bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P260: Superior Oral Anticoagulation Management With Self Testing and Automated Online Management; An Interim Analysis
Authors: Bussey Henry I , Walker Marie B , Bussey-Smith Kristin L , Frei Christophen R
Published: March 2022

Background:
The safety and efficacy of warfarin therapy is critically dependent on control of the international normalized ratio (INR). One-third of 3,587 warfarin-treated patients with their INR time in the therapeutic range (TTR)> 75% had a 50% lower major event rate compared to the one-third whose TTR was < 60%.

Objective:
Assess the impact of three interventions on INR control and management time. Interventions included weekly INR self testing, daily low dose vitamin K, and online management.

Methods:
Sixty-three patients who were at least 18 years of age, had completed at least 7 months of warfarin therapy, and did not have a diagnosis of antiphospholipid antibody or HIV/AIDS provided written informed consent. INR control was assessed for 6 months pre-study and for up to 12 months during the study. INR control was reported as %TTR, %TTR +/- 0.3 INR units, and % time at an INR below 1.5 or above 5. Clinician time required for each “virtual visit” was recorded and 1 minute was assigned for each automated visit.

Results:
Eight of 63 patients were excluded (4 withdrew consent the first week, 3 were early protocol violaters, and 1 had warfarin discontinued at study day 11). Fifty-five patients provided 26.83 patient-years of pre-study data during which the TTR was 56.83%, TTR +/-0.3 INR units was 82.55%, and time below 1.5 or above 5 was 2.41% and 0.09%, respectively. Of 54.14 patient-years of study data, TTR improved to 79.65% TTR, 93.57% for TTR +/-0.3 INR units, and 0.4% and 0.07% for time below an INR of 1.5 or above 5, respectively (see
Table
). Clinician management required 8.94 minutes per 4 “virtual visits” per patient per month.

Summary:
Weekly INR self testing, daily low dose vitamin K, and online automated management improved the TTR by 22%; a degree of improvement that has been associated with a 50% reduction in stroke, heart attack, major bleeding, and death. INRs were rarely very far out of range and management required clinician time of less than 10 minutes per patient per month.

INR Control Pre-Study vs Study Period

End Point
Pre-Study n=55, 26.83 patient-years
Study, n=55, 54.14 patient-years

% Time in Range
56.83
79.65

% Time in Range +/- 0.3 INR units
82.55
93.57

% Time INR < 1.5
2.41
0.40

% Time INR > 5
0.09
0.07

# (%) Patient with TTR > 75%
11 (20)
39 (70.1)

# (%) Patients with TTR +/- 0.3 INR > 75%
17 (30.1)
55 (100)

# (%) Patients with TTR < 60
30 (54.5)
4 (7.3)

# (%) Patients with TTR +/- 0.3 INR < 60%
7 (12.7)
0 (0.0)
Abstract P272: Assessment of Functional Status in Patients Following Coronary Artery Bypass Surgery Using a Short Form of the Heart Surgery Symptom Inventory (HSSI-21)
Authors: LaPier Tanya
Published: March 2022

The purpose of this study was to evaluate the psychometric properties of a subset of items from the Heart Surgery Symptom Inventory (HSSI) that focus on general surgical and sternotomy related factors. The original HSSI is a symptom inventory developed to assess disease-specific functional status in patients recovering from coronary artery bypass (CAB) surgery, using 76-items, organized into 4 subcategories. This study included 27 patients attending outpatient cardiac rehabilitation who had undergone CAB within the past 6 months. Patients completed several self-report instruments including a patient history form, HSSI, and SF-36 Health Survey and a second HSSI at a later time on the same testing day. The original HSSI was abbreviated to include 21 items pertaining to general surgical and sternotomy related symptoms. HSSI scores from the original were compared to scores generated on the short form (HSSI-21) and scores obtained during 2 trials of the HSSI-21 were evaluated for test-retest reliability, using Pearson correlations. HSSI-21 scores were compared to SF-36 scores to evaluate concurrent validity, using Pearson correlations and
t
-test (
P
< 0.05). We found a significant correlation (
r
= 0.91) between original and short form HSSI scores. The test-retest reliability of the HSSI-21 was
r
= 0.97. The correlations between the HSSI-21 and all SF-36 scores were significant and negative since there is an inverse relationship between scores on the HSSI-21 and the SF-36. Results indicate that the HSSI-21 test-retest reliability is excellent. We found a strong relationship between scores on the original and short form of the HSSI. Data suggest that the concurrent validity of the HSSI-21 is similar the original HSSI. In summary, the HSSI-21 can be a useful clinical and research tool to evaluate functional status related to general surgical and sternotomy related symptoms in patients following CAB surgery.
Abstract P275: Incidence and Case-Fatality Rates of Acute Myocardial Infarction in the United States: A Systematic Review
Authors: Awad Hamza H , Anderson Frederick A , FitzGerald Gordon , Gore Joel M , Goldberg Robert J
Published: March 2022

Introduction:
Beginning in the late 1960s, the death rates attributed to coronary heart disease (CHD) in the U.S. declined, including deaths due to acute myocardial infarction (AMI). The decline in AMI related mortality is likely related to both a decrease in the incidence rates of new events in addition to declines in case-fatality rates (CFRs). The purpose of this summary over view is to describe long-term trends in the incidence and short-term CFRs after AMI in the US based on data from population-based community surveillance studies and, secondarily, to examine possible demographic differences in any observed trends.

