bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 323: Association of Heart Failure Length of Stay with Subsequent Re-Admission and All-Cause Mortality
Authors: Nichols Gregory A , Reynolds Kristi , Butler Melissa G , Kimes Teresa M , Chan Wing
Published: March 2022

Length of stay (LOS) during acute heart failure (AHF) hospitalizations may play an important role in the risk of subsequent re-hospitalization or mortality. The purpose of this study was to assess the association between AHF hospital LOS and risk of readmissions and mortality.

Methods:
We identified all members of Kaiser Permanente (KP) in the Northwest, Southern California and Georgia regions who experienced an AHF hospitalization and were discharged alive in 2008-2011 (index hospitalization, n=20,009). We evaluated 3 study outcomes (subsequent re-hospitalization with a primary diagnosis of AHF, subsequent re hospitalization for any reason, and all-cause mortality) each over 1, 6 and 12 months following the index hospitalization. To isolate the independent contribution of LOS, we used KP’s comprehensive electronic medical records to construct multivariable logistic regression models that included a wide range of demographic and clinical characteristics (vital signs and laboratory values), comorbidities (inpatient and outpatient ICD-9-CM diagnoses), and selected pharmacotherapies.

Results:
Patients were 53% male with mean age 74±13 years. The diverse sample included 15% African-Americans, 17% Hispanics and 58% Whites. Comorbidities were common prior to the index hospitalization for AHF (diabetes 41%, hypertension 85%, renal disease 50%, coronary artery disease 45%), and 51% had previously diagnosed heart failure (HF). The proportion of patients with an AHF re-hospitalization was 6.3%, 16.7% and 22.6%; with any re-hospitalization 21%, 47% and 59%; and 6.4%, 18.2% and 25.7% died within 1, 6 and 12 months, respectively. LOS of the index AHF hospitalization did not differ among those who did and did not experience an AHF e re-hospitalization within any of the 3 time frames. However, mean LOS of the index AHF hospitalization was longer for those who had any re-hospitalization within 1 month (4.3 vs. 3.6 days, p<0.001) or 6 months (3.9 vs. 3.6, p<0.001). Compared with survivors, LOS was significantly longer by 1-2 days among patients who died within any time frame (p<0.001 for all). Odds of mortality were 6% greater per index hospitalization day for all time periods.

Conclusions:
In this large diverse sample of patients hospitalized for AHF, longer LOS during the index hospitalization was significantly associated with increased all-cause re-hospitalization within 1 or 6 months and with increased mortality for up to 12 months independent of comorbidities and cardiovascular risk factors.
Abstract 326: High Potency Statins Underutilized in Patients with Atherosclerotic Cardiovascular Disease (ASCVD)
Authors: Rodriguez Fatima , Olufade Temitope , Heithoff Kim , Navaratnam Prakash , Friedman Howard , Foody JoAnne
Published: March 2022

Introduction:
The 2013 AHA/ACC Cholesterol Guidelines advocate that all patients with ASCVD receive high potency statins (HPS). However, little is known about current patterns of HPS use. Therefore, we determined patterns of HPS in ASCVD patients in a large, contemporary managed-care database.

Methods:
Patients ≥18 years old with documented ASCVD with ≥1 LDL-C test from Jan 2004 to Dec 2012 were identified in the Optum Insight database. HPS use was defined as treatment with atorvastatin (40or 80 mg), rosuvastatin (20or 40mg), or simvastatin 80mg. Patients who received other lipid lowering therapies (LLTs) and those who were untreated were identified. We calculated monthly average LDL-C measures and the proportion of patients that achieve LDL-C goals of <70mg/dL and 100mg/dL

Results:
The number of eligible patients ranged from 45, 101 (2004) to 40,846 (2012). Overall, ASCVD patients treated with HPS increased from 13% (2004) to 26% (2012). Among LLT-treated, the percentage of patients that received HPS increased from 20% (2004) to 38% (2012). HPS patients had a slightly lower average LDL-C than non-HPS LLT patients in January 2004 (101.9 ± 33.6 mg/dL versus 104.1 ± 31.8. mg/dL) but the difference increased substantially by December 2012 (85.6 ± 29.3mg/dL versus 94.0 mg/dL ± 32.2 mg/dL). HPS patients were also more likely to attain an LDL goal of <70 mg/dL relative to non-HPS LLT patients and untreated patients. A similar pattern was observed when a goal of LDL<100 mg/dL was used.

Conclusions:
Using a large managed-care dataset of patients with ASCVD, we found that over the past decade HPS use has increased. However, despite the growing use of high-potency statins for this high-risk population, less than 26% of ASCVD patients were prescribed high potency statins by 2012. Further research and interventions are needed to address substantial gaps in care and how best to implement new, national recommendations in order to improve patient outcomes.
Abstract 328: An Outcomes Assessment of Vasodilator Therapy in Pulmonary Arterial Hypertension through Meta-analysis of 31 Randomized Controlled Trials
Authors: Ryan John J , Chatterjee Saurav , Hatton Nathan , Patel Neel , Krumholz Harlan M
Published: March 2022

Rationale:
Pulmonary Arterial Hypertension (PAH), a rapidly progressive disease w/high mortality, has an annual therapy cost up to $100,000/yr. We sought to review the RCTs conducted to evaluate the effect of pulmonary vasodilators (PVDs) on outcomes in PAH.

Methods:
We conducted a systematic review and meta-analysis using MEDLINE, EMBASE, Cochrane Library, Web of Science, and Scopus (inceptions-January 2014) of RCTs in PAH. Data on all-cause mortality and changes in mean pulmonary artery pressure (mPAP), cardiac output (CO), and pulmonary vascular resistance (PVR) were abstracted when available. Summary relative risks (RR) and 95% confidence intervals (CI) for each outcome were calculated using a random effects model comparing various PVDs with placebo/control.

