bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 8: The Membrane-associated Guanylate Kinase Ww and Pdz Domain-containing Protein 1 magi1 is Required for Disturbed Flow-induced Endothelial Inflammation and Atherosclerotic Plaque Formation
Authors: Shin Ikjae , Won Jong Hak , Ko Kyung Ae , Shin Ji-Hyun , McBeath Elena , Thomas Tamlyn , Giancursio Carolyn , RA Quintana-Quezada , Taunton Jack , Hosokawa Hiroshi , Mochizuki Naoki , YEH Edward T.H. , Abe Jun-ichi , Fujiwara Keigi , LE Nhat tu
Published: June 2021

Rationale:
Major chronic inflammatory diseases including inflammatory bowel disease and psoriasis are clinically associated with accelerated atherosclerosis and increased risk of cardiovascular diseases (CVD). Atherosclerosis has long been recognized as an inflammatory process, which is initiated by the inflammation and dysfunction of endothelial cells (ECs). Genome-wide association study (GWAS) has identified a significant association between the deletion in ADAMTS9-MAGI1 locus with inflammatory bowel disease and psoriasis, suggesting a potential involvement of MAGI1 in EC inflammation and its associated events.

Objective:
To investigate the role and regulatory mechanism of MAGI1 as well as MAGI1 post-translational modification in EC inflammation, after various pro-atherogenic stimuli.

Methods and Results:
MAGI1 depletion significantly inhibits NF-κB activation and adhesion molecule expression induced by various pro-atherogenic stimuli in both
in vitro
and
in vivo
. We show that p90RSK associates with MAGI1 WW and PDZ2 domain, which is a crucial step for EC inflammation. In addition, p90RSK activation independently regulates MAGI1 S741 phosphorylation and K931 de-SUMOylation. While MAGI1 S741 phosphorylation is vital for Rap1 and subsequent NF-kB activation via increasing MAGI1-RAPGEF2 interaction, MAGI1 de-SUMOylation induces p90RSK-MAGI1 nuclear translocation as well as nuclear SENP2 T368 and ERK5 S496 phosphorylation. Those events are critical for EC inflammation. In addition, in partial carotid ligation mouse model, we observed a reduction in size of disturbed flow-induced carotid plaque lesion in
Magi1
+/-
/
Ldlr
-/-
mice compared to that in
Magi1
+/+
/
Ldlr
-/-
mice fed with high fat diet, indicating the crucial role of MAGI1 in regulating EC inflammation and atherosclerosis formation.

Conclusion:
These data show the essential role of MAGI1 in regulating EC inflammation, and suggest that phosphorylation and de-SUMOylation of MAGI1 induced by p90RSK activation have distinctive mechanisms, leading to EC inflammation.
Abstract 013: Using the Diabetes Collaborative Registry (DCR) to Estimate the Potential Real-world Impact of the Iris Trial on Improving Outcomes in Patients With Cerebrovascular Disease
Authors: Arnold Suzanne V , Inzucchi Silvio E , Tang Fengming , McGuire Darren K , Mehta Sanjeev N , Maddox Thomas M , Goyal Abhinav , Sperling Laurence S , Einhorn Daniel , Wong Nathan D , Kosiborod Mikhail
Published: June 2021

Background:
Thiazolidinediones use has markedly decreased since concerns arose regarding the CV safety of rosiglitazone. Recently, however, the IRIS trial demonstrated that pioglitazone reduced the risk of MI and stroke in patients with recent stroke or TIA and insulin resistance but without overt type 2 diabetes (T2D). We estimated the current use and potential impact of pioglitazone in patients enrolled in the Diabetes Collaborative Registry (DCR).

Methods:
DCR is a US-based outpatient registry of patients with diabetes or prediabetes seen in cardiology, endocrinology, and primary care practices and currently encompasses 374 practices and 5114 providers. Patients ≥40 years with HbA1c <7% on no diabetes medications (other than pioglitazone), prior stroke or TIA, and no history of heart failure were considered potentially eligible for IRIS. Although IRIS determined insulin resistance based on HOMA-IR levels, these were not available in DCR, and thus HbA1c levels were used as surrogates.

Results:
Among 242,590 patients in DCR with HbA1c data, 58,466 had prediabetes or diet-controlled T2D. Of these, 6,772 (12%) were deemed potentially IRIS-eligible. Mean age was 70 y, 52% were men, and mean HbA1c was 6.0%. Pioglitazone was used in 146 of these patients (2.2%); rates were slightly higher among patients seen by cardiologists vs. endocrinologists vs. primary care (2.6% vs. 1.4% vs. 0.0%, p<0.001). Patients treated (vs. not) with pioglitazone were more likely to be older (73 vs. 70 y), have higher body mass indices (32 vs. 30 kg/m
2
), higher HbA1c (6.1 vs. 5.9%), and concomitant coronary artery disease (69% vs. 56%) (all p<0.02). If all potentially eligible patients in DCR were treated with pioglitazone for 4.8 years, 93 strokes and 86 myocardial infarctions may have been prevented, assuming similar risk reductions in this “real-world” patient population as observed in IRIS.