Methods:
Systematic review of published studies providing data on incidence and/or CFRs after AMI in the U.S. published in English between 1980 and 2009.

Results:
Twenty one out of 436 retrieved articles met our eligibility criteria. Our findings are based on the results of 9 community surveillance studies covering different geographic locations and time periods. Eight studies where done in predominantly White populations. Incidence rates: Studies that had no upper age limits failed to show significant declines in overall incidence rates of AMI over the periods under study. Studies that had an upper age limit reported declines (Minnesota Heart Survey (MHS) 25% decline) or no changes (Atherosclerosis Risk in the Community (ARIC)) in the incidence rates of AMI. Declines were primarily observed in younger White men.

Case-fatality rates:
All studies reported declining short-term (hospital) CFRs (50% decline since the late 1960s). Declines were greatest among younger individuals. Unadjusted CFRs were 1.5 fold higher in women and non-Whites compared to men and Whites, respectively.

Conclusion:
Our review demonstrated encouraging declines in short-term CFRs after AMI while incidence rates did not show similar trends. Aging of the population and changes in AMI definitions might have played a role in the observed trends in AMI incidence rates. Advances in pre-hospital care, management, and critical cardiac care likely contributed to the declines in CFRs observed.
Abstract P277: Long Term Outcomes of Octogenarians Undergoing Percutaneous Coronary Artery Stenting: A Comparison of Bare Metal and Drug Eluting Stent
Authors: Uthamalingam Shanmugam , Kandala Jagdesh , Ahmado Imad , Dewey Robert , Flynn James
Published: March 2022

Background:
Octogenarians have been under-represented in percutaneous coronary intervention (PCI) trials, thus making difficult to choose the best type of stent in this patient population. We compared the outcomes of drug eluting (DES) and bare metal stent (BMS) at one year after implantation in this special population.

Methods:
A total of 320 patients over 80 years undergoing PCI with BMS (n=218) or DES (n=102) between January 2000 and March 2008 were retrospectively studied. In-hospital and one year major adverse cardiac events (MACE) defined as cardiac related death, non-fatal myocardial infarction, target vessel (TVR) and target lesion revascularization (TLR) were compared between the two groups. Cox regression analysis was used for data analysis.

Results:
The cumulative incidence of in-hospital MACE between the BMS and DES group were similar (3.6% vs 2.9%; P=0.32). The one year incidence of MACE event was higher in the BMS group (18.8% vs 9.8%, adjusted relative risk [RR] 2.33; 95% confidence interval [C.I.]: 1.12 to 4.86; P=0.02) Figure-1. Diabetes mellitus was an independent predictor for increased MACE event (adjusted RR: 1.99; C.I: 1.06 to 3.77, P= 0.03). One year cumulative incidence of TLR and TVR was higher in the BMS group (10.0% vs 3.9% adjusted RR : 2.94 ; C.I. 1.01 to 8.59 P=0.05) Figure 2.

Conclusion:
During one year follow up, octogenarians treated with BMS had an increased risk of MACE compared with those treated with DES. DES should be preferred in indications recognized from current PCI guidelines.
Abstract P280: Leptin is Associated With Lower Mortality in Patients With Stable Coronary Artery Disease: The Heart and Soul Study
Authors: Ku Ivy , Farzaneh-Far Ramin , Na Beeya , Whooley Mary
Published: March 2022

Background:
Leptin is an adipocyte-derived cytokine that is thought to be involved in the link between obesity and cardiovascular disease. However, leptin has pleiotropic actions with both protective and harmful effects on the cardiovascular system. Prospective studies evaluating the association between leptin and cardiovascular outcomes have yielded conflicting results.

Methods:
We performed a prospective cohort study of 985 outpatients with stable coronary artery disease. Leptin levels were measured in fasting venous samples using the Millipore Milliplex Map kit. We used proportional hazards models to evaluate the association of baseline leptin levels with subsequent all-cause mortality.

Results:
Over a mean follow-up of 5 years, there were 270 deaths. Each standard deviation increase in log leptin predicted a 14% decreased risk of death (unadjusted hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.76-0.97, p = 0.01). This association persisted after multivariate adjustment for age, gender, ethnicity and waist-to-hip ratio (HR 0.84, 95% CI 0.73-0.97, p = 0.02). After additional adjustment for clinical characteristics (hypertension, history of myocardial infarction, history of congestive heart failure, diabetes, smoking, statin use, exercise capacity) and laboratory biomarkers (cholesterol, creatinine, C-reactive protein, N-terminal pro-B-type natriuretic peptide, and cystatin C), the association remained strong (HR 0.81, 95% CI 0.70-0.94, p = 0.01).

Conclusions:
Leptin is associated with decreased mortality in patients with stable coronary artery disease. This association is independent of known factors affecting leptin levels, including gender and abdominal obesity. Whether leptin has direct effects on coronary artery disease, or functions as a marker of other protective pathways, deserves further study.
Abstract P283: Operator Variation in Coronary Angioplasty and Stenting
Authors: Lawson William E , Wilbert Lisa , Pandrangi Hema , Gomes Carol , Greene William
Published: March 2022

Background:
Post COURAGE trial the treatment of coronary artery disease has become a complex decision process, with many physicians advocating initial revascularization only for medical failures and high risk subgroups. The decision of whether to use Drug Eluting or Bare Metal Stents has also drawn wide attention and has changed practice. We examined the extent of variability with its implications for quality, utilization and health care costs on physician driven interventions compared to the UHC and national comparison benchmarks.

