bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 241: Design and Clinical Outcomes of INSTOR (Interventional Stroke Therapy Outcomes Registry)
Authors: Connors John
Published: March 2022

Background:
In the United States there has been no national stroke registry that tracks emergency intra-hospital processes of care and 90-day clinical outcomes for both IV tPA and/or emergency endovascular (IA) stroke treatment. The Joint Commission and other regulatory agencies now mandate use of a national stroke registry based upon concurring recommendations from the Brain Attack Coalition, the American Stroke Association, and the international Multisociety Quality Improvement Guidelines. (online JVIR, Jan 29, 2013)

Methods and Results:
A custom software development company was employed to create a dedicated on-line national registry for tracking hospital processes and performance trends, and that could perform instant complex multifactorial analyses of clinical outcomes (90-day modified Rankin Score (mRS) based upon numerous patient-specific characteristics. Extensive physician interaction with the software company over a period of years allowed construction of a complex analytical machine with a built-in logic chain for numerous clinical process steps resulting in automatic error detection of out-of-range or impossible answers. The simple self-prompting point and click data entry system typically requires 10 minutes for each stroke alert, 20 minutes for each IV tPA case, and 45 minutes for all aspects of an IA stroke case.

INSTOR

is a HIPAA compliant, point-and-click national registry that tracks processes-of-care as well as clinical outcomes for both IV tPA and endovascular therapies. All major data points are presented as “site” vs. “All”, with “All” being an anonymous aggregate of data from all participating sites.

Conclusions:

INSTOR

presents instant online graphical and numerical results including “door to CT”, “door to IV tPA”, “time for return of laboratory results” and “time to angiography”, etc. Process trends are presented with graphed monthly median data points overlain by a logistic regression trend line. The computerized multisite database also has the capability of automatically sending text massage or email reminders to designated recipients for follow-up events such as discharge information or 90-day mRS.

INSTOR

instantly performs complex multifactorial analyses of numerous measures of clinical outcomes for both IV tPA and endovascular stroke interventions and presents this data in standard stacked bar chart form. Outcomes data results include: all ASA Metrics for ischemic stroke, 90-day mRS for IV tPA, IV + IA, and IA treatment alone, and all data points mandated by the international Multisociety Quality Improvement Guidelines. 90-day clinical Outcomes are also analyzed based upon baseline clinical factors such as original NIHSS, vascular occlusion site, and comorbidities such as atrial fibrillation, diabetes, hypertension, and age.
Abstract 243: Impact of Dual Health Care System Use on Quality of Warfarin Anticoagulation in Atrial Fibrillation
Authors: Than Claire , Xu Xiangyan , Schmitt Susan , Frayne Susan , Phibbs Ciaran , Holmes Tyson , Heidenreich Paul , Moos Rudolf , Berlowitz Dan , Go Alan , Turakhia Mintu
Published: March 2022

Background.
Warfarin anticoagulation for atrial fibrillation (AF) requires routine INR blood testing, usually performed by a single anticoagulation clinic or provider. Regular INR testing improves INR control, and monthly INR testing and adequate time in INR therapeutic range are endorsed quality and performance measures. However, many Veterans with cardiovascular disease use VA and Medicare (MC) services concurrently. We therefore evaluated the association of outpatient dual health care system use with process measures of warfarin management.

Methods.
Using linked VA and MC inpatient, outpatient, drug prescription, and laboratory claims, we identified MC Part A/B eligible, non-MC Advantage, Veterans age ≥ 65 with prevalent atrial fibrillation or flutter who were prescribed warfarin from the VA (index date) between 1/1/2004 and 12/31/2008. The primary predictor was the degree of dual use for INR testing, expressed as the fraction of outpatient INRs obtained in the 12 months post-index date that occurred in Medicare (MC/[VA+MC]). The outcomes were 1) the INR monitoring rate (INRMR), expressed as the proportion of calendar months±6 days in which an INR was performed (consistent with AHA/ACC performance measures) and 2) VA-based time in INR therapeutic range of 2.0-3.0 (TTR).

Results.
We identified 394,854 patients (age 77.2 ± 6.1 years; 1.4% female) with AF and VA-issued warfarin meeting inclusion criteria. Of these, 43.3% used VA only for INR testing, 16.6% used MC only, and 39.1% used both VA and MC. Compared to patients who used VA only, dual health care system users were older and had higher CHADS2 and comorbidity index scores. Compared to patients with VA-only care, the proportion of patients with adequate achievement of performance measures (INRMR = 1.0 or TTR ≥ 60) varied by degree of dual use (p<0.001). Mean TTR was highest among patients with VA-only INR monitoring (Table, p < 0.001).

Conclusion:
More than half of Veterans age ≥ 65 with AF and VA-issued warfarin receive outpatient INR testing in MC. Dual health care system use is associated with lower achievement of process measures of quality of anticoagulation care, which could affect outcomes of stroke, hemorrhage and death.
Abstract 244: Why Registries Matter: Impact of a Comprehensive Telestroke Data Collection Process on Clinical Quality Improvement
Authors: Baraban Elizabeth , Lesko Alexandra , Corless Leslie , Fisher Suzanne , Okon Nicholas
Published: March 2022

Introduction:
Evaluating patient care within a telestroke network is challenging due to lack of appropriate data. The AHA/ASA’s Target Stroke helps address QI programming in larger hospitals, typically PSCs, but may not be appropriate for smaller facilities that lack specialty knowledge and data collection tools. Telestroke has only heightened this need for smaller facilities to measure and track performance to ensure quality care.
Goal:
In an effort to narrow this disparity and incorporate similar data-driven QI projects in our partner sites and therefore network as a whole, the Providence Telestroke Network sought to develop a novel comprehensive registry. Clinical performance measures, such as IV tPA treatment rates, door to CT and door to needle times, were collected to inform our quality improvement processes.

