bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P38: The Great Lakes Regional Stroke Network Swallow Screen Project
Authors: Hedworth Angela , Tonarelli Silvina B , Vazquez Gabriela
Published: July 2021

Background and purpose
A formal dysphagia protocol including a swallow screen can decrease risk of aspiration pneumonia in stroke patients. To date the varying assortment of tools and protocols available is overwhelming. The aim of this project was to assess and summarize the current swallow screen tools and processes utilized by hospitals in the Great Lakes Region and to determine if participating in a work group impacted their swallow screen process.

Methods
A work group was created to evaluate screening tools and processes. The group consisted of nurses, speech language pathologists, stroke program coordinators and neuroscience administrators from over 35 hospitals in the Midwest. One year after the group was formed, a follow up evaluation was sent to participants to determine any changes.

Results
Initial findings revealed a high degree of variance between facilities' tools and processes. Water was used in 86%, 60% included a substance thicker than water, and 6% specifically state the use of straws. The follow-up evaluation had a 74% (n=26) response rate. 48% of those respondents reported modifications to their swallow screen tool as a result of participating in the work group; 33% adopted of a new tool from the literature; 48% reported changing their swallow screen process; and 56% changed their swallow screen training. 44% do not monitor the correlation between swallow screening and aspiration pneumonia.

Conclusions
Respondents reported the most beneficial aspects of this project was the opportunity to see other swallow screens, providing an evidence base for screens in use, and prompting an internal evaluation of their screen/process. Despite The Joint Commission no longer requiring dysphagia in its data collection, all reported they will continue to collect that data. All facilities shared the same challenges with compliance, on-going education, and documentation. Opportunities for improvement were identified: additional analysis and synthesis of screening tools and methodology at the national level; better understanding and process development between speech language pathology and nursing to standardize a universal swallow screen tool.
Abstract P69: Comparison of Index Hospital Resource Utilization and Costs between Patients Undergoing Elective Percutaneous Coronary Intervention (PCI) or Acute Coronary Syndrome (ACS) PCI
Authors: Winget Melissa , Zagar Anthony , Zhao Zhenxiang , Samant Navendu , Borah Bijan
Published: July 2021

Objective:
Evaluate index hospital resource use and costs for non-ACS elective PCI and ACS PCI patients.

Methods:
A national managed care database (affiliated with i3 Innovus) was linked to a large nationally representative hospital database (Premier Perspective) to identify patients, ≥18 years, treated by PCI in the absence or presence of an ACS diagnosis during their index hospitalization between 01/04-12/06. Patients with an ACS diagnosis and PCI 12 months prior to their index hospitalization were excluded.

Results:
Of 2,906 patients, elective PCI patients (35.9%, 1043 of 2906), compared to ACS PCI patients (64.1%, 1863 of 2906), were significantly older (aged 59.6±9.0 vs. 56.5±9.7,
P
<0.001), with a higher baseline Charlson comorbidity score (1.36±1.63 vs. 0.81±1.28,
P
<0.001). Elective PCI patients, had a shorter index hospital stay (2.6 days±1.7 vs. 4.0 days±2.2;
P
<0.001), less time in the ICU (0.71 days±0.63 vs. 1.1 days+/-0.9;
P
<0.0001), with no difference in stent use (96.2% vs. 96.5%;
P
<0.63) and with a lower odds of bleeding (OR: 0.141, 95%Cl: 0.029-0.688;
P
<0.05). Elective PCI patients, compared to ACS PCI patients, had significantly decreased use of (
P
<0.001) index clopidogrel, statins, β-blockers, nitroglycerin, glycoprotein IIb/IIIa inhibitors, ACE inhibitors and a lower use of index coronary procedures; angiography (59.4%, 619 of 1,043 vs. 88.7%, 1,653 of 1,863,
P
<0.001) and echocardiography (6.1%, 64 of 1,043, vs. 34.3%, 639 of 1,863,
P
<0.001). Elective PCI had significantly lower costs ($22,243±$18,617 vs. $28,669±$24,809;
P
<0.001). Factors associated with these index hospital costs were identified using separate generalized linear regression. For elective PCI patients, two factors significantly associated with index hospital costs were a comorbidity score ≥3 (Cost Ratio: 1.512, 95%Cl: 1.274-1.795,
P
<0.001) and baseline clopidogrel use (Cost Ratio: 0.857, 95%Cl: 0.775-0.947,
P
<0.05). For ACS PCI patients, STEMI (Cost Ratio: 1.116, 95%Cl: 1.030-1.0210;
P
<0.01) was positively associated with index costs.

Conclusions:
Patients undergoing elective PCI, compared to ACS PCI patients, have lower index hospitalization resource use and costs reflected by shorter LOS, less time in the ICU and less use of concomitant medications.
Abstract P74: Regional Variations in Physicians' Attitudes Towards Implantable Cardioverter-Defibrillators
Authors: Matlock Dan D , Kutner Jean S , Emsermann Caroline , Al-Khatib Sana , Sanders Gillian D , Dickinson L M , Rumsfeld John S , Masoudi Frederick A
Published: July 2021

Introduction:
The use of Implantable Cardioverter-Defibrillators (ICDs) varies markedly by region of the country. One possible contributor to regional variation could be variability in physicians' attitudes towards ICDs. The objective of this study was to determine if physicians' attitudes torwards ICDs vary by region.

Methods:
A national sample of 10,080 members of the American College of Cardiology were surveyed regarding their attitudes towards ICDs. The survey included a hypothetical scenario asking respondents if they would recommend an ICD to an eligible patient with ischemic cardiomyopathy, followed by questions modifying the scenario by age, sex, and frailty as well as questions measuring attitudes towards ICDs and important factors in ICD decision-making. Respondents were placed into a hospital referral region (HRR) by zip code of their practice. Data were then merged with data from the National Cardiovascular Data Registry where rates of ICD implantation were determined for all Medicare beneficiaries in a given HRR. Multivariate linear and logistic regression analyses determined associations between the regional ICD utilization rate and respondents attitudes.