Methods:
The practice patterns of 11 interventional cardiologists in 2009 were reviewed relative to patient treatment and outcomes for determinants of variation in revascularization practice. Associations were evaluated by Chi square for significance and Pearson's correlation coefficients were calculated.

Results:
There were 1,977 PCI (44.6%) performed on 4,428 patients undergoing cardiac catheterization. PCI as a percentage of total cases varied widely by physician from 22.8% to 58.8%. The use of Bare Metal Stents ranged from 12.7% to 61.4% of cases [25.2% mean; benchmarks 18.4%, 21.8%]; Drug Eluting Stent use varied from 38.6% to 87.3% by operator [74.8% mean]. The number of stents placed/patient was significantly less for Bare Metal Stent cases (1.19-2.0 mean 1.9; benchmarks 1.6, 1.54) than for Drug Eluting Stent cases (1.46-2.92 mean 2.20; benchmarks 1.99,2.18). There was no significant correlation between the number of stents placed and 30 day readmission. There was no significant correlation between cath lab operator volume and conversion rate to angioplasty or to the number of stents placed.

Conclusions:
There is wide variation in revascularization practice that is physician associated. DES stent use has declined from a high of 90% to about 75% with procedures requiring multiple stents favoring the use of DES. Higher PCI revascularization rates and more extensive revascularization were not associated with a short term increase in adverse outcomes, LOS, or readmissions. The long-term outcomes and cost of more aggressive revascularization with PCI are unknown and will merit further investigation.
Abstract P299: A Multi-Method Approach for the Formative Evaluation of the Heart Failure Provider Network
Authors: Sahay Anju
Published: March 2022

Objectives
Heart failure (HF) is associated with high mortality and poor quality of life. Moreover, it is the most common medical reason for admission within and outside of the VA health care system. In July 2006 the Chronic Heart Failure (CHF) Quality Enhancement Research Initiative (QUERI) formed the HF Network - a network of VA providers interested in improving HF care. Over 510 providers from 150 facilities are members of the network. However, the participants' views of the network are poorly understood.

Method
A multi-method approach was used for the formative evaluation of the HF Network. Quantitative data were gathered from members who completed a web-based survey. Responses were obtained pertaining to helpfulness with activities, whether participation influenced them, benefit of participating, etc. Qualitative in-depth interviews with members from non-participating, low-participating and high-participating facilities provide in-depth understanding of goals, influence patterns, barriers and facilitators.

Results
The response rate to the web-based survey was 32%. Respondents reported the HF Network helped them understand facilitators and barriers in setting up or running HF clinic/program (92%), validated own current practice in taking care of HF patients (91%), provided names of contacts from HF Network for networking and potential problem solving (91%), and helped solve implementation-related problem at their facility (66%). Interestingly, respondents who reported that they considered their participation in the network as beneficial also perceived themselves as influential in making changes at own facility to improve care (r=.859, p<.01). Qualitative data substantiates these findings and provides in-depth understanding of dynamics pertaining to influence patterns and suggestions for overcoming barriers for improved care.

Conclusions
The multi-method approach provides deep insight in understanding the perceptions of members of the HF Network pertaining to their involvement in the network's activities as helpful and beneficial to them.

Impact
Through such social networks providers get unique opportunities to implement changes for improved care of patients.
Abstract P307: Implementing an Orientation and Training Program for Quality Improvement in the Office-Based Setting: Initial Observations From the American College of Cardiology Improving Continuous Cardiac Care (IC3) Pilot Program
Authors: Elma MaryAnne , Mitchell Kristi , Kehoe Katie , Thrutchley Duane , Breeding Tracie , Fiocchi Fran , Buchanan Donna , Sasson Joe , Spertus John
Published: March 2022

BACKGROUND:
Organizational change experts and health care practitioners contend that readiness for change is a critical factor to successful change implementation. With the push to EMR adoption, practice guideline adherence, and systematic collection of standardized clinical data in the office setting, the need for continuous support of medical staff is essential in order to improve quality of care.

METHODS:
The American College of Cardiology (ACC) launched a prospective QI project targeting physician practices responsible for the care of cardiac patients in the outpatient setting called IC3, now known as the PINNACLE Registry. To provide resources for practices to join and participate in IC3, an Orientation and Training (OT) Program was launched based on the Transtheoretical Model (TTM) for behavior change. Two complementary activities supported the OT strategy: Care Package (CP) Series and Learning Sessions (LS). Independently, these activities were not intended to affect participant behavior. Training was designed as a combination of passive learning methods and practical tools for applying knowledge in daily practice. The CP and LS were delivered quarterly with a theme reflecting major annual events. Each theme targeted a specific role on the office team. IC3 partnering organizations were consulted to determine components and topics. Each CP consisted of printed and online materials. The LS were webinars, on-demand presentations, or referred offerings from other organizations. LS topics were categorized as IC3 Project, hot topics, and professional development.

RESULTS:
One welcome-themed CP was delivered to 169 practices in June 2009. Twenty LS were offered of which 16 were webinars with an average of 12 practices per webinar. Participant surveys, a practice assessment, and a research project on barriers and facilitators were planned but not implemented due to resource constraints.

