bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 388: Quality Improvement in the Outpatient Setting: Observations from the PINNACLE Registry® 2009 Q4-2013 Q1
Authors: Kehoe Katie , Shultz Sherry , Fiocchi Fran , Li Qiong , Shields Thomas , Devlin Charlie , Ponirakis Angelo , Mullen J. Brendan , Glusenkamp Nathan T
Published: July 2021

Title:
Quality Improvement in the Outpatient Setting: Observations from the PINNACLE Registry® 2009 Q4-2013 Q1

Authors:
Katie Kehoe BSN, MS
1
; Sherry Shultz RN, BSN, CIO
2
; Fran Fiocchi MPH
1
; Qiong Li PhD
1
; Thomas Shields
1
; Charlie Devlin MD FACC, FACP, FASNC
2
; Nathan T Glusenkamp, MA
1
; J. Brendan Mullen
1

; Angelo Ponirakis, PhD
1
;

1
American College of Cardiology, Washington, DC

2
South Carolina Heart Center, Columbia SC

Background:
The PINNACLE Registry® at the American College of Cardiology is the first outpatient practice-based quality improvement program in the United States. Begun as a pilot program in 2007, the registry systematically collects and reports on adherence to clinical guidelines in the care of patients with coronary artery disease, hypertension, atrial fibrillation and heart failure. Over time, these reports offer a unique opportunity for Quality Improvement (QI) in the outpatient setting. The current study aimed to assess the effect of QI in the outpatient setting using PINNACLE Registry data.

Methods:
The South Carolina Heart Center is a cardiovascular practice in Columbia, South Carolina. There are 19 providers, 5 office locations and NextGen EMR. The practice’s Quality Committee and Board meet monthly to review PINNACLE reports and identify areas for QI. This Clinical Quality Improvement Initiative began 10 years ago and consists of physicians, nurses, administrators, medical assistants, a medical record analyst and information systems staff. During this review, providers’ data was not blinded to others. QI Interventions implemented included physician and staff education, improving documentation during the office visit, addition of necessary fields to capture missing data and routine planned internal audits. Between October 1, 2009 and March 31, 2013 a total of 161,873 patient encounters were submitted to the registry. A two-tailed z test was performed to assess the significance in percentage changes between 2009 to 2013.

Results:
The following table showed significant percentage changes in six performance measures indicating interventions implemented by the practice demonstrate significant quality improvement over time from 2009-2013.

Conclusions:
Utilizing their PINNACLE Registry reports, the South Carolina Heart Center identified several areas for QI. Implementing multiple interventions, this practice was able to significantly improve their PINNACLE Reports and the quality of care provided.
Abstract 9: Predictors of Poor Outcome in Patients Not Thrombolysed Due to Mild or Resolving Symptoms ("Too Good To Treat")
Authors: Ali Syed F , Faheem Urooba , Singhal Aneesh B , Viswanathan Anand , Silverman Scott B , Rost Natalia S , Schwamm Lee H
Published: July 2021

Introduction:
A common reason for exclusion of patients with acute ischemic stroke presenting within the time frame for IV tPA is that they are “too good to treat” due to rapidly improving or mild symptoms. Several studies have reported poor outcomes in this group which motivated us to evaluate patient factors associated with poor outcomes.

Methods:
Using our institutional GWTG database, we analyzed 2,745 consecutive stroke admissions (01/2009 - 07/2013). Univariate and multivariable analysis were carried out to determine factors associated with poor outcome, defined as not being discharged home.

Results:
Of the total 2,745 patients, 306 (11.1%) presented within the window for IV tPA but did not receive the treatment due to symptoms too mild or rapidly improving as judged by the treating team. Of these 306, 64.1% were discharged home, 26.5% to IRF, 7.2% to SNF and 2.9% expired/hospice. Patients with poor outcome were older, more frequently Hispanic and presented with more vascular risk factors such as hypertension, diabetes, CAD, PAD and atrial fibrillation than good outcome patients. They also had higher median initial NIHSS. Patients in both groups had similar adherence to early antithrombotics, dysphagia screening and DVT prophylaxis. Poor outcome patients had higher rates of in-hospital complications and a longer hospital length of stay (Table 1). On univariate analysis, factors associated with poor outcome included age [OR 1.50 (1.30 - 1.70), p<0.0001], ethnicity [4.15 (1.25 - 13.81), p=0.020], diabetes mellitus [1.91 (1.11 - 3.29), p=0.019], atrial fibrillation [1.82 (1.02 - 3.25), p=0.042], PAD [9.02 (1.04 - 78.20), p=0.046], NIHSS [1.16 per point (1.06 - 1.27), p=0.001], in-hospital pneumonia (all cases had poor outcome) or UTI [7.04 (1.92 - 25.81), p=0.003]. In multivariable analysis, only age [1.50 (1.30 - 1.70), p<0.0001], ethnicity [6.61 (1.83 - 23.85), p=0.004], NIHSS [1.14 per point (1.04 - 1.26), p=0.007] and UTI [7.30 (1.72 - 31.00), p=0.007] remained significant.

