bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P77: Reduced Inflammatory Response with a Novel Cardiopulmonary Bypass Circuit: A Prospective Randomized Evaluation
Authors: Tononi L , Bisleri Gianluigi , Cheema Faisal H , Siddiqui Osama , Maqbool Baila , Moggi A , Bordonali T , Repossini A , Muneretto Claudio
Published: March 2022

BACKGROUND:
The detrimental effects of inflammation following cardiopulmonary bypass (CPB) result in poor postoperative outcomes in patients undergoing heart surgery. A novel CPB circuit (Admiral, Eurosets, Italy) with its inner surface coated with a proprietary phosphorylcholine coating was hypothesized to elicit a reduced inflammatory response compared to a conventional CPB circuit.

METHODS:
Patients undergoing isolated aortic valve surgery were enrolled in a prospective study and either assigned to Admiral group (Admiral, n=15) or the conventional CPB group (Dideco, n=15). The Admiral oxygenator reduces priming volumes, decreases membrane surface area and incorporates a cell-saver selectively filtering the blood collected through mediastinal cavity before re-transfusion into the patient. The conventional CPB circuit used was a Dideco D903 Avant with an open cardiotomy reservoir. Clinical data and biochemical parameters were measured postoperatively, during CPB and at 1, 18, 36, 48 and 72 hours, respectively.

RESULTS:
Preoperative demographics such as age (68.2±10.4 vs. 70.9±10), Euroscore (6.8±2.3 vs. 6.2±1.1) as well as others did not differ between Admiral and Dideco groups, respectively. The CPB time (Admiral=104±30 vs. Dideco=99±17 minutes, p=NS), aortic cross clamp time (Admiral=73.2±17.5 vs. Dideco=73.8±19 minutes, p=NS) and the incidence of perioperative complications were also comparable. There was a significant decrease in the Admiral group with respect to inflammatory response, assessed by means of D-dimer (Admiral=1332.3±953.9 vs. Dideco=2791.9±1740.7, p=0.02), CRP (Admiral=169.1±164.8 vs. Dideco=57.1±39.3, p=0.04), IL-6 (Admiral=11.8±12.5 vs. Dideco=26.5±24.9, p=0.02) and TNF-a (Admiral=29±28.7 vs. Dideco=45.5±23.6, p=0.03).

CONCLUSIONS:
Although no considerable difference was detected in terms of peri-operative outcomes, the Admiral oxygenator did result in a significant reduction of inflammatory markers in immediately postoperative course primarily due to its enhanced biocompatibility. More powerful studies may yield potentially incremental benefits with Admiral oxygenator in future.
Abstract 25: Relationship Between CT Cardiac Derived Calcium Score and Coronary Angiogram Derived SYNTAX Score
Authors: Sattur Sudhakar , Jagasia Dinesh H , Babayan Zaruhi , Harjai Kishore
Published: March 2022

Background:
Although cardiac CT derived calcium score (CCS) predicts cardiovascular events in individuals with intermediate CAD risk, its role in predicting the degree of obstructive CAD noted on coronary angiogram (CAG) has not been studied. The SYNTAX score (SS) derived from CAG is useful in grading of obstructive CAD. We performed this study to evaluate the relation between CCS and SS.

Methods:
Seventy two patients who underwent cardiac CT as well as CAG within 6 months were included. We excluded 9 patients with zero calcium scores. All CAG were reviewed in a blinded fashion by an experienced interventional cardiologist and SS was calculated. Using Pearson’s correlation analysis, we studied the relation between CCS and SS in all patients (n=72), those with low CCS (CCS=1–400; n=33), intermediate CCS (CCS=401–1000; n=16) and high CCS (CCS>1000; n=23).

Results:
There were significant moderate correlations between CCS and SS in all patients (r=0.54; P<0.0001), in the intermediate CCS (r=0.55; P<0.03) and high CCS groups (r=0.44; P=0.04), but not in the low CCS group (see figure).

Conclusions:
CCS greater than 400 has a significant moderate correlation with SS. Intermediate and high CCS may be useful in predicting the extent of angiographic CAD.
Abstract 1: Hospital PCI Appropriateness and In-Hospital Procedural Outcomes: Insights from the NCDR
®
Authors: Bradley Steven M , Chan Paul S , Spertus John A , Kennedy Kevin F , Douglas Pamela S , Patel Manesh R , Anderson H. V , Ting Henry H , Nallamothu Brahmajee K
Published: March 2022

Background.
Measurement of PCI quality has previously focused on post-procedure outcomes and processes of care. PCI appropriateness provides an assessment of quality as it relates to patient selection and anticipated procedural benefit relative to potential harm. The relationship, if any, between case selection and in-hospital procedural outcomes is unknown.

Methods.
We identified 203,531 consecutive patients from 779 hospitals undergoing non-acute (elective) PCI within the CathPCI Registry
®
between July, 2009 and April, 2011. We examined the association between a hospital’s proportion of inappropriate PCI in non-acute settings (as assessed by the Appropriate Use Criteria (AUC) for Coronary Revascularization) and (1) risk-adjusted in-hospital mortality; (2) risk-adjusted bleeding complications; and (3) use of optimal guideline directed discharge medications (i.e. aspirin, thienopyridine, and statin on discharge).

