bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 276: Gender Disparity in the Treatment of Aortic Stenosis-an Analysis of the National Inpatient Sample 2009-2015
Authors: Tangel Richard , Sethi Ankur , Kassotis John
Published: May 2020

Background:
It is well known that there is a significant gender gap in both the referral and outcomes of patients eligible for cardiac surgery. The impact of transcatheter aortic valve replacement (TAVR) on the gender disparity in the management of aortic stenosis (AS) has not been well established. The aim of this study was to analyze the referrals to and outcomes of both surgical aortic valve replacement (SAVR) and TAVR for management of AS as a function of gender in a contemporary United States population.

Methods:
We used the National Inpatient database 2009-2015 to study the gender distribution of admissions for both SAVR and TAVR for the treatment of AS and its effect on inpatient outcomes. The survey estimation commands were used to determine weighted national estimates.

Results:
During the study period there were 3,443,274 (Males (M) 46.6 ± 0.1%; Females (F) 53.3 ± 0.1%) admissions for AS diagnosis, 325,264 SAVR (M 62.0 ± 0.2%; F 37.9 ± 0.2%) and 56,542 TAVR (M 52.6 ± 0.5%; F 47.3 ± 0.5%). The gender disparity was more prominent in Whites (Wh) than Non-whites (NWh) for both SAVR (Wh M 62.7 ± 0.2%, Wh F 37.2 ± 0.2%; NWh M 57.3 ± 0.5%, NWF 42.6 ± 0.5%) and TAVR (Wh M 53.1 ± 0.5%, Wh F 46.8 ± 0.5%; NWh M 47.2 ± 1.3%, NWh F 52.7 ± 1.3%). Female TAVR patients were older and more likely to have Medicare but less likely to have diabetes, chronic kidney disease (CKD), peripheral artery disease (PAD), prior coronary bypass surgery (CABG) and percutaneous coronary intervention (PCI), and chronic obstructive pulmonary disease (COPD). They also had lower Charlson comorbidity index (CCI). However, female TAVR patients had higher inpatient deaths (OR = 1.34;1.09-1.64), bleeding (OR = 1.51; 1.40-1.62) and stroke (OR = 1.47; 1.16-1.88), but a lower rate of pacemaker implantation (0.86; 0.76-0.97) and acute renal failure (ARF) (OR = 0.78; 0.71- 0.87). SAVR females were older, more likely to have Medicare, hypertension, and heart failure but less likely to have diabetes, CKD, PAD, prior CABG and PCI, and COPD. They also had lower CCI. SAVR female patients had higher inpatient deaths (OR = 1.40; 1.29-1.53), pacemaker implantation (OR =1.19; 1.11-1.28), blood transfusion (OR = 1.40; 1.35-1.45), and stroke (OR =1.19; 1.08-1.30), but lower ARF (OR = 0.80; 0.76-0.83).

Conclusion:
A gender disparity in the management of aortic stenosis continues to exist; however, our study showed that TAVR appears to bridge this gap. The reduction in gender disparity was most pronounced among Non-white patients. Despite having less comorbidities, outcomes after both SAVR and TAVR remain worse in women.
Abstract 280: Ambient Air Quality And Cerebrovascular Disease Outcomes Among Older Adults
Authors: Aitken William
Published: May 2020

Introduction:
Air quality is a major environmental determinant of health, especially among adults living in areas with high levels of air pollution. Given our world’s aging population and increasingly dynamic climate, better understanding the relationship between ambient air quality and cerebrovascular disease outcomes among older adult is increasingly important.

Objective:
To document the relationship between air quality, as measured by particulate matter (PM 2.5) and cerebrovascular disease outcomes, measured by stroke death rates among older adults in the United States.

Methods:
The CDC Wonder database was used to retrieve Environmental Protection Agency's Air Quality System annual average ambient concentrations of PM2.5 and National Center for Health Statistics (NCHS) stroke death and total cardiovascular death rates by county across the United States. Spearman correlation was used to analyze the relationship between these variables.

Results:
Nationally, average ambient concentration of PM2.5 ranged from 3 to 19.7 μg/m3 with a mean of 9 μg/m3 ± 1.9 μg/m3 among 3,108 counties reporting data. Particular matter concentrations had a moderately positive relationship with stroke death rates (0.44, p<0.01) and total cardiovascular death rates (0.45, p<0.01) among adults over age 65.

Conclusions:
Our analysis of ambient air quality and cerebrovascular as well as total cardiovascular death rates demonstrates a moderate correlation between fine particulate matter and poor outcomes. Our data further demonstrates a number of US counties exceed World Health Organization fine particulate matter guidelines. These findings provide compelling evidence for both increased efforts towards improvement of air quality and mitigation strategies to prevent associated negative health outcomes.
Abstract 281: A Network Meta-analysis Exploring High-intensity Atorvastatin In Contrast Induced Nephropathy
Authors: Saith Sunil
Published: May 2020

Introduction:
The utility of pre-procedure statins prior to coronary angiography has been utilized as an adjunct in the prevention of contrast-induced nephropathy (CIN). This has been attributed to the pleotropic and anti-inflammatory effects of the statin. Whether there is a dose and intensity dependent effect on the prevention of CIN is unknown.

Methods:
We performed a hierarchical network meta-analysis on all published randomized-controlled trials up to March 2020 to determine whether high-intensity atorvastatin (40mg or 80mg) was superior to lower intensity atorvastatin (20mg or less) and high-intensity or low-intensity statins. We searched PubMed, MEDLINE, Embase, Web of Science and Cochrane database for randomized-controlled studies without restriction to language. Studies published in Chinese was translated using Google Translate. Network meta-analysis was performed using NetMetaXL version 1.6.1.