Conclusion:
A substantial percentage of patients deemed “too good” for IV tPA were unable to be discharged home. Factors such as advanced age and higher NIHSS should be considered in tPA decision-making to optimize outcomes. Large, multi-center prospective studies are underway to study the predictors of poor outcomes in this group.
Abstract 109: Differences in Cardiovascular Health: Why Hispanic Women Fare Better Then Non Hispanic Women: The Baptist Health South Florida Employee Study
Authors: Veledar Emir , Ogunmoroti Oluseye , Das Sankalp , Rousef Maribeth , Osondu Chukwuemeka , Spatz Erica , Aneni Ehimen , Nasir Khurram
Published: July 2021

Background:
In the United States, Hispanic females have the highest life expectancy, 87 years compared to 81years for white females, 78 years for African-American females and 81 years for Hispanic males. Other ethnic and gender discrepancies are a well addressed issue in cardiac outcomes, but almost nothing is known about the potential cofounders of this striking difference. In this study, we shed light on the variables that potentially relate to the underlying differences in cardiovascular health (CVH) using data from female employees of Baptist Health South Florida, a large nonprofit health care organization.

Methods:
Female employees (7683) with complete data from an annual health fair and health risk assessment (HRA) for 2014 were included in this study. Mean age was 43 ±12 years. We compared results for 4235 Hispanic females (55.1%) to non-Hispanic females (44.9%) for 21 cardiovascular health (CVH) related characteristics, grouped into biometric measurements (12), knowledge (4) and attitudes (5). All variables were dichotomized and Fisher exact test was used to test for differences. Odds ratios are used to express importance of differences and spread of data.

Results:
Hispanic females demonstrated significant advantage over non-Hispanic females in 10 of 12 CVH related measurements grouped into disease conditions and risk factors. Of note, Hispanic women were 62% more likely to have 5 or more CVH metrics. There was no difference in any of the 4 knowledge questions however, Hispanic females had healthier attitudes. They were significantly less inclined to want to increase their time of exercise, and they were also less likely to worry about their weight.

In summary, Hispanic females had better CVH related biometric and behavioral profiles in 15 of 21 variables compared to non-Hispanic females.

Conclusion:
In this presumably healthy working population with equal access to health care and benefits, Hispanic females showed much better values of cardiac risk factors, accompanied with positive attitude toward life. Our findings point to potential pathways of longevity and improved CVH among Hispanic females.
Abstract 124: The Effect of Renal Impairment on The Venous Thromboembolism Recurrence and Major Bleeding Risk and Total Health Care Costs in Patients With Acute Venous Thromboembolism
Authors: Cai Jennifer , Kwong Jackie , Preblick Ron , Zhang Qiaoyi
Published: July 2021

Background:
Renal impairment could be a risk factor for venous thromboembolism (VTE) recurrence and anticoagulation related bleeding in VTE patients. The objective of this study was to assess the effect of renal impairment on the risk of VTE recurrence, major bleeding and total health care costs in patients with acute VTE.

Methods:
In this retrospective analysis of IMS PharMetrics Plus
TM
claims database, patients (≥18 years old) who had ≥ 1 inpatient or ≥ 2 outpatient VTE claims during January 2010-December 2013 (the index period) were identified. Patients who had continuous enrollment eligibility for at least 12 months before (baseline) and 12 months after (follow-up) the index date (first VTE claim) and had no VTE diagnosis and anticoagulant treatment during baseline period were included. Patients who required dialysis or had end stage renal disease were excluded. VTE patients with chronic kidney disease (stage I-IV or equivalent) during baseline based on ICD- 9 diagnosis codes were compared with those without renal impairment. Recurrent VTE was identified by inpatient or emergency department claims associated with VTE diagnosis after hospital discharge of the index VTE event or 7 days after index date for patients with index VTE events treated in the outpatient setting during the follow-up period. Major bleeding events were identified by inpatient claims with a bleeding diagnosis that occurred after an anticoagulant prescription fill among patients receiving anticoagulant therapy. Cox proportional hazards models adjusted for age, gender, index VTE type, health insurance type, outpatient anticoagulant therapy use, and baseline comorbidities was used to assess the risk of VTE recurrence and anticoagulation related major bleeding. Generalized linear model with gamma distribution and log link was used to evaluate the total health care costs (inclusive of medical and pharmacy costs) over the 1-year follow-up period adjusting for the same baseline characteristics.

Results:
Of 20,873 eligible VTE patients (median age 57 years; 50% female), 238 had diagnosed renal impairment. Compared with patients without renal impairment, patients with renal impairment had higher rates for VTE recurrence (24% vs. 18%; adjusted hazard ratio (HR) = 1.32, 95% CI 1.06-1.63, p<0.01), and post anticoagulation major bleeding (4% vs 1%; HR=1.75, 95% CI 1.01-3.03, p=0.046). Patients with renal impairment had higher adjusted mean total health care costs ($41,283 vs. $30,757, p<0.01) than patients without renal impairment.

Conclusion:
VTE patients with renal impairment had higher risk for VTE recurrence and major bleeding associated with anticoagulant therapy, resulting in increased utilization of health care resources than VTE patients without renal impairment.

Sponsorship:
This research was funded by Daiichi Sankyo Inc, Parsippany, NJ.
Abstract 127: Cardiovascular Risk and Outcomes in Patients with Diabetes: Using Medical Education to Improve Care
Authors: Larkin Amy , Healy Colleen
Published: July 2021

Introduction:
Mortality rates due to cardiovascular disease (CVD) are 2-4 times higher among people with diabetes than in those without. Glucose control reduces the risk of any CVD event by 42% and the risk of heart attack, stroke, or death from CVD by 57%. We assessed the hypothesis that continuing medical education (CME) improves knowledge and performance of cardiologists in managing glycemic control and other CV risk factors in patients with type 2 diabetes (T2D).