Results:
We received 1210 responses (response rate 12%) with no difference between responders and non-responders with respect to physician demographics. Physicians in regions of high and low ICD use were equally likely to recommend an ICD in the 60 yo male with ischemic cardiomyopathy scenario (~99%; p = N/A). They were also equally likely to recommend an ICD if the 60 yo patient was female (~99%; p = N/A) or if the 60 yo patient had non-ischemic cardiomyopathy (85 vs. 88% p = 0.85). Multivariate analyses determined that physicians in higher utilization regions were more likely to recommend ICD therapy if the patient was ‘frail’ (32% vs. 21%; p = 0.03) or if he had a life expectancy of less than one year (10% vs 5%; p = 0.05).

Conclusions:
Even when patient-level causes of regional variation are removed through alterations in hypothetical scenarios, cardiologists in regions of high ICD use are more likely to recommend ICDs in frail patients or patients with a life expectancy of less than one year. This suggests that variations in physician attitudes may contribute to regional variations in ICD use.
Abstract P79: Characteristics, Management and Outcomes of Patients with Acute Coronary Syndrome: A Comparison Between the Global Registry of Acute Coronary Events (GRACE) and the Gulf Registry of Acute Coronary Events (Gulf RACE)
Authors: Awad Hamza H , Zubaid Mohammad , Alsheikh-Ali Alawi A , FitzgGerald Gordon , Anderson Frederick A , Gore Joel M , Goldberg Robert J
Published: July 2021

Background:
Developing countries have been under-represented in multinational cardiovascular registries despite playing an important role in global cardiovascular burden. The Arab Middle East is a unique region of the developing world where little is known about the characteristics, clinical practices, and hospital outcomes of patients hospitalized with an ACS. The objective of this study was to compare ACS patients hospitalized in the Arab Middle East to patients enrolled in a multinational ACS registry.

Methods:
The study sample consisted of patients (pts) recruited in 2007 with a confirmed diagnosis of ACS, including 4,445 from the Global Registry of Acute Coronary Events (GRACE) and 6,706 from the Gulf Registry of Acute Coronary Events (Gulf RACE).

Results:
The average age in Gulf RACE was nearly a decade younger than GRACE (56 vs 66 years). Patients in Gulf RACE were significantly more likely to be male (5,071(76%) vs 3,072(69%)), smoke (2,452(37%) vs 1,217(28%)), be diabetic (2,745(41%) vs 1,181(27%)) and have a STEMI (2,619(39%) vs 1,504(34%)), while less likely to be hypertensive (3,364(55%) vs 2,929(66%)) compared to pts in GRACE. Patients in Gulf RACE had a significantly higher odds of receiving aspirin (6,563(98%) vs 4,181(94%)) and statins (6,079(91%) vs 3,574(81%)) and significantly lower likelihood of being treated with ACE inhibitors or ARBs (4,618(69%) vs 3,574 (81%)), β-blockers (4,361(65%) vs (3,858 (87%)) and clopidogrel (3,605(54%) vs 3,274(73%)) during hospitalization. The reperfusion strategy of choice among eligible STEMI patients was thrombolysis in Gulf RACE (1,415(84%) vs 297(24%)), while in GRACE it was PCI (805(66%) vs 139(8%)). While overall unadjusted in-hospital mortality rates were not significantly different between Gulf RACE and GRACE (247(3.7%) vs 167(3.8%)), age stratified rates were higher for Gulf RACE across all strata. After adjustment for additional potential confounders, there were no significant differences in hospital mortality of pts enrolled in the two registries. All P<0.01

Conclusions:
Despite differences in demographics, clinical characteristics, and treatment strategies, short-term mortality rates are comparable between ACS pts enrolled in registries from different geographic settings.
Abstract 5: Regional Variation in Recommended Treatments for Ischemic Stroke and TIA: Get With The Guidelines-Stroke, 2003-2010
Authors: Allen Norrina B , Kaltenbach Lisa , Goldstein Larry B , Olson DaiWai , Smith Eric E , Schwamm Lee , Lichtman Judith H
Published: July 2021

Background:
Prior studies find regional variation in the use of secondary stroke prevention treatments. We determined whether guideline-recommended stroke treatments vary by region for patients treated at Get With The Guideline (GWTG)-Stroke hospitals.

Methods:
Receipt of guideline-recommended interventions (acute IV-tPA, antihypertensive medications, antithrombotics, diabetes medications, anticoagulants for atrial fibrillation, lipid-lowering medications at discharge and smoking cessation) in addition to weight loss education were compared by region among eligible ischemic stroke and TIA patients. GEE models compared regional differences for each intervention adjusted for patient demographics, medical history and hospital characteristics.

Results:
There were 991,995 stroke or TIA admissions (South 37%, Northeast 27.6%, Midwest 19.3%, West 15.9%). Receipt varied by region: tPA ranged from 58.2-67.8%; antihypertensives 87.4-91.1%; antithrombotics 95.6-96.8%; diabetes meds 80.9-84.5%; anticoagulants 90.6-92.5%; lipid-lowering meds 72.5-75.7%; smoking cessation 89.8-92.7%; and weight loss education 49.3-54.7%. In adjusted analyses, the largest differences were in tPA and anticoagulant use (lower rates in the South and Midwest vs. the Northeast, Figure). Interventions tended to be less frequently provided in the Midwest vs. the Northeast.