Results:
We analyzed 49 trials, comprised of 13,395 patients, comparing five arms of treatment: Moderate/High intensity atorvastatin, Low intensity atorvastatin, Moderate/High intensity other statin, Low intensity other statin and None. There were 1,029 events for CIN (7.68%). In pairways comparisons, Moderate/High intensity atorvastatin reduced CIN by 0.70 (95% CI: 0.54-0.91) when compared to placebo. When compared to Moderate/High intensity other statins, the difference was not statistically significant (95% CI: 0.50-1.08).

Conclusion:
Moderate to High Dose Atorvastatin was not superior to other statins in prevention of CIN. Further investigation into the anti-inflammatory properties of statins may be helpful in understanding the role of statins as adjunct treatment to standard of care in preventing CIN.
Abstract 288: The Veterans Affairs Patient Reported Health Status (PROST) System: An Interim Analysis
Authors: Hess Paul L , Plomondon Dennis , Plomondon Mary E , Nuriyeva Maryam , McCreight Marina , Ayele Roman , Rohs Carly , Glasgow Russell E , Rabin Borsika A , Ho P. M , Bradley Steven M
Published: May 2020

Introduction:
Elective percutaneous coronary intervention (PCI) for stable angina is intended to reduce symptoms and enhance quality of life. However, measures of patient-reported health status are not yet routinely collected or used.

Methods:
We developed a telephonic interactive voice response (IVR) system to capture patient-reported health status measures before and after PCI in the Veterans Affairs (VA) Health Care System. The IVR system calls patients to collect Seattle Angina Questionnaire 7 and Rose Dyspnea questionnaire data 1 month prior to PCI and 1 and 6 months after PCI. Reports are provided to primary care and cardiology providers for patients who experience a significant change in health status. We performed a multi-method, interim analysis of sequential roll-out of the IVR system at 6 VA centers, including quantitative process data; semi-structured interviews with 13 patients; and chart review of all patients who experienced a decrement in health status.

Results:
Of 2,113 patients undergoing elective PCI from November 28, 2015, until September 31, 2019, health status data were collected from 692 (32.7%) prior to PCI, 457 (66.0%) 1 month after PCI, and 59 (8.5%) 6 months after PCI (
Figure 1
). A total of 83 (18.0%) decrements in health status occurred. In response, 10 (12.0%) clinical actions were recorded in the medical record: 4 (4.8%) patients were called by providers, 2 (2.4%) had their medication regimen reviewed, 3 (3.6%) had their case reviewed by their primary care provider and/or an interventional cardiologist, and an outpatient clinic visit was scheduled earlier than planned for 1 (1.2%) patient. Many patients did not remember receiving a telephone call; others were “fine” with receiving a call and filling out a survey. Some expressed difficulty with completing the survey owing to a lack of technical literacy or difficulty with hearing. Some patients were reassured by a telephone call, saying “That’s good, because it lets me know that I haven’t slipped through the cracks. It builds confidence that they know how I’m feeling before a procedure.”

Conclusions:
It is feasible to capture patient-reported measures of health status in the real world and integrate their use into routine clinical care. Opportunities to improve the collection and use of patient-reported health status measures persist.
Abstract 289: Variation In 24-hour Physical Activity Patterns By Demographic And Psychological Factors In Women With Myocardial Infarction
Authors: Park Chorong , Larsen Brittany A , Xia Yuhe , Reynolds Harmony R , Spruill Tanya M
Published: May 2020

Introduction:
Despite the importance of physical activity (PA) for cardiovascular health, there is a scarcity of data on objectively measured PA in women with myocardial infarction (MI). We aim to describe 24-hour PA patterns and examine their variation by demographic and psychological factors in women with MI.

Methods:
Participants were enrolled in an ongoing multicenter trial of stress management in women with a history of MI. Participants completed self-reported psychological measures and 7-days of wrist-actigraphy monitoring (GT3X, Actigraph) at baseline (≥2 months post-MI). PA volumes were defined as the average vector magnitude (VM) counts per minute (cpm), a metric incorporating movement across all three axes of the accelerometer. This approach minimizes loss of information related to use of cut-points and describes accumulated 24-hour PA volumes. Hourly VM cpm were plotted to visualize 24-hour PA patterns and compared by age groups, race, elevated depressive symptoms (Patient Health Questionnaire-9 ≥5), and high stress levels (top quartile of Perceived Stress Scale-10). Due to the skewness, VM cpm were log-transformed and linear regression analysis was conducted to identify correlates of overall 24-hour PA.

Results:
Analyses included 85 participants (age = 59.9 ± 13.0, 20% African American, 16% participating in cardiac rehabilitation, 70% elevated depressive symptoms, 25% high stress). Patterns of PA across 24 hours differed by age, race, stress and depressive symptoms (Figure 1). For example, African American women with MI had peak PA later in the day than non-African American women, and less PA overall. Women with high (vs. low) stress had less PA overall and a less pronounced evening drop in PA, which may affect sleep. Those with elevated (vs. low) depressive symptoms showed lower PA levels, especially during the late afternoon and evening. After adjusting for age, race and cardiac rehabilitation, overall 24-hour PA volumes (log of average VM cpm) were significantly lower with higher stress (b = -0.26, p = 0.02) and elevated depressive symptoms (b = -0.22, p = 0.04).