Methods:
Cardiologists who treat patients with coronary artery disease participated in at least 1 of 2 online CME activities within a curriculum on CV risks and outcomes in patients with T2D. Participant responses to a case-based survey after activity completion were compared with responses from demographically similar control groups of nonparticipants. Educational effect size was calculated using Cohen’s
d
formula, with a value of <0.4 representing a small effect, 0.4-0.8 a medium effect, and >0.8 a large effect.

Results:
Participating cardiologists (n = 151) were more likely to make evidence-based practice choices than were nonparticipating cardiologists. Activity 1: Improving CV Outcomes in Patients with T2D Multi-media format Increased Likelihood to Make Evidence-Based Practice Choices Post-Education: 33.5% Effect Size: 0.51 (N = 78) Activity 1: Assessing CV Risk in Patients with T2D Multi-media format Increased Likelihood to Make Evidence-Based Practice Choices Post-Education: 50.3% Effect Size: 0.87 (N = 73)

Domain 1: Managing Glycemic Control and Other CV Risk Factors in Patients with CVD and T2D. Participating cardiologists significantly improved their consideration of comorbid conditions when deciding on a glucose management strategy (73% pre vs. 85% post) and selection of treatment for early intervention (85% pre vs. 96% post).

Domain 2: Identification of Outcomes Data on Glucose-Lowering Agents in Patients with T2D and CVD. Participating cardiologists significantly improved in the recognition of antihyperglycemic agents shown in clinical trials to be safe for high risk CV patients (36% pre vs. 79% post) and in identification of the effect of saxagliptin on CV events in high risk CV patients with T2D (SAVOR TIMI 53 trial) (55% pre vs. 86% post).

Domain 3: Application of Outcomes Data on Glucose-Lowering Agents in Patients with T2D and CVD. Participating cardiologists significantly improved in their selection of a DPP-4 inhibitor as the most appropriate antihyperglycemic agent for patients with T2D and CV risk factors or previous CV events (59% pre vs. 81% post and 53% pre vs. 73% post, respectively).

Conclusion:
This study demonstrated the success of a curriculum-style educational intervention using multimedia technology on improving knowledge and performance of cardiologists which can lead to enhanced management of CV risks and, thus, improved outcomes in patients with T2D and CVD.
Abstract 137: Physician Performance Gaps in Stable Ischemic Heart Disease: Assessing the Impact on Patient Care
Authors: Spyropoulos Jelena , Capparelli Catherine C , Kearns Charles F
Published: July 2021

Study objectives:
Patients with stable ischemic heart disease (SIHD) are often not managed in accordance with clinical guidelines. This study’s objective was to identify educational gaps among cardiologists, and to assess the correlation between their knowledge, skills, and attitudes with evaluating and treating patients with SIHD.

Methods:
A 29-question self-assessment survey was developed, including evidence-based knowledge- and case -based questions with multiple-choice and Likert scale answers, and posted online to healthcare providers for continuing medical education (CME) credit. Confidentiality of survey respondents was maintained and responses were de-identified and aggregated prior to analyses. The analysis of responses included logistic regression to determine relationships between knowledge, skills and attitudes about treatment practices in SIHD. The survey launched on April 10, 2014 and participant responses were collected through May 11, 2014.

Results:
In total, 134 cardiologists completed the survey. Cumulative correct scores averaged 55% among cardiologists. Only 21.6% answered 80% or more questions correctly. A significant positive relationship was found between cardiologist’s knowledge of SIHD and:

–The use of exercise testing in SIHD (r = 0.202; P < 0.01)

–Cardiologists’ attitudes toward the use of a patient-derived questionnaire (r = 0.280; P < 0.01)- A significant relationship was observed between educational gaps and clinical practices of cardiologists (Table).

Conclusions:
The significant positive relationship between cardiologists’ knowledge and their application of evidence-based practice in SIHD supports the need to develop additional education activities that align physicians’ knowledge and performance to improve patient outcomes. Future CME activities should focus on improving knowledge and attitudes of cardiologists to subsequently improve performance and patient care related to the use of validated risk-assessment tools that capture patient-reported outcomes relative to angina classification, guideline recommendations for evidence-based anti-anginal medical therapy, and treatment algorithms in patients with SIHD.
Abstract 149: Distance From an Academic Medical Center: Implications on Medicare Penalties
Authors: McMahon Colin , Sylvester Rachel , Froehlich Ben , Erickson Steve , Kline-Rogers Eva , Eagle Kim A , Bumpus Sherry M
Published: July 2021

Background:
Medicare’s Readmission Reduction program fines hospitals with readmission rates that exceed the national average; however, standardized risk adjustment models do not take into account how far people live from an institution. Larger academic medical centers may be disadvantaged by this oversight. The purpose of this study was to determine if distance travelled could be predicted by length of stay (LOS) and comorbidity.

Methods:
The Bridging the Discharge Gap Effectively (BRIDGE) was accessed to obtain ZIP code, LOS and to calculate the Charlson Comorbidity Index for patients referred in 2012. Mean LOS was compared to national data from the HCUP database for acute coronary syndrome (ACS), heart failure (HF), and atrial fibrillation (AF). Distance from the medical center (MC) to the center of each ZIP code was evaluated for correlation with LOS and comorbidity. Local and Distant patients were defined as patients who lived within or outside a 40 mile radius of the MC.