Conclusion:
Although receipt of many recommended interventions is high, there are regional differences among patients treated at GWTG-stroke hospitals. As the hospitals participated in the same quality improvement program, the reasons for the differences are unclear and require further investigation.
Abstract P121: Left Atrial Function Predicts Heart Failure Hospitalization in Patients with Stable Coronary Artery Disease and Normal Ejection Fraction: Data from the Heart and Soul Study
Authors: Welles Christine C , Ku Ivy , Whooley Mary A , Schiller Nelson B , Turakhia Mintu P
Published: July 2021

Background:
Half of all hospitalizations for heart failure (HF) occur in patients with normal ejection fraction (EF). Because left atrial (LA) function contributes up to thirty percent of left ventricular stroke volume, we hypothesized that LA function would predict HF hospitalization in subjects with normal EF.

Methods:
We performed resting transthoracic echocardiography in 855 patients with stable coronary heart disease (CHD) and normal EF (≥ 50%). We calculated left atrial functional index (LAFI) as [(LAEF x LVOT VTI)/(LAESVI)], where LAEF = LA emptying fraction, LAESVI = LA end-systolic volume indexed to body surface area, and LVOT VTI = left ventricular outflow tract velocity time integral. LAEF was defined as (LAESV-LAEDV)/LAESV). We used Cox proportional hazards models to evaluate LAFI as a predictor of HF hospitalization during a median follow-up of 7.9 years.

Results:
LAFI was normally distributed with a mean of 42.3 ± 18.6 units. During 5621 person-years of follow-up, 106 subjects had a HF hospitalization. Rates of HF hospitalization were inversely proportional to quartile of LAFI: Q1 (0.5-29.2): 47 per 10 person-years; Q2 (29.3-40.8): 18; Q3 (40.8-53.4): 9.5; Q4 (53.4-160): 5.3 (p<0.001). Patients with LAFI in the lowest quartile had over 8 times the risk of HF compared with those with LAFI in the highest quartile (HR 8.7, 95%CI 4.2-18.2; p<0.001). Each standard deviation decrease in LAFI was associated with an over 2-fold greater risk of HF (HR 2.6, 95% CI, 2.1-3.3, p<0.001). After adjustment for age, sex, body mass index, history of heart failure, prior revascularization, creatinine, atrial fibrillation, diastolic dysfunction, left ventricular mass index, left ventricular ejection fraction, and inducible ischemia, participants with LAFI in the lowest quartile still had over 4 times the risk of HF compared with those in the lowest quartile (HR 4.7, 95% CI, 1.7-12.5; p=0.002).

Conclusions:
Reduced left atrial function strongly predicts HF hospitalization in subjects with CHD and normal EF, even after adjustment for a wide range of clinical and echocardiographic covariates. These findings suggest that LA failure plays an important role in HF and may represent a potential target for preventative or therapeutic efforts.
Abstract P122: Predictors of 30-Day Mortality After Heart Failure Hospitalization
Authors: Zoble Robert G , Fowler Erin E , Meadows Jonathan , Zoble Adam , Foulis Philip , Neugaard Britta I , Hariman Robert J
Published: July 2021

Background:
Heart failure (HF) has a high rate of mortality. It would be useful to have, at the time of a HF admission, a method of predicting post-discharge short-term mortality risk.

Methods:
We studied 947 Veterans hospitalized for HF at our VA medical center from January 2004 to December 2008, survived to discharge, had an ICD-9 code for HF as the primary discharge diagnosis, and had complete data for comorbidities, labs, medications and ECG findings. Mortality at 30-days post-discharge was determined and multivariable analyses identified independent predictors of mortality by logistic regression. These were used to develop a mortality risk score.

Results:
Mortality at 30-days occurred in 3.9% (37/947). Independent predictors (p-value <0.05) were substance abuse (OR = 3.10), abnormal admission serum sodium (OR=2.56), abnormal admission troponin (OR = 2.15), absence of dyslipidemia (OR = 2.04), not on a calcium channel blocker at admission (OR = 3.33), and not on an oral anticoagulant at admission (OR = 5.26). Each independent predictor was assigned 1-point and the resulting figure shows the rates of 30-day mortality to be 0.49%, 5.33% and 19.15% for those with risk scores of 0 to 2, 3 or 4, and ≥5, respectively. This represents a 39-fold difference in risk between the low-risk and high-risk patients. The c-statistic for the model was good (c = 0.796).

Conclusions:
Risk for post-discharge short-term mortality can be accurately predicted at the time of initial HF admission by a risk score employing admission labs, co-morbidities and medications. Patients identified as high risk at the time of admission might benefit from more intense inpatient evaluation and closer outpatient care.
Abstract P153: Effect of Statin Transitions in High-Risk Cardiovascular Patients
Authors: Khanderia Ujjaini , Townsend Kevin A , Wolfe Thomas , Taylor Richard , Pop-Busui Rodica
Published: July 2021