Results:
The analysis included 31 RCTs (6,271 patients, 77% female, 70% Caucasian, mean age 47±6yr). Median f/u was 12 weeks (18 trials had f/u of ≤12 weeks, and only 5 followed patients ≥6mos). Although no trial evaluated mortality as the primary endpoint, mortality was reported in 27 of the 31 trials. When analyzed overall PVDs demonstrated a mortality benefit with RR = 0.77 (95% CI = 0.60 - 0.98, I
2
= 0%), however prostacyclins were the only class of agents which independently demonstrated a significant mortality benefit, RR = 0.62 (95% CI 0.39-0.99, I
2
= 0%). Oral PVDs demonstrated no benefit on PAH mortality, RR = 0.85 (95% CI 0.65-1.12, I
2
= 0.0%). Many studies reported ≤1 death in at least one treatment arm, which produced unstable RR estimates and wide CIs. As a result, the mortality benefit and lack of heterogeneity observed in pooled estimates may be driven by these RCTs. When we limited the analysis to only studies with at least 2 deaths in both treatment arms (N=9), the mortality benefit for PVDs was no longer significant (RR 0.86, CI 0.66-1.12, I
2
=0%). Mean change in mPAP with all PVDs was -3.5 mmHg, (95% CI -4.2 - -2.8), compared to placebo 0.6 mmHg (95% CI 0.1 - 1.1), p<0.001. Mean increase in CO with PVDs was 0.6 L/min (95% CI 0.4 - 0.9 L/min) compared to placebo of -0.02 L/min (95% CI -0.15 - 0.1 L/min), p<0.001. PVR decreased by 212 dynes/s/cm
5
(95% CI 178 - 244) in PVD arms and increased by 43 dynes/s/cm
5
(95% CI 12 - 74) in placebo arms, p<0.001. No surrogate marker was predictive of changes in mortality. Patient reported outcomes were reported in 80% of RCTs but there was inconsistency in the measurements reported.

Conclusion:
The RCT literature on PAH medications focuses on short-term studies and surrogate endpoints. None was designed for mortality or patient-reported outcome measures. Only prostacyclins showed a mortality benefit in PAH, however, the mortality benefit for prostacyclins is based on secondary endpoints in small studies. There remains substantial uncertainty about the benefits of these expensive medications based on the existing trial evidence.
Abstract 329: Change in Cognitive Status in the Month Following Hospitalization for an Acute Coronary Syndrome: findings from TRACE-CORE
Authors: Saczynski Jane S , Waring Molly E , McManus David D , Anatchkova Milena , McManus Richard , Parish David , Gurwitz Jerry H , Goldberg Robert J , Allison Jeroan J , Ash Arlene S , Kiefe Catarina I
Published: March 2022

Background:
Cognitive impairment (CI) during hospitalization is associated with poor long-term outcomes but little is known about changes in cognitive status soon after discharge.

Methods:
Adults (n=1,545) without dementia or delirium were interviewed during hospitalization for an Acute Coronary Syndrome (ACS) and at 1-month post-discharge as part of the ongoing Transitions, Risks and Actions in Coronary Events - Center for Cardiovascular Outcomes Research and Education (TRACE-CORE) study. CI was indicated by a score ≤28 on the Telephone Interview of Cognitive Status (TICS; range: 0-41). Patients reported demographic characteristics, anxiety (GAD7), depression (PHQ9), and stress (PSS4). Factors associated with cognitive change categories (consistently impaired, transiently impaired, newly impaired versus not impaired) were examined using adjusted multinomial logistic regression (Table).

Results:
Participants were 66% male, 83% non-Hispanic white, and aged 62±11 years. Of those with CI during hospitalization (16%; n=245), 53% remediated by 1-month. Among the remaining 1300 patients, with normal cognitive function during hospitalization, 5% (n=67) had developed cognitive impairment by 1-month post discharge. Women had higher odds of becoming newly impaired (Table). Low education, health literacy, and numeracy were associated with persistent, transient, and new impairment. Compared to those who lived with a spouse, patients who lived alone were more likely to be transiently impaired, and those who lived with others were more like to become newly impaired. High stress and low social support were associated with persistent impairment.

Conclusions:
For many patients with ACS, cognitive status changes during the transition from hospital to home; thus, assessing cognition both in-hospital and post-discharge is important for detecting patients who could benefit from tailored transitional care, because they are at high risk for decline, or early follow-up for booster discharge instructions and secondary prevention, because there is a good chance of their improving.
Abstract 337: Cognitive Function by Statin Exposure in Elderly Individuals Following Acute Myocardial Infarction
Authors: Swiger Kristopher J , Martin Seth S , Li Yan , Blaha Michael J , Blumenthal Roger S , Alexander Karen P , Cannon Christopher P , Arnold Suzanne V , Spertus John A
Published: March 2022

Introduction:
There remain concerns about the safety of statin therapy in elderly individuals particularly their effects on cognitive function, which may limit their use after an acute myocardial infarction (AMI) despite beneficial effects on morbidity and mortality. We describe cognitive function after new initiation of statin among elderly patients following an AMI.

Methods:
Among AMI patients >65 years of age in a US multicenter registry who were statin naïve, we examined the association between statin prescription at discharge and change in cognition (via Modified Telephone Interview for Cognitive Status [TICS-M]; scores range 0-50; higher scores indicate better cognitive function) assessed at 1 to 6 months after AMI. We conducted a non-inferiority test to evaluate the hypothesis that the mean change in cognitive function was no worse among statin naïve patients recently started on statins compared with those who were not. With the present sample size, we had >85% power to demonstrate non-inferiority, using a threshold of 2.3 points on the TICS-M scale (10% of the mean1-month score). A hierarchical multivariable linear model examined the association between statin therapy and the change of TICS-M scores from 1 to 6 months.

