bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 116: Velocity Max Based Cardiovascular Exercise Prescription Leads to Higher Maximal Oxygen Consumption vs Sub Maximal Graded Exercise Test Cardiovascular Exercise Prescription
Authors: DAS Sankalp , Betancourt Brian , Rouseff Maribeth , Brown Doris , Guzman Henry , Ruiz Angelica , Mora Joseph , Ochoa Terry C , Castro Natalie D , Gilliam Cynthia , Sheriff Shoshana B
Published: April 2019

Introduction:
Graded submaximal exercise tests are a common way to assess cardiovascular fitness and the results are often used to design cardiovascular exercise programming. However, it has been shown that the use of Velocity Max (V
max
) can yield better cardiovascular health and programming results. In current study two exercise regimens were compared among participants of an employee wellness program.

Methods:
Participants were employees of Baptist Health South Florida. Using propensity score matching all participants were matched on Age, Gender, Race, baseline weight, height, A1-c, total cholesterol, fat mass and VO
2
Max. Group A trained 3 times a week, 30 minutes of cardiovascular exercise and 30 minutes of resistance training. Group A underwent pretesting and tested again at 12 weeks. Group A’s cardiovascular prescription was based on HR, RPE, and a general APMHR range of 60% -72.7%. Group A performed steady state long duration cardiovascular activity. Group B’s prescribed intensity consisted of mph and grade based on point of test termination. Group B performed interval training. Group B trained 2 times a week, 20 minutes of cardiovascular exercise and 30 minutes of circuit resistance training. Group B underwent pretesting and tested again every two weeks until week 12. Group B received cardiovascular prescriptions biweekly based on their performance.

Results:
The two-independent samples t-test shows that mean improvement in maximal oxygen consumption (VO
2
max) differs between group A (M = 5.5, SD = 7.6, n = 21) and group B (M = 11.0, SD = 4.8, n = 22) at the .05 level of significance (
t
= 2.8,
df
= 41,
p
< .05, 95% CI for mean difference 1.4 to 9.4). On average Group B participants tend to have better improvement in VO
2
max than Group A participants.

Discussion:
Due to the inherent nature of submaximal graded exercise testing, following the same intensities may under estimate differences in VO
2
among sedentary individuals. For some participants, maintaining speed and incline constant may be self-limiting. With V
max
speed is self-selected and incremental, essentially becoming a self-limited pseudo maximal test. Also, because the heart adapts rapidly to exercise it may not be beneficial to test at 12 weeks using the same self-limited sub max graded test. Using V
max,
you can test and stress the cardiovascular system more frequently attaining greater adaptions.
Abstract 12: Overutilization and Financial Impact of Intravenous Magnesium Repletion - a High Value Care Initiative
Authors: Shah Nimish N , Mathew Christopher , Brown Timothy J , Agrawal Deepak , Das Sandeep R
Published: April 2019

Introduction:
Serum magnesium levels ([Mg]) are often maintained at >2 mg/dl in hospital patients, especially those on cardiology services, despite a poor correlation between serum and total body Mg stores and lack of data supporting routine Mg repletion. Oral Mg oxide (MgO) is as effective as intravenous (IV) Mg sulfate (MgSO
4
) at repleting Mg stores but is significantly more expensive.

Objective:
To determine the frequency and relative cost impact of IV versus oral Mg repletion.

Methods:
We queried our EHR for all instances in which Mg was administered within 24 hours after a serum [Mg] measurement among adults at a large, tertiary-care county hospital from 10/2016 to 10/2018, excluding obstetric and perioperative uses. The data collected included serum [Mg], route of administration, and patient location. Using the hospital medication cost for IV and oral Mg, we determined the potential cost savings of a change in route (medication costs only, not including administration costs). This quality improvement study was deemed exempt from IRB review.

Results:
Overall, there were 46,852 instances of Mg repletion. The IV route was used in 80% cases, of which 53% were for serum Mg ≥ 1.8 mg/dL. The mean serum [Mg] preceding repletion was 1.80 and 1.84 mg/dL for the IV and oral routes, respectively (p<0.0001). The estimated direct cost savings of repleting Mg after a serum [Mg] of ≥ 1.8 mg/dL with 400mg oral MgO instead of 2g IV MgSO
4
was $193,210 over 2 years.

Conclusion:
IV Mg repletion for mild hypomagnesemia was common. The mean serum [Mg] for patients treated by the IV versus oral routes were not meaningfully different, suggesting route differences are not driven by perceived severity of hypomagnesemia. Overall, the pattern of IV MgSO
4
use at our institution suggests widespread overuse with a substantial financial impact. We expect this pattern of use may be present at other institutions, and that cardiologists can play a lead role in reducing unnecessary testing. Further implementation studies of strategies to reduce IV use are warranted.
Abstract 122: Presentations Management and Outcomes of Arab-American Patients Hospitalized with Heart Failure Compared with Age and Gender Matched White American Patients
Authors: ELJack Ammar , Elteriefi Ruaa
Published: April 2019

Background:
Of approximately 200,000 Arab Americans residing in Michigan, 40,000 live in Dearborn, there is very little data exists on the presentations, management, and outcomes of Arab-American patients admitted with CVD. our research purpose is to evaluate whether there are any differences in the presentations, management, and hospital outcomes of Arab-American patients admitted with CHF as compared to the White American population.

Method:
Computerized list of all patients admitted in 2009 with the principal diagnosis of CHF at Beaumont Hospital- Dearborn (BH-D). Arab American cohort identified on the basis of Arabic/Middle Eastern names. Medical records obtained and data variables derived by chart review and age, gender, and same diagnosis matched White American patients chosen as controls and similar data obtained from chart.