Results.
Of the 24,532 patients who received PCI for non-acute indications, 453 (0.2%) died in-hospital and 3699 (1.8%) suffered bleeding events. The hospital proportion of inappropriate PCI in non-acute settings ranged from 0.0% to 58.6%. Categorized as hospital tertiles, the median proportion of inappropriate PCI was 5.3% in hospitals of the lowest-tertile, 10.9% in the middle-tertile, and 20.0% in the highest-tertile. The hospital proportion of inappropriate PCI was not associated with mortality for PCI in non-acute settings (Risk-adjusted mortality ratio; 0.7 vs. 0.7 vs. 0.8 from lowest to highest-tertile, P=0.75 for trend), risk-adjusted bleeding complications (Risk-adjusted bleeding ratio; 0.6 vs. 0.6 vs. 0.6, P=0.81), or use of optimal PCI discharge medications (85.3% vs. 85.7% vs. 85.2%, P=0.58).

Conclusions.
In a national cohort of non-acute PCIs from 779 hospitals, hospital proportion of inappropriate PCI indications was not associated with in-hospital mortality, bleeding, or process of care measures of PCI quality. These findings suggest PCI appropriateness and post-procedural outcomes measure different aspects of hospital PCI quality.
Abstract 133: Comparative Effectiveness of Coronary Artery Bypass Surgery Versus Percutaneous Coronary Intervention for Multivessel Coronary Disease in Community-Based Populations: The Kaiser Permanente Northern California Experience
Authors: Go Alan S , Leong Thomas K , Yang Jingrong , Sung Sue Hee , Hlatky Mark A
Published: March 2022

Background.
Pooled analyses of randomized trials comparing CABG and PCI suggest a modest mortality benefit with CABG in selected patients (adjusted hazard ratio 0.70). However, limited data exist for patients treated in typical clinical practice, and most previously published studies were underpowered to examine variation in outcomes by patient characteristics. We evaluated the comparative effectiveness of CABG vs. PCI in patients with multivessel coronary artery disease, overall and in target patient subgroups.

Methods.
We conducted a retrospective cohort study of adults receiving isolated CABG or PCI for multivessel coronary disease between 1996-2008 within Kaiser Permanente of Northern California, a large, integrated healthcare delivery system. Demographic characteristics, cardiovascular history, comorbidities and longitudinal cardiovascular drug exposure were ascertained from health plan hospitalization, outpatient, laboratory and pharmacy databases. Deaths through 2008 were identified from health plan, state death certificate, and Social Security Administration death files.

Results.
In 28,735 adults with multivessel coronary disease receiving CABG (n=20,664) or PCI (n=8,071), those receiving CABG were more likely to be older and male. In multivariable extended Cox regression analysis that adjusted for potential time-updated confounders, CABG was associated with lower rates of death from any cause (adjusted hazard ratio 0.83, 95% CI: 0.76-0.90) compared with PCI. Compared with PCI, CABG was associated with significantly lower adjusted rates for death in those with and without diabetes, in those aged ≥75 years but not in those 65-74 or <65 years, in men but not women, and in whites but not in blacks or Asians (Figure). Overall and subgroup results were similar using propensity score methods.

Conclusions.
In a large, diverse, community-based cohort of patients with multivessel coronary disease, CABG was independently associated with lower rates of death compared with PCI, but less so than seen in RCTs. Results further varied by patient characteristics, suggesting the need to re-evaluate selection of revascularization type in patients with symptomatic multivessel coronary disease.
Abstract 143B: Association between Insurance Type and Long Term Outcomes in Patients with ST-Elevation Myocardial Infarction
Authors: Cassar Andrew , Shah Nilay D , Lennon Ryan J , Bell Malcolm R , Gersh Bernard J , Ting Henry H
Published: March 2022

Background:
Health insurance coverage has been recently expanded to millions of Americans with the goal of improving access and quality of care. We evaluated long-term outcomes for patients with ST-elevation myocardial infarction (STEMI) with different insurance types.

Methods:
From 2004 to 2010, 970 consecutive STEMI patients who presented to 29 hospitals in Minnesota, Iowa or Wisconsin were treated according to the Mayo STEMI protocol. Demographic, clinical, procedural, and long-term follow up data were prospectively collected. 953 patients were categorized into groups by insurance type - private insurance (PI, n=430), Medicare (MC, n=420), Medicaid (MD, n=68), and uninsured (UN, n=35).

Results:
Median duration of follow-up was 32 months, and mean ages (years) were 55±8 for PI, 75±10 for MC, 49±10 for MD, and 52±9 for UN (p<0.001). Compared to PI patients, MC and MD patients were more likely to have diabetes (both 21% vs 10%, p<0.001); MC patients had more renal failure (4% vs <1%, p=0.012) but UN patients did not differ significantly (DM 12% and CRF 0%). All groups had similar frequency of cardiogenic shock (PI 9%, MC 14%, MD 9%, UN 6%, p=0.08) and comparable door-to-balloon (in minutes(Q1,Q3): PI 69(54,107), MC 79(61,114), MD 83(55,124), UN 76(58,94), p=0.09) and door-to-needle times (in minutes(Q1,Q3): PI 26(19,34), MC 29 (21,39), MD 27(22,34), UN 17(13,21), p=0.06). MC patients had the highest incidence of in-hospital death (7.6%; p=0.003 vs PI 3.0%). Significant differences in all cause mortality between insurance groups were present on 5-year follow-up (Figure). After risk factor adjustment for age (HR 1.89 per decade, p<0.001), female sex (HR 1.16, p=0.40), diabetes (HR 1.89, p<0.001), peripheral artery disease (HR 2.06, p=0.004), heart failure (HR 1.40, p=0.14), cardiogenic shock (4.22, p<0.001) and renal failure (HR 1.62, p=0.20); insurance type was not an independent risk factor for death (p=0.26). When compared to PI, the hazard ratio for UN was associated with a trend for worse survival (HR 2.69, 95%CI 0.94, 7.67, p=0.06) while MC (HR 0.94, 95%CI 0.55, 1.61, p=0.83) and MD patients (HR 1.37, 95%CI 0.52, 3.59, p=0.53) had similar survival after adjustment for covariates.