Results:
Among 317 elderly AMI patients, 262 patients (83%) were prescribed a statin at discharge and 55 were not. There were no significant differences in 1-month (23 exposed vs 22 unexposed; p=0.35) or 6-month (23 exposed vs 22 unexposed; p=0.15) TICS-M scores (see Figure). Statin-exposed patients had an average increase in TICS-M scores from 1 to 6 months of 0.13 points vs. a decrease in score of 0.40 in the unexposed patients (p=0.53). After adjusting for age, education, CVA, HTN, GFR, in-hospital CABG, history of previous MI, depression, and

GRACE score, there remained no significant effect of statin exposure on change in TICS-M (estimate 0.46, 95% CI: -1.25, 2.17; p=0.52).

Conclusions:
Among statin naïve elderly individuals recovering from an AMI, the initiation of statin therapy was not associated with detectable changes in short-term cognitive function. These findings support the general safety of statin therapy for secondary prevention in this population. Future studies are needed to confirm these findings.
Abstract 343: Chronic Kidney Disease is associated with Increased Mortality among Patients Undergoing Peripheral Vascular Intervention
Authors: Xie Joe X , Ho P. M , Dattilo Philip B , Aggarwal Vikas , Glorioso Thomas J , Baron Anna E , Donaldson Darcy , Armstrong Ehrin , Klein Andrew , Giri Jay , Tsai Thomas T
Published: March 2022

Background:
Among patients with peripheral vascular disease (PVD) undergoing surgical revascularization, chronic kidney disease (CKD) is associated with increased postoperative morbidity and mortality. However, the impact of CKD on adverse outcomes among PVD patients undergoing peripheral vascular interventions (PVI) is less well established.

Methods:
Using data from the VA Clinical Assessment, Reporting, and Tracking System (CART) Program, we identified a cohort of patients who received PVI between June 2005 and August 2010 at 33 sites. Excluding patients requiring chronic dialysis, the presence of CKD was defined based on baseline GFR of less than 60 mL/min/1.73 m2 obtained within 30 days prior to the procedure. The outcomes of interest were mortality, progression of CKD to dialysis, myocardial infarction (MI), and limb amputation. Multivariable Cox Proportional Hazards model assessed the association between CKD and adverse outcomes.

Results:
Of 784 patients undergoing PVI, 203 (26%) patients had CKD, 27 (3%) patients were on dialysis and 554 (71%) patients did not have CKD. Patients with CKD were older, and were more likely to have diabetes and CHF. On Kaplan-Meier analysis, CKD was associated with decreased survival (5-year survival probability of CKD compared to non-CKD: 53.7% (44.5%-61.9%) versus 79.3% (74.8%-83.1%), P<0.01) (Figure), which persisted after risk adjustment (HR 1.40; 1.07-1.83). In addition, CKD patients were more likely to have progression to dialysis (HR 6.30; 3.37-11.79). In contrast, there were no significant differences for the outcomes of MI (HR 1.04; 0.47-2.31) or limb amputation (HR 0.90; 0.57-1.44).

Conclusion:
CKD is present among 1 in 4 patients undergoing PVI. CKD is associated with increased risk of mortality and progression to dialysis; however, there is no significant association with MI or limb amputation. Future studies are needed to assess whether there are opportunities to modify the risks associated with CKD among patients undergoing PVI.
Abstract 348: Overutilization of Carotid Duplex Ultrasonography in Evaluation of Cerebrovascular Disease
Authors: Barvalia Mihir , Silber David , Joshi Abinash , DiVita Michael , Wasty Najam , Cohen Marc
Published: March 2022

Introduction:
Carotid Duplex Ultrasonography (CDUS) is one of the non-invasive imaging modalities used to evaluate for carotid artery stenosis. However, it is often used in patients with coronary artery disease (CAD), peripheral artery disease (PAD), syncope, and before heart surgery although its value is unclear. Our study aimed to further investigate the yield of CDUS in these conditions.

Methods:
A retrospective analysis was conducted on 827 consecutive carotid ultrasounds ordered between March 2013 and August 2013 at Newark Beth Israel Medical Center. Clinical variables tabulated were age, sex, smoking status, systemic hypertension, diabetes mellitus, CAD, PAD, carotid bruit and physician indications for ordering CDUS. Significant cerebrovascular disease (sCBVD) was defined as > 60% diameter reduction in internal carotid arteries (ICA) or occlusion in vertebrobasilar system as per Intersocietal Commission for Accreditation of Vascular Laboratories (ICAVL) guidelines.

Results:
Only 88 out of 827 (10.6%) patients had sCBVD. In these 88 cases, most common plaque characteristics identified were irregular hetergeneous and irregular calcified. Risk factors such as age, sex, cigarette smoking, systemic hypertension, diabetes mellitus, CAD or PAD did not make a significant difference in rate of sCBVD (Chi Square=0.72, p=0.95). However, patients with history of carotid endarterectomy (CEA) or carotid artery stenting and presence of carotid bruit had significantly higher proportion of sCBVD (Chi Square=113, p<0.001). Finally, yield of carotid ultrasound was lowest in patients with syncope, pre-operative evaluation for heart surgeries, Orthotopic Heart Transplantation and non-specific neurologic symptoms such as gait imbalance, delirium, visual problems, and paresthesias.