Methods:
The Providence Telestroke Network consists of two PSC hubs and 17 partner sites. Network participants utilize the American Stroke Association’s Get With The Guidelines (GWTG) data collection tool to capture stroke quality measures. Once entered, quality data from all sites are consolidated into a single cloud-based registry. For patients that transfer, clinical information from the partner hospital is automatically matched to the corresponding hub record within the registry. Aggregate patient information is then summarized for quality reviews and performance improvement planning.

Results:
The registry includes information on 1264 patients who received a neurologic consult by hub-based neurologists, of which 37% (n=470) received a formal telemedicine consult and 20% (n=274) resulted in a transfer to our hub facility for a higher level of care. We identified several partner sites that had patient arrival to initiation of IV tPA (door to needle) times in excess of the recommended goal of 60 minutes and door to CT times in excess of the recommended goal of 25 minutes. Initial data review at the start of network participation also found overall treatment rates at the spokes were between 0 to 6%. Quality improvement processes and ED staff education from our hub PSCs were provided to partner facilities to improve door to CT and door to needle times as well as overall IV tPA treatment rates. Door to CT times were changed by up to 54% and door to needle times were changed by up to 24%. IV tPA treatment rates in the partner sites increased by 5-32%.

Implications:
Our comprehensive registry enabled us to identify quality improvement opportunities at partner hospitals and implement appropriate QI processes. As a result, significant improvement in acute stroke care metrics were realized in our partner facilities.
Abstract 246: Reversible Cerebral Vasoconstriction Syndrome and Spontaneous Hemorrhage are the Most Common Causes of Peripartum Subarachnoid and Intracerebral Hemorrhage.
Authors: Smit Laurel J , Song Sarah , Conners James , Cutting Shawna , Lee Vivien
Published: March 2022

Introduction:
Aneurysmal and hypertensive hemorrhages are the most common causes of subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) in the general population, but the peripartum period has several unique characteristics that increase the risk of hemorrhage, including expanded plasma volume, increased vascular tone, hypercoagulability and elevation of catecholamines during delivery. Hemorrhagic and ischemic stroke accounts for 12% of all maternal deaths, and is a significant source of morbidity as well.

Hypothesis:
We hypothesized that peripartum SAH and ICH is due to distinctly different pathophysiologic processes compared to the general population.

Methods:
We conducted a chart review of inpatient stroke service admissions at a large urban academic center between the years 2006 to 2010 for women under the age of 40 with a diagnosis of SAH or ICH. Of those, we identified peripartum patients, determined etiologies for their hemorrhages, and documented pertinent risk factors.

Results:
Fifty-one patients under the age of 40 were identified with SAH or ICH. Of those, eight were peripartum and half were post cesarean section. The two most common etiologies for SAH or ICH were spontaneous hemorrhage, and reversible cerebral vasoconstriction syndrome. Other etiologies included coagulopathy and hypertension/preeclampsia. None of the peripartum hemorrhages were noted to be aneurismal.

Conclusions:
Etiologies in peripartum SAH and ICH differ from the general population. Aneurysmal bleeds were absent in our case series. Rates of SAH and ICH may be higher in patients who underwent cesarean section. In conclusion, peripartum subarachnoid and intracranial hemorrhages have a different pathophysiologic process than in the general population.
Abstract 254: Impact of Medical Study Publication on Cholesterol Medication Prescriptions
Authors: Borden William B , Willage Barton , Bishop Tara F , Mushlin Alvin I , Simon Kosali I
Published: March 2022

Background:
While research publication is associated with changes in clinical practice to varying degrees, it is unknown what spillover effects may change prescriptions of medications that are similar to, but different from, study medications. In 2008, the ENHANCE trial showed no benefit of simvastatin/ezetimibe over simvastatin alone, calling into question the benefit of ezetimibe. We hypothesize that this new ezetimibe information would have a negative impact by decreasing statin prescriptions.

Methods:
In the Source Healthcare Analytics ProMetis database, we performed a pre/post analysis of prescriptions rates for cholesterol-lowering medicines surrounding the January 14, 2008, release of the ENHANCE study results. We quantified prescription rates of the ENHANCE study medication simvastatin/ezetimibe, as well as ezetimibe alone and other cholesterol-lowering medications by class. This allowed us to assess the direct effect of the trial results on the affected drug, as well as potential spillovers to non-trial similar drugs.