CONCLUSIONS:
Standardized, constant, and relevant activities were essential to keep office teams engaged in a complex program like IC3. In applying the TTM to change behavior, each office team needed continuous and specific resources to move from awareness of IC3, to interest in participating, to engagement in collecting data, and to action in submitting data.
Abstract P310: Delayed Discharge in Cardiothoracic Surgical Practice - Do Our Patients Just Not Want to Go Home?
Authors: Kutty Ramesh S , Nair K S
Published: March 2022

Aims:
Patient discharge after non-emergent adult cardiac surgery is influenced by many medical and social factors. Delayed discharge is often due to identifiable and rectifiable factors. This resultant shortened hospital stay allows for more patients to be treated along with lower economic costs incurred in hospital. Patient care guidelines developed enable uniformity of care along with improved efficiency of care.

Methods:
Prospective analysis of data collected at a tertiary level cardiac centre (over 2000 cases/year) in 2008 of urgent and elective adult cardiac surgical cases was compared to UK national length of stay published data. Type of operation, postoperative progress along with factors influencing discharge (physiotherapy, discharge destination, etc) and length of stay were reviewed with weaknesses identified and improvements instituted. Savings of even 1 day/patient produces over $1 million/year to the hospital.

Results:
Data on 220 consecutive admisisons collected (11%, 220 of 2004) of which 175 (80%) were elective and 45 (20%) urgent. Their mean age was 68, BMI 28.6 and 163 (74%) were male. Their mean EuroSCORE was 5.18 with a log EuroSCORE was 6.61%. CABG, valve repair/replacement or a combination of the two accounted for 195 (89%) with complex procedures in the remainder. There were 5 deaths (2%). Mean critical care stay was 2 days with postoperative checks completed between days 4-6. Length of stay (days) noted to be 8.7, 7.9, 8.2 and 12.0 in all, CABG, isolated valve and valve plus grafts respectively. This discharge data was keeping with national data. Clinician related variation in postoperative progress, limitations in carer availability, anticoagulation services, weekend physiotherapy services were identified as limiting factors.

Conclusions:
Delayed discharge is multi-factorial. Our patient population is older with complex surgical problems with identifiable factors that delay discharge. Improved preoperative work-up, with planned convalescence options are essential to efficient care. Protocol driven progress, improved staffing, coordination with local teams, improved physiotherapy cover with a dedicated cardiac surgery discharge coordinator are improvements developed since this review.
Abstract P318: Why Do Some Patients Not Receive Reperfusion Therapy for ST-Elevation Myocardial Infarction (STEMI)? A Field Evaluation With Expert Core Laboratory Electrocardiographic Analysis
Authors: Brown Kevin A , Lambert Laurie J , Nasmith James , Segal Eli , Carroll Céline , Giguère Maude , Bogaty Peter
Published: March 2022

Many apparently eligible patients with ST-elevation myocardial infarction (STEMI) do not receive reperfusion treatment for reasons that remain poorly understood. We explored predictors for not receiving reperfusion treatment, defined as fibrinolysis or urgent referral (≤ 4 hours after triage) for primary angioplasty, in patients with STEMI. A field evaluation systematically reviewed STEMI care in 80 hospitals in 2006-7. Patients with myocardial infarction, acute presenting symptoms, and medical chart mention of STEMI, had a copy of their first electrocardiogram (ECG) interpreted independently at the field evaluation center by 2 cardiologists as being definite STEMI, not STEMI, or uncertain. Left bundle branch block (LBBB) was classified separately. Patients with at least one definite or uncertain ECG interpretation (including LBBB) were considered to have STEMI (n=2,137); of these, 524 (24.5%) did not receive reperfusion therapy. Their 30-day and 1-year mortality was 17.9% and 29.4% compared to 5.6% and 7.8%, respectively, in patients receiving reperfusion treatment (p <0.001). Independent predictors of not receiving reperfusion treatment included: older age, female gender, heart rate >100 beats/min and longer symptom duration. Among patients without LBBB (n=1930), lack of ECG-based agreement for definite STEMI was strongly and independently associated with no reperfusion [OR=6.1; 95% CI: 4.7-8.0]. For only 20.0% of patients not receiving reperfusion treatment did the 2 cardiologists agree on definite STEMI on ECG. Presence of LBBB was also a strong predictor of no reperfusion [OR=13.1 (95% CI: 8.8-19.6)]; only 17.4% of patients with LBBB received reperfusion treatment. Thus, this study confirms the high-risk clinical features and poor prognosis of STEMI patients who do not receive reperfusion and indicates that lack of expert agreement on definite STEMI and presence of LBBB are important predictors of no reperfusion therapy. Further study is needed to determine whether these high-risk patients may benefit from immediate referral for cardiac catheterization.
Abstract P323: Comparison and Validation of Quality of Life Instruments in Optimally-Treated Stable Coronary Patients
Authors: Zhang Zugui , Kolm Paul , Teo Koon K , Spertus John A , Maron David J , O'Rourke Robert A , Hartigan Pamela , Boden William E , Weintraub William S
Published: March 2022

Background:
Measures of quality of life and health status have become important outcomes in clinical trials and in economic evaluations of medical interventions. Even if these measures were from validated instruments, it is necessary to check the instruments' reliability and validity with on-going trial subjects.