Results:
A total of 785 were included in this analysis; mean age was 66.0 + 14.3 years and 60.9% were male. Overall, ACS patients had an average LOS 1 day less than the national average, whereas HF and AF patients stayed respectively 1.6 and 1.3 days longer than the national average. There was a significant difference in mean LOS for both ACS and HF patients who lived greater than 40 miles from the MC, (p=0.014, p=0.046). Although insignificant, Distant AF patients also had a mean LOS longer than that of local patients (p=0.12). For all patients who participated in the study, and for ACS patients in particular, there was a weak, but significant, relationship between LOS and distance from the MC (All: r=.18, n=785, p< .001; ACS: r=0.25, n=217, p<0.001),

Conclusions:
In this sample, LOS is positively correlated with distance from the MC. Because our institution is a large referral center, those referred from a distance are those who likely cannot be managed near their homes. As seen here, more complex HF and AF patients travel greater than 40 miles to receive treatment. Programs designed to decrease readmissions, like BRIDGE, may be less effective in these referral populations who may be less likely to travel for follow-up appointments. Further study is warranted to ascertain if distance should be part of standardized risk adjusting calculations.
Abstract 150: Antithrombotic Use in Nonvalvular Atrial Fibrillation (NVAF): Alignment between Guidelines and Emerging Evidence with Clinician Prescribing Preferences
Authors: Shafrin Jason , Bruno Amanda , MacEwan Joanna P , Campinha-Bacote Avrita , Trocio Jeffrey , Tan Wilson , Romley John A
Published: July 2021

Background:
2014 AHA/ACC/HRS guidelines recommend anticoagulation for NVAF patients with a CHA2DS2-VASc≥2, but do not endorse a specific therapy. Several published indirect treatment comparisons demonstrate similar stroke risk reduction but distinct differences for bleeding risk among novel oral anticoagulants (NOACs) in NVAF patients.

Objectives:
Survey physicians to determine how their preferences over antithrombotic therapies compare with current treatment guidelines and indirect treatment comparisons.

Methods:
An online survey was completed by 200 physicians who regularly treat patients with NVAF. Respondents answered 12 questions comparing two hypothetical antithrombotic treatments that varied across five attributes: stroke risk, major bleeding risk, inconvenience (i.e., regular INR blood-testing/dietary restrictions), dosing frequency and patient out-of-pocket (OOP) cost. Physician willingness to trade higher OOP cost for improvements in other attributes was estimated using a logistic regression. Based on these results, we calculated the share of prescriptions that would be written for apixaban, aspirin, dabigatran, rivaroxaban and warfarin using real-world US patient OOP costs.

Results:
Physicians were willing to trade an increase in monthly OOP cost of $38.21 (95% CI: $22.07-$54.34) for a 1 percentage point (absolute) decrease in annual stroke risk. Physicians also placed a positive value on less inconvenience ($34.46, 95% CI: $8.50-$60.41), and a 1 percentage point reduction in the risk of a major bleed ($14.44, 95% CI: $8.01-$20.88). Physicians did not have a significant willingness to pay to reduce dosing frequency from twice to once per day ($17.16; 95% CI: -0.08-$34.40). Cardiologists and cardiac electrophysiologists had higher willingness to pay for stroke risk reduction than general practitioners ($54.32 vs. $24.74, p<0.001). Based on these preferences, physicians would recommend NOACs to 77% of patients, with apixaban (32%) being the preferred NOAC.

Conclusions:
Similar to findings from indirect treatment comparison studies, physicians largely prefer NOACs_particularly apixaban_compared to warfarin or aspirin for stroke risk reduction in NVAF patients. Additional research is needed to determine why NOACs are underused in practice.
Abstract 159: Medication Adherence Improves Shortly After Acute Coronary Syndrome Admission and Then Declines Over One Year: Findings from TRACE-CORE
Authors: Patel Dimal , Devereaux Randolph S , Teaford George , Dane Francis C , Parish David C , Waring Molly E , Kiefe Catarina I
Published: July 2021

Background:
Incomplete medication adherence is common, results in poor outcomes, and remains resistant to change in patients with acute coronary syndromes (ACS). However, few studies, if any, have reported patterns of adherence at multiple time points during patients’ transition from the hospital to their community.

Objective:
To describe patterns of self-reported medication adherence at admission and over a post-discharge transitional period of 12 months.

Methods:
Adult patients (n=2187) hospitalized for ACS enrolled in the “Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education” (TRACE-CORE) cohort from GA and MA completed the 8-item Morisky Medication Adherence Scale (range: 0-8) in person during hospitalization and via telephone interviews at 1-, 3-, 6-, and 12- month(s) after discharge. High, medium, and low adherence were defined as scale scores of 8, 6-7 and 0-5, respectively and analyzed. Repeated measures ANOVA was used to test for differences in mean adherence across the assessment periods.

Results:
Participants were 66% male, 16% non-Hispanic black, 81% non-Hispanic white, and aged 61.3 ± 11.34 years. High adherence was reported by 25% at baseline, increased to 50.9% at 1-month, and subsequently dropped to 46%, 45%, and 44% by 3,6, and 12 months, respectively (table). Mean adherence scores (n=906) increased from 6.15(SD=1.78) at baseline to 7.05 (1.23) at 1-month then slightly decreased and leveled off [6.95(1.31), 6.93(1.31), 6.89(1.36); p<0.001 for changes over time]. Baseline differed from all other scores and 1-month scores differed from baseline, 6-, and 12-months.

