bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P118: Changes in Patient Predictors of Use of Drug-Eluting Coronary Stents After FDA Warnings in Early 2007
Authors: Pathak Amit P , Pathak Elizabeth B , Srinivas Vankeepuran S , Strom Joel A
Published: March 2022

Objective:
Use of drug-eluting stents (DES) in PCI began to decline in late 2006 after release of scientific findings of higher risk of late stent thrombosis with DES. An emergency meeting of the FDA advisory panel cautioned about complications resulting from off-label use of DES. In this study, we compared early 2006 (pre-controversy) with late 2007 (post-controversy) patient predictors of use of DES vs. BMS for STEMI, NSTEMI, and stable CHD.

Methods:
We compared pre-controversy vs. post-controversy predictors of DES vs. BMS for STEMI (n= 9,341), NSTEMI (n=21,410) and stable CHD (n=23,495) through multivariate logistic regression analysis of hospital discharge data for Florida.

Results:
Throughout the study period, we observed reduced rates of DES implantation in patients with CHF (NSTEMI), cardiomyopathy (STEMI), Medicaid (STEMI and CHD), smoking (NSTEMI and CHD), medication noncompliance (STEMI, NSTEMI and CHD), and drug abuse (STEMI). Compared to the pre-controversy era, new deterrents to DES use post-controversy for STEMI patients were age >75 years, atrial fibrillation (AF), anticoagulation medication (AM), and smoking; while for NSTEMI new deterrents to DES were age >85 years, AF, AM, alcohol abuse and drug abuse. For stable CHD, in the pre-controversy era, patients aged 45-54 years were more likely to get DES, while those with diabetes mellitus were less likely to get DES. In the post-controversy era, new deterrents to DES use were age > 75 years, CHF, AF, peripheral vascular disease, AM, chronic kidney disease, alcohol abuse, or a history of medication noncompliance. Blacks with NSTEMI were more likely to get DES (OR 1.4; 95% CI 1.03-2.01; p=0.03) in the pre-controversy era, but less likely (OR 0.7; 95% CI 0.59-0.83; p<0.0001) in the post-controversy era. In contrast, the likelihood of DES implantation for blacks was significantly lower (OR 0.61; 95% CI 0.43-0.87; p=0.006) for STEMI in the pre-controversy era only and not different for stable CHD.

Conclusions:
In the state of Florida, the reduction in DES use post-controversy is related to older age, presence of co-morbidities like atrial fibrillation requiring additional anticoagulants and patient markers of potential non-compliance with thienopyridines (e.g. alcohol and drug abuse).
Abstract P122: African-American Patients Presenting With Unexplained Syncope Have Significantly Worse 1-Year Outcome When Compared to Non-African Americans
Authors: Aziz Emad F , Pratap Balaji , Musat Dan , Kalal Kiran K , Cordova Juan Pablo , Alviar Carlos L , Dhanekula Nischala , Rao Venkat , Tojino Andre , Aziz Teresita O , Knox Robin , Herzog Eyal
Published: March 2022

Background:
Syncope results in emergency department (ED) visits and hospital admissions. African-American (AA) patients often have multiple co-morbidities that translate to poorer outcome. We thought to evaluate the effect of AA race on outcome in patients with unexplained syncope.

Methods:
We evaluated 902 consecutive patients with unexplained pre-syncope/syncope between September 2007 and January 2009; all patients were enrolled in a prospective institutional registry. The primary endpoint was a composite of readmission for syncope, myocardial infarction (MI), stroke or death. In this study, we compared the outcome of AA to non African-American patients (non-AA).

Results:
There were 252 (28%) AA patients and 650 (72%) non-AA patients. When compared to non-AA patients, AA patients were older (64 ± 20 years vs. 59 ± 23 years, p<0.001) and likely to have hypertension (69% vs. 47%, p<0.001), diabetes (27% vs. 15%, p<0.001), heart failure (12% vs. 5%, p<0.001), and coronary disease (18% vs. 14%, p=0.01). During a follow-up period of 303 ± 140 days, the composite endpoint was observed in 92 (10.2%) patients and included 13 (1.4%) deaths, 5 (0.7%) strokes, 29 (3.2%) MIs and 45 (5%) syncope readmission. Multivariate regression analysis showed history of CAD (OR=1.9 95%CI 1.11-3.12), hypertension (OR=1.8 95%CI 1.03-3.43), diabetes (OR=1.7 95%CI 1.02-2.78) and AA race (OR=2.1 95%CI 1.30-3.28) to be predictors of worse outcome.

Conclusions:
African-American patients presenting with unexplained syncope have significantly worse 1-year outcome than non-AA. This is likely due in part to a higher incidence of significant co-morbidities in AA patients.
Abstract P132: QUICC: Quality Initiative to Improve Cholesterol Care
Authors: Gordon Linda , Maruca Lauren , Ansani Nicole
Published: March 2022

Background:
An initial quality audit identified areas of improvement in cholesterol management for diabetic patients. The goal of this project was to assess the success of targeted quality improvement (QI) initiatives regarding evidence based cholesterol management in this population.

Methods:
Following an initial QI audit the following actions were initiated (~01/2008): clinician education, clinical notes added to disease management database, and electronic medical records critical alerts placed on diabetic patient records regarding cholesterol treatment (prescribing and goal attainment). Eighteen months following the implementation of these initiatives, a retrospective chart review was conducted with identical methodology as the initial QI audit. Inclusion criteria were: diabetic patients aged 18 - 89 years seen in a comprehensive lipid clinic within the past year. Objectives included the change in percent of patients receiving cholesterol medication according to ADA guidelines and change in percent of patients at LDL goal, per NCEP guidelines. T-test was used to analyze data.