Methods:
We used three years of data from the COURAGE study, a randomized trial evaluating the outcomes of optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI) in a total of 2,287 patients with stable Coronary disease. We assessed angina-specific health status via SAQ, overall physical and mental function via RAND-36, and a single, preference-based index measure of health via standard gamble based utility.

Results:
Intra-class coefficients for SAQ were from 0.33 to 0.53, for RAND-36 were from 0.45 to 0.69 in each domain, but was only 0.27 for utility, suggesting that SAQ and RAND-36 were assessments with good consistency and reproducibility, but utility was not. SAQ and RAND-36 were shown to be instruments with trusted internal consistency reliability: Cronbach's alpha values from subscale scores for SAQ were from 0.6 to 0.9, and for RAND-36 were from 0.77 to 0.93; for SAQ as an instrument of angina status were from 0.74 to 0.80, for RAND-36 as an instrument of general health status were from 0.90 to 0.93 across time. The coefficients of variation were 0.38 to 0.60 for each domain of SAQ and 0.33 to 0.82 for each domain of RAND-36, but less than 0.24 for utility across time, indicating that SAQ and RAND-36 reflected the impact of treatment over time, while utility did not. The Canadian Cardiovascular Society Classification, a widely used system for grading angina severity of symptoms, was highly related to baseline scores in each domain of SAQ and RAND-36, but not to the baseline utility, indicating that utility was problematic in measuring the differences in angina severity.

Conclusions:
For stable coronary patients, SAQ was the most reliable instrument in COURAGE, although there is need to consider variation of scores in each domain; RAND-36 while also reliable, was not as good for angina as SAQ; utility from standard gamble program was not a good instrument due to the ceiling effect and we should be cautions about its use.
Abstract P331: The Impact of In-Hospital Postoperative Complications on Health Related Quality of Life in Cardiac Surgery Patients
Authors: Martin Chidima T , Holmes Sari D , Martin Lisa M , Hunt Sharon L , Ad Niv
Published: March 2022

Background:
Reports of successful cardiac surgical outcomes have focused on mortality and morbidity. However, health related quality of life (HRQL) is now being recognized as an important outcome measure. The objective of this study was to assess the impact of in-hospital postoperative complications on physical and mental HRQL in cardiac surgery patients from baseline to 6 and 12 months after surgery.

Methods:
Patients who underwent cardiac surgery since September 2005 were included (n=702). All patients completed the Short Form Health Survey (SF-12) prior to surgery, and at 6 and 12 months after surgery. Norm-based physical and mental components of HRQL were calculated, with higher scores indicating better HRQL. In-hospital postoperative complications were defined using the Society of Thoracic Surgeons guidelines.

Results:
Group 1 (n=533) had no in-hospital postoperative complications and Group 2 (n=169) experienced complications. The groups did not differ at baseline on physical or mental HRQL. There were significant main effects of time (F=32.9, p<0.001) and group (F=14.9, p<0.001) for physical HRQL, which showed an increase in scores over time and higher scores in Group 1. The significant interaction of time by group (F=6.6, p<0.02) indicated that physical HRQL increased more in Group 1 from baseline to 6 months and more in Group 2 from 6 to 12 months. The main effect of time was significant for mental HRQL (F=4.7, p<0.04), which showed an increase from baseline to 6 months and a slight decrease between 6 and 12 months. The interaction of time by group was not significant for mental HRQL. It is interesting to note, however, that the groups increased similarly from baseline to 6 months, but Group 1 showed a decline from 6 to 12 months and Group 2 continued to show an increase in mental HRQL from 6 to 12 months.

Conclusion:
In-hospital postoperative complications significantly affect improvements in HRQL. Patients that did not experience postoperative complications had a significantly better and faster improvement in physical HRQL from baseline to 1 year. Despite these differences in physical HRQL, the two groups increased similarly on mental HRQL. Further study is needed to explore this finding with a larger sample and longer follow-up time points after surgery.
Abstract P332: Younger Patients Report Impaired Mental Functioning in Health-Related Quality of Life After Valve Surgery
Authors: Woolfolk Cshantara L , Holmes Sari D , Henry Linda L , Hunt Sharon L , Martin Lisa M , Ad Niv
Published: March 2022

Background:
Heart valve surgery is indicated for a number of presenting conditions and is performed even in young patients. It is known that younger age can be protective for surgical outcomes, such as mortality, but less is know about how age impacts quality of life in patients undergoing valve surgery.

Objective:
To determine if age was associated with health related quality of life (HRQL) after valve surgery.

Methods:
Patients who underwent valve surgery (stand alone or concomitant) since late 2005 were included in these analyses (N=288). The age range for this sample was 21-87. Patients were divided into tertiles based on age: younger (age < 60 years; n=95), older (age ≥ 60 and < 72; n=93) and oldest (age ≥ 72; n=100). HRQL was measured using the Medical Outcomes Trust Short Form 12 (SF-12) prior to surgery, and at 6 and 12 months post-surgery. The SF-12 mental component summary (MCS) and physical component summary (PCS) scores were calculated to assess differences in HRQL over time based on age groups.

Results:
There was a significant main effect of time for MCS (F=5.6, p<0.006) and PCS (F=39.6, p<0.001) with significant increases in HRQL from baseline through 12 months. No significant interaction of time by age group was found for MCS or PCS. All three groups increased similarly for both MCS and PCS. There was a significant main effect of group for both MCS (F=4.1, p<0.02) and PCS (F=22.3, p<0.001). The younger group had significantly lower MCS scores as compared to the older group (p<0.02), regardless of time point. However, the younger group had significantly higher PCS scores as compared to the older (p<0.04) and oldest groups (p<0.001). The older group also had significantly higher PCS scores than the oldest group (p<0.001).

