bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 30: Behavioral Change after Heart Disease Risk Assessment in Women
Authors: Parashar Sonya , Vacek James L , Simmons Ashley
Published: July 2021

Background:
Heart disease is the leading killer of women in the United States. Unfortunately, most women are unaware of their individual risk. Studies have shown that awareness of cardiovascular (CV) disease risks correlates with positive behavior changes, including increased physical activity and weight loss.

Methods:
The Change of Heart (COH) Program is a university hospital based CV disease risk assessment program. The assessment included baseline weight, height, blood pressure, lipid profile, fasting glucose, and Framingham risk score in women 18 years of age and older. A 90-minute individual discussion of risk and recommendations for healthy lifestyle changes were given.

Follow up questionnaires and newsletters designed to assess and encourage heart-healthy behavioral changes were given at 3 and 6 months after the initial visit to participants. We compared baseline vs. follow up self-reported activity levels and readiness for change.

Results:
At baseline, participants’ average age was 50.6 years, they exercised between 1 to 3 hours each week, and most had either never smoked or had quit smoking. When asked what they thought a woman’s greatest health problem was, 62% answered Heart Disease/Heart Attack. Additionally, 59% of participants felt moderately informed about women’s heart disease and 54% would call 911 if they thought they were having a heart attack. We found a statistically significant improvement in willingness to increase physical activity (p < 0.001), practice good eating habits (p < 0.001), avoid smoking (p <0.01), lose or maintain healthy weight (p <0.001), lower and maintain cholesterol levels (p < 0.001) and blood pressure (p < 0.001) over the course of the study.

Conclusion:
In a population of women who felt that they were moderately well informed on heart disease, only 62% knew that a woman’s greatest health risk was heart disease or a heart attack. Most women showed improvements in readiness for positive heart-healthy behavioral changes. This emphasizes the ability for a cardiovascular risk reduction program to positively influence a woman’s willingness for behavioral change.
Abstract 300: Right Ventricular Ejection Fraction Is Not Different in Ischemic Versus Nonischemic Cardiomyopathy
Authors: Wasemiller Stephen E , Earle Tiffany R , Foster Gary P , Silvet Helme
Published: July 2021

Background:
Patients with left ventricular (LV) dysfunction often have right ventricular (RV) dysfunction though the extent of dysfunction is poorly characterized in different types of cardiomyopathy (CM). Accurate measurement of RV volume is challenging due to its atypical shape; however, gated multidetector computed tomographic 3D reconstructions provide accurate quantification.

Methods:
All patients at VA Loma Linda Healthcare System who underwent cardiac computed tomography angiography between 2005 and 2011 with LV ejection fraction (EF) of ≤40% and adequate images for RV analysis were included in the study. LV and RV volumes were calculated from gated 3 dimensional datasets. Ischemic etiology of CM was determined by standard criteria based on coronary imaging on the same dataset.

Results:
123 patients were included. All the patients were men, with mean age of 62±9 years. Only 6% of the patients had normal RVEF ≥50% whereas 40% had RVEF ≤30%. RVEF and RV volumes did not differ between ischemic and nonischemic CM (Table 1). In the entire cohort, multiple regression analysis showed that RVEF independently correlated with LVEF (r=0.3, p<0.0001), age (r=0.2, p=0.01), and presence of chronic obstructive pulmonary disease (r=0.2, p=0.004). RVEF did not correlate with the presence of CAD (p=0.5) or with the presence of RCA disease (p=0.4).

Conclusions:
The majority of patients with LV dysfunction also have RV dysfunction, however, this was not dependent on the etiology of cardiomyopathy in our cohort.
Abstract 46: Potential of Coronary CT Angiography to Optimize Medical Therapy in Patients Presenting With Acute Chest Pain
Authors: Pursnani Amit , Schlett Christopher L , Zakroysky Pearl , Singh Parmanand , Januzzi James L , Jaffer Farouc A , Truong Quynh A , Hoffmann Udo
Published: July 2021

Background:
Coronary artery disease (CAD) detected by coronary CT angiography (CCTA) independently predicts cardiovascular events. We assessed the potential of CCTA to tailor aspirin (ASA) and statin medical therapy in acute chest pain patients presenting to the emergency department.