Conclusion:
A major increase in high adherence from baseline to 1-month was followed by a slight decline from 3 to 12 months post discharge. The improvement in adherence from baseline may have been prompted by the “teachable moment” resulting from an ACS. Further research may delineate interventional factors during this transition period that may improve long-term adherence.
Abstract 217: Racial Disparities in Echocardiography Use Within The Veterans Administration and Medicare Systems
Authors: Rajaei Sheeva , Groeneveld Peter , Teerlink John , Whooley Mary , Turakhia Mintu , Richman Ilana , Sahay Anju , Kini Vinay , Heidenreich Paul A
Published: July 2021

Background:
There is increasing interest in understanding the factors that influence the use of diagnostic imaging in heart failure in US health systems. However, there is limited data examining overall use and the impact of racial disparities in the VA and Medicare.

Methods:
We analyzed Veterans Healthcare Administration (VA) and Medicare data from 2002 to 2009 to identify veteran patients above the age of sixty-five with a diagnosis of heart failure for at least 1 year. Patients receiving care in both systems were excluded. We examined patients undergoing echocardiography and scintigraphy each year by race and system of care. Multivariate logistic regression analyses were performed adjusting for age, gender and comorbidities.

Results:
A total of 2,917,307 veteran patients were included (263,778 in VA and 1,698,497 in Medicare). Overall use of echocardiography each year was 45.6% for Whites, 51.9% for Asians, 43.2% for Blacks, 39.7% for Hispanics, 42.0% for Pacific Islanders, 40.9% for Native-American and 48.1% for Other. The adjusted odds ratio of undergoing echocardiography was higher for Asians in both systems compared to Whites (Figure). In Medicare, use was lower for Native Americans, Blacks and Hispanics compared to Whites. In the VA, use among Blacks and Hispanics was higher than Whites.

Conclusion:
There are significant differences in echocardiography use between the VA and Medicare systems by race for veterans with heart failure. Whites were more likely to receive echocardiography compared to most races in Medicare but not in the VA.
Abstract 24: Acute Cardiac Care in China: A Needs Assessment
Authors: Ng Marie , Thomson Blake , Li Yichong , Zhou Maigeng , Wang Liming , Philips Bryan , Brown Jonathan , Roth Gregory A , Wang Haidong ,   HeartRescue China
Published: July 2021

Background:
In 2013, stroke and ischemic heart disease (IHD) became the leading causes of mortality and morbidity among adults over age 50 in China. Together they accounted for 3.29 million deaths and over 17% of years of life lost due to disability or premature mortality (DALYs). Despite the increased disease burden, there is a lack of adequate disease surveillance, particularly for acute CVD. This study aims to comprehensively assess the demand and supply for health care services for handling out-of-hospital cardiac arrest (OHCA) and ST-segment elevated myocardial infarction (STEMI) in Beijing and Shanghai, China.

Methods:
A mixed methods approach was adopted. Household surveys were conducted to understand the needs and awareness of OHCA and STEMI. Furthermore, hospital and emergency medical service (EMS) surveys were carried out to determine existing system capacity in treating these conditions. Quantitative data were supplemented with qualitative data to better examine gaps in the delivery of services. A total of 1000 households, 3000 individuals, 4 major (tier one) facilities and 8 EMS stations were sampled in the two districts in each city.

Results:
There was a lack of awareness among the general public in the symptoms of OHCA and STEMI. Delay in treatment was common. Willingness to carry out bystander action was low, and only a small proportion of individuals were CPR-trained. Results from hospital and EMS surveys indicated that facilities and ambulances were sufficiently equipped with technologies to handle OHCA and STEMI. However, timely diagnosis and treatments were hindered by various contextual factors including delays in treatment seeking, high patient volume and limitations in staff training and support.

Conclusion:
The delivery of care for acute cardiac event in the two cities were suboptimal. Interventions are urgently needed. In particular, a holistic approach including the promotion of public knowledge, improvement in frontline health workers’ training and support, as well as enhancement of data registry and monitoring are necessary.
Abstract 247: Wikiheart: A Seamless Web-based Program Involving Patients, Clinicians and Researchers
Authors: Krittanawong Chayakrit , Tweet Marysia S , Hayes Sharonne N
Published: July 2021

Background:
The recent increase in the public’s interest in health matters has been accompanied by greater attention to the development of Web-based programs by many health-related professional and educational services. Wikiheart is a Web-based program that has been designed to narrow the gaps between care and secondary prevention by directly delivering knowledge to patients in their homes and communities.

Purpose:
To develop a Web-based program aimed at educating patients and targeted to the specific learning needs of patients with heart disease and associated risk factors.

Methods and results:
This pilot program is relatively easy to use, web-based educational model. It consists of a collaborative feature, the content of which can be easily edited by users, thus enabling powerful information sharing, interactive chat and article discussions. Participants are categorized into two principal groups: (1) invited or volunteer medical professionals; and (2) patients with their own experiences. This program can be used as an information resource for patients and method of real-time communication between healthcare professionals and patients. This virtual program allows patients to engage with each other, share experiences and become part of an online community. As an online interactive medical reference, this program is also intended to help patients with heart disease learn more about their specific conditions and be educated about preventive measures. For patient confidentiality, password protection would be employed and all clinical images and videos would be required to be de-identified. Material that violates patient privacy will be easily removed.