Efforts to manage healthcare costs include transitioning patients to generic medications. This often includes the statins. Implementation methods and patient selection may affect clinical outcomes of these programs. We measured changes in quality metrics associated with statin transition in high-risk cardiovascular (CV) patients, assessed dose conversion, and identified clinical predictors of successful transition. This retrospective cohort study included adults receiving care in a university health system for ACS, CKD, DM or post- CABG and receiving a statin. Electronic records from 2005 to 2008 were used to identify statin transition (T) or no transition (NT). High (H) and low (L) potency agents, equipotent dosages, and successful transition were defined. Treatment patterns, LDL-C (mg/dL), and medication possession ratios (MPR) were tracked one year after transition. Descriptive, bivariate, and multivariate analyses were applied. The 1,505 patients were 54% male and age 50 + 10 years. Statin transition occurred in 316 (21%) of which 249 (79%) were H to L potency. DM, CKD, ACS, and CABG were present in 70%, 24%, 17%, and 8% of patients. Baseline ACS was present in T (23%) more than NT (15%), p=0.001. Changes in LDL-C were similar in T (+2.2 + 35.4 mg/dL) and NT (-0.4 + 34.6 mg/dL), p=0.34. Adherence (MPR) was higher in T (0.85 + 0.19) relative to NT (0.77 + 0.27), p<0.001. Among T patients, LDL-C goal attainment (<100 mg/dL) and aggressive LDL-C goal attainment (<70 mg/dL) decreased from 65% to 61% (p=0.036) and from 27% to 23% (p=0.015), respectively, from transition to follow-up. For H to L, H to H, L to H, and L to L transitions, LDL-C changes were +8.0 ± 32.2, -36.7 ± 50.5, -24.2 ± 26.9, and -0.2 ± 37.8 mg/dL, respectively (p<0.001). Among H to L transitions, equipotent dose adjustments were made in 174 cases (70%), no adjustment in 44 subjects (18%), and no equipotent dose existed for 31 cases (12%). Adjusted odds of successful transition were higher for equipotent dose transitions (OR 2.83, 95% CI 1.09 to 7.36). In summary, LDL-C control during statin transition in high-risk CV patients is variable, but medication adherence was not diminished. Equipotent dose adjustment is a strong predictor of successful transition but was not made or possible in 30% of patients.
Abstract P6: Vitamin K Antagonist Dosing Methods and Individual Patient Quality of INR Control in the International Active W Anticoagulation Study
Authors: Nieuwlaat Robby , Ng Jennifer , Connolly Stuart J
Published: July 2021

Background
The net benefit of vitamin K antagonists (VKAs) depends on the time spent in the therapeutic range (TTR) for the International Normalized Ratio in individual patients. Evidence-based methods are recommended by guidelines. We assessed VKA dosing methods among ACTIVE W study sites and the association with TTR in individual atrial fibrillation patients.

Methods
ACTIVE W sites received a survey questionnaire after the study to assess VKA dosing methods. Univariable and multivariable linear mixed models, to account for the random effect of clinic-level survey data, were used to assess the association of dosing methods with patient TTR. Patient-level covariates in multivariable analysis were: age, sex, CHADS
2
stroke risk score, mini-mental state examination score, history of VKA use, VKA type, and use of aspirin, amiodarone and insulin.

Results
The questionnaire was returned by 333 of 493 ACTIVE W sites (68%) who had at least one patient randomized to VKA. Responding sites had a higher mean study TTR than non-responding sites (64 vs. 60%; p=0.0101) and were mainly specialized in cardiology (87%). Only 28% of sites managed VKA dosing with an evidence-based method: an anticoagulation clinic, computer dosing system or patient self-management. Also taking in account (non-validated) manual algorithms, 64% of sites managed VKA dosing primarily based on clinical experience. In univariable analysis, patients achieved a higher TTR when managed by an anticoagulation clinic vs. by the study physician (67.3 vs. 62.1%; p=0.0027), when managed using a computer dosing system vs. using clinical experience (72.9 vs. 63.6%; p=0.0026), and when managed using at least one evidence-based method vs. not using evidence-based methods (67.3 vs. 62.8%; p=0.0045). However, when adding patient data in multivariable analysis, these three associations became non-significant (p-values 0.4659, 0.6555 and 0.6058, respectively).

Conclusion
The use of evidence-based VKA dosing methods was reported by only 28% of ACTIVE W sites, but was not significantly associated with an improved TTR when accounting for patient characteristics.
Abstract P71: The Accuracy of Coded Obesity in an Administrative Database
Authors: Martin Billie-Jean , Chen Guanmin , Galbraith Diane , Knudtson Merril L , Ghali William A , Quan Hude
Published: July 2021

Objective:
Obesity is becoming an increasingly prevalent problem. Gathering information on the adiposity of a population is difficult, so being able to take advantage of existing data, such as that in administrative databases, is appealing. The objective of our study was to assess the validity of obesity coding in administrative databases.

Methods:
This study was conducted using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) database and the Discharge Abstract Database (DAD) for Calgary. BMI was calculated within APPROACH; BMI ≥30kg/m2 defined obesity. In the DAD obesity was defined by diagnosis codes 278 (ICD-9-CM) and E65-E68 (ICD-10). Databases were linked using provincial health numbers. The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of a diagnosis of obesity in the DAD was determined using the obesity diagnosis in APPROACH as the referent. The accuracy of coding obesity was compared across demographic categories and diagnoses.

Results:
A total of 17,380 subjects included in the analysis. The study population was largely male (68.8%) and had a mean BMI of 26.96 kg/m2. The overall sensitivity of a diagnosis of obesity in the administrative data was 7.75%. However, it was highly specific at 98.98%, with a NPV of 80.84% and a PPV of 65.94%. When considered by year, there were minor variations in the sensitivity of obesity coding in the administrative data, but it remained poor at under 10% throughout. The prevalence of obesity and the PPV was higher amongst those subjects with conditions associated with obesity, including diabetes and hypertension. Of those coded obese in DAD, the majority (72.89%) were Class I obese; of those not coded obese, 84.31% were Class I obese.

Conclusions:
Obesity coding in the DAD is poor, as reflected in the low sensitivity of the diagnostic code. However, once obesity is coded in this database, it is coded highly accurately. At present, using administrative databases to define cohorts of obese subjects for surveillance is not a viable option.
Abstract P75: Association Between Caregiving, 30-Day Outcomes, and Baseline Risk Status Among Hospitalized Cardiac Patients
Authors: Mosca Lori , Aggarwal Brooke , Mochari-Greenberger Heidi , Liao Ming , Suero-Tejeda Niurka , Comellas Mariceli , Blair Judith , Rehm Lisa , Cheng Bin
Published: July 2021

BACKGROUND:
Caregivers might represent a unique opportunity to improve clinical outcomes among cardiovascular disease (CVD) patients, however prospective data are limited.