Methods:
We included all patients from the Rule Out Myocardial Infarction Using Computer Assisted Tomography (ROMICAT) Trial. This prospective double-blinded observational cohort study included patients presenting with chest pain to the emergency department with low-intermediate risk for acute coronary syndrome (ACS). Patients underwent CCTA prior to admission, followed by standard evaluation. Caretakers were blinded to CCTA results. We assessed medical therapy at presentation and discharge, and determined concordance of CAD status by CCTA with medical therapy dictated by standard care.

Results:
Complete data on medical therapy was available in 358/368 patients (99%), (53±12 years, 61% men) of whom 7 had a contraindication to ASA and 11 to statin. Standard of care included stress testing in 71% of patients. Prescription of ASA and statins increased from admission to discharge (See Figure). At discharge, 33% of patients without CAD were on ASA and 14% were on statin. Conversely, 46% of patients with nonobstructive CAD by CCTA did not receive ASA and 59% did not receive statin at discharge. Only 66% of patients with obstructive CAD were on statin and ASA at discharge. Based on 2011 American College of Cardiology/American Heart Association secondary prevention guidelines, there was discordance between CAD status by CCTA and medical therapy in 51% of patients.

Conclusions:
CCTA has great potential to optimize adherence to secondary prevention guidelines in chest pain patients presenting to the emergency department.
Abstract 56: Change in Midlife Fitness is an Independent Predictor of Heart Failure in Older Age
Authors: Pandey Ambarish , Willis Benjamin , Leonard David , DeFina Laura , Gao Ang , Berry Jarett
Published: July 2021

Background:
Low mid-life fitness is associated with increased risk for heart failure (HF) events decades later. However, the association between changes in mid-life fitness and heart failure risk has not been studied.

Methods:
We included 9050 subjects (15% Females, mean age 48 years) with no prior cardiovascular disease who underwent two cardiorespiratory fitness measurements approximately 8 years apart. Fitness was estimated in metabolic equivalents (METs) according to Balke treadmill time, with low fitness defined as the lowest quintile of fitness and high fitness defined as quintiles 2-5. Change in fitness was defined categorically according to fitness quintiles (see figure legend) and continuously as the change in METs between the two examinations. Baseline data from the CCLS were matched with Medicare administrative claims data from the Center for Medicare and Medicaid Services. Hospitalization for HF was determined from Medicare claims files. The association between change in fitness and HF hospitalization was assessed by applying a proportional hazard recurrent events model to the failure time data and adjusted for traditional risk factors.

Results:
After 60,635 person years of Medicare follow up, we observed 242 hospitalizations for HF. Compared to individuals with persistently low fitness levels in middle-age, individuals who increased their fitness levels had a lower rate of HF hospitalization (0.88 vs. 0.64%/year). After multivariable adjustment for baseline fitness level and other risk factors, each 1 MET increase in middle age fitness was associated with 5% less risk for HF hospitalization in later life [HR 0.95 (0.93-0.97) per MET].

Conclusion:
Change in mid-life fitness is associated with HF risk in older age. These findings suggest that the heart failure risk related to low fitness may be modifiable with exercise training.
Abstract 60: Remnant Lipoprotein Cholesterol and Mortality after Acute Myocardial Infarction: The TRIUMPH Prospective Multi-Center Registry
Authors: Martin Seth S , Joshi Parag H , Blaha Michael J , Kulkarni Krishnaji R , Khokhar Arif , Maddox Thomas M , Havranek Edward P , Toth Peter P , Li Yan , Spertus John A , Jones Steven R
Published: July 2021

Background:
Prior studies suggest a hypercholesterolemia paradox in which acute myocardial infarction (AMI) patients with higher low-density lipoprotein cholesterol have better outcomes, seemingly explained by confounding due to pre-existing statin use and other factors. We sought to examine whether remnant lipoprotein cholesterol (RLP-C) also fits this paradox, and if so, whether the association is explained by potential confounders, including pre-existing statin use.

