bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 235: Revascularization Patterns of Systolic Heart Failure in a Large Urban County Hospital
Authors: Scoma Christopher , Berger Kimberly , Vigen Rebecca , Das Sandeep
Published: March 2022

Background:
Coronary angiography is frequently performed after the initial diagnosis of heart failure to determine etiology and revascularization strategy. Current body of evidence suggests that surgical revascularization conveys a mortality benefit as compared to medical therapy alone, and the role of percutaneous coronary intervention (PCI) is not yet established. The aim of this study is to describe revascularization patterns among patients presenting with systolic heart failure who underwent diagnostic angiography at a large urban county hospital.

Methods:
We evaluated patients presenting to the emergency department with symptomatic heart failure with reduced ejection fraction (HFrEF) without acute coronary syndrome (n=150; average left ventricular ejection fraction of 25%) who underwent coronary angiography between January 2011 and January 2015. We defined surgical coronary artery disease (CAD) as: 1) three-vessel disease, 2) two-vessel disease including the proximal LAD artery, or 3) two-vessel disease including the left main coronary artery. Primary outcomes included intervention (PCI, CABG, or medical therapy [MT] alone) as well as referral for CABG.

Results:
Of patients presenting with HFrEF who underwent diagnostic angiography, 80% (n=120) of patients had obstructive CAD with 36% (n=43) of those patients having surgical CAD. Of those with surgical CAD, 74% (n=32) underwent PCI, 18% (n=8) underwent CABG and 7% (n=3) received MT alone. Of patients with 1-vessel CAD, or 2-vessel CAD without involvement of the proximal LAD artery or left main coronary artery, 81% (n=63) underwent PCI while 19% (n=14) received MT alone.

Conclusion:
Patients presenting with symptomatic HFrEF referred for cardiac catheterization have a high prevalence of obstructive CAD. Most patients with evidence of either surgical or non-surgical CAD during coronary angiography underwent revascularization, with PCI being the dominant revascularization method.
Abstract 243: Contrast Induced Nephropathy; Out of Sight, Out of Mind
Authors: Lawson William E , Wilbert Lisa , Musani Muzammil , Gumersell Kellie , Leippert Yvonne , Pyo Robert
Published: March 2022

Objectives:
Same day cardiac interventions are increasing; concerns that are not immediately apparent may be neglected. We sought to determine if pts at higher risk of contrast nephropathy are identified, appropriately treated and followed.

Background:
Contrast induced nephropathy [CIN] impacts on mortality risk; ranging from transient renal impairment with full recovery, to cumulative impairment, to renal failure and the need for permanent dialysis. Preprocedural modifiable [hydration status, contrast reexposure <72 hrs, nephrotoxic medications], partially modifiable [hypotension & heart failure], and non-modifiable [baseline renal function [eGFR<60], age >75 yrs] risk factors influence risk. Procedural factors [contrast volume, hypotension, IABP patients] increase risk. CIN risk is decreased by optimizing risk factors and hydration, minimizing contrast. Post procedure the Mehran CIN predictor is calculated and a 48 hr post IP or 7 day OP creatinine is obtained to identify CIN.

Procedure:
From 2016-17 pts undergoing interventional procedures exceeding the lab standard for radiation exposure were selected for review as representing a cohort likely to have increased contrast exposure.

Results:
There were 3,996 procedures [2,436 diagnostic, 1,560 interventions] performed in the reviewed period. Of 56 outlier pts, 11 were treated for structural heart disease and 45 underwent coronary angioplasty. Pre procedure risk factors included: age >75 [19/56], DM [19/56], HF [25/56], CKD 3 [12/55; 1 pt on HD]. Opportunities for decreasing contrast: LV gram 7/45, prior contrast exposure within 72 hrs 5/45, multivessel intervention 15/45. Few [7/45] of the pts received periprocedural hydration as recommended by the EHR power plan [cited reason heart failure 25/45]. Contrast use was as high as 475 cc; use of biplane imaging was infrequent. The Mehran CIN risk score was low in 13/55 [7.5% CIN/0.04% HD], intermediate in 36/55 [14.0% CIN/ 0.12 HD], high in 7/55 [26.1-57.3% CIN/ 1.09-12.6% HD]. Pre procedure creatinine was not available in 1 pt and volume of contrast administered undocumented in another pt. 48 hr creatinine was documented in 33/56 pts; 10 of the 33 pts developed post procedure CIN.

Conclusions:
Shortened hospitalizations decrease the awareness of and preventive treatment for CIN. A multidisciplinary team has identified multiple opportunities for practice improvement: provider education, review of the EHR power plan [for modification of pre and intraprocedural risk factors, implementation of correctly dosed fluid repletion with renal consultation for high risk patients, appropriate follow-up of creatinine], Preprocedural calculation and intraprocedural monitoring to achieve low risk contrast volume [(ml)/eGFR <3.7}, interventional report embedding CIN risk score, EHR tracking and audit to ensure implementation with appropriate feedback as necessary.
Abstract 244: ECG Recording Errors Prevalence in a Hospital Setting
Authors: Awan Mohammad , Omar Mazen , Omar Bassam A , Malozzi Christopher , Awan G. Mustafa
Published: March 2022

Background:
Electrocardiographic recording can have many potential errors due to erroneous recording which may impact their proper interpretation and patient care.
OBJECTIVE:
To assess the prevalence of reported ECG errors in a university hospital database with a mix of inpatient and outpatient electrocardiograms (ECG).