Conclusions:
Wikiheart aims to enable the sharing of knowledge relevant to secondary prevention and thus improve the quality of care for patients with heart disease or cardiovascular risk factors. If successfully implemented, the program is likely to enhance researchers’, healthcare providers’ and patients’ learning experiences, and communication within digital world, leading to the improvement of clinic outcome and adherence for patients. Further research is needed in order to identify the best approaches to apply these tools and ultimately boost research productivity, learning experience and patient education.
Abstract 250: Real-world Rates and Costs of Heart Failure Events Among Patients with Hyperlipidemia
Authors: Fox Kathleen M , Punekar Rajeshwari S , Richhariya Akshara , Fisher Maxine D , Gandra Shravanthi R , Cziraky Mark J , Toth Peter P
Published: July 2021

Background:
This real-world retrospective cohort study estimated the rate of heart failure events and total healthcare costs among patients with hyperlipidemia.

Methods:
Patients (aged 18-64 years) with hyperlipidemia diagnosis and/or lipid-lowering medications were identified from the HealthCore Integrated Research Database
SM
from 1/1/2007 to 12/31/2008 and followed until 2/28/2013. Patients were stratified by cardiovascular (CV) risk level as (1) secondary prevention with a history of myocardial infarction, stroke, unstable angina, or revascularization, (2) modified coronary heart disease (CHD) risk equivalent (RE) without a history of CV events but with peripheral artery disease, type 2 diabetes, abdominal aortic aneurysm, ischemic heart disease, stable angina, or TIA, and (3) primary prevention without a history of CV events or CHD RE. Patients with new CV event hospitalization during follow-up were propensity score-matched to patients without new CV events within each cohort. Proportion of patients with heart failure events and incremental total costs during 2 years of follow-up were evaluated.

Results:
Before matching, 62,427 patients had ≥1 CV event (13.2% secondary prevention, 38.4% CHD RE, 48.5% primary prevention). For patients with ≥1 CV event during follow-up, 38.8% of secondary prevention, 42.6% of CHD RE, and 30.0% of primary prevention had heart failure as their index event. Of patients with heart failure index event, 58.3% of secondary prevention, 47.3% of CHD RE, and 30.5% of primary prevention patients had 1 or more heart failure events over 2 years. Among patients with ≥1 heart failure events, 36.2% of secondary prevention, 30.0% of CHD RE, and 17.7% of primary prevention patients had ≥3 heart failure events over 2 years. Among matched patients (85-87% of patients), incremental total cost over 2 years for patients with heart failure as their index event compared with patients without CV events was $56,078 for secondary prevention, $53,247 for CV RE, and $49,637 for primary prevention cohorts.

Conclusions:
The rate and recurrence of heart failure among hyperlipidemic patients is very high and the long term healthcare costs substantial in this real-world 2-year study.
Abstract 256: Baseline Characteristics and Selected Outcomes in Spontaneous Coronary Artery Dissection Patients: Comparison of Cardiac Rehabilitation Participants and Non-participants
Authors: Krittanawong Chayakrit , Tweet Marysia S , Hayes Sarah E , Gulati Rajiv , Squires Ray W , Hayes Sharonne N
Published: July 2021

Background:
Randomized controlled trials and meta-analyses have demonstrated the benefits of cardiac rehabilitation (CR) in patients with acute myocardial infarction (AMI). Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of AMI. However, the benefit of CR has not been well studied in patients with SCAD.

Purpose:
Our objective was to compare the psychosocial and physiological characteristics and outcomes of CR in SCAD patients who participated in CR compared to those who did not.

Methods:
We performed a retrospective descriptive analysis of patients with angiographically confirmed SCAD enrolled in the Mayo Clinic SCAD Registry from January 2010 through December 2014 who had completed questionnaires (n=354). Demographics, clinical characteristics, Generalized Anxiety Disorder 7-Item Scale (GAD-7), Patient Health Questionnaire-9 (depression measure; PHQ-9), and details about participants’ CR participation and experience were collected via medical record review and questionnaires. Univariate analyses were performed to determine the differences between baseline characteristics and outcomes according to CR participation status.

Results:
Mean age of participants at time of SCAD was 46 ± 10 years; 95% were female. Seventy-six percent of participants participated in at least one CR session, and those users averaged 18 ± 12 sessions. A majority of CR participants reported physical and emotional benefits (82% and 75%, respectively). Of those who did not participate in CR, the primary reason was because their healthcare provider did not recommend CR (67%). Other reasons included inadequate transportation (12%), no insurance coverage (8%), cost (2%), no energy (2%), and being too ill (2%). On comparative analyses, CR participants had higher mean GAD-7 scores (4.9 vs. 3.9; p=0.03) and were more likely to increase their amount of exercise (p<0.01).