PURPOSE:
To determine if having a caregiver is associated with 30-day clinical outcomes and baseline risk status among hospitalized CVD patients.

METHODS:
We prospectively studied 4500 consecutive patients admitted to the CVD service line at a university hospital as part of the NHLBI-sponsored
F
amily Cardiac Caregiver

I

nvestigation

T

o Evaluate

O

utcomes (
FIT-O
) Study. Clinical outcomes included rehospitalization or death within 30-days. Patients [N=4500, 59% white, 62% male, 93% participation rate] completed a standardized interviewer assisted questionnaire in English/Spanish about caregiving (paid or non-paid). In a subsample of patients with baseline data available (n=1324), comorbidities, labs, and medications were analyzed by caregiver status. Comorbidity score was calculated using the Ghali Comorbidity Index (range 0-11). The association between caregiving and clinical outcomes was evaluated by logistic regression adjusted for confounders.

RESULTS:
At 30-days, 11% (475/4500) of patients had been rehospitalized or had died. Cardiac patients who had a caregiver vs. those who did not were significantly more likely to have been rehospitalized or to have died within 30-days (OR=1.4, 95%CI=1.2-1.7). This association was similar when analyzed by paid (OR=1.7, 95%CI=1.2-2.3) or non-paid (OR=1.2, 95%CI=1.0-1.6) caregiver status, and was not materially altered when adjusted for demographic confounders. In a subsample (n=1324), cardiac patients who had caregivers vs. those who did not were significantly (p<.05) more likely to have a history of diabetes, renal failure, CVD, COPD, creatinine >2.5 mg/dL, HbA1C ≥7%, comorbidity score >1, and take ≥11 medications. The association between caregiving and 30-day outcomes was not significant after adjustment for demographics, baseline risk factors, and comorbidities (OR=1.2, 95%CI=0.4-3.3).

CONCLUSION:
Cardiac patients who had a caregiver vs. those who did not had significantly higher rehospitalization and mortality rates at 30-days; this association is largely explained by their higher baseline risk status.
Abstract 111: Exclusive Involvement of Interventional Cardiologist in the Decision Making Process Improves Door-to-balloon Time by Significant Shortening of Decision-to-balloon Time Instead of EKG-to-decision Time In ST Elevation Myocardial Infarction
Authors: Zhu Daming , Zhang Yuanyuan , Mustafa Nowwar , Hoban Angela , Murphy Dan , King Susan , Weintraub William , Rahman Ehsanur
Published: July 2021

Background:
We have had a “one call activation system” for primary PCI at our regional academic center since 1999. The ED physician initiated the system with the decision for primary PCI made by cardiologist (interventional or non-interventional) on call. But since July 1, 2009, only interventional cardiologists are involved in the decision making process. Otherwise, the comprehensive strategy remained the same. As we have reported previously, this new strategy resulted in a shortened door-to-balloon (D2B) time. In the present study, we analyzed the D2B timeline intervals to determine where the major gains were achieved.

Methods:
We conducted a retrospective analysis of 665 consecutive patients presenting to our institution with suspicion of acute STEMI during a 30-month period. Group 1 consisted of patients in the 12 months (July 1 2008-June 30 2009) before and Group 2 consisted of patients in the 18 months (July 1 2009-Dec. 31 2010) after the system change was instituted. Mann-Whitney U test and chi-square test were used for statistical analysis.

Results:
218 patients in group 1 were taken to the cath lab of which 180 received primary PCI. 349 patients in group 2 were taken to the cath lab of which 275 received primary PCI. The results were presented in the table.

Conclusions:
Comprehensive strategy with exclusive involvement of interventional cardiologist resulted in a significant decrement in decision-to-balloon time. The EKG-to-decision time did not decrease, contrary to our expectation.
Abstract 118: Home Blood Pressure Monitoring Program improves Management of Hypertension
Authors: Agboola Stephen , Myint-U Khinlei , Kvedar Joseph , Jethwani Kamal
Published: July 2021

Objectives:
Regular self-monitoring of blood pressure is an important aspect of the management of hypertension; it enables the hypertensive patient makes better lifestyle choices informed by the measurements obtained from their blood pressure devices. The BP monitoring program by the Center for Connected Health is aimed at empowering patients to better self-manage their health and facilitating improved communication between patients and providers. This study aimed to evaluate the effectiveness of the blood pressure connect program on lowering blood pressures of participants in the program.

Methods:
The Blood Pressure Connect is a home monitoring program enabling patients to easily collect their blood pressure readings, monitor trends and also share their readings with their providers. Patients measure their blood pressures and upload to a secure web-based platform via modem connection with a home telephone line. Of the 277 hypertensive patients from several Partners affiliated centers enrolled in the program between 7/10/2009 and 11/18/2011, 219 patients aged 22-90 years (59±13 years) were included in the analysis; and 58 (21%) patients were excluded from analysis because they either have only one blood pressure reading or did not upload their blood measurements at all. Paired t-test was used to assess mean change in systolic blood pressure (SBP).

