be warranted.
Abstract 218: Major Therapeutic Cardiac Procedures in the Very Elderly: All-Payer Race-Gender Disparities and Temporal Trends
Authors: Pathak Elizabeth B , Pathak Amit P
Published: July 2021

Objectives:
Major therapeutic cardiac procedures include open heart surgery (e.g., coronary artery bypass graft, valv/septum repairs) (OPEN), insertion/repair of pacemakers, internal defibrillators, and related devices (PACE), and percutaneous coronary intervention (PCI). The use of these procedures among patients aged > 85 years has not been well-described.

Methods:
Inpatient records for adults aged > 85 years were obtained from a comprehensive all-payer hospital discharge database for Florida for 2006-2011. Major cardiac procedures were identified by ICD-9-CM codes. Patient race/ethnicity (non-Hispanic White, Hispanic, non-Hispanic Black), gender, payer, principal/secondary diagnoses, and in-hospital mortality were analyzed for each procedure type. Annual procedure rates were calculated using US Census population estimates.

Results:
There were 2,497,573 person-years at risk for the period 2006-2011, with a total of 1,355,308 inpatient hospitalizations in this very elderly population. Medicare coverage ranged from 88% in Hispanic men (HM) to 96% in White women (WW). Procedure rates were higher in Medicare patients vs. all other payers. PACE was the most common major cardiac procedure (n=32,338), followed by PCI (n=17,046) and OPEN (n=5,916). Population rates of each procedure varied significantly by race/ethnicity and gender (see Figure for PACE rates). In 2011, the rate of PCI for White men (WM) (89 per 10,000, 95% CI 84 to 94) was 20% higher compared to HM, 70% higher compared to Black men (BM), 80% higher than WW and Black women (BW), and 130% higher than Hispanic women (HW). The open heart surgery rate for WM (41 per 10,000, 95% CI 38 to 45) was significantly higher than all other groups: 1.6 times the rate for HM, 2.9 times the rate for WW, 4.1 times the rate for HW, 8.2 times the rate for BM and 10.3 times the rate for BW. In-hospital mortality rates were 1.4% for PACE, 4.3% for PCI, and 8.2% for OPEN. Temporal trends showed declining rates for all procedures over the study period.

Conclusions:
Major therapeutic cardiac interventions are common among the very elderly. Greater inclusion of very elderly patients in clinical trials and outcome studies is necessary to establish the survival and quality of life benefits of these procedures for patients near the end of life.
Abstract 245: Smartwomantm: Feasibility of a Mobile Application to Improve Cardiovascular Risk Factors in Indigent Diabetic Women
Authors: Parashar Susmita , Williams Olubunmi , Wenger Nannette
Published: July 2021

Introduction:
Cardiovascular disease disparately affects women with diabetes mellitus. Among women with diabetes, cardiovascular disease prevention, including risk factor monitoring and lifestyle modification is important but underutilized. Mobile health strategies are emerging communication technologies to improve self management and health behaviours. However, the feasibility of mobile health technology (m-health) to enhance health behaviors in an indigent population is unknown. We developed and examined the feasibility of m-health to improve health behaviors and self-management regarding coronary risk factors in indigent women with diabetes.

Methods:
We developed a smartphone application based on the AHA’s “Life’s Simple 7” prevention module. Mobile technology was integrated into the overall program, with communication enabled devices (weight scales, glucometers, and sphygmomanometers) synchronized to the smartphone. FitBit was used to monitor activity level. We tested the feasibility of the mobile application in the SMARTWOMANTM project which enrolled women with diabetes, without known CVD at an inner city hospital;,these women had suboptimal access to care, limited transportation and resources, and limited health literacy.

Results:
Fourteen women, all African-American were enrolled in SMARTWOMANTM (mean age 52 yrs, 86% with hypertension, hypercholesterolemia and obesity). The overall weekly mobile-application reporting was 85% for blood glucose, 83% for daily steps, and 77% for systolic blood pressure. The majority reported the text messages to be useful (92%) and appropriate in frequency (92%). Participants found positive text messages as a strong reinforcement to healthy behaviors. They indicated that study participation increased their motivation in taking charge of their health, and increased understanding of their health condition and self-management.