Conclusions:
Despite the well-known benefits of CR, in this international registry, only 76% of SCAD patients participated. Lack of recommendation for CR by a health care provider was the primary reason patients did not participate. The majority of patients reported benefits from CR. Higher GAD-7 scores were associated with CR participation, an interesting result requiring further evaluation in a larger or prospective cohort.
Abstract 275: A Prediction Model for Acute Heart Failure Outcomes
Authors: Wu Elise , Davies Glenn , Cook John
Published: July 2021

Objectives:
The Cox proportional hazard (PH) model is commonly used to evaluate the relative impact of risk factors on the baseline hazard of events in reference population. However Cox PH is limited in its ability to incorporate time dependent variables. While building models with fixed cycle lengths, where variable like medical history changes due to treatment intervention, a risk equation could help us better. Parameter risk equations, like Framingham Heart Study equations, can account for the shape of the baseline event rate which enables the estimation of future risk. The purpose of this study is to develop a set of risk equations that account for clinical evidence and biomarkers for acute heart failure (HF) patients to estimate time to discharge, time to in-hospital mortality, time to readmission and time to post-discharge mortality following an HF hospitalization

Methods:
We utilized data from the placebo arm population from Pro-B Type natriuretic peptide Outpatient Tailored Chronic heart failure Therapy (PROTECT) study to develop the risk equations. For each outcome, determining the best risk equation involved two steps, (a) selecting the appropriate underlying distribution, and (b) choosing the right set of risk-factors. Various distributions considered including Weibull, exponential, piecewise exponential, logistic, log normal and gamma distribution. The final distribution was chosen based on model fit and its AIC score. A variety of risk factors were considered including patient characteristics, relevant biomarkers and medical history. The best risk factors were chosen based on clinical relevance, systematic literature review, and how they performed on a maximum likelihood ratio test for the chosen distribution. The predicted value for each outcome was compared to observed values from PROTECT for internal validity and Efficacy and Safety of Relaxin for the Treatment of Acute Heart Failure (RELAX-AHF) study for external validity.

Results:
The gamma, Weibull, piecewise exponential and exponential distributions were selected for the time to discharge, in-hospital mortality, hospital readmission and post-discharge mortality, respectively. The key risk factors included gender, age, SBP, heart rate, ProBNP, GFR, NYHA class, in-hospital diuretic dosage, medication usage and cardiovascular comorbidities. The internal and external validity are confirmed by comparing predicted and observed values from PROTECT and RELAX-AHF study respectively. The predicted and observed LOS is 12.6 and 10.5 days. Although the predicted and observed 30 day post-discharge mortality are 1.20% and 3.30%, the difference between predicted and observed all-cause mortality is 0.1 (11.40% vs 11.3%).

Conclusions:
Since risk factors (i.e SBP and BNP) that change over time were identified as important risk-factors, parametric risk equations were superior to cox PH model.
Abstract 313: Depressive Symptoms, Cardiac Disease Severity, and NYHA Functional Classification Among Patients With Ischemic Heart Disease in the Heart and Soul Study
Authors: Schopfer David W , Regan Mathilda , Whooley Mary A
Published: July 2021

Background:
Patient-reported health status is highly valued by clinicians, investigators and payers as a key measure of health care quality. Little is known about the extent to which patient-reported health status is determined by subjective perception vs. objective measures of disease severity. We sought to compare the associations of depressive symptoms and objective measures of cardiac disease severity with perceived New York Heart Association (NYHA) functional classification in patients with stable ischemic heart disease (IHD).

Methods:
We assessed depressive symptoms (using the 9-item Patient Health Questionnaire), objective measures of cardiac disease severity (exercise capacity, left ventricular ejection fraction (LVEF), left ventricular hypertrophy (LVH), diastolic function, and inducible ischemia), and perceived NYHA symptom burden in 1023 patients with stable IHD. We compared the extent to which patient-reported NYHA functional classification was influenced by depressive symptoms vs. objective measures of disease severity. We also evaluated perceived NYHA functional classification as a predictor of and subsequent hospitalization for heart failure (HF), both before and after adjustment for depressive symptoms.

Results:
Patients with depressive symptoms were more likely to report poor (Class III or IV) NYHA functional status than those without depressive symptoms (44% vs. 17%; p<0.001). After adjustment for traditional risk factors, comorbid conditions, and objective measures of cardiac disease severity, worse NYHA symptom burden was most strongly predicted by depressive symptoms (OR 2.74, 95% CI 1.94-3.87), followed by poor treadmill exercise capacity (OR 2.31, 95% CI, 1.68-3.18), history of HF (OR 1.53, 95% CI, 1.08-2.17), LVEF <50% (OR 1.39, 95% CI, 0.87-2.22), and LVH (OR 1.01, 95% CI, 0.77-1.33). NYHA functional classification was significantly predictive of HF hospitalization even after adjustment for depressive symptoms (HR 1.72, 95% CI 1.46-2.02, p<0.001).

Conclusions:
Depressive symptoms were stronger predictors of perceived symptom burden than objective measures of disease severity. This suggests that depressive symptoms should be considered in the differential diagnosis of poor NYHA functional classification among patients with IHD.
Abstract 317: Costs and Benefits Associated with Transradial Percutaneous Coronary Intervention in China
Authors: Jin Chen , Tang Xin-ran , Dong Qiu-ting , Li Wei , Zhao Wei , Yang Jin-gang , Qiao Shu-bin , Yan Hong-bing , Wu Yong-jian , Xu Bo , Wang Yang , Gao Run-lin , Yang Yue-jin
Published: July 2021

Background:
Transradial percutaneous coronary intervention (TRI) has been increasingly used in the treatment of ischemic heart disease. While there are few studies examining the costs and benefits of transradial vs. transfemoral (TFI) in experienced centers among highly selected patients, treatment patterns and cost data obtained from the United States and European countries might not be generalizable to the developing world.

Methods:
We performed a retrospective analysis of patients undergoing PCI in the largest heart center in China between January and December 2010. Propensity score inverse probability weighting (IPW) method was used to compare costs and in-hospital outcomes between TRI and TFI, while controlling for potential treatment selection inherent in observational research.