Conclusion:
Carotid Duplex Ultrasonography used in a real world hospital setting has very low diagnostic yield in patients presenting with syncope and in pre-operative evaluation for cardiac surgeries. This highlights poor cost-effectiveness of carotid ultrasound in such situations. Furthermore, we propose that randomized trials need to be conducted to optimize its effective utilization.
Abstract 349: Elevated Troponin: How Well Does it Predict a Diagnosis of Acute Coronary Syndrome?
Authors: Burke Lucas A , Agarwal Nayan , Schmalfuss Carsten , Winchester David E
Published: March 2022

Background:
Cardiac troponins are highly sensitive for detection of myocardial necrosis and considered the reference standard for diagnosing acute coronary syndromes (ACS). Due to high sensitivity and widespread use in patients with low likelihood of ACS, the positive predictive value (PPV) of elevated troponin for determining ACS may be limited.

Methods:
From 2006-2007, all patients with elevated troponin ( > 0.03 ng/dL) at our facility were evaluated by an attending cardiologist within 24 hours of a positive troponin in order to determine the presence or absence of ACS. Patients were tracked during their hospitalization with data gathered prospectively in a database maintained for quality purposes. We conducted a cross sectional investigation of patients in this database to ascertain the PPV of elevated troponin for diagnosing ACS. Baseline characteristics and symptoms for patients with and without ACS were compared. Multivariate logistic regression was performed to determine correlations between the diagnosis of ACS and patient characteristics, symptoms and other objective findings.

Results:
1018 patients were included. Mean initial troponin value was higher for patients with ACS (0.42 versus 0.13, p < 0.0001). Overall, the PPV of elevated troponin for diagnosing ACS was only 29.8%. The PPV varied widely depending on the initial symptom reported (highest, chest pain 48.8%; lowest, low energy 2.3%). In multivariate logistic regression, few patient characteristics were correlated with ACS, including smoking (odds ratio [OR] 4.36, 95% confidence interval [CI] 2.45-7.76, p < 0.0001) and hyperlipidemia (OR 1.62, 95% CI 1.16-2.27, p=0.005). New electrocardiogram changes (OR 5.43, 95% CI 3.49-8.46, p<0.0001) and troponin value greater than 10 fold above upper limit of normal (OR 2.79, 95% CI 1.12-6.96, p=0.028) were correlated with ACS. The only symptom correlated with ACS was chest pain (OR 5.00, 95% CI 3.51-7.13).

Conclusion:
Elevated troponin alone has weak PPV for diagnosing ACS when adjudicated by an attending cardiologist. Troponin elevations were observed with various presenting symptoms, and the PPV was dependent on chief complaint. New electrocardiogram changes, level of troponin elevation, chest pain, and smoking were strongly correlated with the diagnosis of ACS.
Abstract 354: Influence of hemoglobin and uric acid level on Re admissions for Heart Failure
Authors: fatima urooj , Ali Fahad , Prasad Hari , Stapleton Dwight
Published: March 2022

Introduction:
Heart Failure admissions account for around 1%-2% of total healthcare expenditures (1).As seen in OPTIME-CHF study there was a prevalence of around 49% (of anemia) in heart failure patients and it was seen as an independent risk factor for the readmission and death (2). Along with this several studies have shown that elevated Uric acid is also associated with increase in readmissions and death. The aim of our study was to retrospectively analyze the readmission in relation to the uric acid and hemoglobin in the heart failure population at a teaching community hospital.

METHODS:
Records of 258 patients with heart failure was studied retrospectively. Hemoglobin at discharge (greater then 10g/dl versus less than 10 g/dl)in relation to readmission within 1 month and between one to six months was studied . Along with this the relationship of uric acid level of less then 7.5 mg/dl versus greater than 7.5mg /dl in relation to readmission within 1 month was studied . Chi square test was used for statistical analysis.

RESULTS:
28.6% of patients with hemoglobin of <10 g/dl were readmitted within 1 month versus 20.60% of patients with the hemoglobin >10g/dl. For the re admissions between 1 and 6 months 21.4% of patients with hemoglobin less then 10 g/dl were readmitted versus 10.6% with the hemoglobin greater then 10g/dl. Similarly, it was seen that in patients with uric acid greater then 7.5 mg/dl 30% of the patients were readmitted in 1 month versus 23.3% with the uric acid of less then 7.5mg/dl.P value was not significant which was thought to be due to small sample size.

Conclusion:
By optimizing the hemoglobin and uric acid levels rate of re admissions can be reduced .

References: World J Cardiol 2012 February 26; 4(2): 23-30
Abstract 361: Clinical Utility and Impact of Revised Continuous Cardiac Telemetry in Identifying Life Threatening Arrhythmias
Authors: Kansara Pranav , Kristi Jackson , Dressler Robert , Weiner Henry , Roger Kerzner , Weintraub William S , Doorey Andrew
Published: March 2022

Background:
Continuous cardiac telemetry (CCT) is used to provide immediate awareness of life-threatening rhythm disorders. When used too widely, many patients (pts) who do not need CCT receive this service, while when used too restrictively; this may place pts at risk.

Methods:
In March 2013, Christiana Care Health System revised CCT utilization standards based on risk stratification per 2004 AHA guidelines. We retrospectively and randomly examined daily call logs from central monitoring department (CMD) for 2625 monitored non-ICU pts during two separate months, November 2012 (old system, 1323 pts) and June 2013 (new system, 1322 pts). The calls were categorized as emergent (EC) and non EC as per pre-determined criteria. Life-threatening rhythms were defined as sustained ventricular tachycardia/fibrillation and asystole.

Results:
The revised CCT system reduced total number of monitored pts by 23% and total no of calls by 44% over a 30 day period. EC frequency was 1.1% for the entire study. There was a single potentially life threatening arrhythmia among the 7200 calls from 2645 pts (ventricular tachycardia that self-terminated in 32 seconds). Only 14% of total EC led to a change in management within 1 hour.