Results:
Fifty-six patients included in this analysis were compared to 134 patients from the baseline analysis. Average age of this population was 66 ± 11 years, 54% (30/56) were male, and 77% (43/56) had coronary disease. There were no differences in demographics between groups. Results of the current data demonstrate cholesterol prescribing according to guidelines was seen in 98% (55/56) of patients overall; 98% (47/48) of patients receiving statins for secondary prevention, and 100% (8/8) of patients receiving statins for primary prevention. These results are significantly higher compared to baseline data where 81% (109/134), 84% (86/102), and 72% (23/32) of patients, respectively, received medication according to guidelines, p<0.05 for all comparisons. In addition, a significantly higher percent of patients achieved LDL goal < 100 mg/dL (71%; 40/56) in this analysis compared to the baseline analysis (61%; 82/134), p<0.05.

Conclusions:
These data demonstrate that QI initiatives, including education, electronic database management, and clinical alerts positively impacts evidence-based prescribing and cholesterol goal attainment in diabetic patients.
Abstract P133: Impact of a Systolic Heart Failure Disease Management Program in Eastern Europe: Tbilisi, Georgia
Authors: Hebert Kathy , Gogichiashvili Ilia , Nozadze Nino , Sagirashvili Eka , Kipshidze Nicholas , Trahan Patrick , Arcement Lee , Marzouka George
Published: March 2022

Introduction
The prevalence and potential for disease management of heart failure is unknown in most low and middle income countries (LMIC) such as Georgia, located in the Caucuses. We examined the feasibility of importing a heart failure disease management program (HFDMP) into this population, which has a particularly high incidence of hypertension.

Methods
This is a prospective, nonrandomized, observational study in which patients with an ejection fraction ≤ 40% were enrolled into a new HFDMP staffed by local cardiologists after they received training in evidence-based HFDM. Medications, ER use, hospital admissions, and mortality during 16 months follow-up were assessed by patient interviews or by phone interviews with family members.

Results
The follow-up period for 400 enrolled patients ranged from 5-16 months. Beta blocker use increased from 7.5% at baseline to 82.4% and ACEI inhibitor use from 19.3% to 90.8%. Mean systolic blood pressure declined from 146 mmHg to 115 mmHg. ER use and hospitalizations were reduced by 42.5% and 54.6% respectively, but were also influenced by the outbreak of war, during which 17.5% (N=70) of patients received follow-up in refugee tents rather than clinic buildings. All cause mortality was 75.9 % during the 16 month follow-up of the study, with 12/23 deaths from war related events.

Conclusion
Importation of a Western HFDMP was demonstrated to be feasible. Use of evidence-based medication increased more than 4-fold, and was associated with blood pressure reduction and apparent reduction in ER visits and hospitalizations. These measures could result in substantial cost savings in resource-limited settings, but assessment of the impact is complicated in unstable areas. Translating effective interventions to LMIC requires sensitivity to local cultures and events of war and a willingness to adapt both clinical goals and strategies to unexpected conditions.
Abstract P145: Implementation of a Simple Computerized Heart Failure Discharge Instruction Tool Lead to Increased Adherence to JCAHO Heart Failure Core Measures and Reduced Heart Failure Readmission Rate
Authors: Uthamalingam Shanmugam , Kandala Jagdesh , Lord Denise , Welch Maureen
Published: March 2022

Background:
Suboptimal adherence to JCAHO (Joint Commission on the Accreditation of Healthcare Organizations) heart failure (HF) core measures have been reported in various hospital settings. Non- adherence to JCAHO HF core measures have been associated with decreased survival. The purpose of this study was to evaluate the impact of implementation of a discharge instruction tool on the adherence to JCAHO HF measures and analyze HF outcomes.

Methods:
A simple computerized discharge instruction tool (DIT) included an electronic check list of four JCAHO HF core measures to be completed and verified by all physicians who discharged acute HF patients; and got implemented at Catholic Medical Center (CMC), New Hampshire from January 2008. We compared the patient data before (January to December 2007; n=219)) and after (January 2008 to June 2009; n=326) implementation of DIT for adherence to four JCAHO HF core measures. All patients were followed for six months to analyze HF readmission rate and cardiac related death.

Results:
Total eligible patients (n=545) with their adherence to the HF core measures and improvement in the adherence to discharge instructions are shown in Table 1 and Figure 1-a/b. Reduction of six-month readmission rate (36.2 vs 27.8%; p=0.03) recognized an approximate saving of $6500.00 per case accounting to a total annual savings of approximately $176,000; with no significant change in the hospital length of stay and cardiac related death.

Conclusions:
A simple DIT achieved an improved adherence to JCAHO HF core measures and CMC acquired a local and regional recognition. Similar DIT could be shared in other hospitals across the nation to achieve improved HF outcomes.
Abstract P155: Perioperative Intra-Aortic Balloon Pump Counterpulsation and Outcomes in Very Elderly
Authors: Kandala Jagdesh , Uthamalingam Shanmugam , Ballari Sarika , Westbrook Benjamin , Baribeau Yvon
Published: March 2022

Introduction:
Indications for use of intra aortic balloon pump (IABP)are low ejection fraction, shock, left main stem disease, unstable angina, refractory angina and redo operation. These were supported by trials which included few very elderly patients (older than 80). Octogenarians are increasingly undergoing Coronary artery bypass surgery often needing IABP use.

Hypothesis:
we plan to test the utility and effectiveness of IABP in improving outcomes in very elderly patients undergoing isolated coronary artery bypass grafting (CABG).