Results:
From December 2007 to September 2008, simvastatin/ezetimibe prescriptions decreased nationally by averages of 70,594, 25,480, and 45,114 per month, for total, new, and refill prescriptions respectively. Ezetimibe total, new, and refill prescriptions decreased nationally by averages of 44,760, 16,141, and 28,618 per month, respectively. Conversely, total, new, and refill prescriptions for statins as a class increased by averages of 151,221, 43,599, and 107,621 per month, respectively. When examining the time immediately after the ENHANCE trial result release, simvastatin/ezetimibe and ezetimibe prescriptions decreased and at a steeper rate. Statin total, new, and refill prescriptions also decreased by 836,608, 208,114, and 628,494 from January to February 2008, respectively (Figure).

Conclusions:
These data suggest that the ENHANCE trial had spillover effects with a transient decrease in statin prescriptions. In light of the deleterious effects of acute statin discontinuation, this finding necessitates further exploration to understand the factors driving these health care decisions, and approaches to disseminating research findings that result in more targeted and appropriate changes in clinical practice.
Abstract 261: Predicting Inpatient Hospital Length of Stay for Acute Health Failure Patients
Authors: Park Jinhee , Friedman Howard S , Navaratnam Prakash
Published: March 2022

Background:
Hospital length of stay (LOS) is a primary driver of costs of care for hospitalized Acute Health Failure (AHF). A predictive model of LOS associated with AHF hospitalized patients would be beneficial in identifying potential high risk patients that may benefit from more intensive interventions.

Objective:
To develop predictive models for the length of inpatient hospital stay based on information available upon admission for AHF.

Methods:
A retrospective study using the MarketScan Hospital Drug Database identified patients with an index admission event with an acute heart failure primary discharge diagnosis (ICD-9 code 428.XX) and diagnosis reference group (DRG),(DRG 127, 291,292 or 293) for hospital admissions between 2006 and 2010. Index hospitalization was identified as the first AHF admission with no admissions in the preceding 90 days. Patient demographics, admission source, hospital characteristics (total number of beds, teaching status, urban-rural), geographic location, Charlson Comorbidity Score (CCI) and select comorbidities were identified within the index admission and served as potential input variables to model the index admission LOS. Variable selection was informed by univariate negative binomial regression models and regression tree models. Final predictive models took the form of full and stepwise negative binomial regression models (predicting LOS) and logistic regression models to predict short (≤ 2 days, approximately 20th percentile) and long (≥8 days, approximately 80th percentile) LOS.

Results:
23,629 distinct admissions were identified with mean LOS 5.5 days. The three strongest predictors of LOS in both the univariate models and the regression tree model were CCI score, nephropathy and cardiac dysrhythmia. The negative binomial model shows that comorbid cardiac dysrhythmias, anemia, nephropathy, thromboembolic disease, COPD and high CCI score were associated with increased LOS. For the logistic regression models predicting the probability of long LOS (concordance=67.3-67.5%), the most important variables were cardiac dysrhythmia, index year, and CCI score. For the logistic regression models predicting the probability of short LOS (concordance=66.3-66.5%), patients with cardiac dysrhythmia, anemia, increasing age and high CCI score were less likely to have LOS≤2 days.

Conclusion:
Across multiple modeling methods and different outcome variable definitions, it was consistently observed that AHF patients with comorbid cardiac dysrhythmia, nephropathy, anemia, higher CCI scores and older patients tended to have increased lengths of inpatient stay for their index hospitalization. Clinicians may use this information in identifying patients with higher risk of longer hospitalizations to optimize inpatient healthcare decisions and cost management strategies.
Abstract 265: Impact of Bleeding on Length of Stay and Inpatient Cost Among Atrial Fibrillation Patients Hospitalized for Congestive Heart Failure
Authors: Amin Alpesh N , Bowdy Bruce D , Johnson Bernadette H , Jing Yonghua , Robinson Scott B , Wiederkehr Daniel
Published: March 2022

OBJECTIVES:
To determine the impact of hospital acquired bleeding in atrial fibrillation (AF) patients admitted for congestive heart failure (CHF) on length of stay (LOS) and total hospitalization cost.

METHODS:
The Premier research database was queried to identify adult inpatients discharged between 2008 and 2011 with a primary diagnosis code of CHF and a secondary code of AF in whom bleeding was not present on admission. Bleeding was identified using ICD-9 diagnosis codes or charge codes for fresh frozen plasma, blood, or transfusion of blood or blood components. In univariate comparisons of patients with and without bleeding, t-tests for continuous variables and chi-squared tests for categorical variables were used (alpha = 0.05). Gamma regression adjusting for demographics, comorbidities and antiplatelet/anticoagulant use were utilized to produce estimates for mean LOS and total hospitalization cost among patients with and without bleeding.

RESULTS:
There were 76,245 patients, average age of 77.4 (SD 11.8) that met the study criteria. Across the entire population, mean LOS was 5.74 (SD 4.54) days, and mean total cost was $11,963 (SD 14,852). Overall, 4,159 (5.5%) patients had a bleed during their hospitalization. After adjustment, the mean estimated LOS was 9.49 (95% CI 9.30-9.68) days in the bleed group and 5.40 (95% CI 5.37-5.42) days in the no bleed group. The adjusted mean estimated total hospitalization cost was greater in the bleed group $21,941 (95% CI 21,425-22,467) vs. $10,757 (95% CI 10,696-10,817) in the no bleed group. Sensitivity analyses adjusting for cardiac related procedures resulted in numerical differences in the estimates, but not the direction or significance of the outcomes.