Conclusion:
In a large US-based outpatient registry, we found that 12% of outpatients with prediabetes or diet-controlled T2D met the main eligibility criteria for IRIS, partly due to the narrow inclusion criteria of the trial but also likely reflective of a general paucity of screening for prediabetes and insulin resistance in this cohort. Pioglitazone was rarely used in these patients but could have a substantial impact on CV outcomes in these eligible patients. The population impact could be even greater if the CV benefit of pioglitazone can be demonstrated in patients with cerebrovascular disease and overt T2D or even the broader population of patients with insulin resistance and cardiovascular disease. The effect of pioglitazone in these patients, who are also at high CV risk, should be the focus of future work.
Abstract 014: Evaluation of Readmission after Acute Myocardial Infarction for Patients Included in Medicare’s Hospital Readmissions Reduction Program
Authors: Martin Lila M , Thompson Ryan W , Ferris Timothy G , Singh Jagmeet P , Laikhter Elizabeth , Bhambhani Vijeta , Wasfy Jason H
Published: June 2021

Introduction:
Medicare’s Hospital Readmissions Reduction Program assesses financial penalties for hospitals based on risk-standardized readmission rates after specific episodes of care, including acute myocardial infarction (AMI). Whether the algorithm accurately identifies patients with AMI who have preventable readmission is unknown.

Methods:
Using administrative data from Medicare, we conducted physician-adjudicated chart reviews of all patients considered 30 day readmissions after AMI attributed to one hospital from July 2012-June 2015. We extracted information about revascularization during index hospitalization. For patients readmitted to the index hospital or an affiliate, we also extracted reason for readmission.

Results:
Of 199 admissions, 66 (33.2%) received PCI and 19 (9.6%) underwent CABG on index hospitalization. The remainder of patients did not receive any intervention, i.e. 39 patients (19.6%) were declined due to procedural risk, 15 (7.5%) because of goals of care and 14 (7.0%) refused revascularization. Forty-six patients (23.1%) had troponin elevation in the absence of an MI and did not have an indication for revascularization. The most common diagnoses of the 161 (80.9%) patients readmitted to the index hospital or an affiliate were infections and cardiac and non-cardiac chest discomfort (Table 1).

Conclusions:
Our results demonstrate that many AMI patients who count towards the Medicare penalty do not receive revascularization during the index hospitalization because of high procedural risk or patient preference. Focusing on these patients may improve readmission metric performance. Furthermore, adding administrative codes for prohibitive procedural risk may improve accuracy of the metric as a measure of quality.
Abstract 036: LDL-Cholesterol Lowering Among Young Adults Who Experience a First Myocardial Infarction
Authors: Collins Bradley , Singh Avinainder , Divakaran Sanjay , Qamar Arman , Baez Julio , Klein Josh , Hainer Jon , Shah Ravi , Polk Donna , Skali Hicham , Plutzky Jorge , Di Carli Marcelo , Nasir Khurram , Bhatt Deepak , Blankstein Ron
Published: June 2021

Background:
Current data suggest patients who have a myocardial infarction (MI) benefit from aggressive LDL cholesterol (LDL-C) lowering. Consequently, initiation of lipid lowering therapy is a class I recommendation post-MI to reduce the risk of future adverse events. We sought to evaluate LDL-C lowering among patients who experience a first MI at a young age.

Methods:
Clinical & billing data were used to identify women < 50 years and men < 45 years who had a first MI from two large medical centers. Type of MI was adjudicated by review of medical records, and only patients with a Type 1 MI were included. The magnitude of LDL-C reduction was calculated by comparing the LDL-C pre-MI to the LDL-C one year later.

Results:
280 patients (age 42 years ± 5; 35% women) with a complete lipid panel prior to MI and 1 year post-MI were included in this analysis. The mean LDL-C was 123 mg/dL pre-MI, and 82 mg/dL post-MI (p<0.0001). In the entire population, the mean reduction in LDL-C post MI was 27% (95% CI, -32% to -23%), although men had a greater reduction than women (32% vs. 16%, p<0.001). When examining the post-MI LDL-C levels, 214 (76%) reached an LDL-C of <100 mg/dL and 115 (41%) reached an LDL-C of <70 mg/dL. Out of patients who had LDL-C>130mg/dL pre-MI (n=114), 82 (71%) reached an LDL-C of <100 mg/dL, and 35 (30%) reached an LDL-C of <70 mg/dL. Notably, 54 (19%) patients had an LDL-C increase at one year.

Conclusions:
Among patients experiencing MI at a young age, LDL-C reduction was only modest (27% reduction). Women had a significantly smaller reduction in LDL-C compared with men. Further research is needed to determine the underlying reasons for the sub-optimal reduction in LDL-C, as well as sex specific differences that may account for these disparities.
Abstract 052: Improved Hospital Outcomes With Hypokalemia on Admission in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia
Authors: de la Rosa Angelo , Tapia Manuel , Ji Yong , Saour Basil , Torosoff Mikhail
Published: June 2021

Purpose:
We hypothesized that advanced circulatory compromise, as manifested by acidosis and hyperkalemia should be associated with worsened clinical outcomes in cardiac arrest patients treated with therapeutic hypothermia.

Methods:
Results of initial admission laboratory studies, medical history, and echocardiogram in 203 consecutive cardiac arrest patients (59 females, 59+/- 15 years old) undergoing therapeutic hypothermia were reviewed. Mortality was ascertained through hospital records. ANOVA, chi-square, Kaplan-Meier, and logistic regression analyses were used. The study was approved by the institutional IRB.