Conclusion:
Improvement in HRQL was shown across all age groups in both MCS and PCS. Despite the fact that the younger patients had the highest physical HRQL, this group had the lowest mental HRQL regardless of time point. These results suggest that valve disease in the younger patients had a detrimental effect on their mental HRQL prior to and after surgery. Further study is needed to investigate the impact of valve disease and surgery on quality of life in younger patients, particularly on how to improve the psychological experience.
Abstract P337: Prediction of In-Hospital Major Bleeding Among Patients With Acute Myocardial Infarction: Results From 90,273 Patients in the Acute Coronary Treatment Intervention Outcomes Network Registry®- Get With the Guidelines™ (AR-G)
Authors: Mathews Robin , Peterson Eric D , Chen Anita Y , Wang Tracy , Chin Chee T , Fonarow Gregg C , Cannon Christopher P , Roe Matthew T , Alexander Karen P
Published: March 2022

Background:
Bleeding is a common complication of acute myocardial infarction (AMI) management and is associated with worse outcomes. Risk estimation is important to guide choice and intensity of therapy and minimize bleeding-related adverse events.

Methods:
Using AR-G data, an in-hospital major bleeding model and risk score was developed. Major bleeding was defined as a HCT drop >12%, ICH, retroperitoneal bleeding or transfusion if baseline HCT >28%, and transfusion if baseline HCT <28% with witnessed bleeding. The model used only baseline variables and was developed (n=72,313) and validated (n=17,960) in STEMI and NSTEMI patients (251 US centers from 1/07 to 12/08). C statistic was tested in the derivation and validation cohorts and across key subgroups.

Results:
Twelve independent factors were identified: heart rate, baseline hemoglobin, female sex, initial creatinine, older age, EKG changes, heart failure or shock on presentation, diabetes, peripheral artery disease, lower weight, systolic blood pressure, and home warfarin use. The model discriminated in the derivation (c=0.73) and validation (c=0.71) cohorts. A score (0-91) was created for the relative odds for major bleeding. Bleeding risk increased tenfold from lowest to highest score: very low risk (3.9%), low risk (7.3%), moderate risk (16.1%), high risk (29%), and very high risk (40%). This trend was consistent across age, sex, and MI type (Figure).

Conclusion:
The AR-G bleeding model and score estimates bleeding risk across a broad range of STEMI and NSTEMI patients. The model provides clinicians an easy-to-use aid to facilitate treatment decision making and may ultimately promote better patient outcomes.
Abstract P34: Hospital Level Variation in Clinical Outcomes for Medicare Beneficiaries Hospitalized With Ischemic Stroke
Authors: Fonarow Gregg C , Smith Eric E , Reeves Mathew J , Pan Wenqin , Olson DaiWai , Hernandez Adrian F , Peterson Eric D , Schwamm Lee H
Published: March 2022

Background:
Mortality and readmission rates after hospitalization for stroke are being considered as metrics of hospital-level quality of care for Medicare beneficiaries. To date, little is known about ischemic stroke mortality and readmission rates at the hospital level and how they vary.

Methods:
We analyzed data from 91,134 Medicare fee-for-service beneficiaries enrolled from 625 Get With The Guidelines-Stroke hospitals between April 2003 and December 2006, which were linked to longitudinal outcome data from CMS. Hospitals with fewer than 25 ischemic stroke patients were excluded. Within each hospital, 30-day, 90-day, and 1 year, death or all-cause readmission rates were calculated with and without risk adjustment.

Results:
There was a median 102 ischemic stroke patients per hospital (25
th
-75
th
54 to 199). In this cohort mean age was 79.4 years, 58% were female, and 81% were white. Prior stroke/TIA was present in 32%, atrial fibrillation/flutter in 24%, diabetes in 28%, and hypertension in 77%. In-hospital mortality was 6.1%; the majority of deaths occurred following discharge (table). More than one in five ischemic stroke patients had death or rehospitalization within 30 days of hospital discharge and nearly two-thirds within 1 year. Risk adjusted rates varied widely by hospital at each time point.

Conclusions:
Hospital-level rates of death or readmission following an ischemic stroke hospitalization are high and vary considerably. Further research is needed to determine preventable causes of rehospitalizations and improve early, intermediate, and long-term outcomes.

Hospital Level Variation in Clinical Outcomes for Ischemic Stroke

Clinical Outcomes, Risk Adjusted
Mean ± STD

10
th

25
th

Median

75
th

90
th

Death (all admissions)

In-Hospital
6.1 ± 3.5%
2.3%
3.7%
5.8%
7.8%
10.6%

30-Day (after admission)
14.2 ± 4.7%
8.6%
11.3%
14.0%
16.6%
19.9%

Death (among hospital survivors)