Methods:
The 1212 ECGs performed during one month were downloaded and individually analyzed for reported errors and artifacts. There were 309 (25.5%) outpatient ECGs and 903 (74.5%) inpatient or emergency department ECGs. The types of errors are reported as absolute numbers and as percentages of the total errors.

Results:
Among 1212 ECGs analyzed, 71 ECGs (5.9%) contained error or artifact statements. Among those, 12 ECGs (16.9%) were precordial lead misplacements. There were 2 ECGs (2.8%) with limb lead reversals. A total of 57 ECGs (80.3%) contained baseline artifacts; 12 ECGs (16.9%) had AC noise artifacts, and 45 ECGs (63.3%) had baseline wander artifacts. Out of the total ECGs with reported errors, 60 ECGs (84.5%) were performed in the inpatient or emergency department setting, while 11 ECGs (15.5%) were performed in the outpatient setting.

Discussion:
Electrocardiography remains the cornerstone of early diagnosis and treatment of cardiac disease in the inpatient and outpatient setting. ECG recording artifacts have been reported with variable frequency, with inpatient recordings likely suffering greater errors, depending on the acuity of the situation. We observed that in the outpatient setting, there was 3.6% (11/309) prevalence of recording error, while in the inpatient and emergency department setting there was 6.6% (60/903) prevalence of ECG recording errors. Despite the overall small percentages, this is an alarming problem, especially with regards to inpatient ECGs when the results often prompt critical treatment decisions. The reason for the discrepancy between inpatient and outpatient ECG errors is not clear. Potential causes may include the intensity of the situation with compromise of proper lead placement, such as use of Mason-Likar configuration or placing leads above the left breast in female patients or unavailability of proper recording surfaces as in trauma or burn patients, but may also be caused by the lack of availability of adequately trained staff especially in the after-hour situations. Adequate training of staff to perform proper ECGs, and creation of robust electrocardiographic interpretation algorithms to recognize more recording errors on-screen before printing is called for.
Abstract 246: Single Center Study of Statin Use Among Renal Transplant Recipients
Authors: Nestasie Michael , Madhana Kumar Aarthi , Doyle Mark , Poornima Indu G
Published: March 2022

Background:
Cardiovascular disease accounts for 50-60% of deaths among renal transplant recipients. Based on the ALERT trial, 2013 Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommend statin treatment in adult renal transplant recipients. The rate of statin prescription in the renal transplant recipients is ill-defined. The aim of our study was to assess the rate of statin use, and its predictors among renal transplant recipients, in a single tertiary care center. For comparative purposes we also obtained data on aspirin use, another common cardiac preventive therapy.

Methods:
By retrospective chart review we collected the following data on patients who underwent renal transplantation in the year 2015 and 2016: demographics, history including hypertension, diabetes mellitus (DM), smoking, coronary artery disease (CAD) and coronary revascularization. In addition, data on the following variables were recorded pre- and post-transplantation: lipid profile, use of statin and non-statin medications along with dose, statin allergy, liver disease, immunosuppressant class and dose and aspirin use. For all parameters, the latest post-transplant data (until December 2017) was included.

Results:
A total of 233 patients were included: median age of 58 (21-79) years, male 66.5%, DM 47%, hypertension 93%, CAD 22%, revascularization 12%, statin intolerance 2% and liver disease 9%. There were 80 (34%) patients on a statin pre-transplant and 95 (41%) patients were on post-transplant. Of 153 patients not on statin pre-transplant, 28 were initiated on a statin post- transplant. Of 80 patients on statin pre transplant, 67 remained on statin post- transplant. Overall, there was 18% increase in patients on statins post- transplantation. Among patients with CAD, 36/52 (69%) patients were on a statin pre-transplant and 40/52 (77%) post-transplant. Among those with diabetes, 54/110 (49%) were on a statin pre-transplant and 62/110 (56%) post- transplant. In comparison, 123 (53%) patients were on aspirin pre-transplant and 165 (70%) patients were on it post-transplant. Based on logistic regression model, the predictors of statin prescription pre-transplant were DM and revascularization, and post -transplant was increasing age, DM. Use of specific class of immunosuppressants did not affect prescription of statin. Lipid panel was only available for 30% of patients pre-transplant and 40% post-transplant.

Conclusion:
In this high risk cohort, a significant proportion of patients who were statin eligible including diabetics, were not prescribed statin. Less than half of renal transplant recipients had a lipid panel documented pre and post- transplant. Patterns of use of cardioprotective medications in the renal transplant population, and its relation to renal and cardiac outcomes needs further study.
Abstract 249: Quality of Medical Advice Provided Online Between Anonymous Members of a Message Board for Implanted Defibrillator Patients
Authors: Knoepke Christopher , Slack Daniel H , Matlock Daniel , Marzec Lucas
Published: March 2022

Background:
As therapeutic interventions across medicine increase in complexity, most patients use the internet to research health issues to inform decisions, including whether or not to accept certain tests, medications, or devices. Online information is available any time and can be reviewed indefinitely by patients, filling some educational needs outside of appointments with care providers. The quality of information patients encounter online varies, and we found no models for examining anonymously-created medical advice in extant literature. We used implanted defibrillator (ICD) treatment, characterized by patient educational and supportive needs across the trajectory of care, as a model. We sought to characterize the quality of medical information provided between commenters on a typical patient-facing internet message board discussing ICDs.

Methods:
Two years’ of discussions appearing on a dedicated message board for ICD patients were qualitatively analyzed using a mixed-deductive framework. Discussions were first analyzed for instances in which members provided medical advice. This advice was then characterized for 1) topical area and 2) quality.