Result:
There were 1,534 patients who presented to BH-D with a diagnosis of CHF in 2009. We had a total of 126 patients, 66 of whom were Arab-Americans and 60 of whom were Caucasians. The clinical presentations of how both groups presented to the hospital were different in both groups. Hypotension was a presenting sign in the Arab American population with a value of 17 % of the population presented with the hypotension as compared to 3% in the Caucasian population (p=0.038). Lightheadedness was also a significant clinical presentation in the Arab American population where 19 percent as compared to 2% of the Caucasian group (p=0.022). Chest pain was seen as a presenting symptom in the Arab American population in which 15 out of 60 patients presented with chest pain as compared to 7 out of 60 in the Arab American population (p=0.032). Dyspnea with and without exertion were similar in both groups with a mean of 0.97 and 0.90 respectively in the Arab American population (p=0.16) and 0.67 and 0.60 respectively in both groups (p=0.47). Acute treatments using evidence based measures such as placing patient on ACE- Inhibitor, beta blocker; nitrate, hydralazine, loop diuretic, IV nitro, dobutamine, and statins were very similar in both of the groups with no significant differences with p values of 0.69; 0.81; 0.84; 0.16; 0.99; 0.28; 0.48; and 0.10 respectively. We found that Arab Americans are more likely to have left ventricular hypertrophy on electrocardiogram than the Caucasian population at 33% versus 12% respectively (p=0.011). Core measures was found to be 100% in both groups of Left ventricular dysfunction, ACE-I/ARB with patients who have left ventricular dysfunction, and smoking cessation counseling. Discharge instructions as a core measure was found to be 90% in the Arab American population and 95% in the White American population.

Conclusion:
This is the FIRST study that evaluated presentations, management, and outcomes in Arab Americans admitted with CHF in a U.S. hospital. There is No DISPARITIES in management of Arab Americans patients admitted with CHF at BH-D.
Abstract 123: Race, Ethnicity, and Sex-Related Differences in Anticoagulation in Patients Newly Diagnosed with Atrial Fibrillation
Authors: Essien Utibe R , Magnani Jared W , Gellad Walid F , Fine Michael J , Hernandez Inmaculada
Published: April 2019

Background:
Oral anticoagulation (OAC) is associated with stroke risk reduction in patients with atrial fibrillation (AF). Blacks and women with AF have higher stroke rates, these disparities largely due to lower use and efficacy of traditional warfarin-based OAC in these groups. Less is known about race/ethnicity and sex-related differences in novel direct-acting oral anticoagulant (DOAC) use. Our aim was to compare OAC and DOAC initiation by sex, race and ethnicity in a national cohort of patients with AF.

Methods:
We used claims data from a 5% sample of Medicare beneficiaries to identify patients newly-diagnosed with AF between 2013-2014. We excluded those without continuous Medicare enrollment. The primary outcome was the initiation of any OAC (warfarin and DOAC- apixaban, dabigatran, rivaroxaban) after AF diagnosis based on prescription fill data. Among OAC initiators, we compared DOAC vs. warfarin use. We used logistic regression to assess the association between sex, race/ethnicity (white, black, Hispanic) and OAC initiation, adjusting for demographics, comorbidities, and stroke risk (CHA
2
DS
2
-VASc score).

Results:
The cohort of 47,952 patients with AF included 17,935 women, 3282 blacks, and 1958 Hispanics. Overall OAC initiation was low (49.2% whites, 48.1% blacks, and 47.5% Hispanics). After adjusting, black (odds ratio (OR) 0.84; 95% CI, 0.78-0.91) and Hispanic patients (OR 0.90; 95% CI, 0.82-0.99) were less likely than whites to initiate any OAC. Women were less likely than men to initiate any OAC, OR 0.59 (95% CI 0.55-0.64). Among OAC initiators, DOAC use was low (35.8% whites, 29.3% blacks, and 40.0% Hispanics). After adjusting, black patients were less likely to initiate DOACs than whites, OR 0.80 (95% CI 0.71-0.90); the odds of DOAC initiation did not differ for Hispanic and white patients; OR 1.10 (95% CI 0.95-1.27). There was no gender difference in DOAC use among OAC initiators, OR 0.98 (95% CI 0.88-1.10).

Conclusion:
In a national cohort of Medicare beneficiaries with newly diagnosed AF, OAC initiation was lower in blacks, Hispanics, and women. Among OAC initiators, black patients were less likely to initiate DOACs, with no differences identified by Hispanic ethnicity or gender. These findings, in a real-world cohort of medically insured patients, show that blacks with AF were less likely to receive novel DOACs - easier to use, potentially safer, and more effective than warfarin in stroke prevention. Identifying modifiable causes of treatment disparities is needed to improve the quality of care for all patients with AF.
Abstract 124: Abdominal Aortic Aneurysm Screening in Symptomatic Peripheral Artery Disease: Insights from the PORTRAIT Registry
Authors: Farooq Awais , Smolderen Kim
Published: April 2019

Introduction:
Peripheral artery disease (PAD) is a risk factor for the development of an abdominal aortic aneurysm (AAA). The screening of symptomatic patients for AAA is considered a reasonable recommendation (Level IIa). We examined AAA screening rates in a cohort of symptomatic PAD patients and explored the factors associated with screening.