Conclusion:
In these non-ICU patients, it was rare that CCT provided an alert to a life-threatening arrhythmia. Arrhythmias leading to treatment changes within 1 hour were also uncommon. Guideline driven use of CCT decreases the overuse of monitors. Low rate of truly emergent arrhythmias in contemporarily managed patients reveals this to be safe.
Abstract 362: Presentation, Management, and Outcomes of Infective Endocarditis at a Tertiary Medical Center
Authors: Kashef Mohammad Amin , Hernandez Jaime , Atreya Auras , Friderici Jennifer , Lagu Tara
Published: March 2022

Background:
Infective endocarditis (IE) has historically caused significant morbidity and mortality, but there are few descriptions of contemporary cohorts of IE patients.

Methods:
We conducted a retrospective cohort study of adult patients admitted to a single tertiary medical center with diagnosis of IE between 2007-2011. Using medical record abstraction and administrative databases, we collected demographic data, comorbidities and clinical data indicating IE severity, management and outcome.

Results:
We identified 180 hospitalizations with a primary or secondary discharge diagnosis of IE and clinical criteria confirming IE diagnosis; 66% were male and 79% were white. Mean patient age was 60 years (SD=18 years) and 29% (52 of 180) of patients were admitted to critical care or step down unit. Risk factors for IE were common: 9% (17 of 180) had previous history of IE, 25% (45 of 180) had prosthetic valve IE, 17% (30 of 180) had intra cardiac devices, 12% (21 of 180) had long term central lines and 14% (25 of 180) were intravenous drug users.

Half of the sample had an infected native mitral valve (90 of 180) and 40% had an infected native aortic valve (72 of 180). Nearly all patients (93%: 173 of 180) had at least 2 sets of blood cultures drawn before starting antibiotics. The most common microorganism detected in blood culture was
Staphylococcus aureus
(41%: 69 of 180), followed by
Streptococcus.viridans
(17%: 29 of 180). Cultures were negative for 4% (7 of 180). Infectious disease consultation was completed in 83% (150 of 180) and cardiac surgery consultation in 45% (81 of 180) of patients.

Echocardiography was performed in 89% (161 of 180) of patients, transthoracic in 69% (125 of 180), and transesophageal in 56% (100 of 180). Among patient who had echocardiography, 17% (28 of 180) had a left ventricular ejection fraction of <50%; 52% (94 of 180) had insufficiency of the infected valve. Perivalvular abscess was reported in 8.9% (16 of 180) and valve perforation in 11% (19 of 180).

The median length of stay was 13 days (interquartile range 9-21days), inpatient mortality rate was 15% (27 of 180; 95% CI: 11.2%-21.2%), and 6-month readmission rate was 10.5% (19 of 180; 95% CI: 6.0%-15.1%).

Conclusions:
In a single academic medical center, IE patients presented with high degree of acuity and found to have frequent complications in echocardiogram. Despite recent advances in medical, surgical, and critical care, many patients had a long hospitalization with relatively high inpatient mortality and readmission rate.
Abstract 369: Symptom Type and Characteristics Differentiate Early from Late Treatment Seekers for Symptoms of Atrial Fibrillation
Authors: McCabe Pamela J , Chamberlain Alanna , Rhudy Lori , DeVon Holli
Published: March 2022

Background:
Delay in seeking treatment for symptoms of atrial fibrillation (AF) represents a missed opportunity for early treatment that is critical for reducing serious complications of AF such as stroke and heart failure. Delays ranging from a few days to years after symptom onset have been reported. Little is known about the symptom experiences and cognitive behavioral responses that differentiate those who seek treatment early after symptom onset from those who delay treatment-seeking.

Purpose:
This study compared symptoms and cognitive behavioral responses of early and late (up to 24 hours versus greater than 24 hours after symptom onset) treatment seekers with symptoms of AF.

Methods:
A descriptive design was used. Participants (N = 150) were recruited from a Midwest academic medical center. Data regarding 1) type and character of symptoms 2) cognitive and behavioral responses to the symptoms and 3) time from symptom onset to seeking treatment were collected using a structured interview. Independent t-tests for continuous variables and Chi-square tests for categorical variables were used to compare treatment seeking groups.

Results:
Participants were 51% female, with a mean age of 66.5 SD = 11.1) years. Early treatment seekers (n = 27) were more likely to experience a rapid heartbeat (p <.01), unremitting symptoms (<.001), report fear associated with symptoms (p = .005), and appraise symptoms as very serious (p <.001). They were less likely to believe symptoms could be self-managed (p <.001). Late treatment seekers (n = 123) were more likely to experience fatigue and dyspnea as primary symptoms (p≤ .01), report intermittent symptoms (p <.001), attribute symptoms to stress (p ≤ .02), deconditioning (p <.001), or lack of sleep (p = .009), and take a “wait and see” approach to managing symptoms (p <.001). There were no differences between early and late treatment seekers for age, sex, marital status, education level, and history of coronary artery disease or heart failure.

Conclusions:
Symptom type and characteristic, and cognitive behavioral responses of early treatment seekers differed from those of late treatment seekers. Experiencing a rapid heartbeat and unremitting symptoms may have helped participants form a cognitive appraisal and behavioral response conducive to early treatment-seeking. Experiencing intermittent symptoms less identifiable with a cardiac origin may have hindered development of cognitive appraisals and behavioral responses that promote early treatment- seeking. Education to promote early treatment-seeking for symptoms should include information about the diverse type and characteristics of symptoms of AF.
Abstract 371: Role of Advanced Care Providers in Post Percutaneous Coronary intervention Care: Analysis of Clinical Outcomes and Insights from 1 year Cohort Study
Authors: Mishra Abhishek , Singh Maninder , Kamboj Mayanka , Sethi Anuradha , Stapleton Dwight
Published: March 2022

Background:
Advanced care providers (ACPs) (nurse practitioners/physician assistants) play a significant role in the United States health care. No prior studies have evaluated the role of ACPs in post percutaneous coronary intervention (PCI) care. Aim of this study was to compare clinical outcomes in patients followed by ACPs as compared to cardiologists after PCI.