Conclusion:
These findings may be considered to identify women with MI who may benefit from interventions to increase PA, which could reduce risk of recurrent CVD. Our data on timing of PA may be helpful in the tailored design of such programs.
Abstract 310: Variability in Patient-Reported Health Status by NYHA Classification: Implications for Clinical Trials
Authors: Tran Andy T , Chan Paul S , Jones Phillip G , Spertus John
Published: May 2020

Background:
A foundation of current clinical trials is to categorize the severity of heart failure (HF) by New York Heart Association (NYHA) classification to ensure that enrolled patients have similar disease severity. Because the NYHA represents a clinician’s assessment of patients’ health status, it may vary from patients’ perspectives and can lead to more or less symptomatic patients being enrolled in clinical trials. We sought to directly compare the ranges of patient-reported health status, as assessed by the well-validated and reliable Kansas City Cardiomyopathy Questionnaire (KCCQ), with NYHA class in recent clinical studies.

Methods:
We used data from 2 contemporary HF clinical trials, HF-ACTION in patients with Heart Failure with Reduced Ejection Fraction (HFrEF) and TOPCAT in patients with Heart Failure with Preserved Ejection Fraction (HFpEF), and 1 prospective cohort study, the KCCQ Interpretability study (KCCQINT) in patients with HFrEF, where both NYHA and the KCCQ were contemporaneously collected. The distributions of KCCQ Overall Summary (KCCQ-os) scores by NYHA and the variation in assigned NYHA classes among patients with KCCQ scores ≥80 (congruent with NYHA Class I) were then described.

Results:
A total of 6,072 patients (mean age 64±12 years, 41% female) were included across the 3 studies. Figure 1 shows marked overlap in KCCQ scores across NYHA classes. In KCCQINT, 148 (27%) out of 545 patients reported a KCCQ-os score ≥80, of whom 39 (26%), 81 (55%) and 28 (19%) were coded as NYHA Class I, II and III. None were classified as NYHA Class IV. In HF-ACTION, 677 (32%) of 2129 patients reported a KCCQ-os score ≥80, of whom 548 (81%), 128 (19%) and 1 (<1%) were coded as NYHA Class II, III and IV, respectively. In TOPCAT, 484 (14%) out of 3398 patients reported a KCCQ-os score ≥80, of whom 410 (85%) and 74 (15%) were considered NYHA Class I-II and III-IV, respectively.

Conclusions:
Although the NYHA is used to identify similarly ill patients for enrollment in clinical trials, there is marked variability within and across studies in patients’ self-reported health status. Future trials should consider patient-reported outcome measures as the basis for defining patient eligibility to enroll a more homogenous cohort of disease severity.
Abstract 320: Follow Through Heart Failure
Authors: Kamat Ishan , Harvey Alexander , Ghergherehchi Ali , Podany Emily , Ho Kim-Trang , Yang Matthew , Agrawal Neeraj
Published: May 2020

Heart failure decompensations accounts for over one million hospitalizations annually and are the most common cause of US hospital admission in patients over 65. While this results in a reduced quality of life for patients, hospital admissions within 30 days of discharge for heart failure are not reimbursed, making this patient population incredibly expensive for hospitals to treat. US expenditure on heart failure exceeds $30 billion annually and is projected to rise by 127% to nearly $70 billion by 2030 as the population ages. Scheduling a follow up appointment within one week of discharge has been shown to reduce rates of readmission. This quality improvement initiative is aimed at improving post-discharge follow up rates in a tertiary referral hospital. The affiliated follow up clinic uses a different electronic medical record (EMR) system, so a system of cross-communication is key. The initial intervention introduced an EMR order that, once placed in the inpatient setting, created an appointment request in the follow up clinic. The cardiology consult nurse practitioner was assigned and educated about the task of entering this follow up order. With this intervention, an increase the number of confirmed follow up appointments scheduled by discharge for patients admitted with acute decompensated heart failure was expected. The initial intervention of introducing an EMR order resulted in a median of 18 patient referrals per month over a period of 5 months. The intervention of introducing a dedicated nurse practitioner the task of placing the order resulted in an increase to 25 orders in the next month. Similarly, the percentage of completed referrals increased from 29% over 5 months to 44% in the last month when a dedicated nurse practitioner was tasked with placing the order for follow up. In recognizing the delicate process of discharging patients with heart failure decompensations, a unified process to organize follow up in a tertiary referral hospital was necessary to communicate with the affiliated clinic. This initial intervention shows promise that continuity of care can be established in an intricate medical system. Further interventions include better equipping the cardiology clinic with personnel to accommodate for the bolus of new post-discharge follow up appointments.
Abstract 321: Association of Specialist Physician Productivity With Trainee and Staffing Levels in the Veterans Health Administration
Authors: Kalwani Neil M , Heidenreich Paul A
Published: May 2020

Background:
The effect of trainee, associate provider, and support staff levels on physician productivity by specialty is unknown. In 2013, the Veterans Health Administration (VHA) introduced a program to measure specialist physician productivity at the practice level, defined as the total work Relative Value Units (RVUs) generated by the physicians in a practice divided by the number of clinical full-time equivalents (FTEs) attributed to that practice. Data from this program can be utilized to understand the effect of specialty practice features on physician productivity.

Methods:
We extracted physician productivity levels and the numbers of trainees, associate providers, administrative support staff, and clinical support staff from fiscal year 2019 workforce reports produced by the VHA Office of Productivity, Efficiency, and Staffing for practices in four representative specialties: cardiology, gastroenterology, neurology, and surgery. We used linear regression to identify associations between physician productivity and trainee and staffing levels, adjusting for the complexity group of included practices as some practices do not perform procedures.