Methods:
The PORTRAIT Registry included patients with new or worsening PAD symptoms across 16 centers in the U.S., the Netherlands and Australia. Medical records were abstracted for documentation of AAA screening in patients who sought care for PAD symptoms up (in the preceding year and up to one month following the index visit). The presence of an AAA was also documented (dilation greater than 3.0 cm). We used a hierarchical logistic regression model to evaluate 24 sociodemographic, clinical and health status characteristics between patients with and without documented AAA screening and examined site variability in screening rates.

Results:
Of the 1275 PORTRAIT patients, 871 (68%) received screening, of whom 63 (7.2%) had an AAA (median 3.4 cm, interquartile range 2.5-7.3 cm). Screening rates between sexes were similar. However, among patients screened for an AAA, men had significantly more documented AAA (8.9% vs. 4.4%, p=0.01). Multivariable analysis found no patient characteristics were associated with screening for AAA (p>0.07 for all), although, there was substantial variation in screening rates across sites (7% to 100%; p<0.001) (Figure 1).

Conclusion:
Our study found that a third of patients who presented with symptomatic PAD did not receive AAA screening. Screening rates varied tremendously by site and did not appear to be related to patient factors. The adoption of AAA screening in symptomatic PAD is suboptimal and begets further efforts to document the value of AAA screening in PAD and improve its feasibility.

Figure 1
. Percent of Patients Screened Across Sites
Abstract 128: The Impact of Hospital Acquisition by a Health System on Admission Allocation
Authors: Gilstrap Lauren G , Beaulieu Nancy , Lyu Peter , Cutler David
Published: April 2019

Background:
The optimal choice of hospital for a particular patient’s admission depends on many factors and many reasons may explain why a patient might not be admitted to the hospital that is best able to meet their needs (e.g. incomplete information about the patient, payment incentives, hospital capacity and hospital affiliation of the clinician making the hospital selection decision). Health systems that include both teaching and community hospitals should be well positioned to improve the allocation of patients to the most appropriate care setting - triaging complex patients or those with serious illnesses to teaching hospitals while triaging healthier patients or those with less severe illnesses to community hospitals. The aim of this study is to determine the impact of health system organization on the allocation of patients with common cardiovascular conditions.

Methods:
Using a difference in differences model, we estimated the proportion of admissions originating from a hospital’s primary service area (PSA) before and after acquisition by a health system. We then stratified patients based on the reason for admission and severity of illness. Admissions were classified as “emergent” or life-threatening, “urgent” requiring prompt medical attention but not immediately life-threatening or “elective.” Most cardiology admissions were emergent (i.e. acute coronary syndrome, shock) or urgent (i.e. heart failure exacerbation).

Results:
Overall, patients who lived in the PSA of a community hospital were 1% more likely to be admitted to a teaching hospital after their community hospital was acquired by a health system that included a teaching hospital. When stratified by admission type, this effect was most pronounced for urgent admissions where patients were 11.3% (p<0.001) more likely to be admitted to a teaching hospital (versus their local community hospital) after acquisition of the community hospital by a health system that included a teaching hospital. Elective admissions were also 1.5% (p<0.01) more likely to occur at the teaching hospital after acquisition of the community hospital by a health system that included a teaching hospital. The acquisition of a community hospital by a health system that included a teaching hospital had no impact on the distribution of emergency (life-threatening) admissions.

Conclusions:
Acquisition of a community hospital by a health system that includes a teaching hospital increased the rate of urgent and elective admissions from the community to a teaching hospital. The was particularly true for urgent admissions, including many cardiology admissions. The impact of this trend on patient outcomes and the cost of care merits future study.
Abstract 131: The Effect of Atrial Fibrillation on the Outcomes and Prognosis of Pulmonary Embolism, a Report From the National Inpatient Sample of 2016
Authors: Haddadin Faris I , Haddadin Sadam , Munoz Estrella Alba , Bandyopadhyay Dhrubajyoti , Haddadin Suhail I , Beidoun Hassan
Published: April 2019

Introduction:
Atrial fibrillation (AF) and pulmonary embolism (PE) have many shared risk factors. A number of studies have shown that PE is associated with higher risk of AF incidence. Recent literature has also shown that AF can increase the risk of PE and is potentially associated with worse prognosis, however these studies are limited.

Methods:
This is a retrospective cohort study based on the 2016 National Inpatient Sample of adults (>18 years) hospitalized for PE as the primary admitting diagnosis and AF as a secondary concomitant diagnosis based on ICD-10 codes. All-cause mortality was our primary outcome while the rate of thrombolytic agents use, mortality following thrombolytic agents administration, CPR utilization, the rate of endotracheal intubation (ET) and mechanical ventilation (MV), length of stay and mean total hospital charge were the secondary outcomes. We used multivariate regression adjusted for age, sex, race, hospital size, hospital location, hospital teaching status, diabetes mellitus, hypertension, dyslipidemia, coronary artery disease, smoking status, chronic kidney disease and Charlson comorbidity index. We used STATA-15 for statistical analysis.

Results:
We identified 185,285 patients admitted for PE in 2016, of whom 13,570 patient had concomitant AF. Mean age was 62 years and 52.4% were females. Our results showed, table 1, that PE with concomitant AF compared to PE without AF significantly increased the risk of all-cause mortality in PE patients (6.96% vs 2.61%, OR 1.99 [1.66-2.39], p <0.001), was associated with higher rate of ET and MV (3.94% vs 1.94%, OR 1.78 [1.41-2.24], p <0.001), had higher CPR utilization (1.73% vs 0.87%, OR 1.86 [1.32-2.63], p <0.001), had a higher mean total hospital charge (54583 $ vs 43880$, p <0.001) and had a longer mean length of stay (5.58 days vs 4.36 days, p <0.001). The rate of thrombolytic agents administration was not significantly different (2.58% vs 2.73%, OR 0.99 [0.75-1.32], p=0.997) but all-cause mortality following thrombolytic agents use was higher for those with AF (0.81% vs 0.35%, OR 2.74 [1.46-5.17], p=0.002).