Results:
Increased mortality was noted with older age, decreased admission pH, elevated admission lactate, lower admission hemoglobin, and pulseless electrical activity or asystole as presenting rhythms (Table). Admission hypokalemia and ventricular fibrillation/tachycardia were associated with improved hospital mortality (Table). Potassium was significantly lower in patients admitted with ventricular fibrillation/tachycardia (3.897+/-0.92) as compared to patients with asystole (4.674+/-1.377) or pulseless electrical activity (4.491+/-1.055 mEq/dL, p<0.0001). In multivariate logistic regression analysis, independent predictors of increased hospital mortality included increased admission potassium (OR 2.0, 95%CI 1.291-3.170, p=0.002)), older age (OR 1.04, 95%CI 1.007-1.071, p=0.017), admission PEA (OR 3.7, 95%CI 1.358-10.282, p=0.011 when compared to ventricular fibrillation/tachycardia) or asystole (OR 17.2, 95%CI 4.423-66.810, p<0.001 when compared to ventricular fibrillation/tachycardia); while decreased mortality was associated with higher hemoglobin (OR 0.8, 95%CI 0.665-0.997, p=0.047).

Conclusions:
Hyperkalemia, pulseless electrical activity, and asystole are predictive of increased hospital mortality in survivors of cardiac arrest. An association between low or low-normal potassium, observed VT-VF, and better outcomes is unexpected and may be used for prognostic purposes. More prospective investigations of mortality predictors in these critically ill patients are needed.
Abstract 065: Hospital Teaching Status and TAVR Outcomes in the United States - Analysis of the National Inpatient Sample (NIS)
Authors: Akintoye Emmanuel , Alliu Samson , Adegbala Oluwole , Aldiwani Haider , Shokr Mohamed , Orhurhu Vwaire , Mahmood Karim , Telila Tesfaye , Ando Tomo
Published: June 2021

Background:
Evidence suggest that medical service offerings vary by hospital teaching status. However, little is known about how these translate to patient outcomes. We therefore sought to evaluate this gap in knowledge in patients undergoing TAVR

Methods:
This study was conducted using the National Inpatient Sample (NIS) in the U.S (2011-2013). Teaching status was classified as teaching vs non-teaching and endpoints were clinical outcomes, length of stay and cost. Procedure-related complications were identified via ICD-9 coding and analysis was performed via mixed effect model

Results:
An estimated 17,020 TAVR procedures were performed in the U.S between 2011 and 2013, out of which 87% were in teaching hospitals. Mean (SD) age was 80 (8) and 47% were females. There was no significant difference between hospital teaching status with regards to procedure-related in-patient mortality, myocardial infarction, or other cardiac, vascular, neurological, respiratory complications, post-op DVT/PE, or sepsis (Fig 1). However, compared to non-teaching hospitals, teaching hospitals tend to have higher risk of acute kidney injury (OR: 1.47 [95% CI, 1.08-1.99]) but lower risk of hemorrhage requiring transfusion (OR: 0.67 [95% CI, 0.50-0.91]). The mean length of stay was higher in teaching hospitals (8.3 days) compared to non-teaching hospitals (7.5 days) (fig 2A), but median cost of hospitalization was higher in non-teaching hospitals (USD 59702 vs 49708) (fig 2B)

Conclusion:
We found that the risks of most TAVR-related complications (except for AKI and hemorrhage) are about the same in teaching compared to non-teaching hospitals. However, length of stay was higher in teaching hospitals while cost was higher in non-teaching hospitals
Abstract 074: Door to Balloon Time in Patients With ST Elevation Myocardial Infarction With and Without Cardiopulmonary Arrest: is Exclusion From Public Reporting Justified?
Authors: Huded Chetan , Kravitz Kathleen , Gullett Travis , Kapadia Samir , Hantz Scott , Ellis Stephen , Menon Venu , Brosovich Deborah , Smith Elizabeth , Khot Umesh
Published: June 2021

Background:
Since 2006 the Center for Medicare and Medicaid Services has allowed hospitals to exclude public reporting of door to balloon (D2B) time data for STEMI patients with cardiopulmonary arrest (CPA) within 90 minutes after hospital arrival, a high risk group with 30% in-hospital mortality. In July 2014, we implemented a high reliability STEMI process with rapid reperfusion goals for
all
STEMI patients treated with primary PCI at our center with no patient exclusions (figure). We studied D2B times for patients with and without in-hospital CPA before and after implementation of our high reliability STEMI process to clarify whether exclusion from public reporting on the basis of CPA is justified.

Methods:
We compared consecutive cases of STEMI treated with primary PCI at our center before (January 2013 to July 15
th
, 2014) and after (July 16
th
, 2014 to October 2016) implementation of a high reliability STEMI process, and we assessed D2B times in patients with and without in-hospital CPA prior to primary PCI. The primary endpoint was the % of patients treated within guideline D2B times (
<
90 minutes for ED presenting patients or
<
120 minutes for inter-hospital transfer patients).

Results:
Over the study period 795 cases of STEMI were treated with primary PCI at our center. The control group constituted 37.4% (297/795) of patients who were treated prior to July 15
th
, 2014, and the high reliability group constituted 62.6% (498/795) of patients treated after July 15
th
, 2014. Patients presenting to our primary ED were 27.3% (217/795), inter-hospital transfer patients were 69.1% (549/795), and in-hospital STEMI patients were 3.6% (29/795). CPA within 90 minutes of hospital arrival occurred in 6.3% (50/795) of patients overall, and CPA was more prevalent in the control group vs the high reliability group (8.8% [26/297] vs 4.8% [24/498], P=0.027). In the control group patients with CPA were less likely to achieve goal D2B times compared to patients without CPA (30.8% [8/26] vs 60.5% [164/271], P=0.003), whereas in the high reliability group there was no difference in the rate of achievement of goal D2B times in patients with vs without CPA (75.0% [18/24] vs 81.6% [387/474], P=0.418).