CONCLUSIONS:
Occurrence of hospital acquired bleeding in AF patients with CHF is associated with a significant increase in the LOS and total hospitalization cost. In this study, adjustment for demographic and comorbidity differences as well as the use of antiplatelets and anticoagulants did not change the magnitude or direction of these associations, though residual confounding cannot be ruled out. In this cohort, bleeding was associated with approximately additional $47 million dollars in cost and 17,000 additional hospital days.
Abstract 266: Impact of Bleeding on 30-Day All Cause Readmission in Atrial Fibrillation Patients
Authors: Amin Alpesh N , Bowdy Bruce D , Johnson Bernadette H , Jing Yonghua , Robinson Scott B , Wiederkehr Daniel
Published: March 2022

OBJECTIVES:
To determine the impact of hospital acquired bleeding assessed in patients admitted for atrial fibrillation (AF) on 30-day all-cause readmission.

METHODS:
The Premier research database was queried to identify adult inpatients discharged between 2008 and 2011 who had a primary diagnosis code for AF and in whom bleeding was not present on admission. Bleeding was identified using ICD-9 diagnosis codes, charge codes for fresh frozen plasma or blood, or charge codes for transfusion of blood or blood components. Descriptive statistics including the outcome of 30-day all-cause readmission were obtained. For comparing patients with and without bleeding, t-tests for continuous variables and chi-squared tests for categorical variables were used (alpha = 0.05). Logistic regression adjusting for demographics, comorbidities and antiplatelet/anticoagulant use were used to produce odds ratio estimates for the odds of a patient having a readmission when comparing patients with and without bleeding.

RESULTS:
There were 143,287 patients, average age of 69.4 (SD 14.5) that met the study criteria. Overall, 2,991 (2.1%) patients had a bleed during their hospitalization. There were 142,138 (99.2%) patients eligible for a readmission defined as not having died during the index hospitalization. The unadjusted 30-day readmission rate was 21.1% in patients with a bleed compared to 10.8% in the no bleeding group (p-value <0.0001) with an odds ratio of 2.22 (95% CI 2.02-2.43). The adjusted odds ratio of having a 30-day readmission was 1.48 (95% CI 1.34-1.62) when comparing the bleed group to the no bleed group. Sensitivity analyses adjusting for cardiac related procedures resulted in numerical differences in the estimates, but not the direction or significance of the outcomes. Overall, the most prevalent primary diagnosis upon readmission was atrial fibrillation (23.5%), followed by heart failure NOS (4.5%), and pneumonia (3.8%).

CONCLUSIONS:
Occurrence of bleeding in hospitalized patients with AF is associated with a significant increase in 30-day readmission. More research is needed to determine whether strategies to decrease bleeding can positively improve readmission rates for this patient population.
Abstract 268: The Use of Coronary Computed Tomography Angiography in Chest Pain Patients in the Emergency Departments Reduces Future Hospital Admissions and Does Not Impact The Need for Cardiac Catheterizations: A busting meta-analysis
Authors: EL-HAYEK Georges , Benjo Alexandre M. , Cavalcante Joao L. , Kumar Shashi , Santana Orlando , Garcia Daniel C , Herzog Eyal , Pierce Walter , Aziz Emad F , Uretsky Seth , Nascimento Francisco O
Published: March 2022

Background:
Coronary Computed Tomography Angiography (CCTA) has been deemed appropriate to use in evaluating chest pain in the emergency department (ED). However, concerns remain regarding downstream resource utilization post CCTA. We performed a meta-analysis of existing studies to address whether there is an increase in downstream testing in patients undergoing CCTA vs. the standard of care.

Methods:
We performed a search of PubMed and Scopus databases from 1966 through October 2012. We evaluated the number of hospital readmissions and subsequent visits to the ED after the initial evaluation. In addition, we evaluated the total number of left heart cardiac catheterizations (CATH), and the need for late non-invasive tests. We used fixed effect analysis when the I
2
was up to 50% and the P at least 0.05, otherwise we used random effect.

Results:
Out of 2333 articles, 4 randomized controlled trials and 3 prospective studies with control groups were included in the analysis. Out of 4466 patients, 2508 underwent CCTA as the initial test and 1958 were assigned to standard of care (SOC) as defined by the investigators which included evaluation with stress testing. In patients evaluated with CCTA, there was a 36% reduction in the chance of future hospital admissions (OR: 0.64, 95%CI: 0.41-0.99; p=0.04) (Figure) and a trend towards fewer ED revisits (OR: 0.63, 95%CI: 0.38-1.07, p=0.09). The total CATH and late non-invasive testing utilization was similar among the groups (p=0.48 and 0.32).

Conclusions:
A meta-analysis of the existing literature suggests that the use of CCTA to evaluate chest pain in the ED results in a reduction in hospital readmissions and ED revisits without an increase in downstream testing.
Abstract 279: Mortality Rate in Patients on Hemodialysis with and without Infected Implantable Cardiac Devices Undergoing Extraction
Authors: Duarte Valeria E , Brunner Michael P , Cronin Edmond , Alves Carlos , Baranowski Bryan , Wazni Oussama , Martin David , Kanj Mohammed , Saliba Walid , Wilkoff Bruce L , Callahan Thomas D
Published: March 2022

Background:
Due to a high frequency of concomitant cardiac disease, many patients with end-stage renal disease on hemodialysis (HD) have indications for cardiac implantable electronic devices (CIED). Patients on HD have increased morbidity and mortality compared to the general population. Additionally, there is increased risk for infection. Limited outcomes data exist for HD patients undergoing transvenous lead extraction (TLE). We sought to compare the mortality rates following TLE in HD patients vs. patients not on HD undergoing TLE. We also compared the mortality rates between these two groups when the indication for extraction was infection (pocket infection or endocarditis).