Conclusion:
AF appears to be an independent risk factor for higher all-cause mortality and worse in-hospital outcomes in PE patients. More studies are needed to further evaluate AF as a potential risk stratifying factor for PE prognosis.
Abstract 138: Effectiveness and Safety of Apixaban Compared to Warfarin among Venous Thromboembolism Patients in the United States Medicare Population
Authors: Hlavacek Patrick , Guo Jennifer D , Rosenblatt Lisa , Keshishian Allison , Russ Cristina , Mardekian Jack , Ferri Mauricio , Poretta Tayla , Yuce Huseyin , McBane Robert
Published: April 2019

Background:
The AMPLIFY randomized clinical trial showed that apixaban was associated with significantly lower major bleeding (MB) compared to warfarin for patients with venous thromboembolism (VTE). The main objective of this study was to compare the risk of major bleeding (MB), clinically relevant non-major bleeding (CRNM), and recurrent VTE among VTE patients treated with apixaban vs warfarin in the US Medicare population.

Methods:
Patients (aged ≥65 years) prescribed apixaban or warfarin within 30 days following a VTE event diagnosed in hospital or ambulatory setting were identified from 01SEPT2014-31DEC2016 using 100% CMS Medicare data. The first apixaban or warfarin prescription claim outside of the hospital was defined as the index date. Patients were required to have had continuous health plan enrollment for 6 months and no parenteral or oral anticoagulant use before the index VTE event. Outcomes were assessed from index date to the earliest of discontinuation, switch, health plan disenrollment, death, 6 months post-index date, or 31DEC2016. One-to-one propensity score matching (PSM) was used to balance patient characteristics. Cox proportional hazard models were used to estimate the risk of MB, CRNM bleeding, and recurrent VTE.

Results:
Among 37,799 patients meeting inclusion criteria, 25,284 patients initiated warfarin (66.9%) and 12,515 patients initiated apixaban (33.1%). Post-PSM, 11,363 matched pairs of apixaban-warfarin patients were identified, with a mean follow-up period of 4.0 and 4.4 months. Mean age was 78 years; nearly 37% of patients were male with a mean Charlson Comorbidity Index score of 2.9 in both groups. Apixaban was associated with a lower risk of MB (HR: 0.76; 95% CI: 0.64-0.91) and CRNM bleeding (HR: 0.77; 95% CI: 0.70-0.84) compared to warfarin. The risk of recurrent VTE was similar among apixaban and warfarin patients (HR: 1.04; 95% CI: 0.75-1.43; Figure).

Conclusions:
Among US Medicare patients with VTE, apixaban was associated with a lower risk of MB and CRNM bleeding and similar risk of recurrent VTE compared to warfarin. These results may be supportive in evaluating the risk-benefit ratio of apixaban for treatment of elderly VTE patients.
Abstract 139: Adherence and Persistence to Direct Oral Anticoagulants for the Treatment of Cancer-Associated Venous Thromboembolism
Authors: King Jordan B , Charlu Malti , Zhu Shiyun , Delate Thomas
Published: April 2019

Background:
Direct oral anticoagulant (DOAC) therapy may be a safe and effective oral alternative to low-molecular-weight heparin (LMWH) or warfarin therapy for treatment for cancer-associated venous thromboembolism. Whether differences exist in adherence and persistence to these medications in this clinical setting is unknown.

Methods:
We identified all Kaiser Permanente members in the Colorado and Northern California regions who experienced a hospitalization for a cancer-associated thromboembolism between 2014-2017 (index event). The primary exposure was the initial anticoagulant regimen used which we defined using outpatient pharmacy dispense records in the 30-days after hospital discharge: 1) DOAC ± an injectable, 2) low-molecular weight heparin monotherapy, or 3) warfarin ± an injectable (index regimen). The primary outcome was medication adherence (i.e., the proportion of days covered) and medication persistence and reasons for non-persistence (i.e., the time to medication discontinuation, regimen change, or death) over the next 6-months. We used Kaiser Permanente’s comprehensive electronic health records to define patient’s demographic and cancer characteristics, comorbidities (inpatient and outpatient ICD-9-CM diagnoses), and other medication use. Multivariable log-binomial models were used to calculate adjusted risk ratios and 95% confidence intervals for adherence >80% and persistence >6 months associated with DOAC use.

Results:
Of the 2,843 patients included, the mean age was 66±13 and 1,523 (54%) were female. Patients receiving DOAC therapy were more likely to be older and have less advanced stages of cancer. In the 6-months post-index, DOAC therapy was associated with higher adherence than LMWH monotherapy and higher persistence than warfarin therapy (Table 1). When non-persistence was observed during the 6 months, the distribution of reasons for non-persistence varied significantly by index regimen with patients receiving DOAC therapy significantly more likely to stop filling the medication as opposed to death or switching regimens.