Conclusion:
High reliability STEMI processes can improve delivery of care for the most vulnerable and highest risk patients.
Abstract 076: Modeling Heterogeneity of Benefit in Patients Eligible for Implantable Cardiac Defibrillators: Insights From the SCD-HeFT Registry
Authors: Khariton Yevgeniy , Nassif Michael , Spertus John A , Arnold Suzanne V , Tang Yuanyuan
Published: June 2021

Background:
Guidelines recommend that patients with heart failure and reduced ejection fraction (<35%; HFrEF), on goal-directed medical therapy be considered for placement of an implantable cardiac defibrillator (ICD) for primary prevention of sudden cardiac death. This recommendation arose from the results of the SCD-HeFT trial, where there was a 7% absolute mortality reduction at 5 years in those who got an ICD. However, the application of these guidelines has been suboptimal and it is unknown if particular patient characteristics drive this benefit.

Methods:
We used patient-level data from the multi-center SCD-HeFT trial to examine the heterogeneity of the primary outcome (5-year all-cause mortality) in 1676 patients randomized to placebo or ICD (excluding those randomized to amiodarone). We used step-wise variable selection to select the variables for the final model. A cox proportional hazards model was then applied to develop a prediction tool to estimate patient benefit with ICD.

Results:
After variable selection, the following variables were found to be significantly associated with an increased risk of mortality over 5 years: older age, male sex, ischemic heart disease, diabetes, higher NYHA class, lower LVEF, diuretic use, lower mean blood pressure, higher blood urea nitrogen, and randomization to placebo (see Figure 1). There was a significant interaction of treatment allocation with diabetes, where the benefit of ICDs was greatest amongst those without diabetes (HR placebo vs. ICD amongst diabetics, 6.33, 95% CI 2.40-20.91; p < 0.001). Conversely, among diabetics ICD therapy was associated with an increased risk of mortality when compared to medical therapy (HR 6.39, 95% CI 2.51-15.95; p < 0.001). The c-statistic for the model was 0.73.

Conclusion:
There is substantial heterogeneity of treatment benefit from an ICD for primary prevention of 5-year all-cause mortality. If validated in a distinct and more contemporary dataset, this model may have an important role in patient selection and shared decision-making.
Abstract 093: Use of Echocardiography Following an Elevated B-Type Natriuretic Peptide Level
Authors: Namdaran Parhum , Heidenreich Paul
Published: June 2021

Background:
Echocardiography (echo) is recommended for those with an elevated B-type natriuretic peptide (BNP) value and no prior diagnosis of heart failure. We sought to examine the rate of echo use following a BNP value over 100 pg/ml.

Methods:
We identified patients in the Veterans Affairs (VA) Health Care System with no prior echocardiography within the past five years, no diagnosis of heart failure within the past 2 years, and a BNP value of ≥100 pg/ml. We examined the use of echo during the six months following identification of an elevated BNP value. Multivariable predictors of echo use were evaluated as well, including demographics, prior medical diagnoses, lab values, and institutional teaching status.

Results:
Among 20,143 patients identified, 6,205 (31%) had an echo during the next 6 months. Among VA hospitals with at least 20 included patients, use of echo ranged from 8.6% to 66% (Figure 1). Patients undergoing echo were younger (mean age 71±12 vs. 74±12, p<0.0001), had higher BNP values (mean value 571±1,524 vs 378±1,127, p<0.0001) and more likely to be of white race (76% vs. 74%, p<0.0001). In multivariate analysis, independent predictors of six-month echo use were age (odds ratio 0.78, 95% CI 0.76-0.80 per 10 year increase), female gender (0.79, 0.66-0.94 vs. male), race (black 0.87, 0.79-0.95 vs. white) and academic affiliation (Council of Teaching Hospital Member (COTH) 2.11, 1.87-2.38, academic but not COTH 1.74, 1.54-1.96 vs. non-academic).

Conclusion:
Following an elevated BNP value, an echocardiogram was ordered in only 31% with a wide range across different VA medical centers. Gender and racial disparities were present.
Abstract 095: Lessons Learned from the BRIDGE Registry: Major Findings From 8 Years of BRIDGE
Authors: Bradford Morgan , Krallman Rachel , McMahon Colin , Montgomery Daniel , Kline-Rogers Eva , Eagle Kim A , Rubenfire Melvyn , Bumpus Sherry M
Published: June 2021

Background:
Readmissions after cardiac hospitalizations are frequent and costly in the United States. Delays in follow-up and lack of adherence to guidelines may contribute to high unplanned readmission rates. Bridging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner (NP) led, transitional care clinic for cardiac patients, aimed at reducing readmissions. Data on patients referred to BRIDGE has been collected since 2009; herein we report a summary of significant findings from these data.

Methods:
A qualitative review of results and conclusions from all published abstracts, oral presentations, and papers from the BRIDGE registry (June 2008-August 2015) was conducted. Content analysis was used to synthesize findings across studies.

Results:
Data from 3982 patients referred to BRIDGE have been collected. Seven themes were identified in the analysis of BRIDGE publications. During BRIDGE, NPs focused on medical history, symptoms, medication management (in 24.8% of visits), patient education, and referrals. In addition to addressing provider priorities, addressing patient concerns (daily living and clinical questions, feelings and fears) was highly salient, resulting in a high level of patient-NP connectedness as evidenced by high patient-reported scores on the Consultation and Relational Empathy scale (mean 43.5 ± 2.8; possible range 0, 50) and the Patient-Doctor Relationship Questionnaire (mean 43.05 ± 3.1; possible range 5, 45). Readmissions within 30 days were consistently lower for acute coronary syndrome (ACS) patients who attended BRIDGE compared to those who did not (6.4% v. 13.1%; p<0.01); similar results were not seen in heart failure (HF) (15.4% v. 15.7%; p=0.944) or atrial fibrillation (AF) (8.5% v. 5.2%; p=0.343) patients. A spike in HF readmissions was seen between 8-14 days post-discharge, suggesting the need for a sooner appointment. However, follow-up within 7 days of discharge did not show reduced readmissions in HF patients. AF readmissions were also difficult to avoid; in a subset of AF patients readmitted within 30 days, 51.1% (n=23) were readmitted for non-AF diagnoses. High risk patients (i.e. those with an adverse event before BRIDGE) were older, had higher Charlson comorbidity scores, and were more likely to have depression. However, marriage was associated with fewer readmissions.