Results:
We identified 82 instances of medical advice within 127 discussions. Advice covered six topical areas: 1) Device Information, 2) Programming, 3) Cardiovascular Disease, 4) Lead Management, 5) Activity Restriction, and 6) Management of Other Conditions. Across all advice, 50.0% was deemed Generally Appropriate, 24.4% Inappropriate for Most Patients, 6.1% Controversial, and 19.5% Without Sufficient Context. Proportions of quality categories varied between topical areas. Representative examples of advice provided between members will be included.

Conclusions:
Patients use online medical information to understand conditions and treatment options. A number of efforts have been made to understand the quality of professionally-created educational content, while ours describes the quality of advice being provided between anonymous members of an online message board. The quality of advice varied considerably, both by topical area and the specificity of advice. This analysis provides a methodologic model by which to describe the quality of patient-generated material available online.
Abstract 263: Assessment of the Relationship Between Body Mass Index and Atherosclerotic Cardiovascular Disease Risk in a University Based Residency Training Program: A Quality Improvement Initiative
Authors: Chang Eric Y , Farooq Amina , Stevens Elyse S , Bakinde Nicolas
Published: March 2022

Background:
The obesity epidemic is a significant health concern, affecting nearly a third of all United States citizens according to the 2013-2014 National Health and Nutrition Examination Survey. Obesity contributes to multiple metabolic and cardiovascular risk factors including diabetes mellitus, hypertension, and dyslipidemia. The atherosclerotic cardiovascular disease (ASCVD) risk calculator is a frequently used tool that aggregates various risk factors to assist physicians in detecting patients that may benefit from statin therapy and risk factor modification. However, this calculator does not directly factor in obesity, which has been found to be associated with multiple cardiovascular comorbidities. Our goal was to assess the correlation between body mass index (BMI) and ASCVD risk scores in order to identify potential targets for intervention to further decrease ASCVD risk.

Methods:
We obtained data from the medical record data warehouse of a primary care outpatient clinic predominantly run by internal medicine residents within a large safety-net hospital from January to December 2015. Patients with a diagnosis of dyslipidemia or hyperlipidemia were identified and electronic medical records were reviewed. ASCVD risk scores were calculated using the American College of Cardiology ASCVD risk estimator. Linear and logistical regression analyses were performed using SPSS software to assess the correlation between BMI and ASCVD risk.

Results:
The patient population was predominantly African American (92%, 1771 of 1919). Obesity (BMI ≥30) was present in 63% (1207 of 1919) of patients. ASCVD scores could be calculated for 914 patients and 90% (823 of 914) of these patients had ASCVD risk scores ≥7.5. However, only 84% (691 of 823) of these patients with elevated ASCVD scores were on a statin. Analyses did not reveal a correlation between BMI and ASCVD risk. However, elevated BMI (>25) conferred an increased odds ratio (O.R.) of having elevated ASCVD risk (>22.5% O.R. 1.58; p value 0.02) in comparison to normal or underweight BMI.

Conclusion:
Obesity rates appear to be higher in our patient population in comparison to national estimates but our mathematical model cannot be used to explain any correlation between BMI and ASCVD risk scores. Obesity did not confer an increased ASCVD risk in comparison to being overweight (BMI 25-29.9). However, both overweight and obese patients had a higher likelihood of having a significantly elevated ASCVD risk score. Future aims include initiating a targeted educational intervention for residents in the continuity clinic to ultimately demonstrate that resident driven intervention is an effective way to address obesity and modify ASCVD risk.
Abstract 27: Anti-Anginal Medication Titration Among Patients With Residual Angina 6-Months After Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From OPEN CTO Registry
Authors: Sheehy Justin P , Qintar Mohammed , Arnold Suzanne V , Sapontis James , Jones Phil , Tang Yuanyuan , Lombardi William , Karmpaliotis Dimitiri , Moses Jeffrey W , Patterson Christian , Cohen David J , Amin Amit P , Nicholson William J , Spertus John A , Grantham J A , Salisbury Adam C
Published: March 2022

Background:
Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) effectively reduces angina symptoms and improves quality of life, but the frequency of new or residual angina (RA) in follow-up after CTO PCI and its relationship with titration of anti-anginal medications (AAM) has not been described.

Methods:
In consecutive CTO PCI patients treated at 12 centers in the OPEN CTO registry, angina symptoms were assessed 6 months after the index PCI using the Seattle Angina Questionnaire (SAQ) Angina Frequency scale (a score <100 defined new or residual angina). AAMs were recorded at discharge and 1 and 6 months after the index CTO PCI. AAM escalation was defined as an increase in the number or dosage of AAMs between discharge and 6-month follow-up. The proportion of patients who had escalation of AAM by 6-month follow-up was compared among those with and without 6-month angina, and analyses were repeated after stratification by the ultimate technical success of their CTO PCI (including follow-up procedures), achievement of physiologically complete revascularization during the index procedure, and presence or absence of angina at baseline.

Results:
Of 901 patients undergoing CTO PCI, 197 (21.9%) reported angina at 6-months. Of patients with RA, 54 (27.4%) had de-escalation, 118 (59.9%) had no change, and 25 (12.7%) had escalation of their AAM by 6 month follow-up. Although patients with residual angina were more likely to have escalation of AAMs, only 12.7% of patients with residual angina had escalation of their AAM regimens in follow-up. Results were similar when stratifying patients by the ultimate success of the CTO PCI, completeness of physiologic revascularization, and presence or absence of angina at baseline (Figure).