Conclusion:
In this large community-treated population, initial anticoagulation therapy with a DOAC was associated with improved adherence and persistence rates compared to traditional therapies.
Abstract 157: Assessment of Financial Hardship From Medical Bills Across the Spectrum of Diabetes Mellitus and Atherosclerotic Cardiovascular Disease Among Non-Elderly Adults in the United States
Authors: Mszar Reed , Grandhi Gowtham R , Valero-Elizondo Javier , Khera Rohan , Desai Nihar , Virani Salim , Blankstein Ron , Blaha Michael , Nasir Khurram
Published: April 2019

Background:
Diabetes mellitus (DM) and atherosclerotic cardiovascular disease (ASCVD) both increase the risk for experiencing an adverse cardiac event and affected individuals often have large medical expenditures. While prior research has evaluated financial burden associated with acute cardiovascular events and comparative healthcare expenditures between DM and ASCVD, less is known about the expressed financial hardship and inability to pay medical bills for individuals with families on the basis of ASCVD and DM status.

Methods:
Using data from the National Information Survey between 2013 and 2017, we examined ASCVD/DM status, financial hardship from medical bills, and an inability to pay medical bills at all for a nationally representative sample of non-elderly adults in the United States between 18-64 years of age.

Results:
Our study population consisted of 121,672 individuals. Approximately 3.1% of the weighted population had ASCVD alone, 5.6% had diabetes alone, and 1.3% had both ASCVD and diabetes mellitus. Nearly 50% of individuals with both ASCVD and DM reported having financial hardship from medical bills (23% being unable to pay medical bills at all) as compared to 28% of those without ASCVD and DM reported financial hardship from medical bills (8% being unable to pay medical bills at all). Individuals having ASCVD concurrently with DM had higher odds of expressing inability to pay medical bills at all when compared to those with DM alone (OR 2.69, 95% CI [2.21, 3.28] vs OR 1.70, 95% CI [1.52, 1.91]) whereas it was not significant when compared to those with ASCVD alone (OR 1.97, 95% CI [1.72, 2.25]).

Conclusion:
Patients with ASCVD and concurrent DM have much higher risk of financial hardship from medical bills compared to individuals with neither ASCVD nor DM. These findings provide strong evidence for clinicians to address these co-morbidities concurrently, particularly among vulnerable populations with limited financial means, emphasizing the importance of primary and secondary prevention along with appropriate lifestyle and therapeutic management.
Abstract 161: Adding Social and Functional Determinants of Health Improves Readmission Risk Prediction in Urban Underserved Adults Hospitalized for Acute Myocardial Infarction
Authors: Nguyen Oanh , Makam Anil N , Clark Christopher R , Das Sandeep R , Halm Ethan A
Published: April 2019

Background:
Although social and functional determinants of health (SFDoH) are increasingly recognized to contribute to increased 30-day readmission risk for cardiovascular illnesses, most health systems lack individual-level data to enable individual risk stratification and targeted interventions to address these needs. We sought to determine whether electronic health record (EHR) data in SFDoH domains collected as a part of routine inpatient care from a safety-net hospital could be used to enhance prediction of 30-day readmissions beyond traditional clinical risk factors alone among underserved adults hospitalized with acute myocardial infarction (AMI).

Methods:
We used Epic EHR data on AMI hospitalizations from 2014-2017 in an urban safety-net hospital in Dallas to predict non-elective 30-day readmissions to any of 75 hospitals in north Texas, using a regional all-payer hospitalization database. We started with the AMI READMITS score, our previously validated model consisting of 7 clinical risk factors. Next, we derived and validated an enhanced model incorporating SFDoH predictors. EHR data for candidate SFDoH predictors included structured, semi-structured, and short free-text fields from demographics, encounter types, note types, and case manager, social worker, and nursing inpatient flowsheets. We selected novel predictors using stepwise backward selection with a threshold of p≤0.20, forcing in the composite AMI READMITS score. We conducted sensitivity analyses using forward selection, lasso regression, and random forest which resulted in similar models. We internally validated our final model using 5-fold cross-validation and compared model performance to the AMI READMITS score.

Results:
Of 1,071 hospitalizations, 154 (14.5%) were readmitted within 30 days. In addition to the composite AMI READMITS score, our final model included 9 SFDoH risk factors, including neighborhood poverty (aOR 1.39, 95% CI 0.91-2.14), address change in the past year (aOR 1.53, 95% CI 0.96-2.46), any opioid use in the past year (aOR 2.35, 95% CI 1.36-4.05), history of durable medical equipment use in the past year (aOR 1.70, 95% CI 1.02-2.82), and ADL impairments in feeding, bathing, and toileting in the past year (aOR 1.81 for all three impairments, 95% CI 0.99-3.29). The AMI READMITS+SFDoH model had better discrimination than AMI READMITS alone (optimism-corrected C-statistic 0.69 vs 0.62, p<0.001), was able to predict a broader range of probabilities for readmission risk (3.6-72.7% vs. 8.2-37.2%), and improved net reclassification (categorical NRI of highest 2 risk quintiles vs. lowest 3 of 0.09, 95% CI 0.00-0.18).

Conclusions:
Incorporating existing EHR data on social and functional determinants of health improved readmission risk prediction after an AMI hospitalization in an urban underserved population.
Abstract 164: Neighborhood Socioeconomic Status is Significantly Associated with Outcomes After Coronary Artery Bypass Grafting
Authors: Patrick William L , Bojko Markian M , Han Jason J , Iyengar Amit , Helmers Mark , Williams Matthew L
Published: April 2019

Objective:
Area Deprivation Index (ADI) is a geographically-derived measure of socioeconomic status composed of 17 education, employment, housing-quality, and poverty measures derived from census data. Block group level ADI has recently been made widely accessible to clinicians. A block group is the smallest geographical unit from which census data is collected, representing a homogenous group of people living on a single city block or rural equivalent. Previous work analyzing the relationship of socioeconomic status with cardiac surgery outcomes has been limited by the use of zip codes as the geographic unit, which comprise a larger and more diverse population.
This study evaluates the association of ADI with outcomes after coronary artery bypass grafting (CABG).