Conclusion:
Timeliness of reperfusion was similar across all insurance groups. After adjustment for baseline clinical variables, there was no significant difference in long-term survival according to insurance type.
Abstract 150: The Impact of Access to Health Care on CVD Risk Factor Management
Authors: Allen Norrina B , Carnethon Mercedes
Published: March 2022

Background and Aims:
A growing number of Americans have difficulty obtaining health care, which is associated with poorer health outcomes. The aim of this study was to examine the impact of access to health care on the management of hypertension and diabetes.

Methods:
We used data from the 2009 BRFSS. Participants who were aged 18 and older, had complete information on health care access and who lived in a state which used the Diabetes module (40 states) or the Actions to Control High Blood Pressure Module (19 states) were included in the analyses for diabetes and hypertension respectively. Health care access was examined as a score (range 0-3) indicating the number of barriers to health care including lack of health insurance, lack of an usual care provider and having not been able to seek care within the past year due to cost. Logistic regression incorporating the complex survey design was used to examine the independent association of health care access to diabetes and blood pressure management among individuals with self-reported physician diagnosis of diabetes and hypertension respectively. Analyses were adjusted for age, race/ethnicity, gender, education, income, BMI, general health status, and time since last physical exam.

Results:
In this study, an estimated 14.8 million Americans had diabetes and 21.2 million had hypertension. 76% had no barriers to health care access, 15% had 1 barrier, 6% had 2 barriers and 3% had all 3 barriers to health care access. Hypertensive individuals with multiple barriers to health care access were less likely to be on antihypertensive medication and were less likely to eat healthier or exercise to reduce blood pressure as compared to individuals with no barriers to health care (Table). Diabetic Americans with poor access to health care were less likely to be taking insulin, to be checking glucose levels daily, to be checking their feet daily or to receive the recommended health care assessments (Table).

Conclusions:
Americans with difficulty obtaining health care are less likely to comply with recommendations for hypertension and diabetes management. The management and control of hypertension and diabetes is important to reduce complications.
Abstract 152: Variation in Use, Costs, and Hospital Profitability for Outpatient Interventional Procedures using Vascular Closure Devices: A Descriptive Analysis
Authors: Clark Mary Ann , Okpala Laura , Richner Randel
Published: March 2022

Objective:
To describe the patterns of care and costs associated with vascular closure device (VCD) use in interventional cardiology and peripheral vascular interventions in hospital outpatient departments from a Medicare perspective.

Methods:
Medicare outpatient use of vascular closure devices was identified using Health Care Procedure Coding System (HCPCS) code C1760 billed by hospitals during 2010 and found in Medicare’s Outpatient Prospective Payment System (OPPS) Limited Data Set (LDS). Hospital volumes, charges, costs, and reimbursements were summarized by hospital and by Hospital Referral Region (HRR) as defined by the Dartmouth Atlas of Health Care. Hospital contribution margins (profitability) for procedures using vascular closure devices were calculated as well.

Results:
We found a total of 272,589 vascular closure devices billed for both interventional cardiology procedures (75%, 205,612 of 272,589) and peripheral vascular interventions (25%, 66,977 of 272,589). The rate of vascular closure device usage was higher among diagnostic and therapeutic interventional cardiology procedures than peripheral vascular procedures (34%, 205,612 of 604,322 versus 24%, 66,977 of 277,342). Total vascular closure device costs billed to Medicare in outpatient hospital settings were $82.1 million. Average device cost per procedure was around $300. The top 5 hospitals for VCD use were different for interventional cardiology versus peripheral interventions. Additionally, the top 5 hospitals that used VCDs for interventional cardiology procedures were primarily due to diagnostic catheterizations and not interventions.

Conclusions:
Frequent users (hospitals) of VCDs seem to be associated with diagnostic use as opposed to interventional use. VCDs are more widely used with cardiovascular procedures versus peripheral procedures. There is significant variation in VCD use across the country, seemingly unrelated to total interventional procedure volume.
Abstract 157: Increased Rates of Intravenous Thrombolysis for Acute Stroke in California Correlate with Expansion of Acute Stroke EMS Routing Protocols, 2006-2010
Authors: Song Sarah , Cheng Eric , Ayad Miriam E , Saver Jeffrey L
Published: March 2022

Background:
Primary stroke centers (PSCs) have been observed to have better stroke outcomes, and to have higher IV intravenous tissue-type plasminogen activator (IV tPA) utilization rates. Emergency medical services (EMS) began using routing protocols to direct suspected acute stroke patients to PSCs in the first decade of the century. We sought to determine the impact of county-level EMS stroke routing protocols on IV tPA utilization rates in California (CA).

Methods:
We extracted county-level patient discharge data from Office of Statewide Health Planning and Development database, an all-payer database including all hospitalizations in CA from 2006-2010. We used Diagnosis Related Group codes to identify all patients hospitalized for stroke, and patients who received a thrombolytic agent for stroke. We contacted EMS departments in CA and worked with the American Heart Association to determine which counties were utilizing EMS routing protocols and the year implemented. Using chi-square, we compared tPA usage in routing counties vs. non-routing counties. Among counties that implemented routing protocols, we compared tPA usage 1 year pre- and post-routing protocol implementation.