Conclusions:
Data from the BRIDGE registry have shown that clinic attendance reduced ACS readmissions; has characterized older, depressed patients with higher Charlson comorbidity scores as being those most likely to be readmitted; and has identified areas for improvement in transitional care (e.g. AF and HF) where readmissions are difficult to avoid. Continuous quality improvement and real-time monitoring of patient outcomes have translated this research into more prompt transitional care, illustrating the importance of registry-based research.
Abstract 103: Hospital-Level Differences in Use of Do Not Resuscitate Orders in PaWith Pneumonia, Acute Myocardial Infarction, and Congestive Heart Failure in California
Authors: Kolli Sanketh , Reynolds Evan , Chakrabarthi Apurba , Banerjee Mousumi , Nallamothu Brahmajee
Published: June 2021

Background:
Hospitals vary in their use of Do Not Resuscitate (DNR) orders. Whether this variability in DNR use is consistent across multiple diagnoses at a hospital or is unique to certain diagnoses is unknown.

Methods:
Using the California Office of Statewide Health Planning and Development (OSHPD) Database for the years of 2010 and 2011, we identified all patients 18 years or older who had a DNR order placed within 24 hours of admission. We selected patients with one of three primary diagnoses: pneumonia (PNA), acute myocardial infarction (AMI), and congestive heart failure (CHF). Hospitals with less than 10 patients with these diagnoses were excluded. A Generalized Linear Mixed Model (GLIMMIX) with hospital random effect was used to determine the unexplained variation in DNR across hospitals, after adjusting for patient age, gender, race, and primary diagnosis. Analyses were stratified by primary diagnosis. Based on the GLIMMIX model, we calculated intra-class correlation coefficients (ICCs) in each cohort of primary diagnoses.

Results:
265 hospitals had over 10 patients with one of the primary diagnoses. Risk and reliability-adjusted DNR rates ranged from a little over 0.8% to 54.5% with a mean DNR rate of 10.1% (Figure). The ICC of the full cohort of patients was 0.22; ICCs for PNA AMI, and CHF were 0.19, 0.18, and 0.25, respectively. All ICCs were ~0.20, suggesting that 20% of the unexplained variability in DNR use was attributable to hospital differences after accounting for patient-level factors. For each condition, there was a strong positive pairwise correlation between risk and reliability-adjusted DNR rates for the other 2 diagnoses, also supporting a hospital-level effect.

Conclusion:
Approximately 20% of the unexplained variability in risk and reliability-adjusted DNR rates is attributed to differences across treating hospitals. This may reflect variability in hospital culture factors, such as aggressiveness of care, early care limitation, and patient-doctor relations. Failure to account for these differences may unduly impact hospital ranking measures.
Abstract 112: Statin Utilization in the Outpatient Clinic of a University Based Residency Training Program
Authors: Chang Eric , Adedinsewo Demilade , Calcano Camille , Egbuche Obiora , Chaudhry Aneese , Bakinde Nicolas , King Marshaleen , Onwuanyi Anekwe
Published: June 2021

Background:
Current guidelines released in 2013 recommend statins for five specific patient groups including persons with clinical atherosclerotic cardiovascular disease (ASCVD) and diabetes. National estimates of statin utilization in 2012 report statin use in persons with ASCVD at 58.8% and 63.5% among persons with diabetes. A recent review also showed suboptimal statin prescription rates prior to 2013, with only 23% being prescribed a statin at goal dose. Our goal was to assess statin prescriptions in a large resident run outpatient clinic and identify factors affecting statin prescriptions as potential targets for intervention to improve compliance with the guidelines.

Methods:
We obtained data from the medical record data warehouse of a primary care outpatient clinic within a large safety-net hospital from Jan–Dec 2015. The clinic is predominantly run by internal medicine residents and supervised by general internal medicine attending physicians. Patients with a diagnosis of ASCVD and diabetes were identified and electronic medical records abstraction was done to identify persons who were prescribed a statin (regardless of dose). Bivariate analyses were conducted to identify potential factors affecting statin prescriptions.

Results:
Our patient population was predominantly African American, representing more than 70% of our clinic patients. We found 87% of persons with ASCVD and 70% of persons with diabetes were on statin. We found no differences in statin prescriptions by demographic characteristics among persons with ASCVD. Among patients with diabetes, younger age (p<0.01), female sex (p<0.05), non-black race (p<0.05) and private insurance/lack of insurance (p<0.01) were associated with a lower likelihood of being prescribed a statin.