Methods:
We conducted a retrospective cohort study including patients on HD who underwent TLE between August 1996 and December 2009. Mortality rates were obtained using the Social Security Death Index and were compared to mortality rates of patients not on HD undergoing TLE during this same time period.

Results:
The study population included 63 patients (median age 70.0, IQR 18.3) on HD at the time of TLE. The control population included 2557 patients (median age 67,2, IQR 20.0 ) that underwent TLE during the same time period. Procedural mortality rate was 0.002% in the control group and 0% in the HD group. Mortality at 30 days, 1 year, and 3 years was significantly higher in HD patients (23.8%, 54.0% and 92.1%) compared to non HD patients (1.91%, 10.24%, and 20.41%). In the HD group, patients with pocket infection or infective endocarditis had higher mortality rates at 30 days, 1 year, and 3 years (27.45%, 60.78%, and 92.15%) than patients undergoing TLE due to infection but not on hemodialysis (2.9%, 13.28% and 25.55%).
(Table 1)

Conclusions:
Despite equivalent and very low procedural mortality rates in patient on HD compared to control, subsequent mortality rates in patients on HD at the time of TLE far exceeds the mortality rate after TLE in patients not on HD. Mortality rates are elevated even further in patients on HD that undergo TLE for infection.
Abstract 281: Adherence and Persistence for Antiarrhythmic and Rate Control Agents in Newly Diagnosed Atrial Fibrillation: Findings from the TREAT-AF Study
Authors: Jackevicius Cynthia A , Ho Michael , Xu Xiangyan , Heidenreich Paul A , Plomondon Meg , O’Donnell Colin , Tsadok Metyal , Pilote Louise , Tu Jack V , Turakhia Mintu P
Published: March 2022

Background:
Atrial fibrillation (AF) is an emerging epidemic, often treated with medications for rate or rhythm control. Adherence to these medications is important since patients may not receive optimal benefit if not taken as intended. Our study assessed patient adherence to AF medications in the Veterans Administration (VA), the largest US integrated healthcare system.

Methods:
The Retrospective Evaluation and Assessment of Therapies in AF (TREAT-AF) study is a retrospective cohort study of patients with newly diagnosed AF treated in the VA. National inpatient, outpatient, pharmacy claims and lab data were used to identify patients between 10/1/04 - 9/30/08 and who survived at least one year following diagnosis. We identified drug prescriptions for all antiarrhythmic (AA) and rate control drugs (RC) dispensed within 90 days after first AF diagnosis (index date). For each drug, we estimated adherence by calculating the 1-year medication possession ratio (MPR) and persistence by calculating continuous use within 1 year.

Results:
In 115,081 patients with newly diagnosed AF, the most common initially prescribed AAs were amiodarone, sotalol, and propafenone, and RCs were metoprolol, digoxin, and diltiazem. Among AAs, adherence was highest with sotalol (MPR 0.82+/-0.31) (Table) . Among RCs, adherence was highest with metoprolol (MPR 0.85+/-0.32) (Table). Good adherence (>80% MPR) was variable for AAs (27%-68%) and for RCs (44%-66%). At 1-year, persistence to AAs and RCs was low in general, with persistence ≤70% for each of the top three medications in each category.

Conclusion:
Among patients with newly diagnosed AF, adherence and persistence rates with AAs and RCs are variable and low in general. Continuous persistence is lower for both AAs and RCs compared with mean adherence using the MPR measure. Effectiveness of AF therapies may be compromised by poor medication adherence and persistence to these commonly prescribed medications. Future studies on predictors and outcomes of poor adherence in AF are needed.
Abstract 283: Diabetes and Dissection: An Analysis from the International Registry of Acute Aortic Dissection
Authors: Taub Rachel , Hutchison Stuart , Montgomery Daniel G , Kline-Rogers Eva , Pyeritz Reed E , Fattori Rossella , Evangelista Arturo , Ehrlich Marek P , Voehringer Matthias , Trimarchi Santi , Bossone Eduardo , Myrmel Truls , Isselbacher Eric M , Nienaber Christoph A , Eagle Kim A
Published: March 2022

Background:
Studies have shown that diabetes is less prevalent in acute aortic dissection (AAD) or aortic aneurysm patients (pts) than it is in those with coronary artery disease or heart failure. While diabetes has been found to inhibit aortic aneurysm development in laboratory animals, little is known about its impact on AAD.

Methods:
Of 3,662 pts enrolled in the International Registry of Acute Aortic Dissection, 248 (6.8%) were diabetic. Diabetic and non-diabetic pts with type A (TA) (n=2371, 6.2% diabetic) and type B (TB) (n=1291, 7.9% diabetic) AAD were compared in this study.