Conclusions:
One in 5 patients reported angina 6-months after CTO PCI. Although patients with new or residual angina were more likely to have escalation of AAMs in follow-up compared to those without residual symptoms, only one in 7 patients with residual angina had escalation of AAMs. These results were similar in key subgroups. Although it is unclear whether this finding reflects maximal tolerated therapy at baseline or therapeutic inertia, these findings suggest an important potential opportunity to further improve symptom control in complex stable ischemic heart disease.
Abstract 271: Variations in Troponin Utilization in the Veterans Affairs Health System
Authors: Chui Philip W , Hauser Ronald G
Published: March 2022

Background:
Cardiac troponin is a sensitive marker of myocardial necrosis and is used throughout Veterans Affairs (VA) facilities to identify Veterans who are having an acute coronary syndrome (ACS). However, underutilization of troponin testing can lead to underdiagnoses of ACS while inappropriate overutilization of troponin testing may result in unnecessary hospital admissions, stress testing, and invasive procedures. Variations in troponin utilization may contribute to differences in the care of Veterans with suspected ACS, but the degree of variations in troponin utilization is unclear.

Methods:
We created a cohort of Veterans that included all patients with a troponin result from 2012-2016 extracted from VHA data. Patients with an uninterpretable result were excluded. We calculated for each VA facility the percentage of abnormal troponin results and then compared the percentage of abnormal troponins across facilities.

Results:
Our cohort consisted of 1,192,575 Veterans from 130 VA facilities who met inclusion for our criteria with an associated 4,383,938 number of troponin results. Overall, 848,340 (19.4%) troponin results were abnormal from 195,153 patients (16.4%). There was large variation across VHA sites, ranging from less than 0.6% to 42.7%, in the rates of abnormal troponin results [Figure].

Conclusions:
There is substantial variation across facilities in the variation of abnormal troponin results. We aim to utilize this data to study additional facility-level, clinician-level, and patient-level factors that may be contributing to this variation. Future findings may allow us to identify interventions that can improve quality of care in the workup of acute coronary syndrome across VA facilities.
Abstract 272: Female Sex and Variations in Troponin Utilization
Authors: Chui Philip W , Hauser George R
Published: March 2022

Background:
There are well-described sex differences in the utilization of invasive procedures and outcomes for patients with suspected acute myocardial infarction (AMI). Cardiac troponin testing currently is instrumental in the diagnosis of AMI, but the factors that affect troponin testing variations are currently unknown. We sought to investigate whether there is an association between sex and variations in troponin utilization in the Veterans Health Administration.

Methods:
We developed a database of Veterans that included all Veterans with a reported troponin result from 2012-2016 across 130 VA facilities. We then linked each troponin result with patient, provider, and facility-level factors including patient demographics, death date, location of troponin testing, facility-level complexity, and troponin reference range. We then performed a multivariate logistic regression to compare the odds of a male having an abnormal troponin result as compared to a female.

Results:
Our cohort included 1,192,575 Veterans of which 7.7% were female with the mean age 67. Of the 195,153 patients with an abnormal troponin result, 189,767 (97.2%) were male and 5,386 (2.8%) were female. The median percentage of abnormal troponin results across VA facilities was 17 (interquartile range[IQR]: 8-29%) for males, and the median was 8% (IQR: 4-14%) for females (Figure). After multivariate adjustment, we found that men were significantly more likely to have an abnormal troponin result than women (OR: 1.50 95%, CI [1.41-1.58]).

Conclusion:
There is significant variation in the utilization of troponin testing across VA facilities. Our findings suggests that a patient’s sex may help explain the variation in troponin utilization. Further studies should explore whether sex differences in troponin testing account for discrepancies in outcomes and procedure utilization for patients with AMI.
Abstract 279: Eligibility and Cost Estimates for Anti-inflammatory Therapy for Atherosclerotic Disease: Implications of the CANTOS Trial for the US Adult Population
Authors: Khera Rohan , Saxena Anshul , Hong Jonathan , Arrieta Alejandro , Ross Joseph S , Krumholz Harlan M , Nasir Khurram
Published: March 2022

Background:
The CANTOS trial supports the use of canakinumab to target residual inflammatory risk for secondary cardiovascular prevention. To better understand the potential impact of these findings, we use nationally representative data to estimate the number of US adults who qualify for therapy with canakinumab and the projected cost burden on the US health system based on its current pricing.

Methods:
In National Health and Nutrition Examination Survey (NHANES) 2005-10, we identified all adults with a prior MI and elevated hsCRP ≥2 mg/L, and fulfilling all eligibility criteria for CANTOS. Further, we also assessed the number of individuals not receiving statins who might be potentially eligible. Statin non-users were considered potentially eligible if they would have had hsCRP ≥2mg/L even after assuming a maximal hsCRP lowering of 50% with statin therapy in all patients. We used survey methods to obtain weighted estimates for the eligible adults in the US population. Annual costs were estimated at $60000/year for canakinumab therapy.