30-Day (after discharge)
10.0 ± 4.3%
5.1%
7.1%
9.7%
12.0%
15.6%

90-Day (after discharge)
15.7 ± 5.0%
9.7%
12.7%
15.3%
18.3%
21.9%

1-Year (after discharge)
26.7 ± 6.0%
19.2%
23.2%
26.5%
29.9%
34.2%

Rehospitalization

30-Day
14.5 ± 5.0%
8.5%
11.3%
14.3%
17.3%
20.7%

90-Day
29.8 ± 6.5%
22.2%
25.6%
29.8%
33.8%
37.8%

1-Year
56.2 ± 7.2%
47.8%
51.5%
55.9%
61.2%
64.8%

Death or Rehospitalization

30-Day (after discharge)
21.5 ± 5.8%
14.8%
18.0%
21.5%
24.8%
28.7%

90-Day (after discharge)
37.2 ± 6.6%
29.3%
33.2%
37.2%
40.7%
45.5%

1-Year (after discharge)
61.9 ± 6.6%
53.9%
57.7%
61.9%
66.4%
69.9%
Abstract P341: Poor Childhood Dental Care: A Risk Factor for the Development of Coronary Artery Disease and Potential New Target for CAD Prevention
Authors: Matsumura Martin , Trapp Taylor , Ahmed Shameer
Published: March 2022

Background:
Accumulating evidence supports a relationship between periodontal disease (PD) and coronary artery disease (CAD). The mechanism of the increase in CAD among PD patients is thought to involve chronic inflammation resulting from PD. As a result, the American Academy of Periodontology recommends screening for CAD in patients with severe PD. In the present study we hypothesized that preventive dental care in childhood would be associated with reduced CAD in adulthood, and that this effect would be independent of traditional CAD risk factors.

Methods:
Patients (n=223) at a single dental clinic were invited to answer a questionnaire regarding present CAD and PD disease as well as risk factors for CAD. In addition, a detailed history of childhood dental care was obtained.

Results:
Ninety-one patients (41%) had CAD and 72 (32%) had PD. Significantly more patients with PD reported a history of CAD vs. those without PD (51% vs. 29%, p=0.002). Patients who reported a history of regular dental checkups and prophylaxis as children had significantly less CAD compared to those without regular childhood dental care (24% vs. 54%, p<0.001). In contrast, there was no difference in prevalence of CAD among patients who reported regular dental brushing in childhood vs. those who did not (33% vs. 40%, p=NS), suggesting that professional dental prophylaxis was required for achievement of a CAD-protective effect. In a logistic regression model, poor childhood dental care remained strongly associated with CAD even the traditional risk factors of smoking, hypertension, and male sex were controlled for. The relationship between childhood dental care and CAD did not appear to be wholly explained by the occurrence of PD in patients with poor dental care: even in patients without PD, childhood dental care remained associated with reduced CAD (20% with dental care vs. 43% without dental care, p=0.002).

Conclusions:
Poor childhood prophylactic dental care is a potential new risk factor for development of CAD. Screening for poor dental care in addition to traditional risk factors may add to the assessment of CAD risk, and including dental education and intervention in programs targeted to reduce CAD risk factors in adolescents may impact on the incidence of CAD in adults.
Abstract P350: Predicting the Restenosis Benefit of Drug-Eluting vs. Bare Metal Stenting Prior to Angiography: A Tool for Patients and Clinicians
Authors: Yeh Robert W , Jones Philip G , Wolf Robert E , Normand Sharon-Lise T , Cohen David J , Ho Kalon K , Cutlip Donald E , Kugelmass Aaron D , Spertus John A
Published: March 2022

Background:
While drug-eluting stents (DES) are associated with lower restenosis rates compared with bare metal stents (BMS), they require prolonged thienopyridine use and may be associated with higher rates of stent thrombosis. Recent work has demonstrated that the absolute risk reductions of DES (i.e. the restenosis benefits) vary by clinical and angiographic features. However, to engage patients in the decision-making surrounding stent type, the benefits of alternative stents must be shared
prior
to angiography so that they can participate in a non-sedated state. To address this challenge, we created multivariable models based on clinical characteristics available prior to PCI to predict restenosis one-year after DES or BMS.

Methods:
Patients undergoing PCI in Massachusetts between 4/03 and 9/06 were identified and 1-year target vessel revascularization (TVR) outcomes determined. Parsimonious multivariable logistic regression models were constructed, using pre-angiographic data from NCDR versions 2 and 3, to identify clinical factors associated with TVR. The final models for DES and BMS consisted of 12 and 10 sociodemographic and clinical variables, respectively, chosen by backwards elimination while maintaining 95% of the predictive ability of the full models. We simulated random combinations of risk factors to determine the range of predicted restenosis benefit for DES vs. BMS.

Results:
A total of 19577 DES and 5255 BMS admissions were included in the development cohort and 9809 DES and 2597 BMS admissions were used in a validation cohort. The c-statistics for the models for predicting TVR after BMS and DES were 0.60 and 0.61 in the derivation cohorts, and 0.615 and 0.62 in the validation cohorts. Good calibration was observed in all models. Depending on the simulated clinical profile, the relative risk of TVR after BMS vs. DES ranged from < 1.0 to > 10.

Conclusions:
We generated multivariable models to predict TVR with DES or BMS based on clinical variables available
prior
to PCI that are comparable to previously published models that include procedural variables. The predicted relative risk of TVR for DES vs. BMS varies widely based on patients' clinical characteristics. These models may be useful in engaging patients in stent selection prior to PCI.
Abstract P351: Ethnic Differences in the Risk Estimates of Novel Biomarkers for Future Cardiovascular Outcomes
Authors: Zalawadiya Sandip K , Veeranna Vikas , Niraj Ashutosh , Pradhan Jyotiranjan , Jacob Sony , Afonso Luis
Published: March 2022

Background:
Elevated inflammatory markers, haemostatic factors as well as homocysteine predict cardiovascular disease (CVD) events and mortality. Although racial/ethnic disparities in CVD risk factors and outcomes exist, comparative data on the predictive utility of novel biomarkers for future CVD events in US ethnic groups is limited.