Results:
A total of 122 cardiology, 112 gastroenterology, 118 neurology, and 123 surgery practices with at least 0.5 clinical FTE were included. Physician (practice) productivity ranged from 2153 to 12,497 (mean 6899) RVUs/FTE for cardiology, 1189 to 13,435 (mean 7080) RVUs/FTE for gastroenterology, 1753 to 11,322 (mean 4154) RVUs/FTE for neurology, and 1761 to 8792 (mean 4251) RVUs/FTE for surgery. Physician productivity was positively associated with the number of trainees per clinical FTE for cardiology [coefficient 818 (95% CI 260, 1376) additional RVUs/FTE] and surgery [coefficient 253 (95% CI 56, 451) additional RVUs/FTE] but not for other specialties. Only neurologist productivity was positively associated with the number of associate providers per clinical FTE [coefficient 1095 (95% CI 128, 2061) additional RVUs/FTE]. There were no significant associations between physician productivity and the numbers of administrative and clinical support staff per clinical FTE.

Conclusion:
There is significant variation in VHA physician productivity across practices within each specialty. Physician productivity is positively associated with the number of trainees in a practice for some specialties, including cardiology, suggesting that trainees in those specialties may enhance physician productivity. The relationship between physician productivity and trainee and associate provider ratios varies by specialty. These specialty-specific associations can inform efforts to improve VHA physician productivity.
Abstract 325: Prasugrel vs Ticagrelor for Dapt Therapy in Patients With Acs Undergoing Pci; A Systematic Review and Meta-analysis of Randomized Controlled Trials
Authors: Al-Abdouh Ahmad , Amr Mahmoud , Savji Nazir , Zhao Di , Hasan Rani K , Michos Erin D
Published: May 2020

Introduction:
Dual antiplatelet therapy (DAPT) with a P2Y12 inhibitor added to aspirin is considered the standard of care for patients with acute coronary syndrome (ACS) undergoing percutaneous intervention (PCI). Prasugrel and ticagrelor are commonly used P2Y12 inhibitors. However, few head-to-head randomized controlled trials have been performed to directly compare the efficacy and safety of these two agents when used in patients with ACS undergoing PCI.

Methods:
We searched PubMed/MEDLINE and Cochrane library. The primary endpoint was major adverse cardiovascular events (MACE). Secondary outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), stent thrombosis, major bleeding, and all bleeding event. Estimates were calculated as random effects risk ratios (RRs) with 95% confidence intervals (CI).

Results:
Six trials with 6807 patients were included [
FIGURE
]. There were no significant differences in MACE (RR 0.93; 95% CI [0.72-1.20]; p = 0.59; I
2
= 26%), all-cause mortality (RR 0.92; 95% CI [0.73-1.17]; p = 0.51; I
2
= 0%),cardiovascular mortality (RR 0.99; 95% CI [0.75-1.31]; p = 0.96; I
2
= 0%), MI (RR 0.87; 95% CI [0.60-1.27]; p = 0.48; I
2
= 27%), stent thrombosis (RR 0.64; 95% CI [0.39-1.04]; p = 0.07; I
2
= 0%), major bleeding (RR 0.94; 95% CI [0.70-1.26]; p = 0.68; I
2
= 6%), and all bleeding events (RR 0.92; 95% CI [0.77-1.09]; p = 0.32; I
2
= 0%) when ticagrelor was compared to prasugrel.

Conclusion:
There are no significant difference of MACE, all-cause mortality, cardiovascular mortality, MI, stent thrombosis, and bleeding between prasugrel and ticagrelor for DAPT in PCI for ACS based current clinical trial data. However, the most recently published and largest of these trials suggests a reduction in MACE. More such comparisons are warranted to inform clinical practice.
Abstract 331: Area Specific Differences for Quality of Care and Outcomes in Ischemic Stroke in China
Authors: Wang Meng , Li Zi-Xiao , Wang Chun-Juan , Yang Xin , Wang Yong-Jun
Published: May 2020

Background:
Former studies suggest differences in stroke care associated with race, age or gender. We sought to find whether such disparities existed in different areas in patients hospitalized with stroke among hospitals participating in the China Stroke Center Association.

Methods:
In-hospital mortality and 4 stroke performance measures among 660,225 patients admitted with ischemic stroke in the Eastern, Central and Western regions of China in the China Stroke Center Association between 2015 and 2019.

Results:
After adjustment for both demographics and diseases history variables, western patients had lower odds relative of receiving intravenous thrombolysis (Eastern: OR, 1.78; 95%CI, 1.72 to 1.84; Central: OR, 1.55; 95%CI, 1.50 to 1.60), early antithrombotics (Eastern: OR, 1.95; 95%CI, 1.90 to 1.99; Central: OR, 1.86; 95%CI, 1.81 to 1.90), dysphagia screening (Eastern: OR, 1.03; 95%CI, 1.01 to 1.04; Central: OR, 0.83; 95%CI, 0.81 to 0.84) and NIHSS (Eastern: OR, 1.18; 95%CI, 1.16 to 1.20; Central: OR, 1.50; 95%CI, 1.48 to 1.53). However, the in-hospital death was higher in eastern and central regions (Eastern: OR, 0.48; 95%CI, 0.43 to 0.54; Central: OR, 0.51; 95%CI, 0.45 to 0.57).