Methods:
Patients who underwent isolated CABG in the University of Pennsylvania health system between 2002 and 2018 with a valid home address were assigned an ADI based on their corresponding 2010 Census Block Group. The association between ADI and each STS post-operative outcome was assessed with univariable analysis using a Wilcoxon rank sum test with continuity correction. A multivariable logistic regression model was created for each STS post-operative outcome using variables in the 2008 STS risk model for CABG with ADI as an additional variable.

Results:
The 6,751 patients who met the inclusion criteria were from 19 states with a median predicted STS risk of post-operative major morbidity and mortality of 16.6% (IQR 7.0% to 19.9%) and median ADI of 31 (IQR 17 to 50). ADI was not normally distributed by Wilcoxon signed rank test (p < 0.01). ADI was significantly associated with stroke (p = 0.03), renal failure (p < 0.01), prolonged ventilation (p < 0.01), reoperation (p = 0.05), and composite morbidity and mortality (p < 0.01) in univariable analysis. When included in a multivariable logistic regression model ADI was significantly associated with renal failure (p = 0.02), prolonged ventilation (p < 0.01), and composite morbidity and mortality (p < 0.01).

Conclusions:
ADI is associated with STS post-operative outcomes. When included in a multivariable model, ADI remains highly associated with outcomes. Inclusion of block group level socioeconomic status in prediction models may significantly improve risk prediction.
Abstract 183: Predictors of Good Functional Outcome at Discharge in Stroke Patients with Depression in the Florida Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study
Authors: Starosciak Amy K , Spring Samantha , Zevallos Juan , Wang Kefeng , Gutierrez Carolina M , Dong Chuanhui , Romano Jose G , Sacco Ralph L , Rundek Tatjana
Published: April 2019

Background:
Stroke is the fifth leading cause of death in the US and results in major disability. Modifiable factors that increase risk of poor outcome need to be identified. Depression is related to worse post-stroke outcomes with Hispanics having a higher burden of stroke and depression than non-Hispanics. The goal of this study was to determine the effect of ethnicity and prior depression on post-stroke outcomes.

Methods:
We analyzed 80,687 cases (84 institutions) from the FL-PR Stroke Registry (2014-2017). Pre-existing depression was identified by prior history or use of anti-depressant medications. Univariate analyses of patient characteristics (age, race/ethnicity, insurance), medical history [prior stroke/TIA, hypertension (HTN), diabetes mellitus (DM), dyslipidemia, tobacco, peripheral vascular disease (PVD), atrial fibrillation (AF), heart failure (HF), and chronic renal insufficiency (CRI)], mode of arrival, initial stroke severity (NIHSS), and independent ambulation prior to stroke, and multilevel multivariate logistic regressions using discharge modified Rankin Score (mRS) and ambulatory status were developed.

Results:
Of 80,687 cases analyzed, 10,085 (12.5%) had depression: 15% white, 7% black, 11% Florida Hispanic, 7% Puerto Rico Hispanic. In multivariate models, depression decreased the likelihood of good clinical outcomes (mRS 0-2, OR: 0.85, 95% CI 0.78, 0.92; independent ambulation at discharge, OR: 0.86, 95% CI 0.80, 0.94). Age ≥65, black, female, Medicare, no insurance or Medicaid, NIHSS ≥5, prior stroke/TIA, HTN, DM, AF, PVD, HF, CRI, and arrival by EMS were negatively associated with mRS 0-2; whereas dyslipidemia and premorbid independent ambulation showed positive association (p<0.05). Age ≥ 65, black, female, Medicare, initial NIHSS ≥ 5, history of stroke or TIA, HTN, DM, PVD, HF, CRI, and arrival via EMS were negatively associated with independent ambulation at discharge; whereas history of dyslipidemia or being a smoker and independent ambulation prior to stroke showed a positive association (p<0.05).

Conclusions:
Pre-stroke depression adversely affected functional outcomes at discharge. Various comorbidities also negatively impacted functional outcome, whereas independent ambulation and dyslipidemia prior to stroke increased likelihood of good outcome. Future studies should evaluate if antidepressant medications and intensive management of risk factors improve delayed outcomes.
Abstract 196: Omission of Heart Transplant Recipients from the Appropriate Use Criteria for Revascularization and Impact on High-Volume Heart Transplant Centers
Authors: Xie Joe , Kobashigawa Jon , Kennedy Kevin , Henry Timothy , Tabak Steven , Krebbs Robert , Shaw Leslee , Abbott J D , Book Wendy , Rab S T , Spertus John , Goyal Abhinav
Published: April 2019

Background:
For heart transplant recipients, guidelines endorse routine coronary angiography and percutaneous coronary intervention (PCI) to screen for and treat cardiac allograft vasculopathy (CAV). However, current Appropriate Use Criteria for Revascularization (AUC-R) do not recognize CAV as a unique PCI indication, and thus PCI for CAV is often labeled “rarely appropriate (RA).” The AUC-R’s omission of CAV patients, and its impact on RA PCI rates and hospital pay-for-performance reimbursement have never been described.

Methods:
Using NCDR CathPCI Registry data, we identified all elective PCIs from 96 Medicare-approved heart transplant centers between 2009Q3 and 2017Q2. NCDR-reported rates of RA elective PCI were compared before and after exclusion of CAV patients using paired t-tests. The annual pay-for-performance financial incentives potentially lost by heart transplant centers were estimated based on AUC-R performance thresholds published by Anthem Blue Cross and Blue Shield’s Quality-In-Sights®: Hospital Incentive Program (Q-HIP®).