Results:
Of 58 counties in CA, 19 were identified to have implemented acute stroke EMS routing protocols in years 2006 and 2010. Across this 5 year period, use of tPA among counties without a concurrent EMS routing protocol was 2.1% [1663/79148], whereas use of tPA among counties with a concurrent EMS routing protocol was 3.1% [4853/154962] (p<0.001). Among the 39 counties that have not yet implemented EMS routing protocols, tPA use increased from 1.3% to 3.1% from 2006-2010. In the same time period, the 19 counties with EMS routing protocols showed tPA use increased from 2.3% to 4.4%. Further analysis was performed for counties whose data for tPA usage 1 year pre- and post-routing were available: San Francisco County (2007); Alameda, Kern, San Mateo Counties (2008); Los Angeles, Orange, Sacramento, San Diego Counties (2009). Counties that implemented EMS acute stroke routing protocols increased tPA rates usage from 2.6% in the year before routing to 4.0% in the year after routing (p<0.001).

Conclusions:
Counties with EMS protocols to route acute stroke patients to PSCs have higher IV tPA rates than non-routing counties. Routing counties are also seen to increase their rate of IV tPA after beginning implementation of routing protocols. To continue to improve acute stroke care through the usage of IV tPA, current non-routing counties should consider implementing routing protocols to transport acute stroke patients to PSCs.
Abstract 193: Ambulatory Patients with Type 2 Diabetes Have Low Levels of Aerobic Fitness and Suboptimal Adherence to Guideline-Recommended Minimum Physical Activity
Authors: Jarvie Jennifer L , Ayers Colby R , Snell Peter G , Gore Odette , Lakoski Susan G , Berry Jarett D , McGuire Darren K
Published: March 2022

Purpose:
Lifestyle intervention remains the cornerstone for prevention and treatment of type 2 diabetes (T2DM). However, levels of fitness and adherence to physical activity recommendations in this population have been poorly quantified to date.

Methods and Results:
Subjects with medically-treated T2DM and prevalent cardiovascular disease (CVD) or CVD risk factors were recruited from outpatient clinics at a single academic medical center. All subjects underwent maximal exercise treadmill testing with measurement of peak oxygen consumption (VO2peak) and completed a 7-Day Physical Activity Recall interview (7D-PAR). A total of 150 subjects participated, with a mean age of 54.9 ± 9 years; 41% women; 40% Black, 33% White, and 21% Hispanic; mean BMI 34.5 ± 7.2 kg/m2; mean HbA1c 7.7 ± 1.8%; 41% insulin use; and median T2DM duration 7 years (IQR 4 - 12 yrs). Seventy-two percent had hypertension, 73% hyperlipidemia, and 35% prevalent CVD. Mean VO2peak scaled to fat-free mass (VO2peak-FFM) was 27.4 ± 6.5 ml/kg-FFM/min (for context, threshold of <19 ml/kg-FFM/min used for cardiac transplant candidacy). Mean energy expenditure estimated by the 7D-PAR was 34.3 ± 4 kcal/kg/day (7% above a completely sedentary state). Sleep comprised 56.7 hrs/week (IQR 48.8 - 64 hrs); most of the net weekly reported activity was light (105.5 hrs; IQR 98.3 - 114.8 hrs), with little moderate (2.1 hrs; IQR 0.7 - 5.2), and rare reported hard (n = 31 subjects) or very hard (n = 12 subjects) activity. Forty-seven percent failed to achieve the minimum recommended physical activity for health (1.4 kcal/kg/day of moderate, hard, or very hard physical activity).

Conclusion:
Patients with T2DM at highest CVD risk report extremely low levels of physical activity, associated with low measured fitness by cardiopulmonary exercise testing. Continued efforts to develop systems and processes to close this therapeutic gap remain important.
Abstract 228: A Cost-effectiveness Analysis Of Universal Pulse Oximetry Screening To Detect Critical Congenital Heart Disease In U.s. Newborns
Authors: Peterson Cora , Grosse Scott D , Cassell Cynthia H , Oster Matthew E , Olney Richard S
Published: March 2022

Background and objective:
In 2011, critical congenital heart disease (CCHD) was added to the Recommended Uniform Screening Panel for newborns. Most state legislatures have not yet mandated pulse oximetry screening to detect CCHD, and evidence that the screening is cost-effective might be influential in these decisions. This study aimed to estimate the cost-effectiveness of universal newborn pulse oximetry screening for CCHD in the U.S. from the hospital system perspective.

Methods:
A model was developed to estimate the direct medical costs and health effects of screening all newborns. The health benefits were the number of timely (prior to birth hospital discharge) detected CCHD and life-years saved with the screening compared to existing practice. The analysis focused on ductal-dependent CCHD lesions amenable to pulse oximetry detection. The time horizon was the neonatal period. Costs were not discounted, though future life-years were discounted at 3%. Model inputs related to the epidemiology of CCHD, treatment outcomes, and efficacy of pulse oximetry screening to detect CCHD were derived from published literature.

Results:
The cost of screening was an estimated $3.83 per newborn, with an incremental cost of $4,693 per life year gained as a result of the screening. Using current U.S. hospital-based births, it was estimated that 248 more cases of CCHD would be identified at birth hospitals and 110 infant deaths averted annually with universal screening.