Methods:
We performed a retrospective analysis of very elderly patients who underwent coronary artery bypass from 01/2001 to 12/2008. Statistical analysis is performed by STATA.

Results:
A total of 450 patients older than 80 underwent CABG during eight years. The mean age of the total subjects was 83.16+/- 2.48. A total of 35 (7.78%) patients underwent perioperative IABP of whom 14 (40%) died. Mortality among Non-IABP group was 7.47% (31/415).This was statistically significant at p<0.000.Higher mortality in IABP group was seen across all the subset of patients with accepted guideline based indication including shock, low EF, Left main stem disease, Unstable angina. Higher mortality was also seen in other risk factors like CHF, renal failure. Patients who underwent IABP placement experienced other adverse outcomes like longer mean extubation time of 151.6 hrs (CI 24-301 ) compared to 27.03 hrs ( CI 19 - 34.07) in Non-IABP group. Need for more than two inotropes was 44% (11/25) in IABP whereas it was 4.84 % (17/351) in Non-IABP group. No clear relation to postoperative atial fibrillation was found. Post operative renal failure was 9.38 (3/32) in IABP group compared to 2.24(9/401) in Non IABP group with a p <.01.We didn't had enough power to look into post-operative Cerebrovascular accident. In multivariate regression analysis after adjustment for confounding variable placement IABP has higher mortality with an OR 2.31 (1.14-3.48) p<.0001

Conclusions:
In very elderly patients mortality rate is very high even for indications supported by ACC/AHA guidelines. We need prospective studies focusing on very elderly patients.
Abstract P16: Cultural Competency to Reduce Stroke Disparities - A Patient Perspective
Authors: Yancy Clyde W , Foster Jill A , Salinas Gregory D , Sanchez Andrew R , Casebeer Linda L
Published: March 2022

Background:
Increased physician cultural competence has been recommended to reduce racial disparities in stroke and cardiovascular (CV) disease. Culturally appropriate care may be especially important to enhance primary stroke risk reduction for blacks and other high-risk populations. To better understand the extent of culturally competent care, this study explored patient perceptions of their primary care physician (PCP).

Methods:
A survey derived from the Patient-Reported Provider Cultural Competency (PRPCC) scale assessed history-taking and explanatory behaviors of PCPs, patient satisfaction and trust. The survey was mailed to adults in 25 counties in the stroke belt region (6% margin of error), with a small incentive offered for participation.

Results:
Responses from 1181 patients were analyzed. Respondents were mostly white (54%) or black (42%) and had a mean age of 56 years. Respondents' PCP was most often a family physician (66%) and either white (72%) or black (19%). Patient-reported omissions in PCP history-taking were common and occurred more frequently than explanatory behaviors. The biggest omissions involved PCP failure to assess (61%) and invite (52%) family participation in health care decision-making. The most common explanatory omission involved never directing patients to community resources (40%). More than 85% of patients felt satisfaction and trust toward their PCP. White patients reported more frequent assessment of traditional healing remedies than black patients. Otherwise there were no differences by patient ethnic group. Trust and satisfaction was similarly high towards black and white physicians, but both history-taking and explanatory behaviors were reported at higher frequencies for black physicians.

Conclusions:
Many PCPs in the South inadequately assess cultural health determinants and underutilize optimal communication methods. These gaps may have adverse consequences when white physicians care for black patients with CV risk factors, but may not be apparent to either party. Interventions that enhance cultural sensitivity and promote physician skill in effective communication and cross-cultural brokering may strengthen treatment alliances to reduce CV risk and reduce disparities in stroke.
Abstract P167: Prediabetics Improve CV Risk Profile by Reducing Stress
Authors: Kashani Mariam D , Eliasson Arn H , Vernalis Marina N
Published: March 2022

Background:
High stress levels trigger a negative cascade of hormones mediated in part by cotropin-releasing factor, CRF. The effect of CRF on cortisol is well known but recent science has demonstrated its pivotal role on insulin levels as well. Currently, pharmacologic agents are being developed to assist patients with this proposed hyperinsulinemia.

Objective:
We sought to examine the effect of stress along with its hormonal mediators on a prediabetic population.

Methods:
Subjects entering a 6-month cardiovascular (CV) risk reduction program (to improve sleep, exercise, nutrition and stress) completed questionnaires including the Perceived Stress Scale (PSS), anthropometric measures and a cardiac-relevant lab panel. Differences between subjects with high stress (PSS≥23) and those with low stress (PSS<23) were analyzed by t-test.

Results:
Of 24 prediabetic subjects, 12 (50%) scored high on the PSS (mean 29.5±4.9 vs 18.4±3.3). These high-stress subjects demonstrated higher mean insulin (20.6±11.7 vs 10.8±4.2, p<0.01), higher insulin resistance, as demonstrated by HOMA, (5.3±2.9 vs 2.8±1.2, p<0.01) and greater percent body fat (38.8±7.6 vs 30.7±8.5, p<0.02), than their low-stress counterparts. There were no differences in glucose or weight between the two groups at baseline.

Conclusion:
High stress correlates with numerous unhealthy metabolic states which place patients at higher risk for CV disease. Prediabetic patients can significantly improve their CV risk profile by reducing stress. We hypothesize that an integrative lifestyle change program may interrupt the negative sequence of events caused by CRF and potentially provide prediabetic patients an adjunct to their CV risk reduction action plan.