Results:
Diabetic pts were on average older than non-diabetic for both TA (67.7 vs 61.4 years, p<0.001) and TB (67.8 vs 63.2 years, p<0.001). Pts with TA AAD and diabetes were more often managed medically (18.5%, 27/287 vs 11.7%, 260/2225, p=0.015), while TB diabetic pts were more likely to undergo endovascular procedures (29.4%, 30/102 vs 20.8%, 247/1189, p=0.045).

TA diabetics had more in-hospital myocardial infarction (12.9%, 18/139 vs 6.8% 143/2099, p=0.007). Both TA and TB diabetics had more acute renal failure in hospital (TA: 34.3%, 48/140 vs 24.4% 513/2105, p=0.009; TB: 27.7% 28/101 vs 16.8%, 188/1118, p =0.006). In-hospital mortality was similar between groups. TB diabetics had significantly higher follow-up mortality on Kaplan-Meier analysis (p=0.028).

Conclusion:
Diabetes does not appear to impact treatment selection or in-hospital mortality for pts with AAD. However, it is important to note that diabetic pts demonstrate lower rates of follow-up survival, a trend that reaches significance in type B pts. The lower prevalence of diabetes among IRAD pts compared to other cardiovascular diseases suggests that diabetes may impact the development of AAD.
Abstract 284: Association of Veteran Status with Hypertension Prevalence in Women
Authors: Finkelstein Joseph , Mutambudzi Miriam , Cha Eunme
Published: March 2022

Background:
The high prevalence of hypertension in the US adult population represents a serious public health challenge. High hypertension rates result in substantial cardiovascular morbidity and mortality and in elevated health care expenditures. A better understanding of risk factors for development of hypertension in adults may contribute to hypertension prevention efforts. Currently, it is unclear whether veteran status is associated with hypertension risk in women. The goal of this project was to assess the association between veteran status and risk of developing hypertension in women.

Methods:
The Integrated Health Interview Series (IHIS) is a harmonized dataset for the U.S. National Health Interview Survey (NHIS). Using the IHIS 1997-2010 dataset, population-based prevalence of hypertension among female veterans was compared to non-veterans. For the purpose of analysis, only Whites and African Americans were included in the sample dataset. Veterans were participants who answered ‘Yes’ to the question, “Have you ever been honorably discharged from active duty in the U.S. Army, Navy, Air Force, Marine Crops, or Coast Guard?” Diagnose of hypertension was self-reported. Regression models were performed to evaluate the association between veteran status and the risk of hypertension. Socio-demographic factors and health behaviors were accounted for in the analysis. Sampling weights that adjust for the complex design of the IHIS were applied to all analyses presented. Statistical analyses were performed using SAS version 9.0.

Results:
Veteran African American women aged 18-40 years of age had a hypertension prevalence rate of 14.8% while non-veterans had a prevalence rate of 14.2%. In White women the prevalence of hypertension was 8.7% among veterans and 7.9% in non-veteran civilians. Hypertension prevalence in African American women older than 40 was 39.1% among veterans and 56.4% in non-veterans (p<0.0001). In White women of the same age-group the prevalence of hypertension was 37.7% among veterans and 39.6% in non-veteran civilians (p<0.005). After adjusting for age, marital status, poverty level, Body Mass Index (BMI), education, smoking, alcohol drinking, and exercise, African American veterans were 24% less likely to have hypertension than non-veteran civilians with statistical significance (OR 0.76, CI 0.6-0.9). There was a 2% risk reduction for hypertension for White veterans but without statistical significance.

Conclusion:
The prevalence of hypertension was significantly lower in female veterans than in non-veteran females. African American female veterans were 24% less likely to have hypertension than non-veteran African American females, and this association remained significant after adjusting for socio-demographic and health behavior factors.
Abstract 285: Impact of Prescription Refill Reminders for Clopidogrel Therapy in Patients Receiving Drug-Eluting Stents
Authors: Davis Estella M , Tepley Robyn M , Packard Kathleen A , Hilleman Daniel E
Published: March 2022

Purpose:
Premature discontinuation of antiplatelet therapy in ACS patients receiving a drug-eluting stent (DES) can be associated with increased morbidity and mortality. The purpose of this study was to determine if refill notification reminders for clopidgrel by a pharmacist would improve long term adherence and outcomes for patients receiving a DES.

Methods:
A prospective, randomized, controlled study was conducted to evaluate adherence to clopidogrel for up to one year in ACS patients receiving a DES. Patients randomized to the Pharmacist Reminder group were contacted by a pharmacist on a monthly basis with a refill reminder for their clopidogrel prescription and the ability to discuss any medication issues. Patients randomized to the No Reminder group did not receive any refill reminder notification from a pharmacist. Both groups were contacted at 6 and 12 months to complete a follow-up survey. Pharmacy refill records were evaluated to determine monthly adherence and actual out-of-pocket expenses for clopidogrel up to one year after enrollment. Adherence was assessed by both the proportion of months covered (PMC) and complete continuous adherence over 1 year. A PMC of >80% was considered adherent. Patients were enrolled from September 2007 to August 2009. Assuming premature discontinuation rates of 5% and 14% for Pharmacist Reminder and No Reminder groups respectively, 120 patients were required to detect significance with an alpha level of 0.05 and a power of 0.80.