Conclusion:
Pulse oximetry screening is a life-saving program and is cost-effective by usual standards of health economic evaluation. The results of this analysis might contribute to policymakers’ decisions on universal pulse oximetry screening and may inform other stakeholders, including health care systems and payers, about likely budget impacts. Further analyses of CCHD hospitalization and screening costs can improve these model estimates.
Abstract 233: Patient Factors Minimally Impact Experience with Informed Consent Documents for Percutaneous Coronary Intervention
Authors: Coylewright Megan , Gosch Kensey L , McNulty Edward J , Spertus John , Ting Henry H
Published: March 2022

Background:
In light of well-known deficiencies in the process of informed consent for percutaneous coronary intervention (PCI), we developed and tested a personalized consent form, PRISM; this was shown to improve patients' participation in the consent process, understanding of procedural risks, and engagement in shared decision-making when compared to original PCI consent forms. It is unknown whether patient factors traditionally known to impair the consent process, including socioeconomic status, literacy and numeracy, were associated with greater benefit from the PRISM consents.

Methods:
We interviewed 590 patients receiving original consent documents and 527 receiving PRISM consents and compared the rates of reviewing the consent form, recalling a risk of bleeding and engaging in discussions about stent type using hierarchical modified Poisson regression analysis. The interaction of patient factors (age, gender, education level, insurance status, literacy and numeracy) with PRISM on outcomes was assessed.

Results:
Overall, few patient characteristics were associated with outcomes, including review of consent forms, knowledge transfer, or engagement in shared decision-making (see Table), although older patients were less likely to discuss stent types with their doctors (RR=0.84/decade for original and 0.93/decade for PRISM). Those with more than a high school education were less likely to review original consents (RR=0.77; 95% CI=0.66, 0.89) compared to those with less education; this difference was eliminated with the PRISM consents (RR=1.0; 95%CI=0.82, 1.23; p-value for interaction = 0.01).

Conclusions:
PRISM consent forms led to improved participation in the consent process and knowledge transfer in a 9-center study; there was little variance by sociodemographic, economic, literacy or numeracy factors, both with original consents and with PRISM.
Abstract 237: Retrospective Validation of Pre-Hospital Electrocardiogram with Zoll E-Series Monitoring System for Field Identification of ST Elevation Myocardial Infarction Patients
Authors: Kado Herman S , Wilson Ryan E , Strom Joel A , Box Lyndon C
Published: March 2022

Background:
Rapid reperfusion of ST elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention (PCI) improves outcomes. Systems have been developed in many areas to identify STEMI patients in the field using pre-hospital electrocardiograms (ECGs). The Zoll E-Series (ES) is a defibrillator/monitoring system that utilizes the GE Medical Systems 12SL interpretive algorithm to assist with identification of STEMIs. There is a lack of significant data measuring the accuracy of the Zoll ES and its algorithm, especially in the setting of a large urban population.

Methods:
We retrospectively looked at 307 consecutive ECGs transmitted by one emergency medical service (EMS) provider to an urban primary PCI facility from October 2009 to January 2011. All transmissions were from Zoll ES monitors. Multiple ECG computer interpretations were screened and filtered out to those labeled ***ACUTE MI***. A retrospective chart review was performed to determine the clinical outcome for each transmission in order to determine the performance of the interpretive algorithm in this population.

Results:
Overall, 307 ECGs were analyzed. A total of 7% (20 of 307) were confirmed STEMIs (Table 1). The computer reading shows a sensitivity of 95% (20 of 21) and specificity of 94% (268 of 286). There is a positive predictive value (PPV) of 53% (20 of 38).

Conclusions:
The initial data from this study shows that the Zoll ES has a remarkably high sensitivity of 95% but a poor PPV of 53%. This may be due to multiple confounders that result in STEMI “mimics.” The Zoll ES helps provide a pre-hospital ECG that serves as a powerful and life saving tool in the field. However, due to the low PPV, these findings reinforce that the pre-hospital ECG needs to be combined with an appropriate clinical history and additional human interpretation. Further studies analyzing a larger population of patients should be conducted to further assess the value of using this tool.
Abstract 257: Practice Variation is a Significant Contributor to Secondary Prevention Medication Use: Insights from the NCDR PINNACLE Program
Authors: Maddox Thomas M , Chan Paul S , Spertus John A , Tang Fengming , Jones Phil , Ho P. Michael , Bradley Steven M , Tsai Thomas T , Peterson Pamela N
Published: March 2022

Background:
Secondary prevention medications for eligible CAD patients include antiplatelets, lipid lowering agents, beta-blockers (BB) and angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB). However, use of these therapies is variable. The contribution of practice-level factors to variation in medication use is unknown. In addition, the contribution of practice-level factors relative to patient factors is also unknown.

Methods:
We evaluated CAD patients in cardiology practices participating in the NCDR PINNACLE program, a national office-based cardiac quality improvement registry, between July 2008 and December 2010. Patients eligible for treatment were grouped by Class I indications for therapy: antiplatelets and lipid lowering agents in all, BBs in post-MI patients, and ACEIs/ARBs in those with diabetes or with reduced left ventricular ejection fraction (≤40%). Mean practice rates of therapy use were calculated. Next, hierarchical regression models assessed the effect of practice on therapy use, adjusted for patient factors, using the median rate ratio (MRR). The MRR compares the likelihood of treatment for identical patients from two randomly selected practices. In general, MRRs ≥ 1.2 indicate significant variation by practice. Finally, the magnitude of contribution of patient factors, expressed in ORs, to variation in therapy use was assessed.

Results:
Our cohort consisted of 277,526 patients in 62 practices. The mean practice rate was 80.8% for antiplatelets (range 41.2–100%), 79.5% for lipid lowering agents (range 33.9–100%), 77.6% for BBs (range 35.2–100%), and 73.8% for ACEI/ARBs (range 39.1–100%). Adjusted MRR between practices was 1.19 for antiplatelets, 1.19 for lipid lowering agents, 1.20 for BBs, and 1.19 for ACEIs/ARBs. Almost all patient-level factors were smaller in magnitude than the MRR for practice-level variation (see Table).