Methods:
In this observational study, we evaluated 381 patients who underwent successful PCI from Jan to Dec '11 and were discharged alive. In this group-practice based model at a tertiary health care center, ACPs independently provide primary cardiac care to patients post PCI, in collaboration with cardiologists. We compared all cause mortality and major adverse cardiovascular (MACE) at one year amongst patients followed by cardiologists (n=164) and ACPs (n=144). We excluded 73 patients who crossed over from one provider type to the other during follow up.

Results:
Baseline characters of the study groups are shown in table 1. These patients were similar with regards to baseline co-morbidities, except for a higher proportion of hypertension and prior myocardial infarction/PCI amongst patients followed by ACPs. Both the groups experienced similar mortality (3% [5/164] for cardiologists vs. 6.3% [9/144] for ACPs, p=0.178) and MACE (12% [20/164] for cardiologists vs. 13% [19/144] for ACPs, p=0.792) at 1 year. Individual outcomes are shown in table 2.

Conclusion:
In this study, ACPs provided an equally effective care to patients post PCI as compared to cardiologists, with comparable all-cause mortality and MACE. With expanding role of ACPs, more studies are needed to compare other parameters such as cost effectiveness and patient satisfaction.
Abstract 374: Quality Improvement Program to Optimize Pre-Operative Evaluation of Elective Cardiovascular Surgery Patients Reduces Complications and Improves Length of Stay
Authors: Porten Brandon R , Strauss Craig E , Mueller Joshua J , Garberich Ross F , Sun Benjamin C , Abdelhadi Raed H , Henry Timothy D
Published: March 2022

Background:
Pre-operative evaluation of elective cardiovascular (CV) surgery patients is limited by varying electronic health records and primary care physician adherence to guideline recommendations. A standardized pre-operative evaluation protocol may optimize medical management prior to elective surgery and reduce common post-operative complications, such as atrial fibrillation (AF), which is associated with increased adverse events and length of stay (LOS).

Methods:
In April 2013, a quality improvement program was implemented at a high volume center to standardize pre-operative evaluation of elective CV surgery patients. A comprehensive real-time decision support tool was developed based on consensus recommendations for optimal care. Patients qualifying for prophylactic amiodarone based on the PAPABEAR trial received prescriptions upon pre-operative evaluation. Using a shared electronic medical record we reviewed all elective coronary artery bypass graft and/or valve surgeries from April-December 2013. Any complication, post-operative AF, stroke, observed/expected mortality, LOS and percent geometric mean LOS were compared between patients with 1) pre-operative evaluation + amiodarone; 2) pre-operative evaluation + no amiodarone; 3) no pre-operative evaluation + no amiodarone.

Results:
Among 190 elective CV surgery cases, 28 (14.7%) patients received standardized pre-operative evaluation and qualified for prophylactic amiodarone, 100 (52.6%) received pre-operative evaluation without amiodarone and 62 (32.6%) received no pre-operative evaluation or amiodarone. Pre-operatively evaluated patients receiving amiodarone had the lowest any complication (p=0.009) and post-operative AF (p=0.047). Mean LOS, percent geometric mean LOS and observed/expected mortality were lower but did not reach statistical significance. There were no differences in post-operative stroke (Figure).

Conclusions:
A standardized pre-operative evaluation protocol in combination with prophylactic amiodarone in appropriate patients was associated with lower overall complications and a reduction in post-operative AF and LOS. Standardized protocols may enable health care providers to optimize pre-operative management of elective surgery patients and improve care quality and outcomes.
Abstract 12: Variation in the Use of Guideline-directed Medications Prior to Cardiac Defibrillator Implantation
Authors: Roth Gregory , Poole Jeanne , Zaha Rebecca , Zhou Weiping , Skinner Jonathan , Morden Nancy
Published: March 2022

Objective:
Guideline-directed medical therapy (GDMT) is recommended prior to implantation of a primary prevention cardioverter-defibrillator (ICD). We examined GDMT use prior to primary prevention ICD implantation among Medicare beneficiaries.

Methods:
Using the National Cardiovascular Data Registry ICD Registry from 2007-2011, we identified recipients of a primary prevention ICD for the indication of heart failure with an ejection fraction <40%. We then selected the subset of these patients enrolled in a fee-for-service Medicare prescription plan in the 120 days immediately preceding ICD implant. GDMT was defined as filling one or more prescriptions for a renin-angiotensin inhibitor (RAI) and a heart-failure approved beta blocker (HFBB). We identified patients with any fills and with optimal prescription supply (at least 80% of days covered) in the 90 days prior to ICD implant. We determined the proportion of patients receiving GDMT overall and for each U.S. hospital referral region (HRR). We used logistic regression to identify patient characteristics associated with receipt of optimal GDMT and to model the association between GDMT receipt and 1 year mortality.

Results:
Among 433,882 patients in the ICD registry who were enrolled in Medicare, we identified 25,473 that met Medicare prescription benefit enrollment criteria. Just 60% of these patients filled one or more prescription for both GDMTs (HFBB 76%, RAI 73%). Of those with some GDMT fills, just 38% received sufficient supplies to cover 80% of days. The HRR-level proportion of patients filling any GDMT ranged from 44%-78%. Patients were significantly less likely to receive GDMT if they were male, did not receive a low-income prescription benefit subsidy, had NYHA class 4 symptoms, renal failure, a history of ventricular tachycardia, or their most recent ejection fraction assessment within 1 month prior to implant. Ejection fraction was not associated with receipt of GDMT. Those filling GDMT were significantly less likely to die within 1 year (odds ratio 0.69 adjusted for age (95% CI 0.64, 0.75)).