Conclusions:
Western patients with stroke received fewer evidence-based care processes than central or eastern patients. Quality of care improvement in stroke should be focused on the west. The high mortality of the east and central probably resulted in that better hospitals in these areas received more severe patients substantially.
Abstract 332: Racial Differences in Prescribing of Sodium Glucose Cotransporter-2 Inhibitors and Glucagon-like Peptide-1 Receptor Agonists Among Veterans With Type 2 Diabetes and Coronary Artery Disease: Findings From the Veteran’s Administration Clinical Assessment, Reporting, and Tracking Program
Authors: McNeal Demetria M , Peterson Pamela , Ho Michael M , Saxon David , Henderson Kamal H , Hess Paul , Valle Javier A , RAGHAVAN SRIDHARAN , Schwartz Gregory G , Salahuddin Taufiq , Richardson Vanessa
Published: May 2020

Background:
Recent trials have shown improved cardiovascular benefit associated outcomes with sodium glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) treatment in patients (pts) with type 2 diabetes (T2D) and high cardiovascular (CV) risk. We examined the extent to which this new evidence has been applied in routine clinical care and whether race influenced differences in prescription rates between patients.

Methods and results:
We used data from the US Department of Veterans Affairs’ Clinical Assessment, Reporting, and Tracking (CART) Program (2015-2017 inclusive). Pts were deemed SGLT2i- or GLP-1RA-eligible based on EMPA-REG OUTCOME and LEADER trial criteria. Rates of use were examined among eligible pts by race/ethnicity in unadjusted and multivariable logistic regression models adjusted for age, insurance type, service connection, and clinical site. From 84 sites, 21,053 patients were eligible for an SGLT2i and 1,520 (7.2%) had one prescribed. Recipients of SGLT2i were younger (65.59 years vs 68.29 years) had a higher mean HbA1c (8.27% vs 8.02%) and were more likely white (86.0 % vs 82.6%). Compared to black pts, whites had higher odds of receiving the medication, OR = 1.38; 95% CI 1.05,1.85; p < 0.01. Among 11,913 Veterans eligible for an GLP-1RA, 477 (4.0%) had one prescribed. Recipients were younger (65.84 years vs 68.96 years), had a higher mean HbA1c (8.55% vs 8.09%) and were more likely white (83.6% vs 81.8%). Compared to black pts, whites had higher odds of receiving the medication, OR = 1.43; 95% CI 1.09, 1.92; p = 0.013. Representation of other racial/ethnic groups was insufficient for comparison.

Conclusion:
Appropriate prescription of SGLT2i or GLP-1RA was less likely among black than white US Veterans at high CV risk. Our results suggest that while overall uptake of these medications has been slow, there are substantial racial differences that exist concerning the prescribing of these medications. In view of these findings, additional research is needed to further investigate both institutional and clinical factors which may adversely affect the prescribing of SGLT2i and GLP-1RA in African American Veterans.
Abstract 333: Cardiovascular Disease Risk Factor Disparities in the US Veteran and Civilian Population
Authors: Soofi Muhammad , Garg Swapnil , Markert Ronald , Agarwal Ajay
Published: May 2020

Background:
The mortality rate of US Veterans is greater than that of civilians, and US Veterans experience disproportionately higher burden of medical comorbidities. Disparities in coronary artery disease (CAD) incidence and its risk factors between US veterans and civilians has not previously been reported. This study seeks to identify disparities in the incidence of CAD and CAD risk factors in US veterans and the general population.

Methods:
A total of 1535 consecutive US Veterans presenting for left heart catheterization (LHC) were reviewed. We present risk factor burden, LHC outcome, and mortality with mean follow-up time of 112 ± 65.2 months.

Results:
At mean follow-up of 112 months (9.3 years), all-cause mortality was 68.3%. 12.7% had normal coronaries (NC), 14.9% had non-obstructive coronary artery disease and 72.3% had obstructive coronary artery disease (ObCAD). Mean BMI was 30.0; 87.8% had hypertension (HTN), 78.1% had hyperlipidemia (HLD), 52.2% has reduced ejection fraction (rEF), 45.5% had diabetes (DM), and 17.5% had chronic kidney disease (CKD). In order of decreasing Cox hazard, six risk factors (CKD, rEF, PVD, HTN, obesity and DM) were independent predictors of mortality.

Conclusion:
Mortality and incidence of ObCAD in US veterans are notably greater than in the American general population (per the CDC National Health Report) and other developed countries (per the WHO NCD Report). Compared to the general population, there is greater burden of HTN, HLD, DM and CKD in US Veterans. Among US Veterans, CKD carried a greater HR compared to HTN and DM, with no significant HR for HLD. This differs markedly from the general population studied in the REACH registry which established HTN, HLD and DM as the greatest predictors of cardiovascular mortality. The low hazard of HLD was likely secondary to its ubiquity in most patients in the cohort, regardless of CAD status. US Veterans have unique healthcare needs and our study guides which risk factors need to be managed to improve disparities in US Veteran health.
Abstract 338: Qtc Prolongation in Patients With Left Ventricular Heart Failure and Its Relation to Increased Mortality and Hospitalizations
Authors: Kapoor Anmol , Singh Amanpreet , Singh Armandeep
Published: May 2020

Background:
Cardiovascular disease (CVD) is the second leading cause of death among Canadians for decades. It is also no surprise that heart failure rates are on the rise. 600,000 cases of heart failure are diagnosed yearly in Canada. The aim of our investigation was to conduct a retrospective observational study to investigate if prolonged QTc intervals lead to increased re-hospitalization and mortality in patients suffering from Left Ventricular Failure.

Methods:
We performed an observational case series with a retrospective chart review of 356 CHARM clinic patients who have been diagnosed with Left Ventricular Heart Failure from August 2017 till June 2019. The primary endpoint was to look at patients with left ventricular Heart failure, QTc interval recorded and their files where verified from Alberta’s health care portal to see if re-hospitalizations increased and/or mortality happened. Pre-cautions taken not to include patients with Cardiac re-synchronization therapy and congenital prolonged QTc interval in the study. Patients in Group A were HF patients who had prolonged QTc interval and Group B HF patients with Normal QTc interval. Bazett formula was applied to the QT and correct to Heart rate accordingly.