Conclusions:
Among practices participating in the PINNACLE program, significant variation in guideline recommended treatments among CAD outpatients exists. Practice setting, independent of patient factors, was associated with variation in treatment and was similar in magnitude to most patient factors. Our findings suggest that practice setting is an important contributor to variability in secondary prevention medication use. Accordingly, to improve the use of evidence-based CAD therapies, quality improvement efforts targeting practice-level factors should be evaluated.
Abstract 296: Factors Associated with Inadequate Prenatal Care in Women with Pre-Gestational Hypertension
Authors: Sergeev Alexander V , Nyirati Christina M
Published: March 2022

BACKGROUND:
Pre-gestational hypertension (HTN) remains a compelling problem, both cardiological and obstetrical. It can increase risk of unfavorable maternal and neonatal outcomes, especially in patients without adequate prenatal care. Little is known about factors associated with inadequate prenatal care in women with pre-gestational HTN, beyond racial and ethnic disparities.

HYPOTHESIS:
We hypothesized that social factors are associated with inadequate prenatal care in pre-gestational HTN women, beyond race/ethnicity-related disparities.

METHODS:
A case-control study of adequacy of prenatal care was conducted in 1,635 women with pre-gestational HTN who were living and gave birth in the State of Ohio in 2010. The comprehensive births data for the year 2010 were obtained from the Ohio Department of Health. Cases were identified as those with inadequate prenatal care; controls were identified as those with adequate-plus, adequate, or intermediate care, as defined by the Adequacy of Prenatal Care Utilization Index (the Kotelchuk Index). Adjusted odds ratios for inadequate care in pre-gestational HTN women in relation to their demographic and socio-economic characteristics were obtained using multivariable logistic regression (SAS software).

RESULTS:
A total of 14.4% (235 of 1,635) pre-gestational HTN women received inadequate prenatal care. In pre-gestational HTN women, adequacy of prenatal care was statistically significantly associated with their level of educational attainment and marital status, even after adjustment for race and ethnicity. Compared to pre-gestational HTN women with a higher educational level (at least some college or higher), pre-gestational HTN women with a lower educational level (high school or below) were 1.69 times more likely to receive inadequate prenatal care as measured by the Kotelchuk Index (began prenatal care late and/or completed less than 50% of the recommended visits) (OR 1.69, 95% CI 1.20-2.38, p<0.01). Unmarried pre-gestational HTN women were statistically significantly more likely to receive inadequate care than their married counterparts (OR 1.57, 95% CI 1.09-2.27, p=0.02). Compared to white pre-gestational HTN women, black (OR 2.52, 95% CI 1.76-3.62, p<0.001), Asian (OR 3.82, 95% CI 1.50-9.71, p=0.01), and Native American (OR 4.84, 95% CI 1.03-22.87, p=0.04) pre-gestational HTN women were at higher risk of receiving inadequate care. No statistically significant difference between Hispanic and non-Hispanic pre-gestational HTN women was observed.

CONCLUSIONS:
Although white women with pre-gestational HTN are at lowest risk of receiving inadequate prenatal care, these disparities cannot be attributed to race and ethnicity only. Pre-gestational HTN women with lower educational attainment and unmarried women are at higher risk of receiving inadequate prenatal care. Pre-gestational risk stratification and management of HTN in women during pregnancy by the cardiologist are warranted.
Abstract 31: Hyperglycemia During MI Hospitalization Predicts Subsequent Diabetes: Insights from the VA IHD-QUERI Cardiac Care Follow-Up Clinical Study (CCFCS)
Authors: Maddox Thomas M , Gylys-Colwell Ina , McDermott Kelly , Ho P. Michael , Tillquist Maggie , Lowy Elliott , McGuire Darren K , Stolker Joshua M , Kosiborod Mikhail
Published: March 2022

Background:
Among non-diabetic patients hospitalized with an acute myocardial infarction (AMI), in-hospital hyperglycemia is associated with adverse outcomes. This phenomenon may be due to undiagnosed diabetes (DM), which could have implications for in-hospital screening and post-discharge follow up. While high rates of newly-diagnosed DM have been reported in AMI patients, whether majority of these cases occur among those with in-hospital hyperglycemia is unknown.

Methods:
We examined a national cohort of AMI patients hospitalized in the VA between 10/2005 -7/2009, who did not have known DM, were not diagnosed with DM during hospitalization, and survived at least 6 months post-discharge. We assessed rates of inpatient hyperglycemia (defined as mean hospitalization glucose ≥140mg/dL) and DM diagnosis during 6 months after hospitalization (defined as ICD-9 diagnosis codes, prescription of any glucose-lowering medication, or HbA1c value ≥ 6.5%). Predictors of DM diagnosis were assessed using a multivariable logistic regression model.

Results:
Among 7875 non-diabetic AMI patients, 484 (6.1%) had inpatient hyperglycemia. Hyperglycemic patients were older, had greater AMI severity and burden of comorbidities, and were more likely to be treated with insulin during hospitalization. Six months following discharge, 100 (20.7%) hyperglycemic patients were diagnosed with DM, compared to 308 (4.2%) normoglycemic patients (p <0.0001). After multivariable adjustment, in-hospital hyperglycemia remained a significant predictor of 6-month DM diagnosis (OR 5.15, 95% CI 3.97, 6.69). Other factors associated with DM diagnosis are listed in the Table.