Results:
Of the 17689 adults sampled in NHANES during 2005-2010, 16608 (94%) had hsCRP testing. Of these, 684 (3.0%), representing an estimated 6.8 million (95% CI 5.7-7.8 million) US adults, had a history of MI (Figure 1). Among those with a prior MI, 42% did not report using a statin. Among statin-users, 44% had an hsCRP<2 mg/L (32% overall). After applying CANTOS inclusion and exclusion criteria, 21% (unweighted n=128) of adults with a prior MI on statin therapy, representing 1.4 million (95% CI 1.1-1.8 million) US adults, were canakinumab-eligible. A further 9% of AMI patients would be eligible after accounting for statin-associated hsCRP lowering in statin non-users (Figure 1). Cumulatively, 31% (unweighted n=207) of adults with a prior MI, representing 2.1 million (95% CI 1.6-2.5 million) US adults would potentially qualify for canakinumab therapy. The treatment of 5% to 100% of all CANTOS-eligible US adults would cost payers $6-$124 billion/year.

Conclusion:
Nearly 1 in 3 or 2.1 million US adults with a prior MI are potential treatment candidates. Assuming current canakinumab prices would incur an annual financial burden of up to 124 billion dollars in the United States. Further work is needed to define the population that achieves favorable value with treatment.
Abstract 34: Determinants of Successful Completion of Cardiac Rehabilitation When Secondary Prevention Programs Are Made Universally Accessible
Authors: Frisbee Stephanie J , Suskin Neville , Stranges Saverio , Pierce Adam , Ricci Joseph
Published: March 2022

Background:
Cardiac rehabilitation programs (CRP) after a cardiovascular event are standard-of-care worldwide, though participation remains very low (estimated at 14%-35% in the US and <15% in Ontario). Removing health care system (HCS) barriers to accessing CRPs is essential to realize patient and population level health benefits, and to understand patient barriers to completion of CRP.

Objectives:
To develop a regional delivery system for CRP that removes HCS barriers to CRP so that patient factors affecting CRP participation and completion can be ascertained.

Methods:
One health care region (HCR) in Ontario implemented a regional CRP that was fully integrated into the HCS. The integrated CRP (HCS-I-CRP) automated referrals to an HCR-wide coordinating center which directed patients to a to a CRP in a local, community-based setting (LCB-CRP) within a 30-minute drive. The CRP was standardized across all LCB-CRPs. Information related to the referral, initiation, and completion of the CRP was collected and analyzed.

Results:
Referral and eligibility criteria were intentionally broad and included any cardiovascular admission within 1 year, or any cardiovascular intervention, procedure, or diagnosis. Automated inpatient and community referrals were received for cardiac or non-cardiac related hospitalizations (62% and 29%, respectively), or ambulatory health care visits (9%). The age distribution of patients referred from hospital and community sources was similar, though community referred patients were less complex (lower Johns Hopkins Adjusted Clinical Group (JH-ACG) category). In comparing the patient characteristics of those who completed vs. those who started but did not complete the CRP, the following patterns were observed: (1) completion rates were nearly identical across hospital and community all referral sources; (2) older patients were more likely to compete the CRP (72% for 70-89 years old vs. 57% for 40-49 years old); (3) while there were more referrals for men (61.5%) than women, the completion rates for men and women were nearly identical; (4) neighborhood income quintile of patients was not associated with completion of the CRP; (5) sicker patients were less likely to complete the CRP (higher resource utilization band, JH-ACG, and Charlson index); and (6) patients with heart failure were least likely to complete the CRP (58.8% vs. 66.8% for all other diagnoses).

Conclusions:
Our results suggest that an HCS-I-CRP with automatic referral to a LCB-CRP within a 30-minute drive removed traditional barriers to completing CRP: there were no socioeconomic or gender differences in CRP completion, and elderly patients had higher completion rates. Sicker patients were least likely to complete CRP. Mechanisms to identify these patients earlier and / or support their completion of these programs to reduce disease morbidity should be developed.
Abstract 4: Variation in Published Stroke Rates Results in Wide Variation in the Net Clinical Benefit of Anticoagulation for Atrial Fibrillation
Authors: Shah Sachin J , Eckman Mark H , Aspberg Sara , Go Alan S , Singer Daniel E
Published: March 2022

Background:
The risk of ischemic stroke without anticoagulation for a given CHA
2
DS
2
-VASc score varies significantly across published cohorts. The resulting impact on the net clinical benefit of anticoagulation in atrial fibrillation (AF) is not known. We aimed to determine the effect of variation in published stroke rates on the net clinical benefit of anticoagulation.

Methods:
A decision analysis study. We used ischemic strokes rates corresponding to CHA
2
DS
2
-VASc scores from four studies - ATRIA study, SPORTIF, Swedish AF study, and the Danish National Patient Registry - in a 28-state Markov state transition model that compared the benefit of oral anticoagulation vs. no anticoagulation. During each monthly cycle, patients face a chance of stroke and hemorrhage, either of which may lead to death, neurologic sequelae, or symptom resolution. The simulation ran for the entire life expectancy of the patient. We applied this decision analytic model to a cohort of 33434 patients with incident AF (Jan 06 to Jun 09) in the Kaiser Permanente Northern and Southern California integrated health care delivery systems.

Results:
Of the 33434 patients, 27122 had a CHA
2
DS
2
-VASc score ≥2. Among those with CHA
2
DS
2
-VASc score ≥2, use of ATRIA Study stroke rates yielded the lowest population benefit (2576 QALYs, 0.06 expected median per person, IQR -0.02 to 0.18), while the Danish National Patient Registry stroke rates yielded the greatest population benefit (28934 QALYs, 0.70 expected median per person, IQR 0.38 to 1.47). The CHA
2
DS
2
-VASc threshold at or above which the population derives the greatest net clinical benefit from anticoagulation varies based on the stroke rates used: CHA
2
DS
2
-VASc ≥3 using ATRIA Study stroke rates, ≥2 using Swedish AF study stroke rates, ≥1 using SPORTIF and ≥0 using the Danish National Patient Registry stroke rates.