Conclusion:
Statin prescriptions among patients with ASCVD and diabetes appear to be higher in our patient population compared to prior national estimates, however statin prevalence remains suboptimal. Our next steps are to begin a targeted educational intervention for residents in the continuity clinic and ultimately demonstrate that resident driven intervention is an effective way to increase compliance with the guidelines.
Abstract 114: Relationship Between Duration of QRS Complex and Long Term Mortality in U.S. Veterans With Atherothrombotic Risk Factors
Authors: Patel Amish , Pollock Jonathan , Roberto Edward Sam , Aung Thein Tun , Markert Ronald , Agarwal Ajay
Published: June 2021

Background:
The 12-lead electrocardiogram (ECG) remains a cost-effective diagnostic tool in risk stratification for cardiovascular disease. Little is known of the prognostic value of QRS duration but recent reports suggest that a prolonged QRS duration may be associated with adverse outcomes. We investigated the relationship between QRS duration and long term mortality in Veterans with atherothrombotic risk factors.

Methods:
We retrospectively collected data from a Veterans Affairs (VA) medical center for consecutive patients (October 2001 to January 2005) to determine the long term mortality rates associated with different intervals of QRS duration in patients who presented for coronary angiography.

Results:
Of the 1193 charts reviewed, 1186 had a QRS duration reading recorded. For these 1186 patients the mean follow-up period was 103±52 months. Mean age was 63.2±10.8 years with 98% male. Mean body mass index was 30.0±5.9. The prevalence of comorbidities was: hypertension (88%), hyperlipidemia (79%), obstructive coronary artery disease (73%), left ventricular hypertrophy (50.4%), diabetes mellitus (45%), peripheral vascular disease (17%), and cerebrovascular accident (8%). Mean left ventricular ejection fraction (LVEF) was 47±13%, and mean PR interval was 172.5±30.5 milliseconds (ms). Most patients were on beta-blocker (82%). Among patients with bundle branch blocks (BBB), left BBB was present in 4.6% and right BBB was present in 6.9%. Mean QRS duration was 102.2±23.6 ms. As the QRS duration increased by intervals of 10-milliseconds, the mortality rate (%) increased [QRS ≤100 (40.7%), 101 to 110 (51.3%), 111 to 120 (66.3%), >120 (71.2%), p<0.001]. Among patients with QRS duration >120, mortality was higher in those >150 vs. 121 to 150 (79.7% vs 65.7, p=0.045). While QRS duration was a significant univariate predictor of morality, QRS duration is not significant when adjusted for 10 covariates listed above (odds ratio = 1.00 [95% Cl = 0.98 to 1.01], p = 0.72).

Conclusion:
Long term mortality was higher as QRS duration increased. QRS duration had utility in predicting mortality within this cohort of US Veterans with atherothrombotic risk factors.
Abstract 119: Comparison of Gated SPECT, Echocardiography and Angiography Ejection Fractions
Authors: Kolakalapudi Pavani , Omar Mazen , Omar Bassam , Malozzi Christopher
Published: June 2021

Background:
Gated stress studies with Thallium previously suggested that SPECT overestimated the ejection fraction obtained with other modalities, limiting its use.

Objective:
To compare ejection fractions (EF) obtained from post pharmacologic stress gated SPECT using Technicium99m with EFs estimated by transthoracic echocardiography (TTE) or cardiac catheterization (angio).

Methods:
From a university-based outpatient stress lab, 502 stress tests performed over 14 months were reviewed; 126 gated pharmacologic stress tests were analyzed. Contemporaneous TTEs were available in 114, and angios in 26 of the studies. The stress nuclear protocols included a slow walk and the stress agent was regadenoson in the majority of the studies. Mean EF reported from the post-stress gated SPECT, TTEs, and angios were tested with ANOVA. The absolute variance in EF between each two contemporaneous groups was averaged and compared using a 2-tailed student t-test to the other groups.

Results:
The mean EFs obtained from SPECT, TTE and angio were 64 ± 12%, 58 ± 9% and 53 ± 6% respectively (P < 0.01). The absolute variance in SPECT-TTE and SPECT-angio were 9.2 ± 6.4% and 10.3 ± 7.7% respectively (P < 0.05 vs TTE-angio); TTE-angio absolute variance was 5.6 ± 4.8%.

Discussion:
Studies have conflicted with regards to reliability of gated SPECT-derived left ventricular volumes and ejection fractions. Although lack of correlation has been suggested, overestimation of ejection fraction has also been described. In this study we found a tendency for SPECT to overestimate the ejection fraction in post-stress gated studies compared with echocardiography and cath. Although several factors may have contributed to this observation, it is possible that the SPECT EF is augmented by the vasodilator effect of the stress pharmacologic agent. Further studies are needed to better qualify these findings. Meanwhile, given the importance of accurate quantification of a resting ejection fraction, especially as it relates evaluation of significant of valvular abnormalities or device therapy in heart failure, reliance on a SPECT-derived ejection fraction may cause undue delay in therapy.
Abstract 124: Recovery From Acute Myocardial Infarction in China: A Report From China PEACE Prospective Study of Acute Myocardial Infarction
Authors: Lu Yuan , Liu Jiamin , Wang Yongfei , Welsh John , Zhang Haibo , Guan Wenchi , Li Jing , Li Xi , Zheng Xin , Hou Libo , Spertus John A , Masoudi Frederick A , Krumholz Harlan M , Jiang Lixin
Published: June 2021

Introduction:
Despite a dramatic increase in the incidence of acute myocardial infarction (AMI) in China, little is known about patient’s health status in the year following discharge. We studied the change in angina frequency and angina-related quality of life at 1 year after AMI among Chinese patients.