Results:
The data from 356 patients with heart failure revealed the following Patients with Heart failure and prolonged QTc interval- 35% had re-hospitalizations while heart failure patients with normal QTc interval had a re-hospitalization rate of 13%. Mortality was also seen higher in Group A versus Group B. It must be noted that Medications that prolonged QT interval was also accounted for and notifications were made as to the presence of arrythmia in patients with increased QT intervals. Presence or increased incidence of arrhythmia there by leads to increased chances of mortality and re-admission. Group 1 had the consumption of medications that increased QT interval more prevalent that Group 2.

Conclusion:
Prolongation of QTc interval should be noted as an important prognostic factor into the re-admission and mortality rate of patients with heart failure as subtracting various flawing factors. Further resources and investigation should be conducted to truly figure out if QTc prolongation leads to mortality.
Abstract 339: Urban and Rural Patients Receive Different Care for Atrial Fibrillation
Authors: Zeitler Emily P , King Ashleigh C , Gilstrap Lauren , Austin Andrea
Published: May 2020

Background:
Atrial fibrillation (AF) accounts for substantial resource utilization that is expected to increase as the US population ages. Management strategies for AF vary widely based on patient preference, physician specialty training, available resources, and other factors, but the impact that geography has on treatment variations for AF is unknown.

Objective:
We seek to evaluate differences in AF patient characteristics and management between urban and non-urban Medicare beneficiaries.

Methods:
Our cohort included all Medicare fee-for-service beneficiaries meeting the CMS chronic conditions warehouse definition of AF from 2013-2017. Beneficiaries were designated as urban and non-urban by rural-urban commuting area codes. AF procedures were tabulated based on CPT codes. The use of AF related medications was tabulated based on prescriptions for drugs of interest in Medicare Part D.

Results:
During our period of interest, Medicare AF patients were average age 79 yrs, and 52% were female. Urban patients were more likely to be black and have chronic kidney disease, diabetes, and ischemic heart disease. The average CHADS2VA2SC score was high (4.90 SD 1.71) and not meaningfully different between urban and non-urban groups. Most advanced interventions for AF increased over time driven mostly by increases in AF ablation (Figure). However, compared with non-urban patients, urban patients were more likely to undergo AF ablation (1.81 vs 1.42%, p<0.001), Watchman implantation (0.15 vs 0.11%, p<0.001), and cardioversion (0.06 vs 0.05%, p=0.015). Non-urban patients were more likely to be prescribed amiodarone (7.08 vs 6.09%, p=0.002) and warfarin (8.84 vs 7.40%, p<0.001) compared with urban patients and were less likely to be prescribed a direct oral anticoagulant.

Conclusions:
Despite urban and non-urban Medicare patients with AF being similar with regard to demographic and clinical characteristics, treatment of AF varied in important ways between these groups. In general, urban patients were more likely to receive interventional care for AF which, in some cases, has known associated benefits with regard to quality of life, morbidity, and mortality. Further work is needed to understand differences in outcomes between these two groups and to develop policy solutions to reduce treatment disparities.
Abstract 353: Association Between Hospital Resuscitation Team Leader Credentials and Survival Outcomes for In-hospital Cardiac Arrest
Authors: Hejjaji Vittal , Chakrabarti Apurba , Nallamothu Brahmajee K , Iwashyna Theodore J , Krein Sarah L , Trumpower Brad , Kennedy Marci , Chinnakondepalli Khaja , Malik Ali O , Al-Badarin Firas , Chan Paul S
Published: May 2020

Background:
It is unclear if survival rates for in-hospital cardiac arrest (IHCA) vary across hospitals depending on whether resuscitations are typically led by an attending physician, physician trainee, or a non-physician. We sought to determine the association between resuscitation team leader credentials and IHCA survival.

Methods:
A nationwide survey was done in 2018 to elicit information on resuscitation practices across hospitals participating in the Get With The Guidelines-Resuscitation registry for IHCA. Using responses from the question of “Who typically leads codes at your institution”, we grouped hospitals based on their typical type of resuscitation team leader: attending physician, physician trainee, or non-physician. Responses from the survey were linked to survival outcomes within the registry. We compared risk-adjusted hospital rates of survival to discharge, return of spontaneous circulation [ROSC] and favorable neurological survival for 2015-2017 between these 3 hospital groups using multi variable hierarchical regression.

Results:
Overall, 193 hospitals had a minimum of 20 IHCAs and completed the study survey, representing a total of 44,477 IHCAs (mean age of 65.0 ± 15.5, 40.8% were females). Most hospitals had resuscitations led by physicians, with 121 (62.7%) led by an attending physician, 58 (30.0%) by a physician-trainee, and 14 (7.3%) by a non-physician. Risk-standardized rates of survival to discharge were similar across hospitals, regardless of whether resuscitations were typically led by an attending physician, physician trainee, or non-physician (25.6±4.8%, 25.9±4.7%, and 25.7±3.6%, respectively;
p
= 0.88). Similarly, there were no differences between the 3 groups in risk-adjusted rates of ROSC (71.7±6.3%, 73±6.3%, and 73.4±6.4%; P = 0.30) and favorable neurological survival (21.6±7.1%, 22.7±6.1%, and 20.9±6.5%; P = 0.50; Figure).