Methods:
The study comprised 6814 asymptomatic men and women (52.85%), aged 45-84 yrs without prior cardiovascular disease, enrolled in the Multi-Ethnic Study of Atherosclerosis [MESA] obtained from NHLBI Data repository. 6270 asymptomatic men and women [1384 Hispanics, 2409 Caucasians, 753 Chinese and 1724 African Americans] with a host of novel biomarkers drawn were considered for this analysis. The CVD events were defined as
ALL CVD
events and
HARD CVD
events per MESA protocol (see Table).

Results:
A total of 302 all CVD events and 203 hard CVD events were identified during a mean follow up of 4.6 years. We observed significant ethnic differences in the prognostic utility of novel biomarkers for cardiovascular risk assessment, in a large multi-ethnic population of US adults free of clinical cardiovascular disease. While homocysteine emerged as a robust biomarker across racial cohorts, most other biomarkers analyzed predominantly predicted events in Caucasians (see Table).

Conclusion:
These findings raise serious concern about the prognostic potential or generalizability of risk stratification tools across racial subsets and underscore the need for further ethnicity-specific research in this area.
Abstract P354: Perioperative Mortality Risk for Cardiac Surgery is Estimated More Accurately by Statistical Methods Than by Physicians' Subjective Assessment
Authors: Raza Syed S , Johnson Deborah J , Roukoz Henry , Adabag Selcuk
Published: March 2022

Background:
The elderly and patients with comorbidities are undergoing heart surgery in greater numbers than before. The decision to recommend or deny heart surgery to these higher-risk patients hinges upon their predicted perioperative mortality, estimated by either previously-validated statistical risk scores or physician's subjective assessment. The aim of this study is to compare these two methods of risk estimation in their calibration and ability to discriminate the deceased from survivors.

Methods:
We included 4731 consecutive patients who underwent coronary artery bypass (CABG) or valve surgery at the Minneapolis Veterans Affairs (VA) Medical Center between 1987 and 2009. All patients were prospectively entered into a national database. Perioperative mortality risk, estimated by the national VA mortality risk score and the physician's subjective assessment, were
prospectively
recorded.

Results:
Mean age was 66±10, 75% of patients underwent CABG and 164 (3.5%) died perioperatively, within 30 days. Both methods overestimated perioperative mortality (Physician's mean estimate 5.7%; statistical mean estimate 4.5%; observed mortality 3.5%). The statistical model discriminated between death and survival significantly better than the physician's assessment (C-index = 0.79 vs. 0.74; p = 0.02). Physician's risk estimate was higher than the statistical risk estimate for patients undergoing CABG or valve surgery alone or in those with low/moderate preoperative risk. However, paradoxically, physicians' estimate was lower than the statistical estimate in patients with mortality risk >10% (mean estimate 11.6% vs. 17.3% respectively; p <0.0001).

Conclusions:
In patients undergoing heart surgery, statistical risk estimate is a more accurate discriminator of perioperative mortality than the physician's subjective assessment. However, both methods overestimate the observed mortality.
Abstract P357: A Simple Mortality Risk Score for Calcific Aortic Stenosis
Authors: Zoble Robert G , Hariman Robert J , Fowler Erin E , Curtis Anne B
Published: March 2022

Background:
Calcific aortic stenosis (CAS) of the elderly is associated with high mortality. It would be useful to have a simple and accurate tool (risk score) to identify risk.

Methods:
We retrospectively reviewed all echocardiograms at our hospital from October 2006 to March 2008 and identified 208 veterans aged 65 years or older with CAS, aortic valve peak gradient >30 mmHg, but no prior aortic valve surgery. Aortic valve peak gradient, age, clinical co-morbidities, tobacco and alcohol use, creatinine (Cr) and hemoglobin (Hb) data were analyzed. Variables with significant odds ratios for 1-year mortality were entered into a regression model.

Results:
All-cause 1-year mortality was 16.3%. Significant odds ratios for mortality were found for Hb =< 10.0 g/dL (OR=13.3, p<0.0001); alcohol abuse (OR=3.76; p=0.008) and heart failure (HF) history (OR=2.88, p=0.027). The c-statistic for this model was good (c=0.848). Aortic valve peak gradient did not add to the model, but all subjects were required to have a gradient >30 mmHg to be included. A risk score was developed by assigning 2 points to Hb of 10 g/dL or lower, 1 point to alcohol abuse, and 1 point to HF. The figure plots survival vs. risk scores and predicts very low (2.9%), low (14.4%), intermediate (41.2%), high (52.4%), and very high (100%) 1-year mortality for scores of 0, 1, 2, 3 and 4, respectively. This represents a >30-fold range of mortality risk.

Conclusion:
For CAS patients 65 years or older with aortic valve peak gradient >30 mmHg and no prior aortic valve surgery, our simple risk score identifies a wide range in 1-year mortality risk and allows prediction of mortality risk with a high degree of predictive accuracy (c-statistic=0.85).