Conclusion:
Using current guidelines, variation in published off-anticoagulation stroke rates results in tenfold variation in the estimated net clinical benefit of anticoagulation. Guidelines should better reflect the uncertainty of the current approach that uses a CHA
2
DS
2
-VASc threshold to recommend anticoagulation.
Abstract 6: Characteristics and Outcomes of Ischemic Heart Failure Patients With Improved Ejection Fraction After Coronary Revascularization
Authors: Wang Shaoping , Peng Ding , Dunlay Shannon M , Chamberlain Alanna M , Liu Jinghua , Borah Bijan J
Published: March 2022

Background:
Heart failure (HF) with improved ejection fraction (HFiEF) is defined as a new subset in addition to the subsets of HF with reduced EF (≤40%; HFrEF) and HF with preserved EF (>40%). The characteristics and outcomes of patients with ischemic HFiEF after coronary revascularization are unknown.

Methods and Results:
We identified 1,816 patients with coronary artery diseases and reduced EF (≤40%) in a large hospital in China, who underwent either coronary artery bypass graft surgery (n=1,126) or percutaneous coronary intervention with drug eluting stent (n=687) from January 2005 to December 2014. All patients had EF reassessment during follow-up. The improvement of EF peaked at 3 months and persisted for more than one year after revascularization. Thus, 589 patients who had EF reassessment between 3 to 12 months after revascularization were included in the definitions of HFiEF and HFrEF patient cohort and subsequent survival analysis. 367 (62.3%) patients had EF >40% which constituted HFiEF cohort while 222 (37.7%) patients with EF≤40% constituted HFrEF cohort. Using stepwise logistic regression, we identified preoperative EF (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.11;
P
=0.006), left ventricular end-systolic diameter (OR, 0.93; 95% CI, 0.91-0.95;
P
=0.000) and history of myocardial infarction (OR, 0.61; 95% CI, 0.42-0.88;
P
=0.008) were associated with being in HFiEF group. Using Cox proportional hazard models, HFiEF patients had lower risk of all-cause mortality (hazard ratios [HR], 0.39; 95% CI, 0.23-0.68;
P
=0.001), sudden cardiac death (HR, 0.32; 95% CI, 0.14-0.75;
P
=0.009) and death due to HF (HR, 0.13; 95% CI, 0.03-0.52;
P
=0.004) compared to HFrEF patients. Nonproportional outcome of composite end points (i.e., combination of all-cause mortality, HF hospitalization and repeat revascularization) between HFiEF and HFrEF groups was detected by using the Schoenfeld residuals. By using flexible parametric model, patients with HFiEF had similar risk of composite end points in the first 5 years (HR, 0.84; 95% CI, 0.53-1.31;
P
=0.433), but significantly lower risk during years 6 to 11(HR, 0.12; 95% CI, 0.03-0.56;
P
=0.007). In the HFiEF group, the risk of death were age (HR, 1.07; 95% CI, 1.02-1.12;
P
=0.008), current smoking (HR, 5.62; 95% CI, 1.93-18.18;
P
=0.002) and history of myocardial infarction (HR, 2.89; 95% CI, 1.05-7.93;
P
=0.039). By contrast, in the HFrEF group, the risk factors were moderate or severe mitral regurgitation (HR, 1.81; 95% CI, 1.06-3.11;
P
=0.031) and estimated glomerular filtration rate (HR, 0.97; 95% CI, 0.95-0.99; P=0.014).

Conclusions:
Patients with ischemic HFiEF have distinct clinical characteristics and favorable outcomes. Our data support HFiEF as a distinct HF category in ischemic HF patients after revascularization therapy.
Abstract 7: Health Care System Re-Design to Achieve Universal Access to Cardiac Rehabilitation Services: Implications for Population Health and Health Policy
Authors: Frisbee Stephanie J , Suskin Neville , Stranges Saverio , Pierce Adam , Ricci Joseph
Published: March 2022

Background:
The efficacy of cardiac rehabilitation programs (CRP) is well established, and completion of such programs after an event is standard-of-care in guidelines worldwide. Despite universal recommendations, participation in CRP is alarmingly low: estimated at 14%-35% in the US, and <15% of eligible patients in the Canadian province of Ontario. The inability to achieve even 50% participation in CRP represents a failure of health care systems (HCS) to deliver effective, high-quality services. Such a failure is particularly vexing in Canada, where the central tenet and legal requirement of the HC-S is universal access to all medically necessary services.

Objectives:
A team of health care providers and administrators in Ontario used a systems integration approach to re-design the HCS in one health care region (HCR) to make an evidence-based CRP universally available. The key features of this HCS-integrated CRP (HCS-I-CRP), its adoption, and population health impact are reported here.

Methods:
By design, the HCS-I-CRP included harmonized criteria that triggered automatic referral to a HCR-wide coordinating center, which then directed eligible patients to a CRP provided in local, community-based setting (LCB-CRP). Fourteen LCB-CRP, available within a 30-minute drive from most all locations in the HCR, were trained to provide a standardized CRP. Detailed patient outcomes were tracked in a centralized database. Using administrative data, within-HCR participation rates were monitored, and population level health impacts between the HCR implementing the HCS-I-CRP and all other HCRs in Ontario were compared for the 2 years prior and 1 year after the HCS-I-CRP implementation.