Conclusion:
Among hospitals in a national registry, IHCA resuscitations were usually led by physicians. However, there was no association between a hospital’s typical resuscitation team leader credentials and IHCA survival outcomes.
Abstract 354: Non-ST-Elevation Myocardial Infarction: Admissions, Rate, and Timing of Revascularization in The United States
Authors: Case Brian C , Yerasi Charan , Wang Yanying , Forrestal Brian J , Hahm Joshua , Dolman Sarahfaye , Weintraub William S , Waksman Ron
Published: May 2020

Objectives:
This study aimed to evaluate non-ST-elevation myocardial infarction (NSTEMI) rates, revascularization timing, and mortality rates using the Nationwide Readmissions Database (NRD).

Background:
Clinical trials have shown improved outcomes with reduced mortality with an early invasive approach for NSTEMI. However, real-world data are lacking.

Methods:
The study cohort was obtained from the 2016 NRD dataset. We used the International Classification of Diseases, Tenth Revision, to identify patients who underwent diagnostic angiography and subsequently received either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Finally, revascularization timing and mortality rates (in-hospital and 30-day) were extracted.

Results:
Our analysis included 748,463 NSTEMI admissions in 2016. Of these admissions, 50.1% (374,988) underwent diagnostic angiography with 38.9% (253,492) revascularized: 77.6% (197,945) PCI and 22.4% (57,254) CABG. Patients with more comorbidities tended to have more delayed revascularization. PCI was most commonly performed on the day of admission, 32.9% (65,155). This differs from CABG, which was most commonly performed on Day 3 after admission, 13.7% (7,823). The in-hospital mortality rate increased after Day 1 for PCI patients and after Day 4 for CABG patients, whereas 30-day in-hospital mortality for both populations increased as revascularization was delayed (Figure 1).

Conclusions:
Our study shows that mortality generally increased as revascularization was delayed, while sicker patients tended to have longer delays until revascularization. However, confounding variables prevent definite causal attribution. Randomized clinical trials are needed to evaluate whether very early revascularization (<90 minutes) is associated with improved long-term outcomes in high-risk patients.
Abstract 362: National Trends in Use of Sacubitril/valsartan
Authors: Ozaki Aya , Krumholz Harlan M , Mody Freny V , Jackevicius Cynthia
Published: May 2020

Background:
Sacubitril/valsartan (Entresto
®
), available since 07/2015 to treat heart failure (HF) with reduced ejection fraction, reduced HF morbidity and mortality in the PARADIGM-HF trial at a mean daily dose of 375mg. The recommended starting dose is 49/51mg BID with up-titration to the target maintenance dose of 97/103mg BID. The uptake and pattern of dosage up-titration of sacubitril/valsartan in the real-world setting is understudied. Therefore, we characterize sacubitril/valsartan utilization patterns over time.

Methods:
We conducted a population-level cohort study using the IQVIA National Prescription Audit database from 08/2016-07/2019. Primary variables included the number of prescriptions (Rx) dispensed over a 3-year period and the proportion of Rx in the most recent 1-year period by dose, Rx types, prescriber and patient.

Results:
Over 3-years, 3.3 million sacubitril/valsartan Rx were dispensed. The number of Rx/month increased 5.6-fold, from 30,454 Rx to 175,605 Rx. Cardiologists prescribed 59% of Rx. However, non-cardiologists had a greater increase (7.5-fold) in prescribing over time than cardiologists (4.9-fold). During the most recent year, 49% of Rx were for the lowest dose of 24/26mg, followed by 31% for the intermediate 49/51mg dose, and 21% for the highest 97/103mg dose. There were more refill Rx than new Rx for all doses. For higher doses, more Rx were written by cardiologists than non-cardiologists (49/51mg: 59% vs. 41%; 97/103mg: 59% vs 41%, for cardiologists vs. non-cardiologists, respectively) (p<0.0001). There were fewer Rx for the target dose (97/103mg) in the oldest age than the youngest age category (11% for age 85+ vs. 24% for age 40-64 years).

Conclusions:
In the real-world setting, only 1 in 5 sacubitril/valsartan Rx dispensed in 2018/19 were for the target dose of 97/103mg with even lower use in the elderly population. The number of Rx prescribed by non-cardiologists has increased steeply, yet higher doses were prescribed more often by cardiologists. Given that these lower doses may not provide the same clinical benefits shown with higher doses in the PARADIGM-HF trial, identification of barriers or risk factors for underdosing of sacubitril/valsartan and its clinical implications warrants further evaluation.
Abstract 364: Evaluating the Impact of Economic Disparities on the Distribution of Wearable Cardioverter-defibrillator in Patients Post Myocardial Infarction With a Reduced Ejection Fraction
Authors: Grant Jelani , Patil Rhea , Mackenzie Colin , Costa-Fernandes Gilson , Olarte Neal , Jacobs Mark , Colombo Rosario A , Sancassani Rhea
Published: May 2020

Background:
Current guidelines recommend wearable cardioverter-defibrillator (WCD) for primary prevention of sudden cardiac death (SCD) in patients with ischemic cardiomyopathy and ejection fraction (EF) less than 35% if they are within 40 days of an ischemic event or within 90 days if revascularized. We sought to assess what impact economic factors have on determining which patients receive a WCD and their post-discharge outcomes.

Methods:
This is a single-center, retrospective cohort study investigating outcomes in patients admitted for myocardial infarction at a large, academic, tertiary referral center, who qualified for WCD over an 18-month period. Patients were stratified based on if a WCD was received or not upon discharge. Demographic, clinical, and diagnostic cardiovascular information, including EF, were obtained. Low income patients were identified as living in an area where median household income is less than $30000 annually.