Results:
Of 168,802 elective PCIs performed in heart transplant centers, 1,854 (1.1%) were for CAV. CAV patients, compared with non-heart transplant recipients, were more frequently asymptomatic (81.9% vs. 33.4%, p<0.001) and had lower rates of prior stress testing (15.0% vs. 58.4%, p<0.001), resulting in higher RA PCI rates (66.0% vs 16.9%, p<0.001). In transplant centers, the absolute difference in RA rates (before vs. after exclusion of CAV patients) was directly associated with the proportion of total PCIs performed in CAV patients (p<0.001,
Figure
). In a sample of 16 heart transplant centers participating in Q-HIP® during the 2017 calendar year measurement period, 2 (13%) centers could have each observed reimbursement increases estimated at ~$90,000 dollars if their Q-HIP® scorecards were re-scored after excluding CAV patients.

Conclusion:
Two-thirds of PCI cases in CAV patients are deemed RA by the AUC-R. The failure of the AUC-R to recognize CAV as a unique PCI indication may lead to inflated RA PCI rates and has the potential for substantial negative pay-for-performance implications in heart transplant centers. The AUC-R should recognize CAV as a unique PCI indication so that heart transplant centers are not penalized for performing PCI for CAV.
Abstract 197: Predictors of Early Left Ventricular Ejection Fraction Recovery in Patients Following Transcatheter Aortic Valve Replacement
Authors: Yunus Raza , Alzahrani Talal , McCaffery James , Ismail Haneen , Lewis Jannet , Solomon Allen , Choi Brian , Krepp Joseph , Nagy Christian , Choi Andrew , Reiner Jonathan
Published: April 2019

Background:
Transcatheter aortic valve replacement (TAVR) is recommended by guidelines in severe aortic stenosis (AS) in patients with high or intermediate surgical risk. However, AS and reduced left ventricular ejection fraction (LVEF) is associated with worse clinical outcomes. Many of these patients will have LVEF recovery after TAVR. The purpose of this study was to evaluate the predictors of early LVEF recovery.

Methods:
All patients with a baseline LVEF < 50% who underwent TAVR and had an echocardiogram within one-month post-TAVR (n=39) at a single center were included to determine the factors that predict an improvement in early LVEF. A 10% increase in LVEF within one month was used as a definition of early improvement in LVEF. Chi-square and T-test were used to examine differences in baseline characteristics between subjects with and without improvement in early LVEF.

Results:
The patient cohort was 77 ± 9 years, 76.9% male, STS 6.2 ± 3.7. Among the 56% who had an improvement in early LVEF, they were more likely to have a lower left ventricular end diastolic diameter (LVEDD) (5.0±0.8 cm vs. 5.7±0.6 cm; p-value = 0.01) and left ventricular end systole diameter (LVESD) (3.7±0.8 cm vs. 4.5±1.1 cm; p-value = 0.02). These patients were more likely to have a higher interventricular septum diastolic thickness (IVSd) (1.2±0.2 cm vs. 1.0±0.2 cm; p-value = 0.01) and less likely to have a pre-existing peripheral vascular disease (PVD; 13% vs. 50%; p-value=0.01).

Conclusion:
Our study suggests that LVEDD, LVESD, IVSd, and PVD may be used to predict early improvement in LVEF. These factors need to be further prospectively validated to determine patients who are more likely to benefit from TAVR.
Abstract 199: The Clinical Outcome and Economic Impact of the 2017 ACC/AHA Guidelines on Hypertension in China
Authors: Wang Zengwu , Wang Xin , Guang Hao , Chen Zuo , Zhang Linfeng , Zhang Zugui , Dong Ying , Zheng Congyi , Kang Yuting , Hu Hao , Weintraub William S , Gao Runlin
Published: April 2019

Background:
In 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) published guidelines on the diagnosis and treatment of high BP (blood pressure) in adults. The impact of clinic outcome and economy need to be estimated for adopting the guidelines in China.

Methods:
Data from a nationally representative sample in China were analyzed. The prevalence and treatment were calculated based on the criteria of the 2017 ACC/AHA and 2010 Chinese guidelines among participants aged ≥35 years old. Direct medical costs, as well as the averted disability adjusted of life years (DALYs) and cost saving from cardiovascular disease (CVD) events prevented by controlling hypertension, were also estimated.

Results:
The prevalence and treatment rate of hypertension was 32.0% and 43.4% according to the 2010 Chinese guidelines. Based on the 2017 ACC/AHA guidelines, another 24.5% of the adult population (estimated 168.1 million) would be classified with hypertension; of which about 32.1 million hypertensive patients would need to be pharmaceutically treated to reach the current treatment rate of 43.4% (
Table 1
). As a result, an additional 288.1 billion Chinese currency Renminbi (RMB) of direct medical cost will be required for the lifetime. The new guidelines would reduce lifetime costs by 22.77 billion RMB, while preventing 1,292,881 DALYs lost due to CVD events (
Table 2
).

Conclusions:
Application of the 2017 AHA/ACC guidelines in China will substantially increase the prevalence of hypertension and produce a large increase of therapy costs, although it would prevent CVD events and save DALYs. The newly released 2018 Chinese Blood Pressure Management Guidelines defined normal BP as systemic BP<140/diastolic BP<90 mm Hg.
Abstract 199.1: Incidence and Outcomes of Acute Kidney Injury Requiring Renal Replacement Therapy in Patients on Percutaneous Mechanical Circulatory Support with Impella CP for Cardiogenic Shock; a Single Center Experience
Authors: Saad Shaukat Muhammad Hamza , Fahad Fadi , Yager Neil
Published: April 2019

Background:
Acute kidney injury (AKI) complicating cardiogenic shock is associated with increased short-term mortality. We hypothesize that early HD or CRRT for AKI in patients with Impella-CP for cardiogenic shock improves survival.