Results:
A total of 114 patients were enrolled in the study with 53% (N=60) patients in the No Reminder group and 47% (N=54) in the Pharmacist Reminder group. The majority of patients were male (75%) with an average age of 62 years. Approximately 18% had a previous stent and had taken clopidogrel previously. Of the total population, 89% were adherent (102/114) with a PMC >80%, 2.6% (3/114) had a PMC 60-79%, and 7.9% (9/114) had a PMC <60%. Similarly, 88% (100/114) had complete continuous adherence to clopidogrel over 1 year. More patients in the Pharmacist Reminder group had continuous adherence to clopidogrel over 1 year (91% vs. 85%, p=NS) and a PMC >80% (93% vs. 87%, p=NS) compared to the No Reminder group. More patients who were not adherent to clopidogrel reported recent hospitalizations through follow-up (33% vs. 10%, p=NS). No significant improvement in long term adherence to clopidogrel was found through pharmacist reminder on a monthly basis, however the enrollment goal was not met and other factors could have influenced adherence.

Conclusions:
For patients receiving a DES for ACS, 1 in 9 patients was nonadherent to clopidogrel at 1 year. Pharmacist refill reminder can positively impact long term adherence to clopidogrel. Nonadherence to clopidgrel was associated with a higher rate of hospitalization. Further research is necessary to determine which factors impact long term adherence to clopidogrel in patients receiving a DES.
Abstract 288: Vitamin C Decreases Atrial Fibrillation In Cardiac Surgery Patients But Vitamin E May Decrease Response: A Randomized-controlled Trial Meta-analysis
Authors: Kumar Shashi , Benjo Alexandre M , Pamidimukala Chaithanya K , Javed Fahad , Garcia Wallacy , Macedo Francisco Y , Garcia Daniel C , Santana Orlando , Nascimeto Francisco O , Pierce Matthew , Herzog Eyal , Aziz Emad F
Published: March 2022

Background:
Due to the population aging, atrial fibrillation (AF) is becoming a more prevalent disease, it also commonly presents as a cardiac surgery complication. Randomized controlled trials (RCT) concerning anti-oxidant vitamins for atrial fibrillation (AF) prophylaxis have yielded inconsistent outcomes. Similar inconsistencies were found in other cardiovascular studies, as the HOPE and FATS studies, suggesting that vitamin E in special may not be helpful, perhaps harmful.

Methods:
All randomized controlled trials on anti-oxidant vitamins supplementation for atrial fibrillation prevention for patients undergoing cardiac surgery were sought in Medline and Cochrane databases during May 2012. Data was extracted by 3 reviewers.

Results:
Seven studies were found, three with vitamin C, two with Vitamin E and two combining both. We found an overall significant 60% decrease in the overall chance for AF occurrence mostly driven by (Figures1A and 1B) as the studies with vitamin E or vitamin C and E combined (Figures 1 C and 1D) did not show a statistically significant difference. When all studies with Vitamin E alone or in combination with Vitamin C (Figure 1E).

Conclusions:
Vitamin C supplementation decreases the incidence of post cardiac surgery AF but the data on Vitamin E is inconsistent, it may even decrease the Vitamin C benefit. As vitamin self-supplementation is extremely common in the US, large trials are extremely important not only for benefit confirmation but to exclude potential harms.
Abstract 294: Association Between Exercise Frequency, Performance, and Health-Related Quality of Life in Heart Failure Patients
Authors: Lewis Eldrin , West Erin K , Takeuchi Madoka , Robinson Sylvia , Pfeffer Marc A , Forman Daniel E
Published: March 2022

Background:
Heart failure (HF) is one of the leading causes of morbidity and mortality in the United States. Exercise intolerance and impaired quality of life (QOL) are common limitations. Cardiopulmonary exercise test (CPX) is used for risk stratification and diagnosis of ischemia in HF patients. In HF patients interested in rehabilitation protocols, higher exercise capacity has been linked to better QOL. The primary objective is to determine the association between QOL and exercise parameters in an
unselected
HF population.

Methods:
English-speaking HF patients scheduled for routine CPX were approached prospectively. Each consenting person completed 2 page survey on home environment, exercise routine, and QOL. Disease-specific QOL was measured using the Minnesota Living with Heart Failure Questionnaire (MLHF), a 21-item instrument that assesses perceptions of QOL related to their HF (scored 0 to 105 with lower score representing better QOL). Generic QOL was measured using a one-item visual analog scale (VAS), scored 0 to 100 with higher score representing better QOL. Patients were stratified by age, disability, exercise routine, HRR

>

18 at 1minute, working status, emotional support, gender, live alone, and peak RER>1. Results of CPX were measured [e.g., heart rate recovery in 1 minute (HRR), peak oxygen uptake (peakVO2), respiratory exchange ratio (RER)]. Data was analyzed with Chi-square, t-test, and ANOVA using STATA.

Results:
We enrolled 167 patients (Mean age 54
+
11, Female 26%, peakVO2 15.7±6, peak RER 1.2±.12). The MLHF score was 44
+
28 and mean VAS score was 61.9±22. QOL is worse among patients who are younger (P=0.0042), non-working (51.3 VS. 34.1, P-0.001), and disabled (54.7 VS. 38.3). There is no association between QOL and exercise frequency, gender, emotional support, or living alone. Patients with HRR
>
18 had better MLHF scores (38.0±28 vs. 52.9±26, p<0.001). PeakVO2 is moderately correlated to MLHF scores in all age categories; however, patients who lived alone did not have a strong correlation between peakVO2 and MLHF (r2=-0.256, p=0.21 vs. r2=-0.47, p<0.001).