Results:
More than 11,000 patients were referred through the HCS-I-CRP to a LCB-CRP. The estimated overall participation and completion rates were 31% and 67%, respectively. Population health impacts in the HCR implementing the HCS-I-CRP included (p<0.05): larger HCR-wide reduction in visits to family practitioners, cardiologists, and internists for any cardiac reason; larger HCR-wide reductions in hospitalizations, emergency department visits, and visits to cardiologist and internists for acute coronary syndrome; and larger HCR-wide reductions in visits to family practitioners and cardiologists for heart failure. Reductions in HCR-wide mortality for acute coronary syndrome approached significance (p=0.097).

Conclusions:
The adoption of a HCS-I-CRP was extremely successful: referrals actually exceeded the capacity of LCB-CRPs and enrollment, unfortunately, had to be capped. Despite this, statistically significant, population level health benefits were observed. We anticipate that adoption of a province-wide HCS-I-CRP, initiated and buttressed by provincial policy, would achieve near universal access to CRP and population health benefits similar to or greater than those reported here.
Abstract 8: Association Between Abnormalities in Myocardial Perfusion and Patient-reported Angina Among Patients With Known Coronary Artery Disease: PET vs. SPECT Comparison
Authors: Al Badarin Firas , Patel Krishna , Spertus John , Arnold Suzanne , Bateman Timothy , Kennedy Kevin
Published: March 2022

Background:
Although the burden of angina would be expected to be intricately linked with the degree of myocardial ischemia, prior work with stress echocardiography and SPECT myocardial perfusion imaging (MPI) have shown these two measures to be poorly correlated. We examined the association of positron emission tomography (PET) MPI, which can more accurately characterize myocardial ischemia, with angina.

Methods:
Patients with known CAD who were referred for a clinically-indicated vasodilator MPI at Saint Luke’s Hospital (Kansas City, MO) were included. All patients underwent both SPECT and PET MPI and completed the Seattle Angina Questionnaire (SAQ) at the time of MPI. SAQ angina frequency (AF) and physical limitation (PL) scores were compared across the spectrum of ischemic burden (no ischemia, <5, 5-10 and >10% ischemic myocardium) with PET and SPECT.

Results:
Among 322 patients with CAD undergoing MPI (mean age 66.3 ± 9.7 years; 64.9% men), mean SAQ AF and PL scores were 78.5 ± 19 and 83.3 ± 19.8, respectively. A total of 72 patients (44.7%) with PET and 67 (41.6%) with SPECT had at least mild ischemia on MPI. There was no association with burden of angina by SAQ AF or PL scores and degree of ischemia by PET or SPECT MPI (Figure).

Conclusion:
We found no association between patient-reported angina and the burden of ischemia, regardless of the modality used. These findings suggest that other complex, multi-system pathways likely impact perception of pain and description of angina in patients with CAD, and that direct measurement of patient-reported symptoms needs to supplement physiologic assessment of ischemia.
Abstract 11: Impact of DES Versus BMS on Quality of Life Following Percutaneous Coronary Intervention: Insights From the TRIUMPH Registry
Authors: Chhatriwalla Adnan K , Stolker Joshua M , Kennedy Kevin F , Venkitachalam Lakshmi , Jones Philip G , Cohen David J , Spertus John A
Published: March 2022

Background:
While drug eluting stents (DES) are known to reduce restenosis, as compared with bare metal stents (BMS), the comparative effectiveness of stent type on health status outcomes after acute myocardial infarction (AMI) is unknown.

Methods:
We compared 6-month health status outcomes in 1,583 AMI patients enrolled in the 26-center TRIUMPH study who were treated exclusively with DES (n=974) or BMS (n=609). Patient-reported health status was assessed with the Seattle Angina Questionnaire (SAQ) and the physical and mental summary scales of the Short-Form 12 (SF-12). A multivariate linear regression model was used to examine the association between stent type and patient-reported health status after extensive adjustment for 25 demographic, clinical and procedural variables, including baseline health status.

Findings:
Patients were predominantly Caucasian (77.8%) and male (73.2%), with a mean age of 59±11 years and a high prevalence of cardiovascular risk factors, including hypertension (58.9%), dyslipidemia (48.5%), and diabetes (23.7%). Baseline health status was similar in the DES and BMS groups, and both groups experienced significant improvements in their health status within 6 months. At 6 months, treatment with DES was associated with significantly greater improvements in the SAQ quality of life (+3.61, 95% C.I. 1.55-5.67), SAQ physical limitation (+5.63, 95% C.I. 3.25-8.00), and SF-12 mental component (+1.38, 95% C.I. 0.37-2.39) scores at 6 months. Changes in the SAQ treatment satisfaction, SAQ angina frequency, and the SF-12 physical component scores were not statistically different between groups.