Results:
Average interval between baseline and final blood pressure measurements was 154 days. According to the JNC-7 classification of blood pressures, 11% had normal SBP, 48% were pre-hypertensive, 30% had stage 1 hypertension and 11% had stage 2 hypertension. Overall, SBP decreased by 6mmHg (95% CI= 4 -8mmHg, p-value <0.0001). SBP decreased by 1mmHg (95% CI=-2 -3mmHg p-value = 0.51), 12mmHg (95% CI= 8 -15mmHg, p-value < 0.0001) and 25mmHg (95% CI=18 - 32mmHg p-value <0.0001) in pre-hypertensive, stage 1 and stage 2 hypertension respectively but increased by -7mmHg (95% CI= -13 - 1mmHg) in those with normal blood pressure.

Conclusion:
The results show that the program is extremely successful in helping lower the blood pressures of patients with hypertension. These patients belong to a variety of practices, are on different medications and for disparate lengths of time. Despite these differences, all active patients had very similar changes in blood pressure, varying only by their starting blood pressure. Those with established hypertension (stage 1 or 2) saw the most significant change, indicating where the maximum rewards of this program lie. These results reflect the applicability of remote monitoring tools in managing chronic conditions effectively and efficaciously.
Abstract 187: Loop Diuretic Therapy in Acute Decompensated Heart Failure among Premier Hospitals
Authors: Bikdeli Behnood , Strait Kelly , Dharmarajan Kumar , Partovian Chohreh , Kim Nancy , Li Shu-Xia , Krumholz Harlan
Published: July 2021

Background:
Although loop diuretics are frequently used for patients with heart failure (HF), little is known about the variation in patterns of diuretic therapy in US hospitals. We sought to describe such treatment patterns among a diverse group of hospitals.

Methods:
We studied HF hospitalizations occurring during 2009-10 in Premier Inc. hospitals participating in a collaborative project to pool administrative and charge data, which includes information about drug types, average daily dose, and duration of therapy. We excluded hospitals with less than 25 HF hospitalizations. For ease of comparison, all diuretic doses were converted to bioequivalent doses of intravenous (IV) furosemide: 40mg IV furosemide ∼ 80mg oral furosemide ∼ 20mg (oral or IV) torsemide ∼ 1mg (oral or IV) bumetanide. Summary statistics were calculated.

Results:
Among 366 studied hospitals (264,675 HF hospitalizations), use of any loop diuretic had an interquartile range (IQR) from 92% to 96% (median: 94%). At the hospital level, the average daily dose IQR varied from 45mg to 64 mg (median: 55 mg) and the median duration of therapy was 4 days (IQR: 4 to 4; median: 4), as was the median length of stay. The IQR for use of furosemide varied from 89% to 94% (median: 92%), and its median average daily dose had an IQR from 40mg to 60 mg (median: 53 mg). Hospital use of bumetanide had an IQR from 2% to 11%, and hospital use of torsemide had an IQR from 0% to 4% (medians of 5% and 1%, respectively). The variation in median average daily dose for bumetanide and torsemide was greater than for furosemide (bumetanide IQR: 79mg to 127 mg, with median of 89 mg; torsemide IQR: 53mg to 120 mg, with median of 80 mg). Use of IV diuretics on the last day before home discharge had an IQR from 16% to 33% (median: 24%) across hospitals.

Conclusion:
US hospitals administer loop diuretics, particularly furosemide, to the vast majority of HF inpatients. The duration and daily dosage of therapy was similar across most hospitals. In contrast, a minority of hospitals used bumetanide and torsemide for several patients. The daily dosage of these agents showed more marked variation. We observed a high rate of intravenous diuretic use on the last day of hospitalization, with considerable variation across hospitals.
Abstract 203: Evaluation of Acute Radial Artery Injury Following Transradial Percutaneous Coronary Intervention by Optical Coherence Tomography
Authors: Arora Vinay , Shivaraju Anupama , Vidovich Mladen , Shroff Adhir
Published: July 2021

Background:
Recent evidence has shown a reduced bleeding risk and resultant decreased morbidity and mortality when the transradial approach is utilized over the transfemoral approach for percutaneous coronary intervention (PCI). However, transradial catheterization may introduce acute and/or chronic injury to the radial artery limiting its use for future procedures and as a bypass conduit. Our goal was to utilize optical coherence tomography (OCT) to evaluate the incidence of acute radial artery injury in patients following transradial PCI.

Methods:
In this observational study OCT (C7 Dragonfly catheter, St. Jude Medical Systems, St. Paul, MN) was used to evaluate the radial artery of 25 patients at the University of Illinois and Jesse Brown Veterans Affairs Medical Centers in Chicago, IL following transradial PCI. Specific injuries assessed for included radial artery dissection and thrombus formation. Diameter and cross sectional area of the artery were taken proximally and distally. Measurements were taken independently by two separate readers to account for inter-reader variability.

Results:
The radial artery was assessed in 25 patients following transradial PCI. The mean BMI of our patient population was 27.8 kg/m2. A 5Fr sheath was used in 24% (n=6) cases and a 6Fr sheath was utilized for the remaining 19 cases. In 8 cases the sheath was upsized from a 5 to 6 F. The average length of artery scanned was 39.4mm with a mean proximal cross sectional area of 7.56 mm2 and distal area of 7.08 mm2. An average of 4.4 catheter exchanges were made per case. A small intimal tear was noted in the radial artery of one patient. No other dissections or thrombi were noted.

Conclusion:
Based on our initial observation, the incidence of acute radial artery injury following transradial PCI is very low (1/25) and overall transradial PCI is a safe modality. When compared with prior studies we believe the factors that decreased the incidence of acute radial artery injury in our population were related to larger arterial cross sectional area, higher mean BMI, and ultimately a lower sheath size to artery diameter ratio.
Abstract 216: Left Ventricular Enlargement and Heart Failure Events: Is Bigger Better?
Authors: Raiszadeh Farbod , Yedlapati Neeraja , Piña Ileana L , Spevack Daniel M
Published: July 2021

Background:
Since stroke volume (SV) is a function of ejection fraction (EF) and end-diastolic volume (EDV) (SV = EF x EDV), we hypothesized that increased EDV may be advantageous in systolic heart failure (HF), allowing the left ventricle to supply increased cardiac output.