Conclusion:
Prior to primary prevention ICD implantation, GDMT use appears inadequate overall and varies widely by region. Greater GDMT use should improve heart failure outcomes and may decrease the number of patients meeting an indication for ICD implantation. Understanding drivers of high and low use would inform policies aimed at optimizing this care.
Abstract 128: Catheter-based Ablation May Improve Survival in Patients with Acute Decompensated Heart Failure with Reduced Ejection Fraction and Atrial Fibrillation or Flutter with Rapid Ventricular Response
Authors: Alqasrawi Musab , Joseph Lee , Eshcol Jayasheel , Doshi Hardik , Iqbal Omer , Mesubi Olurotimi , Worden Nicole , Krothapalli Siva , Bhave Prashant , Giudici Michael
Published: March 2022

Background:
There is no current evidence regarding safety and efficacy of various rhythm control strategies such as Amiodarone, electrical cardioversion (DCCV), catheter based ablation and other anti-arrhythmic drugs (AAD) for acute control of rapid ventricular response (RVR) in hospitalized patients with atrial fibrillation or flutter (AF/AFL) and acute decompensated heart failure with reduced ejection fraction (ADHFrEF).

Methods:
Single center retrospective study from our registry of hospitalized patients with ADHFrEF and rapid AF/AFL over a 5-year period

Results:
We included 52 patients with ADHFrEF and rapid AF/AFL (mean age, 64.3±13.9 years; 39 (75%) males; mean left ventricular EF [%], 29.4±8.1; median follow up duration [months], 13 [interquartile range, 5.3-19]): 30 (57.7%) received amiodarone, 19 (36.5%) received DCCV, 10 (19.2%) received catheter ablation and 1 (1.9%) received other AAD. Patients who were treated with catheter ablation had significantly higher rates of survival to median follow up and to hospital discharge compared to those who were not treated with ablation. There were no significant differences in symptoms control, major bleeding event, systemic embolism, worsening HF, procedure related complications, and length of hospital stay between patients treated with and without amiodarone, DCCV and catheter ablation (Table 1). New onset AF/AFL, new HF, left ventricular EF, NYHA functional class, and loading with AAD did not predict response to DCCV (P = 0.22-0.87) (Table 2).

Conclusion:
Acute control of rapid AF/AFL in hospitalized patients with ADHFrEF using catheter ablation significantly improved survival. Catheter-based ablation may be a safe and efficacious treatment option for these patients.
Abstract 133: Impact of COPD on Patients With Cardiovascular Disease
Authors: Mannem Santhosh R , Ahn Hyeong Jun , Miyamura Jill , Juarez Deborah , Chen John , Seto Todd
Published: March 2022

Background:
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality and the third leading cause of death in the US. Little is known about the impact of COPD on pts with cardiovascular disease, although it is a common coexisting condition.

Methods:
We used a statewide, all-payer hospital discharge database in Hawaii to identify pts discharged from 2011-13 with a primary diagnosis of acute myocardial infarction (AMI) or heart failure (HF). We compared characteristics and outcomes of pts with and without a secondary diagnosis of COPD. Multivariable logistic regression was used to assess associations between COPD and 30d readmission and inhospital mortality.

Results:
Overall, 6,581 pts accounted for 10,080 HF admissions and 6,520 pts accounted for 7,556 AMI admissions. COPD was noted in 11.5% of HF, 6.2% of AMI and 8.8% of pts with HF or AMI. After controlling for potential confounders, COPD was independently associated with 30d readmission for HF (OR=1.16, 95% CI: 1.00-1.33) and HF or AMI (OR=1.26, 95% CI: 1.11-1.42), with a trend for AMI alone (OR=1.19, 95% CI: 0.93-1.53). There was a trend for higher mortality with COPD for HF (OR-1.09, 95% CI: 0.80-1.50), AMI (OR=1.26, 95% CI: 0.91-1.75), and HF or AMI (OR=1.10, 95% CI: 0.87-1.37).

Conclusion:
Among pts hospitalized for HF or AMI, having COPD was associated with higher 30d readmission but similar inhospital mortality. As <10% were diagnosed with COPD, further work is needed to determine if it is under-reported in this population.
Abstract 135: Clinical Decision Making Utility of Stress Echocardiography in Contemporary Managed Patients with Suspected Coronary Artery Disease
Authors: Wild Nicholas C , Shultz John , Topliceanu Alexandru , Torosoff Mikhail
Published: March 2022

Background:
We have investigated outcomes of contemporary management in patients undergoing stress echocardiography for evaluation of chest pain.

Methods:
Records of 294 consecutive patients who underwent a stress echocardiogram at a single tertiary care center were reviewed. Demographic, clinical data, and outcomes were collected. ANOVA, chi-square, and logistic regression analyses were used. Mean follow up length was 37 months. The study was approved by the IRB.

Results:
This study cohort included 46% women, with an average age of 61 +/- 10.6 years old; 20% were current smokers, with history of CAD in 26%, CHF in 4%, hypertension in 40%, diabetes in 14%, and peripheral vascular disease in 4%. Baseline medical treatment included beta blockers in 46% and ACE inhibitors in 24%. The majority (94%) of these patients underwent a dobutamine stress echocardiogram.

Fifty five of the 294 patients had ischemia during the test. Males were twice as likely to have ischemia during the stress test compared to females (24% vs. 12% p=0.009). There was a trend towards increased prevalence of ischemia in diabetics (26% vs. 17% p=0.175) and in smokers (24% vs. 17% p=0.262).