Methods:
Retrospective chart-review identified 34 patients requiring Impella-CP for cardiogenic shock between January 2015 and December 2017. AKI was defined as increase in serum Cr >=0.3mg/dl or >=50% from baseline. Based on this definition, three groups were differentiated; no AKI, AKI without HD/CRRT and AKI+HD/CRRT. Pre-existing dialysis dependent patients were excluded. 30-day cardiovascular mortality (CV) was compared.

Results:
Of the 34 patients on Impella-CP for cardiogenic shock, 13 did not have AKI; 12 had AKI but did not receive HD/CRRT; and 9 received HD/CRRT for AKI. 30-day CV mortality was higher in the AKI without HD/CRRT group compared to no-AKI group [75% (9/12) vs 30.8% (4/13), p 0.03]. There was no significant difference in 30-day CV mortality of the AKI+HD/CRRT and no-AKI groups [22.2% (2/9) vs 30.8% (4/13), p 0.48]. In the 9 patients who received HD/CRRT, the indication was AKI not responding to diuretics. No other indications for HD were noted in all 34 patients. Hemoglobin >=11g/dl (p 0.008) and use of Calcium Channel Blockers (p 0.04) were associated with decreased incidence of AKI (Table 1). Mean serum creatinine was higher in the AKI+HD/CRRT than AKI without HD/CRRT group (p=0.01, Table 2).

Conclusion:
Despite the increased 30-day CV mortality associated with AKI in patients on Impella-CP for cardiogenic shock (p 0.03), there is no significant difference in 30-day CV mortality of patients who received HD/CRRT for AKI and those without AKI (p 0.48). Early initiation of HD/CRRT for AKI in patients on Impella-CP for cardiogenic shock may improve short-term CV mortality.
Abstract 202: Digoxin Does not Decrease Readmission Rate in Patients Hospitalized with Acute Heart Failure and Reduced Ejection Fraction
Authors: Alreshq Rabah , Torosoff Mikhail
Published: April 2019

Background:
Clinical trials have shown that digoxin reduces hospital admissions in patients with chronic systolic heart failure (HF). However, there is paucity of data in the effect of digoxin use on readmission rate after hospitalization for decompensated HF.

Objective:
To evaluate the role of digoxin use in the 30- and 90-day HF readmission rate after hospitalization for acute heart failure and reduced ejection fraction (HFrEF).

Methods:
This was a retrospective cohort study of 2506 consecutive patients enrolled in Get With The Guidelines-HF registry and admitted to a single academic center with acute HFrEF between 2008 and 2017. HFrEF patients were divided into 2 groups; digoxin treated (n=737) and non-digoxin treated (n=1769). Mean age was 65.7±14.5; 70% were males, 75% were Caucasians. Multivariate logistic regression analysis was performed to assess the independent effect of digoxin on HF readmission rate.

Results:
Compared to the rest of the cohort, digoxin treated patients were more commonly male (74 vs 69%; p=0.041) with increased prevalence of atrial fibrillation or flutter (44 vs 29%; p<0.001) and significantly lower LV ejection fraction, (26 vs 28%; p<0.001), despite younger age (64.7±14.7 vs 66.2±14.4 years; p=0.015) and lower prevalence of coronary artery disease (52 vs 57%; p=0.014), chronic kidney disease (18 vs 26%; p<0.001), and hypertension (56 vs 66%; p<0.001). Patients treated with digoxin upon discharge had higher 30-day (22 vs 18%; p<0.001), and 90-day (9 vs 8%; p=0.014) HF readmission rate in comparison to patients not treated with digoxin. On multivariate analysis, when adjusted for significant co-morbidites, digoxin independently increased the HF readmission rate (adjusted OR1.4, 95%CI 1.16 -1.67, p<0.001).

Conclusions:
In our study, digoxin treatment in patients with acute HFrEF was independently associated with increased HF readmission rate. Further clinical trials are warranted to evaluate the effect of digoxin on outcomes of acute HFrEF.
Abstract 205: A Systematic Review of Cardiac Rehabilitation Participation: Barriers and Facilitators
Authors: Amraotkar Melissa
Published: April 2019

Patients participating in cardiac rehabilitation (CR) after a cardiac event have fewer hospital readmissions and better clinical outcomes compared to non-participants. However, these services are underutilized. The purpose of this systematic review is to identify barriers and facilitators associated with participation in cardiac rehabilitation for secondary prevention of heart disease. Studies were eligible for inclusion if they were quantitative, in English, published between 2008 and 2018, peer-reviewed, and included measures of barriers and/or facilitators of CR attendance. A literature search was performed in MEDLINE and CINAHL. Thirty-seven quantitative studies were included in the final review. Barriers to CR participation included: female gender, depression and hopelessness, low educational level, lack of knowledge regarding CR, low income, and having comorbidities. Facilitators of CR included: hospitalization at facility using automatic referral to CR and/or nurse liaison to transition patient to outpatient CR, chest pain during MI, ST elevated MI (STEMI), more invasive treatment of MI, being married, younger age, and living in close proximity to a CR facility. Individuals choose to participate in CR programs based on a multitude of factors. Interventions should focus on modifiable barriers and facilitators such as patient education and consideration of patient attitudes toward CR.