Change at 6 mo
Low stress n=12
High stress n=12
p value

PSS
1.4±8.3
-14.4±9.3
<0.01

Insulin (ug/dL)
3.4±7.7
-11.8±11.8
<0.01

CRP (mg/dL)
0.3±0.41
-0.2±0.7
<0.03
Abstract P174: Omega-3 Index: An Independent Predictor of 1 Year All-Cause Mortality in Myocardial Infarction (MI) Patients
Authors: Abuannadi Mohammad , O'Keefe James H , Spertus John A , Kennedy Kevin F , Harris William S
Published: March 2022

Introduction:
The omega-3 index, which reflects the red cell membrane content of eicosapentaenoic acid plus docosahexaenoic acid, has been recently suggested as a modifiable cardiovascular risk factor. Case control studies showed that lower omega-3 fatty acid levels are associated with a higher risk of sudden cardiac death, acute coronary syndrome and myocardial infarction (MI). A cut-off point of 4% has been suggested as the point below which the risk increases. However, the prognostic value of the omega-3 index in the setting of acute MI is unknown.

Methods:
Baseline omega-3 index levels were measured in patients enrolled in a prospective, 24-center MI registry (TRIUMPH). One-year mortality data were collected. Cox proportional hazards regression models of 1-year mortality were developed to determine the association of an omega-3 index level <4% with mortality, independent of other clinically important demographic and clinical factors (Figure).

Results:
Among 1424 MI patients who had their baseline omega-3 index levels measured, the mean (SD) age was 59.1(12.4), 45.2% (644) had an admission diagnosis of ST-elevation MI, and 27% (387) had an omega-3 index level <4%. Overall 1-year mortality was 5.6% (80/ 1424). In the fully-adjusted model, an omega-3 index of <4% was independently associated with mortality at 1 year (hazard ratio = 2.0 [95% CI (1.2, 3.3)]; Figure)

Conclusion:
Lower omega-3 fatty acid levels were independently associated with all-cause mortality in this MI cohort. Since omega-3 levels are modifiable, use of the omega-3 index to direct secondary preventive measures, including fish oil supplementation, may prove beneficial in the post-MI population.
Abstract P182: A Particular Combination of Risk Factors of Metabolic Syndrome is Associated With Higher Risk of Mortality Among Those With Metabolic Syndrome Irrespective of Level of Coronary Artery Calcium Burden
Authors: Rana Jamal S , Gransar Heidi , Friedman John , Hayes Sean , Thomson Louise , Wong Nathan , Rozanski Alan , Shaw Leslee , Berman Daniel S
Published: March 2022

Background:
It was recently shown that individuals who enter the metabolic syndrome (MetS) having a combination of central obesity, high blood pressure (BP), and hyperglycemia had a 3-fold increased risk of mortality. We evaluated if this particular triad versus combination of any three out of five risk factors used to define MetS is associated with an increased odds of presence of coronary artery calcium (CAC) and risk of increased mortality.

Methods:
We followed 5840 participants from the EISNER study. The average follow up time was 5.8 ± 1.7 years. MetS was defined according to the Adult Treatment Panel III criteria. Met S A was defined as combination of central obesity, high BP and hyperglycemia. We used multivariable logistic regression to evaluate the odds of having positive CAC. Additionally we performed multivariable Cox proportional hazard analyses adjusted for age, smoking and sex, to evaluate the risk of mortality.

Results:
There were a total of 113 deaths on follow up. The average age was 54 ±10 yrs. Of all the participants 29.8% had no risk factors for Met S, 19.5 % had Met S, and 4.8 % had Met S A. The adjusted odds ratio (OR) for developing CAC for both types of Met S were similar (OR 2.0, CI 1.7-2.4; OR 2.1, CI 1.6-2.8). As compared to participants with no risk factors and 0 CAC, participants with Met S and 0 CAC did not have statistically significant higher risk of mortality. The risk of mortality became two fold when CAC was ≥ 400. However Met S A had significant higher risk of mortality irrespective of CAC burden (table).

Conclusions:
The triad of central obesity, high BP and hyperglycemia of Met S confer higher risks of incident mortality among those with MetS. This risk was evident irrespective of level of CAC burden. Our study may have implications for further risk stratification and risk modification among individuals with Met S.

Table:

HR adjusted for Age, smoking and gender

No Risk Factors + CAC 0
Met S + CAC 0
Met S A + CAC 0
Met S + CAC ≥ 400
Met S A + CAC ≥ 400

Mortality HR 95% CI
Reference
1.7 (0.95-3.2)
2.3 (1.1-4.8)
1.9 (1.03-3.4)
2.4 (1.1-5.0)
Abstract P185: Metabolic Syndrome and Cardiovascular Risk - A Comparative Analysis of Waist-Cricumference and Waist-Height-Ratio for Predictive Accuracy
Authors: Zalawadiya Sandip K , Veeranna Vikas , Niraj Ashutosh , Pradhan Jyotiranjan , Jacob Sony , Afonso Luis
Published: March 2022

Introduction:
Metabolic syndrome (MS) is an adverse predictor of cardiovascular outcomes. Recently, waist height ratio (WHtR) is shown to correlate better with future cardiovascular risk factors than other anthropometric measures. We sought to determine whether replacing waist circumference (WC) with WHtR in metabolic syndrome diagnostic criteria per National Cholesterol Education Program (NCEP) guidelines improves predictive accuracy for future cardiovascular disease (CVD) events.

Methods:
The study cohort consisted of prospectively evaluated 6,702 healthy adults aged 45-84 years enrolled in the Multi-Ethnic Study of Atherosclerosis [MESA] study [Age-: 62±10 years, 47% males, 1473 Hispanics, 2575 Caucasians, 799 Chinese and 1855 African Americans]. Metabolic syndrome (MSwc), at baseline, was defined by NCEP guidelines (n=2,208). Metabolic syndrome (MSwhtr) was redefined using WHtR (≥ 0.5 in both male and females) in place of WC, keeping rest of the components constant as recommended by NCEP (n=2,590). CVD events were defined as All CVD (CVDa) per MESA protocol (See
Table
). Unadjusted and adjusted Cox-proportional hazard analysis was performed. Harrell's C-statistics were calculated for the most adjusted models.