Conclusions:
Elevated glucose during AMI hospitalization is a strong predictor of incident DM, with greater than 1 in 5 non-DM hyperglycemic patients being diagnosed with DM within 6 months after discharge. Our findings suggest that non-DM AMI patients with hyperglycemia warrant formal DM screening during or shortly after AMI hospitalization.
Abstract 316: Favorable Long Term Rates of Revascularization and Myocardial Infarction with Optimal Medical Therapy: No Effect of Second Opinion Status for Invasive Management
Authors: Saini Vikas , Mamuya Wilfred , Aggarwal Deepa , Carolan Padraig , Bilchik Brian , Blatt Charles , Ravid Shmuel
Published: March 2022

Long-term outcomes of patients (pts) with stable coronary artery disease (CAD) are needed to properly assess the efficacy of Optimal Medical Therapy (OMT). Whether pts who seek a second opinion (SO) regarding OMT are at higher risk by virtue of the first opinion for invasive management is unknown. As part of a prospective cohort study of OMT in pts with stable CAD without prior coronary artery bypass graft (CABG), we ascertained opinion status at entry and the end-points of myocardial infarction (MI) and revascularization (revasc) as of 2005. Out of 693 pts, opinion status was available in 646 pts; of these, 118 were SO for invasive evaluation and management. Management decisions were based on history, physical examination, and non-invasive data; coronary anatomy was available in only 50% of the SO cohort. During follow up, the decision to intervene depended on stability of symptoms, LV function, and treadmill exercise duration. Revasc was defined as percutaneous coronary intervention (PCI) or CABG. MI was defined as meeting two of the three WHO criteria or a typical pattern of MI on a myocardial perfusion study or 2-D Echocardiography. Assessment of clinical predictors of each endpoint used stepwise multivariate Cox modeling with 0.15 as level of entry and 0.8 as level of removal. Variables significant at the 0.05 level in a univariate model as well as SO status were included.

Results:
The mean age of the cohort was 67.3 years, and the majority of pts (53.9%) had class 1 or 2 angina. During mean follow-up time of 6.9 years there were a total of 252 revascularization events and 114 MIs, of which 11 were fatal. SO patients were younger with a mean age of 63.9 years. Coronary anatomy was available in 39% of the entire cohort, and 50% of the SO group. The strongest predictor of MI or revasc in Cox models was a change in clinical stability of CAD. For Revasc, other predictors were BMI, total cholesterol, diastolic BP, and angina at entry; for MI, other predictors were resting ejection fraction and treadmill duration. SO status was not a predictor of either event.

Conclusions:
Long term rates of revasc and MI in pts with stable CAD managed with OMT were low, and comparable to the medical arms of the COURAGE and BARI2D trials. Our study extends those results to a longer follow up period. SO status
per se
was not a predictor of either revasc or MI, suggesting that pts with a previous recommendation for invasive management who sought a SO did not represent a higher risk sub-group.
Abstract 332: Indeterminate Troponins are Predictive of Worse Long-term Outcomes in Patients With Unstable Angina
Authors: Sattur Sudhakar , Harjai Kishore , Orshaw Pam , Garg Mukesh
Published: March 2022

Background:
Indeterminate troponins (IT) are known to be associated with worse in-hospital and short-term clinical outcomes. However the effect of IT on long-term clinical outcomes has not been studied.

Methods:
We included all patients with unstable angina (USA) who underwent PCI at a tertiary multi-specialty hospital. Indeterminate and negative troponins were defined as per the troponin assay manufacturer’s recommendation. Patients were classified into indeterminate troponins (IT) group and negative troponins (NT) group. We compared long-term clinical outcomes (Death, MI, Death/MI, Target Vessel Revascularization [TVR], Major Adverse Cardiac Events [MACE- death, MI and TVR] and Stent Thromosis [ST]) between the two groups.

Results:
We had 94 patients in the IT group and 853 patients in the NT group. Mean follow up duration was 1422 ± 664 days. Kaplan Meier analysis showed that IT were associated with more death (p=0.0012), MI (p=0.0003), death /MI (p=0.0001) and MACE (p=0.0025) at long-term follow up. After multi-variate adjustment for all the statistically different baseline clinical and angiographic characteristics between the two groups, IT remained an independent predictor of death, MI, death/MI and MACE in long-term follow up.

Conclusions:
Indeterminate troponins are associated with significantly worse clinical outcomes in long-term follow up. Indeterminate troponins add incremental prognostic information in patients with USA and should be factored in risk stratification and management of these patients.
Abstract 62: Impact of Once-Daily vs. Twice-Daily Dosing Frequency on Adherence in Chronic Medications among Patients with Non-Valvular Atrial Fibrillation
Authors: Laliberté FranÇois , Nelson Winnie W , Schein Jeff R , Rondeau-Leclerc Jonathan , Lefebvre Patrick , Duh Mei Sheng
Published: March 2022

Objective:
Multiple daily dosing may be negatively associated with patient medication adherence, but the findings are inconclusive. This study aims at comparing adherence to chronic medications for once-daily (QD) vs. twice-daily (BID) dosing in patients with non-valvular atrial fibrillation (NVAF).

Methods:
We analyzed the PharMetrics Integrated Claims database from 2004 to 2009. Adult patients with continuous insurance coverage, newly initiated on a QD or BID diabetes or hypertension medication, and having at least 1 AF diagnosis (ICD-9 427.31) were included. Patients with observed valvular heart disease or valve replacement procedures during the 180 days before the index fill date were excluded. The observation period started on the index date until the earliest of switching to another drug class, health plan disenrollment, and end of data availability. Compliance was calculated in two ways: medication possession ratio (MPR) and proportion of days covered (PDC). Adherence was defined as a MPR or PDC ≥ 0.8. Multivariate logistic regressions were conducted to compare the probability of adherence, adjusting for baseline demographics, index medications, comorbidities, pills burden, and healthcare costs.