Conclusions:
Among unselected patients undergoing PCI for AMI, DES use was associated with a greater improvement in patient-reported health status measures during 6 month follow up as compared with BMS. Further investigation is needed to determine the mechanisms of this benefit and whether it is sustained during longer term follow up.
Abstract 2: Impact of Race and Hospital Racial Makeup on Readmissions for Heart Failure
Authors: Joynt Karen E , Jha Ashish K
Published: March 2022

Reducing racial/ethnic disparities in health care is a policy priority, and heart failure (HF) is a particularly important area of focus, not only because HF is the most common cause of hospitalizations and readmissions in the Medicare program, but because black patients suffer a disproportionate burden of this disease. Prior studies have shown that black patients may have higher readmission rates than white patients, but the reasons for these differences are unclear. We sought to determine whether racial disparities in readmission rates for HF were due to the
site
where black and white patients received care. We used national Medicare data from 2006-2007 to categorize hospitals based on the proportion of black patients they cared for, designating those in the top decile as “minority-serving.” We created risk-adjusted generalized linear regression models, with patient race and hospital racial makeup as our primary predictors, and 30-day readmission as our primary outcome. Forty percent of all black patients and five percent of all white patients were cared for at minority-serving hospitals. In risk-adjusted analyses, black patients had higher 30-day readmission rates than white patients (24.1% vs. 23.3%, p<0.0001). However, in stratified analyses, we found that there were no disparities in readmission rates at non-minority-serving hospitals (Table), and black patients at non-minority-serving hospitals had significantly lower admission rates than white patients at minority-serving hospitals. These results were unchanged after controlling for length of stay, hospital characteristics, and proportion of Medicaid coverage in a hospital. Our findings suggest that racial disparities in readmissions are largely due to the site at which care is provided. Focusing quality improvement efforts at poor-performing, minority-serving hospitals has the potential to improve quality of care for all HF patients while simultaneously reducing disparities in HF care.

Minority-serving hospitals

Non-minority-serving hospitals

Black patients
White patients
P value for comparison, black v. white
Black patients
White patients
P value for comparison, black v. white

Model 1 (Patient characteristics only)
26.2%
25.1%
0.006
23.3%
23.1%
0.33

Model 2 (Model 1 plus length of stay)
26.0%
25.1%
0.014
23.3%
23.2%
0.75

Model 3 (Model 2 plus hospital characteristics)
25.4%
24.3%
0.005
23.0%
22.8%
0.49

Model 4 (Model 3 plus percent Medicaid)
25.0%
24.0%
0.008
22.8%
23.0%
0.51
Abstract 4: Acute, Hospital-Acquired Anemia is Associated With Increased Mortality and Worse Health Status in Patients With Acute Myocardial Infarction
Authors: Salisbury Adam C , Alexander Karen P , Reid Kimberly J , Spertus John A , Masoudi Frederick A , Rathore Saif S , Wang Tracy Y , Bach Richard G , Marso Steven P , Charlap Esti , Kosiborod Mikhail
Published: March 2022

Background:
While the association between chronic anemia and poor prognosis after AMI is well established, some patients develop new anemia during hospitalization. This hospital-acquired anemia (HAA) often occurs in the absence of bleeding, and is potentially preventable, but whether it has implications for mortality and health status after AMI is unknown.

Methods:
Using the 24-center TRIUMPH registry of AMI patients, we defined HAA as normal hemoglobin (Hgb) on admission but anemia at discharge, (see Figure footnote for criteria). Mortality and health status over 12 months were compared between those with moderate/severe HAA (discharge Hgb < 11.0 g/dl, n=348), mild HAA (discharge Hgb 11.0 to lower limit of normal; n=973), chronic anemia (present on admission, n=950) and no anemia (n=1588). We used Cox models to evaluate the relationship between HAA and 12-month mortality, and repeated measures models (1, 6 and 12-month SF-12 physical component scores) to study the association between HAA and health status, after adjusting for site, GRACE risk score and the presence/severity of in-hospital bleeding (TIMI minimal, minor, major).

Results:
Compared to pts without anemia, moderate/severe HAA and chronic anemia were independently associated with higher mortality and worse health status (Figure). The outcomes of patients with mild HAA were similar to those without anemia.

Conclusions:
Moderate/severe HAA is associated with increased mortality and worse health status 12 months post-MI, independent of comorbidities and bleeding. This highlights an important potential opportunity to improve care by developing HAA prevention strategies in patients hospitalized with AMI.
Abstract P105: Clinical Factors Associated With Left Ventricular Ejection Fraction Disparity in Patients With Left Ventricular Dysfunction Undergoing Multimodality Imaging
Authors: Khalid Adnan , Al-Amoodi Mohammad , Bhatti Salman K , House John A , O'Keefe James H , Main Michael L
Published: March 2022

Background:
Drug and device therapy of heart failure is increasingly determined based on left ventricular ejection fraction (LVEF) partition values. Many patients undergo both single photon emission computed tomography (SPECT) and echocardiographic assessment of LVEF. Significant disparity frequently exists between these 2 techniques, even when testing is performed near simultaneously in clinically stable patients.

Objective:
We aimed to determine clinical predictors of LVEF disparity in patients undergoing multimodality testing.

Methods:
Between January 2006 and July 2007, 2937 patients underwent both echo and SPECT testing within a 7 day period. Of these, 119 patients had an LVEF <50% by 1 or both techniques, and an absolute LVEF difference between the 2 techniques of at least 10%. A control group comprising of 118 patients had an LVEF <50% by 1 or both techniques, and an absolute LVEF difference between the 2 techniques of less than 10%. In a logistic model with a stepwise selection method 30 candidate clinical variables were available to be selected in the model.

Results:
The predictive model resulted in five variables: Atrial Fibrillation, Severe mitral regurgitation, Left ventricular hypertrophy, high basal heart rate during echocardiogram and Paced rhythm. The model obtained good predictability(c=0.82) and fit (Hosmer-Lemeshow p=0.51). The point estimates and odds ratios are shown in the figure below.

Conclusions:
In patients with LVEF < 50%, atrial fibrillation, severe mitral regurgitation, left ventricular hypertrophy, high basal heart rate during echocardiogram and paced rhythm are associated with a >10% LVEF disparity between the two imaging techniques.