The presence of ischemia was associated with a 40% increase in mortality (14.5% vs. 10.5%) and an approximately 3-fold increase in MI (9.1% vs. 2.9% p=0.0679).

Patients with ischemia during stress testing were ten times more likely to have invasive cardiac evaluation and changes in medications compared to patients without ischemia during stress testing (41.5% vs. 4.1% p<0.001) or undergo invasive evaluation without a change in medications (24.5% vs. 3.3% p<0.001).

Invasive evaluation was not associated with a reduction in mortality (13.4% vs. 10.4% p=0.349). However, change in medications alone was associated with increased mortality (16.7% vs. 9.7% p=0.04).

Conclusions:
In the majority of contemporary managed patients with suspected coronary artery disease, stress testing is likely to have a normal result. When abnormal, it typically leads to invasive evaluation and/or medication changes. The small sample size of patients with ischemia in our study limits our ability to discern the effects of invasive evaluation and/or medicine changes on outcomes. Additional studies of this important subject are needed.
Abstract 141: Predictors of the Utilization of QT Interval Lengthening Medications in the Atherosclerosis Risk in Communities (ARIC) Study
Authors: Alburikan Khalid A , Savitz Samuel T , Whitsel Eric A. Whitsel A , Tisdale James E , Soliman Elsayed Z , Kucharska-Newton Anna M , Stearns Sally C , Rodgers Jo E
Published: March 2022

Objective:
Prolongation of corrected QT interval (QTc) is associated with increased morbidity and mortality. We examined the predictors of the use of QTc prolonging medications (QTPM).

Methods:
We included 15,792 ARIC participants with a resting, standard 12-lead electrocardiogram and ≥ 1 measure of QTc over up to four triennial examinations between 1987 and 1998 (54,638 person-visits). Participants with missing data were excluded (n=1,668). To optimize clinical applicability, QTc was calculated using Bazett’s equation. At each visit, we identified participants using ≥ 1 CredibleMeds classified QTPMs, age > 65 years, females, and those with LVH, or QTc > 500 ms at the prior visit. We used linear regression (random and fixed effects models) for 37,233 person-visit observations from visits 2-4 to determine predictors of the use of QTPMs. The following known risk factors and potential predictors for QTc lengthening were assessed: age, female sex, LVH, and QTc at the prior visit. Standard errors were corrected for repeat observations per person. Additional risk factors will be assessed in future analyses.

Results:
Among person-visit observations from Visit 2-4 (mean age 59.7, 55% female, 9% LVH, mean QTc 431), 16% (n= 5,153) of participants were using one or more QTPM. Preliminary results suggest three of the four identified risk factors predicted use of QTPMs: age, sex, and QTc at prior visit. Prolonged QTc at prior visit was associated with a lower probability of using QTPM. In contrast, use of QTPMs was positively associated with a joint effect of age and female sex. The latter is concerning given older females are at increased risk for QTc prolongation.

Conclusions:
In this preliminary analysis, several predictors of QTPM use emerged. Future analyses will include additional predictors and assessment of outcome will adjust for these predictors.
Abstract 147: Contrast Induced Nephropathy; a Continued Concern
Authors: Lawson William E , Hamo Carine , Decristofaro Joseph , Wilbert Lisa , Gumersell Kellie , Leippert Yvonne , Caillias Patricia , Santora Carolyn
Published: March 2022

Background:
Contrast induced nephropathy [CIN], because of its delay in onset, is often not clinically appreciated. While delayed assessment of renal function may show substantial recovery of renal function, episodes of CIN contribute to further deterioration of renal function. Angioplasty is currently predominately performed “ad hoc”, with the anatomy defined at the time of the procedure, increasing the contrast load. Concerns have also increased with the routine Emergency Room use of “triple rule out” contrast CTA (coronary obstruction, aorta dissection, pulmonary embolism) for chest pain, shortened stays and a reduction in “unnecessary” post procedure testing decreasing the detection and apparent incidence of CIN.

Objectives:
Procedural management of patients undergoing Catheterization [Cath] and Angioplasty was analyzed using Failure Modes and Effects Analysis [FMEA] and Mehran’s formula for predicting risk of CIN and weighting of risk factors to predict severity. The likelihood of occurrence and detection were derived from the cohort of patients undergoing Cath at Stony Brook University Hospital. For patients undergoing Cath preprocedural concerns included; preop hemodynamic assessment, unknown baselines (renal function, hematocrit), diabetes mellitus, inadequate hydration, estimation of maximum contrast load to avoid CIN, avoidance of nephrotoxic agents. Procedural concerns included: contrast type and volume, hydration/ end organ perfusion, use of IABP, unnecessary procedures/potential staging. Post procedural concerns included: adequacy of hydration, follow-up monitoring of renal function.

Results:
Procedural analysis reveals multiple opportunities for intervention to decrease the likelihood of CIN. The interventions most likely to improve the risk of CIN were identified as adequacy of hydration and limitation of contrast administration. Follow-up monitoring of renal function, with involvement of nephrology for management if indicated, was also deemed critical. Changes to the preprocedural order set in the EMR have been proposed to decrease the NPO interval, propose default hydration, suggest holding nephrotoxic drugs, provide an estimated maximal contrast volume. The ACIST injector will be reset to provide lower default contrast delivery. Education of physicians and staff to monitor and limit contrast use as possible is also underway.

Conclusions:
The risk of CIN can be lessened by appropriate recognition and treatment. FMEA in conjunction with the Mehran CIN prediction formula provides an effective means of identifying procedural concerns that can be appropriately targeted in the Cath Lab.