Results:
Total of 319 CVDa events [n=171 (7.44%) in MSwc group and n=190 (7.34%) in MSwhtr group] were identified during a mean follow up of 4.6 years. Results are displayed in the
table
.

Conclusion:
Predictive accuracy of MS re-defined with WHtR and MS defined with WC per NCEP criteria is comparable.

Risk of CVDa and Metabolic Syndrome

Metabolic Syndrome per NCEP guideline [MSwc]
Re-defined Metabolic Syndrome with WHtR [MSwhtr]

Models
HR (95% CI) p-value
Models
HR (95% CI) p-value

2.45 (1.97-3.06) 0.000

2.43 (1.95-3.05) 0.000

MSwc + X
2.39 (1.91-2.99) 0.000
MSwhtr + X
2.28 (1.82-2.85) 0.000

MSwc + Y
1.97 (1.56-2.49) 0.000
MSwhtr + Y
1.93 (1.53-2.43) 0.000

MSwc + Z
1.89 (1.47-2.44) 0.000
MSwhtr + Z
1.83 (1.43-2.35) 0.000

Harrell's C (MSwc + Z) -: 0.7517

Harrell's C (MSwhtr + Z) -: 0.7531

Abbreviations: HR - Hazard Ratio; CI - Confidence Interval; CVDa - All Cardiovascular Disease events

X = Age, Sex, Race

Y = X + Hypertension, Use of Hypertension Medications, Total intentional exercise, Total cholesterol, Use of Statins, Smoking [>100 cigarettes ever in life]

Z = Y + C-reactive Protein + Serum Insulin level

CVDa includes
- Myocardial infarction(MI), Resuscitated Cardiac Arrest (RCA), Definite Angina, Probable Angina (if followed by Revascularization), Stroke, Stroke Death, coronary heart disease (CHD) Death, Other Atherosclerotic Death, Other CVD Death.
Abstract P195: Cardiovascular Practitioner's Perspectives on Guilt as a Motivational Tool
Authors: Woskob Larissa , Jones Nora L , Wiegers Susan E , Beach Mary C , Kirkpatrick James N
Published: March 2022

Objective:
Encouraging lifestyle change is a key facet of cardiovascular care, but health professionals report frustration and frequently feel ineffective in efforts to engage patients in behavior modification. In this study, we sought to define cardiovascular practitioners' perspectives on using guilt as a motivational tool.

Methods:
We conducted and audio recorded semi-structured interviews with 24 cardiovascular practitioners. Subjects were given a definition of guilt, asked to comment on how often they encountered patients who felt guilty, describe how they responded to those patients, and describe how guilt as a motivational tool might or might not promote lifestyle changes. Interviews were transcribed and coded to identify major themes.

Results:
Most (n=23/24) practitioners reported encountering patients who felt guilty for not taking better care of themselves. There was no consistent response to guilt: 3 practitioners used fear, 6 induced further guilt, 8 provided education, 5 reassured, and 9 used a ‘starting over’ approach. Practitioners did not agree on whether guilt was an effective motivator; some believed it was (‘My thing is ‘do you want to see your kids grow up, do you want to walk your daughter down the aisle?’ that's guilt, that's healthy guilt and I do use it. And it hits them right in the best spot.'), others did not (“I do think it's harmful because it lowers the self-esteem.”). Several practitioners (n= 8) referenced their own personal experiences or background; only one subject referenced literature on behavior change.

Conclusions:
Most cardiovascular practitioners encountered guilt in patients over lifetyle. There was no standard approach to the use of guilt in motivation, suggesting the need for more research and training on how to address guilt in cardiovascular patients.
Abstract P202: Long-Term Outcomes and Use of Combination Evidence-Based Medical Therapy After Acute Coronary Syndromes
Authors: Lahoud Rony , Howe Michael , Montgomery Dan , Stahlbaum Danielle , Jackson Elizabeth A
Published: March 2022

Background:
Several medications have been shown to reduce mortality in patients with acute coronary syndrome (ACS); however long-term outcomes related to use of combinations of these medications is limited.

Methods:
Data on demographics, comorbidities and ACS management from 2,687 consecutive patients admitted with ACS between January 1999 and March 2006 were included. A composite appropriateness score (number of drugs received/number of drugs indicated) was created for discharge use of evidence-based medications (EBMs) including anti-platelet agents, beta-blockers, ACE-inhibitors and statins. Multivariate models were used to examine the impact of EBM score on two-year mortality with adjustment for the components of the Global Registry of Acute Coronary Events (GRACE) risk score and gender.

Results:
A total of 216 patients died during follow-up. Women were older, had more comorbidities, and were less likely to receive all 4 EBMs (69.5% vs. 77.8%, p < 0.001) than men. Patients who received all 4 EBMs (appropriateness score IV) were more likely to be alive at two years compared to patients who received < 1 EBM (OR 0.29, 95% CI, 0.17 - 0.49). When men and women were examined separately, a similar pattern was observed (OR 0.30, 95% CI 0.14 - 0.63 for men, and OR 0.28, 95% CI 0.13 - 0.61 for women) for those receiving all 4 EBMs at discharge compared to those who received < 1 EBM.