Methods:
Among 3,336 patients admitted for AMI to 53 hospitals from December 2012 to May 2014 in the China PEACE Prospective Study of Acute Myocardial Infarction, Angina frequency and angina-related quality of life were assessed with the Seattle Angina Questionnaire (SAQ) at the time of hospitalization and 1 year later. Scores ranged from 0 to 100 points, with higher scores indicating fewer symptoms and better quality of life. We categorized both 1-year scores and changes in scores to support clinical interpretability. We considered a clinically poor outcome at 1 year to be an angina frequency score ≤ 60 (daily/weekly angina) or quality of life score ≤ 50 (poor/fair quality of life). A 1-year change in score ≥ 5 was improvement, a change between -5 and 5 was interpreted as no change, and ≤ -5 was interpreted as being significantly worse at 1 year than before the AMI.

Results:
Participants’ average age was 60.6 years (±11.9) and 22.8% were women. The response rate was about 75% and non-responders had similar characteristics compared with responders. At baseline, the mean scores were 86.3±21.9 for angina frequency and 66.7±24.0 for quality of life, with 16.3% having daily/weekly angina and 38.8% poor quality of life. One year later, 36.3% of patients had had a clinically important improvement in angina, 49.0% had no change, and 14.7% had worse symptoms. Similarly, 52.7% experienced a clinically important improvement in quality of life, 18.2% had no change, and 29.1% had worse quality of life. At 1 year after AMI, 5.5% of patients still had severe angina symptoms and 20.9% had poor quality of life.

Conclusion:
There is substantial variability in Chinese patients’ symptom and quality of life recovery after AMI and more work is needed to understand the causes of this variability and how best to improve symptoms and quality of life after AMI in China.
Abstract 127: Differences in Care Patterns, Health Status, and Outcomes of Atrial Fibrillation in Patients With and Without Diabetes: Findings From the ORBIT-AF Registry
Authors: Echouffo Tcheugui Justin B , Shrader Peter , Thomas Laine , Gersh Bernard J , Kowey Peter , Mahaffey Kenneth W , Singer Daniel E , Hylek Elaine M , Go Alan S , Peterson Eric D , Piccini Jonathan P , Fonarow Gregg C. Fonarow C
Published: June 2021

Objective:
Diabetes is a common among patients with atrial fibrillation (AF). However, little is known on the impact of diabetes on symptoms, health status, care and outcomes among AF patients. We assessed whether symptoms, health status, care and outcomes differ between AF patients with and without diabetes.

Methods:
This observational cohort study included 9,749 patients with AF from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation registry, a prospective, nationwide, multicenter outpatient registry of patients with incident and prevalent AF enrolled at 174 sites between June 2010 and August 2011. The outcomes were symptoms, health status, and AF treatment, as well as 2-year risks of death, readmission, thrombomebolic events, heart failure (HF) and AF progression.

Results:
Among AF patients; those with diabetes (29.5%) were younger and more likely to have hypertension, chronic kidney disease, HF, coronary heart disease, and stroke. Patients with diabetes had a lower Atrial Fibrillation Effects on Quality of Life score (80.6 [IQR: 62.5 - 92.6] vs. 82.4 [IQR: 67.6 -93.5];
P
= 0.025), but a higher CHA
2
DS
2
-VASc score (5 [IQR: 4 - 6] vs. 4 [2 - 5];
P
<0.0001) and were more likely to receive anticoagulation (
P
<0.001). Diabetes was associated with higher mortality, with a greater overall (adjusted hazard ratio [aHR]: 1.63 [95% CI: 1.04-2.56] for age<70 vs. 1.25 [1.09-1.44] for age ≥70) and cardiovascular (2.20 [1.22-3.98] for age<70 vs. 1.24 [1.02-1.51] for age ≥70) mortality risks before age 70 years. Diabetes conferred a higher risk of non-cardiovascular (CV) death (1.29 [1.06-1.56]), sudden cardiac death (1.53 [1.04-2.26]), hospitalization (1.15 [1.09-1.22]), CV hospitalization (1.13 [1.05-1.22]) and non-CV and non-bleeding-related hospitalization (1.19 [1.10-1.30]); but no increase in risks of thromboembolic events, bleeding related hospitalization, new-onset HF, and AF progression. The use of oral anticoagulants (OAC) modifies the relation of diabetes and all-cause hospitalization, with a higher risk among those on OAC (1.21 [1.12-1.29]).

Conclusions:
Among patients with AF, diabetes was associated with worse AF symptoms and lower quality of life, as well an increased risk of death and hospitalizations, but not with the risk of thromboembolic or bleeding events.
Abstract 130: The Tufts PACE Clinical Predictive Model Registry: Update 1990 Through 2015
Authors: Wessler Benjamin S , Lundquist Christine , Natto Zuhair , Janes William A , Ajlan Muhammad , Paulus Jessica , Raman Gowri , Lutz Jennifer , Kent David M
Published: June 2021

Background:
Clinical Predictive Models (CPMs) estimate the probability of clinical outcomes and hold the potential to improve decision making and individualize care. The Tufts Predictive Analytics and Comparative Effectiveness (PACE) CPM Registry is a comprehensive database of cardiovascular (CVD) CPMs. The Registry was last updated in 2012 and there has been substantial growth in the number of CPMs that are available.

Methods and Results:
We updated a systematic review of CPMs for CVD to include articles published from January 1990 to March 2015. The Registry now includes prognostic (n=1047) and diagnostic (n = 27) CPMs. There was a 3-fold increase in the number of CPMs published between 2005 and 2014, when compared to 1995 and 2004 (
Figure)
. There are 1074 models included in this database representing 68 distinct index/ outcome (I/O) pairings. 792 (72%) of the CPMs were derived from either North American (n = 448) or European (n = 344) populations. The database contains 265 CPMs predicting outcomes for patients with coronary artery disease, 187 CPMs for population samples at risk for incident CVD, and 158 models for patients with prior stroke. 697 (65%) CPMs report a
c-
statistic and overall the median reported
c-
statistic was 0.77 [IQR, 0.09]. Of the 10 most common index conditions, discrimination was highest for CPMs predicting outcomes following cardiac arrest (14/27 reporting, median
c-
statistic 0.83 [IQR, 0.08]). Discrimination was lowest for CPMs predicting outcomes for patients with other types of arrhythmias (16/22 reporting, median
c
-statistic 0.71 [IQR 0.07]). Of the CPMs included in this Registry only 422 (39%) report some measure of model calibration.