Results:
Of 5,307patients undergoing PCI, 4,684 (88.3%) received TRI. Those undergoing TRI were younger, were less likely to be female, less likely to have prior myocardial infarction, PCI, or CABG, and more often presented with STEMI. After IPW adjustment, TRI was associated with fewer bleeding complications (BARC≥3 0.7% vs. 2.2%, OR 0.36, 95% CI 0.18-0.68), major adverse cardiovascular event (a composite of death, myocardial infarction, BARC bleeding≥3 or unplanned revascularization; 1.8% vs. 4.0%, OR 0.49, 95% CI 0.31-0.79), and shorter length of stay (6.1 vs 8.3 days, adjusted difference -1.5 days, 95% CI -1.9 to -1.2;
Table
). TRI was associated with a cost saving of $1,261 (95% CI $967-$1,557) as compared with TFI. The cost saving was mainly driven by reduced procedural-related cost ($761) from differential use of vascular closure device and lower hospitalization cost ($217) related to shorter length of stay. Similar results were found in clinically relevant groups of myocardial infarction (STEMI and NSTEMI), acute coronary syndrome (STEMI, NSTEMI, and unstable angina), and stable angina.

Conclusions:
Compared with the TFI approach, TRI was associated with fewer complications, shorter length of stay, lower costs, and improved in-hospital outcomes.
Abstract 367: Measurement of Lumen Dimensions in Non-stented and Stented Coronary Arteries: A Meta-analysis of Frequency Domain Optical Coherence Tomography versus Intravascular Ultrasound
Authors: Bhatheja Samit , Panchal Hemang , Barry Neil , Rahman Zia , Paul Timir
Published: July 2021

Background:
Intraluminal coronary morphology is traditionally evaluated by Intravascular Ultrasound (IVUS). Frequency Domain Optical Coherence Tomography (FD-OCT) is a novel method for evaluation of coronary lumen dimensions. Current literature has paucity of data with limited sample size comparing FD-OCT to IVUS. The objective of this meta-analysis is to compare the FD-OCT versus IVUS in assessment of lumen dimensions in non-stented and stented coronary arteries.

Methods:
PubMed and the Cochrane Center Register of Controlled Trials were searched through January 2015. Seven studies (n=169 vessels) comparing FD-OCT versus IVUS procedures in assessing lumen dimensions in non-stented and stented coronary arteries were included. Outcomes were minimum lumen area, minimum lumen diameter and maximum lumen diameter. The mean difference (MD) with 95% confidence interval (CI) was computed and p<0.05 was considered as a level of significance.

Results:
FD-OCT measured significantly smaller minimum lumen area and maximum lumen diameter compared to IVUS in non-stented vessels (MD: -0.86 mm
2
, CI: -1.18 to -0.55, p<0.00001 and MD: -0.21 mm, CI: -0.35 to -0.06, p=0.006, respectively). Minimum lumen diameter was not significantly different between two groups in non-stented coronary arteries (p=0.21). In stented vessels, no significant difference was found in measurement of minimum lumen area (p=0.34) and minimum lumen diameter (p=0.41) between FD-OCT and IVUS.

Conclusion:
The results of this study suggest that FD-OCT maybe a better modality to evaluate the severity of stenosis in non-stented coronary arteries. FD-OCT is comparable to IVUS in measuring lumen dimensions in stented vessels.
Abstract 382: Geographic Access to Transcatheter Aortic Valve Replacement Relative to Other Cardiac Services: A Statewide Analysis
Authors: Dayoub Elias J , Nallamothu Brahmajee K
Published: July 2021

Objective:
We determined geographic access to transcatheter aortic valve replacement (TAVR) in Michigan, and compared it to the access of other invasive cardiac services; namely, percutaneous coronary intervention (PCI), non-transplant cardiac surgery, and cardiac transplant surgery.

Methods:
A geographic information systems analysis was performed using the 2010 U.S. Census Survey and hospital data from the state of Michigan to construct maps of service areas around hospitals providing TAVR, PCI, non-transplant cardiac surgery, and cardiac transplant surgery. Hospital service areas ranging from 5-miles to 75-miles driving distance were included in the analysis. Geographic access was calculated as the percentage of the population living within the hospital service areas providing the four types of cardiac procedures studied in this analysis.

Results:
A total of 15 hospitals provide TAVR in Michigan in 2015. For TAVR clinical sites, the mean number of beds, total annual discharges, and total annual patient days are 571, 28,946, and 140,859, respectively. Of the 9,883,640 persons in Michigan, 2,365,783 (23.9%) live within 5 miles, 7,856,455 (79.5%) live within 30 miles, and 9,004,943 (91.1%) live within 50 miles driving distance of a hospital offering TAVR. In general, these proportions mirror those for PCI (8,857,148 [89.6%] living within 30 miles) and non-transplant cardiac surgery (8,814,143 [89.2%] living within 30 miles), as opposed to cardiac transplant surgery (5,481,122 [55.5%] living within 30 miles) (Figure).

Conclusions:
Nearly 4 of 5 Michigan residents live within 30 miles driving distance of a hospital providing TAVR. Relative to other invasive cardiac services, TAVR is more similar in geographic access to PCI and non-transplant cardiac surgery than it is to cardiac transplant surgery. These findings may have implications for whether TAVR remains a highly specialized procedure or becomes a more broadly available option for aortic stenosis.