Conclusions:
Receipt of combination EBMs after ACS is significantly associated with decreased long-term mortality among both men and women.
Abstract P209: Obesity in Middle School Students: Are Self-Efficacy and Body Mass Index Related?
Authors: Eagle Taylor , Jackson Elizabeth A , Iyer Preeti , Gurm Roopa , Erickson Steven , Gakenheimer Lindsey , Geiger Zachary , Smolarski Joseph , Smith Cydni A , Im Henry , Olomu Ikponmwosa , Kline-Rogers Eva , Rogers Bruce , Eagle Kim A
Published: March 2022

Background:
Childhood obesity represents the nation's #1 health problem. Understanding the underpinnings of this epidemic, including children's perception of self-efficacy (SE), is critical to designing effective interventions.

Methods:
We measured body mass index (BMI) and conducted surveys in 208 middle school students(St), average age 11.7 years, with 11 questions relating to SE as part of a school-based intervention program in 5 Ann Arbor and 2 Ypsilanti Middle schools (PHS). Consenting St agreed to BMI using standard height-weight conversion adjusted for age. The 11 survey questions were scored from 1-5, 5 the most positive. A total SE score was calculated (per St), scores ranging from 11 (lowest SE) to 55. A scatter-plot was created comparing BMI to SE score using linear regression for all St and by gender.

Results:
Of the 109 girls and 99 boys in the study, 34% were overweight/obese (>85
th
percentile for BMI); 20% obese (>95
th
%). Obesity was more common in boys; girls more underweight. SE scores varied from 27 to 54; BMI from 14-39. There was no significant linear association between BMI and SE scores overall (Figure), however, a trend was observed for lower SE with higher BMI among girls.

Conclusions:
In PHS, 34% of Ann Arbor/Ypsilanti St are overweight or obese. We observed no significant correlation between BMI and a global SE score. This is not surprising in a society which has increasingly viewed overweight as the norm. The trend for lower SE in girls with higher BMI requires confirmation in a larger cohort.
Abstract P221: Coronary Artery Bypass Grafting versus Percutaneous Coronary Intervention for Patients With Severe Left Ventricular Dysfunction: Superior Outcomes With Surgery
Authors: Nagendran Jeevan , Norris Colleen M , Graham Michelle M , MacArthur Roderick G , Keiser Teresa M , Maitland Andrew , Meyer Steven R
Published: March 2022

Background:
The efficacy of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with multivessel coronary artery disease (CAD) has been well-defined by randomized controlled trials. However, patients with severe left ventricular dysfunction (ejection fraction <35%; EF) were under-represented in these trials. We sought to compare the outcomes of patients with multivessel CAD and EF<35% undergoing CABG vs. PCI.

Methods:
We used APPROACH, a clinical data collection initiative, capturing all patients undergoing cardiac catheterization and revascularization in the province of Alberta, Canada, to identify 2477 patients with multivessel CAD and EF<35% undergoing CABG (n=1242) or PCI (n=1235) between 1995 and 2008.

Results:
Patients undergoing CABG were slightly older (65.8 vs. 65.3 years; p=0.269), more likely to have three vessel CAD (62% vs. 56%; p<0.001), male gender (85% vs. 77%; p<0.001), diabetes (39% vs. 27%; p<0.001), peripheral vascular disease (PVD; 14% vs. 8%, p<0.001), congestive heart failure (CHF; 46% vs. 41%, p=0.012), and COPD (21% vs. 16%, p=0.005). Unadjusted survival at 1, 5, and 12 years in the CABG vs. PCI groups was 90% vs. 86%, 75% vs 71%, and 47% vs. 48%, respectively (p=0.394). After controlling for differences in baseline risk factors, CABG was associated with improved long term outcomes. Multivariable logistic regression identified PCI was significantly associated with a higher risk of death compared to CABG (adjusted hazard ratio, 1.20; 95% CI, 1.03 to 1.40). Other significant predictors of poor long-term survival included COPD (adjusted hazard ratio, 1.19; 95% CI, 1.01 to 1.40), renal failure (adjusted hazard ratio, 2.33; 95% CI, 1.80 to 3.04), CHF (adjusted hazard ratio, 1.19; 95% CI, 1.04 to 1.37), diabetes (adjusted hazard ratio, 1.21; 95% CI, 1.06 to 1.40), PVD (adjusted hazard ratio, 1.31; 95% CI, 1.09 to 1.59), and prior CABG (adjusted hazard ratio, 1.30; 95% CI, 1.04 to 1.62).

Conclusion:
In patients with multivessel CAD and left ventricular dysfunction, CABG was associated with better survival than PCI after adjustment for baseline risk profile differences. Further research exploring the factors leading to use of a particular revascularization modality is required.
Abstract P229: Ibutilide Therapy for Atrial Fibrillation - Five-Year Experience in a Community Hospital
Authors: Schrumpf Phillip E , Giudici Michael C , Paul Deborah L , Fischer William J , Cervantes David G
Published: March 2022

Body: Background
Ibutilide fumarate is a class III antiarrhythmic agent whose sole indication is the acute conversion of atrial fibrillation or atrial flutter to sinus rhythm. Ibutilide blocks potassium channels and activates slow inward sodium channels, which delays repolarization. These actions prolong the action potential in atrial and ventricular refractory periods, leading to arrhythmia termination. Many institutions restrict the use of ibutilide because of the potential risk of polymorphic ventricular tachycardia (PMVT). Limitations include administration only in the presence of a physician, use only in certain monitored units, or an Intensive Care Unit.