Conclusions:
There is continued growth and substantial redundancy of CPMs for a wide spectrum of CVD conditions. While the number of CPMs continues to increase, model performance is often inadequately reported and calibration is infrequently assessed. More work is needed to understand the potential impact of this literature.
Abstract 140: Effects of Smoking Co-Morbidities and Obesity on NonHemorrhagic Stroke Outcomes
Authors: Amato Danielle , Pieper Justin , Ashamalla Michael , Torosoff Mikhail
Published: June 2021

Background:
Smoking is a known risk factor for ischemic stroke, while increased BMI has been associated with improved outcomes in patients with cardiovascular disease. We investigated the relationship between smoking, BMI, and outcomes in patients with non-hemorrhagic stroke.

Methods:
Study cohort consisted of 610 consecutive patients treated for non-hemorrhagic stroke at a single academic medical center. Retrospective chart review was conducted. Long-term outcomes were ascertained through Social Security Death Index. The study was approved by the institutional IRB.

Results:
The prevalence of smoking was 42%. There were more male smokers (48% vs. 35% females, p<0.001). The mean BMI was similar in smokers and non-smokers (29+/-12.7 vs. 28.8+/-14, p=0.842). Similarly, associations between smoking and hypertension, peripheral vascular disease, dyslipidemia, end-stage renal disease, and systemic evidence of atherosclerosis by TTE were not statistically significant. However, age of a smoker at the time of admission for non-hemorrhagic stroke was 5 years younger than in a non-smoker (60.7+/-15 vs. non-smokers 65.3+/-17.5, p<0.001).

The mean follow up length was 51.4+/-1.3 months in smokers and 48.6+/-1.0 months in non-smokers. Observed crude mortality of 22.2% in smokers and 24.3% in non-smokers (p=0.559) was not significantly different in patients with normal, or increased BMI. However, smokers with non-hemorrhagic stroke died at significantly younger age (64.8+/-14.6 vs. 69.2+/-17.1, p=0.001). Additionally, there were trends towards increased mortality in smokers with BMI <18.5 kg/m2 (10.2 vs. 5.3% in non-smokers, p=0.226), dyslipidemia (38% vs. 24% in non-smokers, p=0.054) and chronic renal disease (64% vs. 36% in non-smokers, p=0.889).

Conclusion:
Smokers present with non-hemorrhagic stroke at a significantly younger age than non-smokers and die at much younger age during follow-up. While in our cohort smoking was not linked to other traditional risk factors for non-hemorrhagic stroke, it was associated with increased mortality in patients with decreased BMI, dyslipidemia, and with renal disease. “Protective” effect of increased BMI was not observed in smokers.
Abstract 153: Rural Systems of Care: Real World Observations and Trends in ST Elevation Myocardial Infarction Patient Characteristics, and Correlations of Arrival Mode to Outcomes
Authors: Mikesell Scott , Sather Jeffrey , Gallagher John , Mullvain Richard , Stys Tomasz , Cook Mindy , Myers Gary , Scharnott Michelle
Published: June 2021

Background:
Minnesota, North Dakota and South Dakota have been enhancing statewide systems through infrastructure and clinical education regarding ST-elevation myocardial infarction (STEMI) since 2010 in an attempt to equalize access to timely reperfusion in rural areas. A trend in faster time to reperfusion has been observed for STEMI patients who transfer directly to Percutaneous Coronary Intervention (PCI) capable facilities via Emergency Medical Services (EMS) and receive a pre-hospital 12-lead ECG in comparison to those who first present to a non PCI capable facility. This improved time to STEMI recognition and reperfusion may be associated with improved outcomes.

Methods:
Data was collected via ACTION Registry-GWTG from 2012-2015. The cohort was defined as STEMI patients who received PPCI with interfacility transfer (n=1010) and without (n=376) and who receive a pre-hospital 12-lead ECG (n=1078) and do not (n=308). The association between mode of transport, time to PPCI, and outcomes including LV function, in hospital clinical events, and in-hospital mortality were analyzed by unadjusted association. Multivariable adjustment was performed using covariates from the previously developed and validated ACTION mortality model to determine the independent association between arrival mode and outcomes.

Results:
The direct transfer group demonstrated shorter cumulative times (79 vs. 145 min., p=<0.001) to coronary reperfusion as compared to the interfacility transfer group. The pre-hospital ECG group experienced a shorter time to transfer (40 vs. 55 min., p=<0.001) to a PPCI center consistent with earlier system recognition and activation for a STEMI patient. The direct transfer and pre-hospital ECG groups had a statistically significant less risk of in-hospital cardiogenic shock, congestive heart failure, cardiac arrest and death as a composite end-point, p=0.011 & <0.001 respectively. During the years of 2012 to 2015, the performance of pre-hospital ECGs has increased.

Conclusion:
Implementation of Mission Lifeline programming was associated with significantly lower risk of in-hospital shock, congestive heart failure, cardiac arrest and death in STEMI patients presenting via EMS through increased utilization of pre hospital ECG, education, and hospital triage and procedural PPCI streamlining.