Conclusions:
Among indigent African-American women with diabetes and no known CVD, the development and use of mobile health application was feasible and resulted in increased patient satisfaction and positive reinforcement to healthy behaviors.
Abstract 256: The Differences in Predictors of Osteoporosis between Genders Using Warfarin
Authors: Abdulameer Alhashimi Aseel Hadi , Abdulrazzaq Al-Ani Hadeer Akram , Talib Al-Ani Iman Nazar , Syed Sulaiman Syed Azhar , Hussein Hanan Hussein
Published: July 2021

Background:
Osteoporosis, chronic, progressive disease of multifactorial etiology, is systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue with consequent increase in bone fragility. It is most common metabolic bone disease in sexes, races, and ages, therefore, screening at-risk population is essential. Warfarin increases the risk of osteoporosis because of its acting as vitamin K antagonist which is essential as co- factor in bone formation.

Objectives:
is to determine which gender and race (Malay, Chinese, and Indian) are more affected by the risk of osteoporotic condition and as osteopenia and osteoporosis dependent on definition of World Health Organization which based on bone mineral density (BMD) for each standard deviation (SD) reduction in BMD the relative risk of osteoporosis is increase 1.5-3 times.

Methods:
quantitative ultrasound machine is used to measure the T-score (BMD) for 270 subjects were divided in two groups; first group involved males and the second involved females. The subjects were also categorised based on using of warfarin more than one year of therapy and compared which factures influence on reduction of BMD.

Results:
There were 149 females showed significant difference of mean T-score of them when divided in two groups, the first group females less or equal to50 year’s old, non-using warfarin, premenopausal status, females had no history of fracture. Second group included females more than 50 years old, using warfarin more than one year, postmenopausal status, and had history with fractures. While no significant difference for males based on warfarin use. Results showed, Chinese females had more risk of osteoporosis (osteopinia, osteoporosis), than females non-using warfarin (odds ratio [OR] =2.4, 95% CI: 1.04- 5.75). Finally 25% changing of T-score for females was explained by interactions of risk factors; first using of warfarin more than 1 year and races and the second for using of warfarin more than one year and patients aged more than 50 years old.

Conclusion:
Chinese females with age more than 50 years old are more susceptible for the lower levels of BMD when they used warfarin therapy more than one year.
Right Atrial and Ventricular Adaptation to Chronic Right Ventricular Pressure Overload
Authors: Gaynor Sydney L. , Maniar Hersh S. , Bloch Jeffrey B. , Steendijk Paul , Moon Marc R.
Published: July 2021

Background—

Increased mortality in patients with chronic pulmonary hypertension has been associated with elevated right atrial (RA) pressure. However, little is known about the effects of chronic right ventricular (RV) pressure overload on RA and RV dynamics or the adaptive response of the right atrium to maintain RV filling.

Methods and Results—

In 7 dogs, RA and RV pressure and volume (conductance catheter) were recorded at baseline and after 3 months of progressive pulmonary artery banding. RA and RV elastance (contractility) and diastolic stiffness were calculated, and RA reservoir and conduit function were quantified as RA inflow with the tricuspid valve closed versus open, respectively. With chronic pulmonary artery banding, systolic RV pressure increased from 34±7 to 70±17 mm Hg (
P
<0.001), but cardiac output did not change (
P
>0.78). RV elastance and stiffness both increased (
P
<0.05), suggesting preserved systolic function but impaired diastolic function. In response, RA contractility improved (elastance increased from 0.28±0.12 to 0.44±0.13 mm Hg/mL;
P
<0.04), and the atrium became more distensible, as evidenced by increased reservoir function (49±14% versus 72±8%) and decreased conduit function (51±14% versus 28±8%;
P
<0.002).

Conclusions—

With chronic RV pressure overload, RV systolic function was preserved, but diastolic function was impaired. To compensate, RA contractility increased, and the atrium became more distensible to maintain filling of the stiffened ventricle. This compensatory response of the right atrium likely plays an important role in preventing clinical failure in chronic pulmonary hypertension.