Methods
Over a five-year period, 238 patients, 151 male/87 female, mean age 67.1 years, received intravenous ibutilide at our institution. Ibutilide was administered in four clinical settings: Emergency Department (n=80), Intensive Care Unit (n=11), Telemetry (n=107), and the Cardiac Catheterization /Electrophysiology Laboratory (n=40). Ibutilide was administered by infusion of one milligram over 15 minutes followed by a 15 minute waiting period, the infusion was repeated. The infusion was discontinued if the patient converted to sinus rhythm.

Results
Conversion to sinus rhythm occurred in 59% of patients outside the cath/EP lab. The incidence of PMVT was 1.7%. Three patients had brief, non-sustained polymorphic ventricular tachycardia and one patient had a sustained PMVT. Our data suggest that ibutilide is safe and efficacious drug when ordered by experienced physicians in properly selected patients in a variety of monitored settings. Ibutilide is ordered at our institution almost exclusively by cardiac electrophysiologists and emergency physicians who routinely consult with the electrophysiologists prior to administration. No deaths occurred in our five-year series. As a result of this study, the policy at our institution is that ibutilide may be administered by nurses on telemetry units.

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Abstract P230: Risk of Venous Thromboembolism in Acutely Ill Medical Patients and the Influence of Timely Ambulation
Authors: Amin Alpesh N , Girard Frederick , Samama Meyer M
Published: March 2022

Background:
Ambulatory status is often considered a criterion for stopping prophylaxis for venous thromboembolism (VTE) in medically ill patients.

Methods:
A subgroup analysis of the Prophylaxis in Medical Patients with Enoxaparin (MEDENOX) trial was performed according to ambulatory status. Ambulatory status was defined as the ability to attain autonomous walking distance of > 10 meters assessed at visit day 10 ± 4. Incidence of VTE and bleeding was evaluated.

Results:
The majority of patients (607 of 1084) were ambulatory at visit day 10 ± 4, with a mean time to ambulation of 4.4 days. Thromboprophylaxis was provided for a mean of 7.3 days in the ambulatory subgroup and 7.9 days in the non-ambulatory subgroup. Main results are displayed in the graph. Major bleeding was not significantly different between enoxaparin 40 mg once daily versus placebo in the ambulatory (1 of 212 vs 1 of 190, respectively) or non-ambulatory subgroups (5 of 146 vs 3 of 169). In a multivariate logistic regression model to assess which factors influenced the probability of individual patients becoming ambulatory, ambulatory patients were less likely than non-ambulatory patients to be aged > 75 years (OR 0.57; 95% CI 0.43-0.75;
P
< 0.0001) and to have a previous history of VTE (OR 0.61; 95% CI 0.38-0.95;
P
= 0.03). Provision of VTE prophylaxis or placebo did not affect ambulatory status.

Conclusions:
Despite timely mobilization, medically ill patients who become ambulatory in hospital remain at substantial risk of VTE and have significant VTE risk reduction with enoxaparin 40 mg once daily, as also observed in non-ambulatory patients. Ambulatory status is significantly influenced by baseline characteristics.
Abstract P238: The Economic Burden of Hypertriglyceridemia
Authors: Nichols Gregory A , Arondekar Bhakti , Garrison Louis P
Published: March 2022

One-third of US adults has elevated triglyceride levels, but the medical care costs associated with this common lipid abnormality have not been described. Using an observational cohort design, we analyzed the comprehensive electronic medical records of all 108,324 individuals aged 18 or older who had triglyceride (TG) measurements in 2008 and were members of Kaiser Permanente Northwest for the entire year. After assigning patients to TG categories of < 150, 150-199, 200-499, and ≥500 mg/dl, we calculated and compared annual direct medical costs. To isolate the independent contribution of TGs, we adjusted costs for age, sex, body mass index, blood pressure, smoking history, other lipid fractions, and health conditions such as cardiovascular disease, diabetes, and renal disease. Of the 108,324 study subjects, 64.1% had normal TG levels (<150mg/dl), 16.4% had borderline high levels (150-199mg/dl), 18.0% had high TG levels (200-499mg/dl) and 1.5% had very high TG levels of ≥ 500mg/dl. Unadjusted costs followed a stepped association with TG levels. After adjustment, patients with TG levels ≥ 500mg/dl had significantly higher mean total costs ($8,567; 99% CI $7,034-10,100) than those with levels of < 150mg/dl ($6,186; $6,058-6,314), 150-199mg/dl ($6,449; $6,196-6,702), or 200-499mg/dl ($6,376; $6,118-6,634). The differences were driven by both outpatient and pharmaceutical costs. Inpatient costs were also higher among those with TG levels ≥ 500mg/dl but did not reach statistical significance. Severe hypertriglyceridemia is associated with higher medical costs on the order $2,100 to $2,400 per annum (33-38%) independent of resource-intensive comorbid conditions.
Abstract P239: Cost-effectiveness Of Iobenguane I 123 Injection (123I-MIBG) Imaging For Patient Treatment Selection In The Prevention Of Sudden Cardiac Death
Authors: Spalding James , Gricar Joseph
Published: March 2022

OBJECTIVE:
To evaluate the costs, benefits, and incremental cost-effectiveness of non-invasive imaging of cardiac sympathetic innervation using 123I-MIBG in patients with chronic left ventricular dysfunction at increased risk for sudden cardiac death as compared to current risk stratification methods for selection of patients for implanted cardiac defibrillators (ICD) versus medical therapy.

METHODS:
A Markov model was developed to evaluate the impact of using 123I-MIBG for evaluating NYHA II or III heart failure (HF) patients with LV ejection fraction (EF) < 50% for treatment with an ICD. 123I-MIBG risk-stratification was used to guide the treatment decision between ICD and medical therapy. The source of data for predicted probabilities, expected mortality rates, and treatment costs in year 2009 dollars are from the published literature and the AdreView Myocardial Imaging for Risk Evaluation in Heart Failure (ADMIRE-HF) study. The model was developed from a societal perspective using a one-month cycle time, 3% discount rate and a lifetime time horizon. Sensitivity analysis was completed on cost, efficacy and relative risk ratios.