Methods:
Echocardiograms from 968 consecutive patients seen in our hospital’s HF clinic were reviewed. Left ventricular volumes were measured both at end systole and end diastole using the bi-plane Simpson’s method and were indexed to body surface area. EF was calculated using (EDV-ESV)/EDV. Dates of subsequent HF events (death or admission for HF exacerbation) were obtained from our database.

Results:
Systolic HF (EF < 50%) was found in 649 of the study subjects. Increased SV index was associated with increased EDV index. The strength of this association varied with EF, Figure. In a bivariate Cox regression model, lower SV index and higher EDV index were each independent predictors of HF events. Increase in EDV by 50 cc was associated with a 20% increase in HF events, p<0.001. Decrease in SVI by 5 cc was associated with 5% increase in HF events, p<0.001. These associations were limited to those with systolic HF. The associations between both EDVI and SVI and HF events were not confounded by patient age, sex and New York Heart Association Class.

Conclusion:
Increased EDV index was independently associated with increased HF events, indicating that LV enlargement in HF is not favorable. These findings underscore the individual contributions of the components of EF (SV and EDV) in predicting HF outcomes.
Abstract 263: Adequacy of Low-density Lipoprotein Cholesterol Management Following Percutaneous Coronary Interventions
Authors: Ford Benjamin , Shah Amit D , Parikh Samip , Sharma Gyanendra K
Published: July 2021

Background:
Pharmacological intervention with statin therapy in patients with coronary heart disease (CHD) is associated with long-term reduction of morbidity and mortality. Current Adult Treatment Panel III (ATP III) guidelines recommend an optimal goal of low-density lipoprotein cholesterol (LDL-C) < 100mg/dL in patients with CHD. The most recent percutaneous coronary intervention (PCI) guidelines recommend that it is reasonable to target a LDL-C <70 mg/dL in patients with CHD undergoing PCI. The purpose of this study was to assess the adequacy of LDL-C level management at different time intervals following PCI in patients with obstructive CHD.

Methods:
A retrospective chart review of 415 patients who underwent PCI for CHD in a tertiary care academic medical center located in the Southeast. Data was gathered for patients with PCI from November 2008 to October 2009 and was used to evaluate lipid levels from one to twelve months post-PCI. Of the 415 total, 171 patients (mean age: 62 years, 43% (74 of 171) females, 38% (65 of 171) African Americans) met the inclusion criteria (regular follow up at our institution for at least twelve months after PCI) and were included for statistical analysis.

Results:
Statin therapy was initiated in 91% (156 of 171) of patients who underwent PCI for CHD before hospital discharge. LDL-C level below the desired goals of 70 mg/dL and 100 mg/dL were achieved in 17% (29 of 171) and 36% (61 of 171) of patients, respectively, one month after PCI. Improvement was noted over the following months with 26% (45 of 171), 30% (51 of 171), and 32% (55 of 171) of patients meeting goal LDL-C levels below 70 mg/dL by 6 months, 9 months, and 12 months, respectively. Furthermore, 51% (87 of 171), 43% (74 of 171), and 64% (109 of 171) of patients met a LDL-C goal less than 100mg/dL by 6, 9, and 12 months, respectively. These results did not differ by age, sex, or race when analyzed by chi-square test (p-values > 0.05).

Conclusion:
Our findings indicate that despite 91% of patients being discharged on statin therapy, only 32% of patients achieved goal LDL-C of 70mg/dL or below and 64% of patients below LDL-C of 100mg/dL at twelve months follow up after PCI. The results highlight a real life example of suboptimal LDL-C management in this high risk population. These findings emphasize the need to determine the factors responsible for this suboptimal management and to develop a mechanism for optimizing therapy with statins after PCI to prevent major cardiac adverse events.
Abstract 265: Million Hearts
TM
and the PINNACLE Registry
®
: Preliminary Data
Authors: Glusenkamp Nathan T , Mullen Brendan , Fiocchi Fran , Drozda Joseph P , Oetgen William J
Published: July 2021

Introduction:
In September 2011, the Centers for Medicare & Medicaid Services and the Centers for Disease Control launched the
Million Hearts
campaign - a national public health initiative with the goal of reducing the number of heart attacks and strokes suffered in the US by 1 million over the next 5 years. Multiple federal agencies and private health care institutions have committed to become
Million Hearts
partners and bring their resources to bear in order to achieve this goal. The
Million Hearts
goal will be reached by the substantial reduction of dietary sodium and
trans
fats and by improving the “ABCS” of clinical prevention: Aspirin use for indicated conditions, Blood pressure control, Cholesterol treatment, and Smoking cessation counseling or medications. These four clinical performance measures are within the ken of practicing physicians and are readily measured in the American College of Cardiology’s (ACC) PINNACLE Registry. As a
Million Hearts
partner, the ACC pledged to provide data and engage in performance improvement initiatives to increase compliance with the four clinical measures. In this study, we compared compliance rates from PINNACLE to the
Million Hearts
baseline estimates for the nation and to their 2017 cardiovascular goals.

Methods:
The PINNACLE Registry contains data from more than 2.5 million outpatient encounters recorded over the past four years - representing approximately 800,000 discrete patients. Around 1,000 providers electronically submit data to PINNACLE and receive quarterly performance reports. Data queries determined PINNACLE provider compliance with analogs of the four
Million Hearts
performance measures.