Results:
Total of 8,256 QD and 2,441 BID patients with NVAF initiating the target chronic medications were identified. For the QD and BID group respectively, means (SD) age were 57.3 (14.0) and 56.9 (13.8) years (p=NS); 34% and 33% were females (p=NS); means (SD) duration of exposure to therapy were 447 (400) and 406 (374) days (p<.001). Based on MPR, 75% of QD patients compared to 70% of BID patients were adherent (p<.001). For PDC at 3, 6, 12 and 18 months, the proportions of adherent patients for the QD and BID groups were 74% vs. 68%, 65% vs. 58%, 57% vs. 50%, and 51% vs. 44% (p<.001 for all comparisons), respectively. The adjusted odds ratio (95% CI) of adherence for the QD relative to BID group was 1.22 (1.09 - 1.36) based on MPR and 1.23 (1.07 - 1.41) based on PDC at 12 months.

Conclusions:
This study demonstrates that NVAF patients treated with QD dosing regimens for chronic medications were associated with approximately a 22% higher likelihood of adherence than those on BID regimens, regardless of whether Medication Possession Ratio or Proportion of Days Covered was used to define compliance.
Abstract 67: Retrospective Validation Of An Algorithm For Field Identification Of ST Elevation Myocardial Infarction Patients By Emergency Medicine Services Using A
STEMI Alert Clinical Tool
Authors: Wilson Ryan E , Kado Herman S , Strom Joel A , Box Lyndon C
Published: March 2022

Objectives:
We reviewed data to validate the use of a simplified
STEMI Alert Clinical Tool
for EMS personnel to use to activate cardiac cath labs for patients presenting with STEMIs.

Methods:
We retrospectively reviewed all ECGs transmitted by one EMS provider to an urban primary PCI facility from October 2009 to January 2011. We then applied the
STEMI Alert Clinical Tool
(Table 1) to determine if the patient would have qualified for cath lab activation from the field. A retrospective chart review was performed to determine the outcomes of each transmission within the corresponding time frames.

Results:
A total of 307 ECGs were transmitted during the selected time frame. A total of 10.7% (33 of 307) met criteria for cath lab activation based on the STEMI alert clinical tool. Of these 63.6% (21 of 33) were true positives and 36.4% (12 of 33) were false positives. The sensitivity of a positive alert was 95.5% (21 of 22) and the specificity was 95.8% (273 of 285). The positive predictive value (PPV) was 63.6% (21 of 33). One STEMI patient was missed by the clinical tool because the ECG did not read ***ACUTE MI***. The negative predictive value (NPV) was 99.6% (273 of 274).

Conclusions:
The data from this study shows that use of a
STEMI Alert Clinical Tool
has a relatively low PPV but a very high NPV. Thus, pre-hospital activation of cath labs may not be necessary for patients who fail to meet the STEMI alert criteria. In contrast, despite use of this tool a portion of patients will falsely activate the cath lab. Although this strategy may increase the risks of unnecessary financial and man power utilization to the hospital system, the risk of missing a STEMI can be high. Analyzing a larger patient population will be required to further define the value of using this clinical tool. Table 1 - Clinical Tool - All 7 must be "yes" to activate cath lab
Abstract 105: Normal Coronary Rates for Elective Angiography in the VA Health Care System: Insights from the VA CART Program
Authors: Bradley Steven M , Maddox Thomas M , Stanislawski Maggie A , O’Donnell Colin I , Grunwald Gary K , Tsai Thomas T , Ho P. Michael , Peterson Eric D , Rumsfeld John S
Published: March 2022

Background.
Prior studies have shown that rates of normal coronary arteries with elective coronary angiography vary considerably among U.S. community hospitals. It has been suggested that this variation may in part reflect incentives in fee-for-service care. The rates of normal coronaries within an integrated healthcare system are unknown.

Methods.
Using national data from the VA Clinical Assessment Reporting and Tracking (CART) Program, we evaluated all VA patients who had elective coronary angiography from October 2007-September 2010 at the 76 VA cardiac catheterization labs. Normal coronary angiography was defined as <20% stenosis in all vessels. We assessed patients’ demographics, risk factors, noninvasive preprocedural testing, and angiographic findings. To assess hospital-level variation in normal coronary rates, we categorized hospitals by quartiles as defined by their proportion of normal coronaries.

Results.
Overall, 5,108 of 22,001 patients (22.8%) had normal coronary angiography. Hospital proportions of normal coronaries varied modestly (median hospital proportion 21.2%, interquartile range, 17.3% to 26.1% range, 7.9% to 56.6; Figure 1). Patients with normal coronaries were more likely to have low Framingham risk scores (36.6% versus 16.5%, p<0.001), less likely to undergo a preprocedural stress test (70.3% versus 77.8%, p<0.001), and among those with stress testing, less likely to have results positive for ischemia (42.6% versus 47.2%, p<0.001). By hospital quartile of normal coronary rates, patients at hospitals with lower normal coronary rates were more likely to undergo stress testing prior to angiography (79.8% vs. 78.6% vs. 77.4% vs. 64.4%, p<0.001).

Conclusions.
About 1 in 5 patients undergoing elective coronary angiography in the VA had normal coronaries. This rate is lower than prior published studies in other systems. However, the observed hospital-level variation in normal coronary rates suggests barriers to consistent patient selection for diagnostic coronary angiography despite an integrated care delivery system.