Conclusion:
Routine exercise is not associated with better QOL in an unselected HF population. Performance on CPX was associated with QOL regardless of age. Although emotional support is not linked with QOL, those getting support from siblings tended to have a worse QOL than others. Strategies to improve QOL among HF patients should focus on factors beyond exercise.
Abstract 306: Evaluation of The Effectiveness of Disease Management Programs Physician Directed Communications in a General Cardiology Practice
Authors: SUBRAMANIYAM PREM SRINIVAS , KUMARI PRIYANKA , ANGIREKULA MANOHAR , AMARAM SUDHIR , BOCCALANDRO FERNANDO
Published: March 2022

BACKGROUND:
Disease management programs (DMP) issue frequent physician directed communications (PDC) to cardiology practices with the objective to assist the practitioners using an evidence-based approach. Although PDC have become widespread, the usefulness of this intervention in Cardiology is unknown. The objective of this study is to evaluate the effectiveness of established cardiology DMP-PDC in a general community cardiology practice.

METHODS:
A prospective cohort study evaluating all DMP-PDC received in a general cardiology practice from 6/2011 to 12/2012 was completed. The study included three fellowship trained board-certified cardiologist that examined the usefulness of DMP-PDC using a standardized questionnaire. Demographic data, pharmacological profile, type of DMP, general appropriateness based on current ACC/AHA guidelines, patient individual appropriateness, inappropriate recommendations and whether the DMP-PDC was effectively implemented in clinical practice was examined.

RESULTS:
188 consecutive DMP-PDC were evaluated. Demographic characteristics (60% males / mean age: 67±13 Yr) of the cohort were as expected for a general cardiology practice. Recommendations were available from different DMP [Medco (30.3%), CVS Caremark (25.5%), Aetna Active (25.5%), United Healthcare (8.5%) and other (10.2%)]. 152 (81%) DMP-PDC were appropriate in the general clinical context but not implemented based on individualized appropriateness criteria: 35 (19%) directed to the wrong physician, 39 (21%) already implemented prior to the DMP-PDC, 45 (24%) considered to add no clinical benefit based on individual appropriateness, 14 (7%) based on outdated evidence-based information, 7 (4%) implemented in practice without success prior to the DMP-PDC, 5 (3%) directed to patients not in the practice, and 7 (4%) for other reasons. 28 (15%) DMP-PDC were inappropriate: 9 (5%) due to an incorrect patient diagnosis, 2 (1%) due to intolerance to the intervention proposed, 2 (1%) due to a pharmacological interactions with other medications, 7 (4%) due to compliance related-issues and 8 (5%) were DMP-PDC based on incorrect medications. Among all recommendations reviewed, only 15 (8%) were actually effectively applied in clinical practice.

CONCLUSION:
DMP-PDC can be useful in formulating general patient evidence-base recommendations, but are ineffective tools in clinical practice due to individual patient related factors that prevent implementation, and thus; unlikely to translate in improvement in health care delivery.
Abstract 310: Action-Oriented Participatory Intervention and Outcomes in Patients with Heart Failure: Findings from the African American Heart Failure (Pilot) Study
Authors: Liu Longjian , Nguyen Cathy , Ariola Karen , Liu Feng Feng , Zhao Wei , Subramanya Raghunandan Dudda , Hankins Shelley , Eisen Howard J
Published: March 2022

Objectives:
The prevalence of heart failure (HF) has significantly increased in recent decades. It disproportionately affects African Americans (AA). However, evidence on how to improve the quality of care among AA patients with HF is scarce. In the study, we aimed to test the hypothesis that an action-oriented participatory intervention approach would significantly improve patients’ adherence to healthcare and outcomes.

Methods:
A randomized sample of 152 AA patients with HF stages A to D participated in the study. Of them, 73 received standard healthcare, and 79 received standard healthcare plus an action-oriented intervention using HF-focused education instruments. After health assessments (physical and lab tests) and health instrument-based survey at baseline in person at clinical site, participants were followed at 3 and 6 months at their re-visit to hospital or by phone call.

Results:
Of 152 patients (M: 68, F: 84), the proportions of those with HF stage A, B, C, and D were 26.5%, 19.1%, 22.1% and 10.3% in men, and 52.4%, 21.4%, 21.4% and 4.8% in women, respectively. Of them, 121 completed the first (3 M), and 39 had both the first and second (6 M) follow-up. Significant improved scores of knowledge to HF etiology and self-efficacy were observed at the first follow up, and scores of self-care skills at the second follow-up in both intervention and control groups. As compared to control group, the improvement of knowledge to HF etiology and self-efficacy scores in the intervention group were significantly higher in the first follow-up (p<0.01), and self-care skill scores were in both the first and second follow-ups (p<0.01). Significant improvement in adherence to medication and healthy behaviors were observed in intervention group (p<0.01). There was a tendency of improvement in quality of life at the first and second follow-up in the intervention group although they did not reach statistical significance.

Conclusion:
An action-oriented participatory intervention may offer a new approach to improve knowledge, disease control and outcomes in patients with HF.