Results:
Fifty-four patients were included in this study and mean age of all patients was 62.5 (± 10.19) years old. The mean EF was comparable between those discharged with versus without a WCD (24.88 ± 7.13 and 24.5 ± 7.5, respectively; p=0.860). Patients who were discharged without a WCD were more likely to be self-pay or receiving Medicaid (3.6% vs 38.5%; 17.9% vs 23.1%), and more likely to come from a low-income area (47.36% vs 55.55%). During a follow up period of 40 and 90 days, the mortality in those without WCD trended to be higher, approaching statistical significance (p = 0.09). Two patients from each cohort received an ICD following the defined period.

Conclusion:
The current WCD guidelines were based on observational studies. The results from the first randomized control trial investigating WCD use (VEST trial) have led to questions regarding its actual benefit. However, important limitations to VEST include low WCD usage, and non-compliance to wearing the WCD. Here we have demonstrated that WCD use in patients with immediate post-infarct cardiomyopathy with reduced EF trended towards improved mortality. Economic factors negatively impact who receives this life-saving device. Future directions from our study include stratifying patients based on severity of disease (e.g. severely reduced EF (<25%), evidence of new onset reduced EF and prioritizing patients likely to be more compliant). More studies are needed to further investigate economic disparities associated with use of the WCD.
Abstract 367: Are We Over-utilizing Echocardiogram for the Evaluation of Syncope Patients?
Authors: Aggarwal Ankita , Jain Anubhav , Sourabh Sourabh , Goel Mishita , Zaidi Warda , Gill Rumeet , Al-Fityan Mohammad , Kumar Sarwan
Published: May 2020

Background:
Syncope is one of the most common reasons for emergency department visits. The most common causes of syncope include vasovagal, orthostatic, neurogenic and cardiogenic. In some cases, history and physical examination can point towards a specific cause. While in most cases, history and physical alone are insufficient to indicate an obvious etiology. Patients with cardiogenic syncope have an increased rate of all-cause mortality as well as mortality associated with cardiovascular events. The risk of missing these serious conditions often results in low-risk patients being admitted for further workup and undergoing extensive investigation including a transthoracic echocardiogram (TTE). However, the utility of such testing including TTE in patients with a negative initial evaluation with history, physical exam and ECG is uncertain. The aim of this study was to assess the utility of TTE in the evaluation of patients admitted with syncope with an initial negative evaluation

Methods:
It is a retrospective study. Data was collected from all the patients admitted to the hospital for the workup of syncope from January to October 2019. Baseline characteristics including age, sex and ethnicity were collected for each patient. Data was also collected in regard to their significant cardiac past medical and family history. History of present illness and physical examination at the time of admission was noted. Patients were divided into two groups based on if the medical evaluation indicated a cardiogenic etiology. Cardiac testing data including EKG and TTE were included in the analysis. Abnormal EKG was defined by the presence of bradycardia, arrhythmia, QT prolongation, bundle branch blocks, heart blocks and left ventricular hypertrophy. Positive TTE findings were defined as low ejection fraction, significant left ventricular outflow tract obstruction, significant valvular abnormalities, wall motion abnormality and presence of pericardial effusion. Collected data were analyzed using Chi-square test and multiple linear regression.

Results:
The mean age of the study group was 72 years with 45% of males. Out of the total of 93 patients included in the study, 57(61%) patients had a TTE done. Out of this only 10(17%) patients had positive TTE. Only 2 patients with positive TTE had a negative EKG. In these two patients, the history was, however suspicious for cardiogenic syncope. A significant association of positive TTE findings with abnormal EKG (p-value: 0.003) was found. The odds of having a positive TTE finding when the EKG was negative was only 6%. These results remained significant with multiple linear regression analyses.

Conclusions:
TTE is being overutilized in the evaluation of patients presenting with syncope to rule out cardiac etiology. A thorough history and complete physical examination along with the basic cardiac testing including EKG can help reduce the overutilization
Abstract 372: Ischemic Evaluation in the Ed: Low BOSS Score Associated With Higher Readmission Rates
Authors: Eisinger Gregory , Slivnick Jeremy , Shaver Adam , Sheets Evan , Silkowski Molly , Trovato Vincenzo , Harfi Thura , Bradley Elisa A , Milks Michael W
Published: May 2020

Background:
The ideal diagnostic test for suspicion of CAD in the emergency department (ED) is unknown. We developed the
Buckeye Optimality Stress Score
(BOSS) to assess ischemic evaluation (IE) appropriateness and impact on ED readmission.

Methods:
The BOSS score assigns points for each type of IE based upon published guidelines. We retrospectively calculated the BOSS score on all ED patients with IE orders (8/2017-11/2017). IE orders were assigned a category of
optimal
vs.
suboptimal
reflecting whether or not the IE with the highest BOSS score was used (
optimal
) or not (
suboptimal
).

Results:
In total, 251 patients were referred from the ED for IE (54 ± 12 years old, women 132 (53%)) of which 182 (73%) had a suboptimal BOSS score. The modality most likely to be optimal was CTA, accounting for 29 (44%) of all IE orders. Patients with diabetes, HTN and CAD were more likely to have a suboptimal BOSS. Cardiology was consulted in 75 (30%), and this was associated with higher CTA IE orders (26 (36%) vs. 26 (15%), p<0.001). Re-presentation to the ED was more likely in those with a suboptimal BOSS on initial IE order (11 (6.1%) vs. 0 (0%), p<0.04).

Conclusion:
The majority of IE orders from the ED received a suboptimal BOSS, perhaps indicating a gap in understanding of current IE guidelines. These patients were more likely to return to the ED for continued symptoms. Further prospective study of the utility of BOSS score in predicting recurrent presentation and subsequent testing is warranted.