Results:
see attached jpg

Conclusion:
Baseline performance measures in PINNACLE are favorable compared to the
Million Hearts
initial national estimates and 5-year goals.
Million Hearts
goals are population-level targets based on national survey data whereas PINNACLE patients are, by definition, in care, so some elevation of rates in the latter cohort is to be expected. There is, however, room for improvement in three of the four PINNACLE baseline performance measures. Concordant with the plans of the
Million Hearts
executive and scientific leadership, initial improvement efforts developed by the ACC will be directed toward improvement in blood pressure control of patients in the PINNACLE Registry. As the
Million Hearts
initiative moves forward, we can undertake formal efforts to learn from the higher rates of measure adherence and performance seen in cardiology practices by using top PINNACLE sites as a source for modular best practices around the ABCS.
Abstract 269: A Successful Blended Facilitation Approach with Internal and External Facilitators to Implement the VA Hospital-To-Home (H2H) Initiative: CHF QUERI
Authors: Sahay Anju , Gholami Parisa , Heidenreich Paul A
Published: July 2021

A Successful Blended Facilitation Approach with Internal and External Facilitators to Implement the VA Hospital-To-Home (H2H) Initiative: CHF QUERI

Objectives:
Reducing readmission rates for heart failure (HF) patients is the primary goal of the VA and the CHF QUERI. It is also the goal of Hospital to Home (H2H) national quality improvement (QI) initiative cosponsored by the American College of Cardiology and the Institute for Healthcare Improvement. According to Rogers’ Diffusion of Innovation Theory (2003) social networks significantly affect performance and innovation. Additionally, the Promoting Action on Research Implementation in Health Services (PARIHS, 2008) framework emphasizes the function of dynamic relationships among evidence, context and facilitation. In January 2010 the CHF QUERI through its HF Network launched the “VA H2H” QI initiative to implement the national H2H initiative at the VA facilities. Blended facilitation approach was used with the HF Network's leadership being the “external” facilitators and the opinion leaders (OLs) at each facility being the “internal” facilitators.

Methods:
A total of 122 VA facilities were identified with >100 discharges during 2007-2008. Using the sociometric method OLs were identified to be “internal” facilitators. Members were to nominate up to 2 providers at own facility (physician/nurse/other/self) as the OL. Then OL teams were asked to participate in the VA H2H. As “external” facilitators the HF Network's leadership conducted web-based meetings and provided tool-kit and consultation to members at all 122 facilities. Periodic surveys were used to track projects (or interventions) recently initiated based on VA H2H, planned based on VA H2H, or ongoing to reduce HF readmissions not based on VA H2H initiative.

Results:
Members from 66% facilities (n=81) responded with 1-2 nominations for OLs. Members from the remaining 34% facilities (n=41) either responded with no nominations (n=3) or were non-responders (n=38). Overall, 47 facilities (39%) reported a total of 243 projects. Among them, 44 facilities had OLs (94%) with 234 projects (96%). In sharp contrast, the remaining 3 facilities (6%) with no OL had only 9 projects (4%). The 44 facilities with OLs reported 37 recently initiated VA H2H projects (versus 3 VA H2H projects at facilities without OL); 40 VA H2H projects being planned (versus 0 project at facilities without OL); and 149 projects ongoing not in response to VA H2H (versus 6 projects at facilities without OL).

Conclusions:
Facilities with OLs were very successful in implementing the VA H2H initiative.

Impact:
Use of OLs may be effective in implementing non-mandated QI initiatives to improve care for all VA HF patients.
Abstract 282: Dabigatran Etexilate is Associated with Shorter Hospital Length of Stay Compared to Warfarin in Patients with Nonvalvular Atrial Fibrillation
Authors: Fonseca Eileen , Walker David R , Hill Jerrold , Hess Gregory P
Published: July 2021

Background:
Warfarin and dabigatran etexilate (DE) are oral anticoagulants used to reduce the risk of stroke among patients with nonvalvular atrial fibrillation (NVAF). This study examined whether hospital length of stay (LOS) differed for the two therapies.

Methods:
LOS was evaluated for patients hospitalized with a primary or secondary discharge diagnosis of atrial fibrillation (AF) between 1/1-3/31/2011, with DE or warfarin administered during hospitalization, and excluding patients with a valvular procedure. Patients were identified from a hospital Charge Detail Masters database, consisting of 184 hospitals. Differences in LOS by therapy were estimated using propensity score-matched samples selected by nearest neighbor matching within a caliper of 0.20 standard deviations of the logit, without replacement and a 2:1 match. Covariates used to estimate the propensity score included age, gender, CHADS
2
score, comorbid conditions and hospital attributes. LOS was also analyzed in patient subgroups identified by use of specific bridging agents (low-molecular weight heparin, unfractionated heparin, combination of the heparins, or no bridging agent) and a subset categorized as newly diagnosed NVAF.

Results:
Matched samples included 2,372 warfarin and 1,186 DE patients selected from 19,725 warfarin and 1,190 DE patients. Covariates used for the propensity score were not significantly different in the matched samples. LOS was 1.06 days shorter for DE compared to warfarin (DE: 6.16 days vs. warfarin: 7.22 days, p<0.01). In the 4 subgroups identified by choice of bridging agent, LOS was significantly shorter for DE in 3 (0.8 to 1.4 days, p<0.011), but not the fourth (0.9 day, p=0.3). In the subset of newly diagnosed NVAF, LOS was not significantly shorter for DE when AF was the primary discharge diagnosis (0.5 day, p=0.15), but was 2.47 days shorter for DE patients (p<0.01) when AF was a secondary discharge diagnosis. Limitations of the study were small sample sizes in some subgroups and potential of residual confounding.

Conclusions:
Among hospitalized patients with NVAF receiving an oral anticoagualant, patients receiving DE had a shorter length of stay compared to patients receiving warfarin.