RESULTS:
123I-MIBG had an incremental cost-effectiveness ratio (ICER) of $100,910 versus standard stratification methods. The number needed to screen to prevent one death over 5 years was 20. The model was sensitive to changes in utility values ($91,737 - $112,123 / QALY), efficacy of ICD in low risk patients ($90,003 - $115,375/QALY) and efficacy of ICD in high risk patients $59,364/QALY - Current Practice Dominates). The model was not sensitive 123I-mIBG cost, even at 200% of baseline ($104,068).

CONCLUSIONS:
123I-MIBG is a relatively cost-effective screening strategy versus current methods that can prevent sudden cardiac deaths within as few as 20 patient screenings. Further research on the use of AdreView in real-world settings is warranted.
Abstract P242: Trending Positive Clinical Benefits & Significantly Lower Costs With Niacin Extended-Release Compared to Ezetimibe in Patients Receiving On-Going Statin Therapy
Authors: Webb Silky F , Quimbo Ralph , Simko Robert , Cziraky Mark
Published: March 2022

Objective:
To compare cardiovascular (CV) and economic outcomes among a community-based population initiating adjunct therapy with niacin extended-release (NER) for broader management of the lipid panel vs. ezetimibe (EZE) for continued LDL-C reductions.

Methods:
Statin-treated (simvastatin 20 mg/day or equivalent) patients aged ≥30 years initiating adjunct therapy with NER or EZE between 1/1/05-11/30-08 (index date) and ≥1 pre-index lipid panel (LDL-C <100 mg/dL and HDL-C <50 or <55 mg/dL for men and women, respectively) within the Healthcore Integrated Research Database were included. Patients with AST/ALT elevations or liver disease were excluded. Primary outcome was first occurrence of a major adverse CV event (MACE), defined as IHD, PVD, revascularization, or stroke; secondary outcomes were MACE+all-cause mortality and the total of MACE-related medical costs and pharmacy charges for anti-hyperlipidemic therapy. CV risk between NER and EZE were compared using Cox proportional hazards models with a pair-wise approach while generalized linear models with a log link function and gamma distribution were used to compare costs. Multivariate analyses controlled for age, gender, geographical region, co-morbidities, and baseline lipid values.

Results:
A total of the 452 patients initiated adjunct therapy with NER (n=186) and EZE (n=22). The NER cohort was younger (58.3±9.7 vs 60.4±9.7,
P
=0.0235), less likely to be female (17.7% vs 34.6%,
P
<0.0001), and had a shorter follow-up period (200.0 vs 363.2 days,
P
<0.0001). The NER cohort had a lower frequency of MACE (1.6%) vs EZE (4.5%), with an adjusted hazard ratio (aHR) of 0.39 (95%CI: 0.09-1.65). A similar trend was observed for the MACE+all-cause mortality with an aHR of 0.30 (95%CI: 0.08-1.27). These findings correspond to significantly lower adjusted costs for patients receiving NER ($2706; 95%CI: 2347-3119) vs EZE ($3489; 95%CI: 3101-3926) (
P
<0.0001).

Conclusions:
The trend of positive clinical benefits from this real-world analysis are consistent with those of the ARBITER-6/HALTS study and suggest that treating beyond LDL-C with NER in secondary risk patients receiving simvastatin 20 mg/day or equivalent may reduce CV risk and associated costs.
Abstract P264: The Health and Economic Impact of Switching From Atorvastatin to Generic Simvastatin in the Netherlands
Authors: Liew Danny , Webb Kate , Meerding Willem Jan
Published: March 2022

OBJECTIVES
Since January 2009, Dutch clinicians have been required to rationalize the prescription of branded statins using an authorization form. This has led to significant switching of patients from atorvastatin to generic simvastatin. However, data from Q1 2009 indicated that 34% of this switching occurred at less than equipotent doses. We sought to assess the potential impact of this.

METHODS
A Markov micro-simulation model was populated with 1046 Dutch patients drawn from the PHARMO Institute database who were being prescribed atorvastatin in December 2008. Risks of cardiovascular disease (CVD) were estimated from a calibrated Framingham risk equation. Follow-up occurred for 20 years or until age 100. Decision analysis estimated the marginal effects of switching all patients to generic simvastatin. Dose-specific, lipid-modifying effects of the two statins and CVD costs were sourced from published data. Annual discount rates of 4% and 1.5% were applied to costs and health effects, respectively.

RESULTS
Of the 1046 subjects on atorvastatin, 207 (19.8%) were predicted to develop CVD over 20 years. In the switched-to-simvastatin group, the predicted number was 229 (21.9%), equating to a ‘number needed to harm’ of 48. Although switching led to a net cost saving of 549 Euro per subject, each also lost 0.015 life-years and 0.029 QALYs. These equated to ICERs of 36,653 Euro and 18,716 Euro per life-year and QALY gained, respectively (atorvastatin vs simvastatin). Sensitivity analyses, which included a 20% decrease in the percentage of switches to less potent simvastatin doses, indicated the results to be robust.

CONCLUSIONS
In the Netherlands, many patients are being switched from atorvastatin to generic simvastatin at inferior doses, which may be increasing CVD risk. Maintaining patients on atorvastatin is sound from a health economic perspective.

[
Disclaimer:
the views expressed in this abstract are only those of the authors, and not necessarily those of the PHARMO Institute.]