Methods:
We examined the 2,465 patients participating in lipid testing in TRIUMPH; a prospective, 24-center U.S. study of AMI outcomes. Lipoprotein cholesterol subfractions were directly measured during AMI hospitalization by density gradient ultracentrifugation (Atherotech, Birmingham, AL). RLP-C was defined as the sum of very low-density lipoprotein fraction 3 cholesterol (VLDL
3
-C) and intermediate-density lipoprotein cholesterol (IDL-C). We assessed the association with 2-year mortality by Cox regression models adjusting for GRACE score, site, age, sex, race, insurance, education, tobacco use, diabetes mellitus, hypertension, alcohol use, physical activity, body mass index, statin use, and high-density lipoprotein cholesterol.

Results:
Patients were 58±12 years old (mean±SD) and 68% were men. After 2 years of follow-up, 226 (9%) patients died. The mortality rate was 12.4% in the lowest tertile of RLP-C (0 to <16 mg/dl), 8.5% in the middle tertile (16 to <24 mg/dl), and 6.9% in the highest tertile (24 to 120 mg/dl) (P=0.0003). In multivariable Cox regression, a one SD increase in RLP-C (11 mg/dl) was associated with a 23% lower risk of 2-year mortality (HR, 0.77; 95% CI, 0.65 to 0.90). Similar results were found for the individual components of RLP-C: for a one SD increase in VLDL
3
-C (4 mg/dl), HR, 0.72; 95% CI, 0.60 to 0.86; for a one SD increase in IDL-C (8 mg/dl), HR, 0.78; 95% CI, 0.66 to 0.91.

Conclusion:
Compatible with a hypercholesterolemia paradox, higher RLP-C levels were associated with lower mortality 2 years after AMI. This observation remained consistent after adjustment for statin use, as well as demographic, socio-economic, and clinical risk factors, suggesting that unknown protective factors may explain these paradoxically better outcomes with higher RLP-C levels.
Abstract 95: Nonvalvular Atrial Fibrillation Emergency Department Encounters where Dabigatran Etexilate was Administered are Associated with Lower Admission Rate Compared to Encounters where Warfarin was Administered
Authors: Fonseca Eileen , Walker David R , Hess Gregory P
Published: July 2021

Background:
Warfarin and dabigatran etexilate (DE) are oral anticoagulants (OAC) that reduce stroke risk among patients with nonvalvular atrial fibrillation (AF). However, DE does not require titration and INR monitoring. This study examined whether emergency department (ED) rate of admissions differed between the two therapies.

Methods:
Admission rate was evaluated for hospital encounters initiated in the ED, with a primary or secondary discharge diagnosis of AF between 1/1/2011-3/31/2012, with DE or warfarin administered during the encounter, and excluding encounters of valvular AF patients. Encounters were identified from a hospital Charge Detail Masters database containing 387 eligible hospitals. Samples were propensity score matched using nearest neighbor within a caliper of 0.20 standard deviations of the logit, without replacement, and a 2:1 match. Admission rates were estimated for encounters representing previously-treated patients and those representing treatment-naive patients using binominal generalized linear models, fitted by generalized estimating equations (clustered by hospital). Covariates estimating the propensity score and admission rate included age, payer type, use of bridging agents, AF as primary or secondary diagnosis, CHADS
2
and HAS-BLED scores, comorbid conditions, and hospital attributes. As a sensitivity analysis, admission rate was also estimated from the unmatched sample.

Results:
Matched samples included 2,688 warfarin and 1,344 DE ED encounters of previously-treated patients out of 15,053 and 1,367 ED encounters, respectively; and 2,578 warfarin and 1,289 DE ED encounters of OAC-treatment-naive patients out of 8,361 and 1,406 ED encounters, respectively. There were too few (n<5) matched encounters where the patient had prior OAC use but were new to the drug administered during the encounter, so these were excluded. No covariates used in matching had standardized mean differences > 10% after matching. Among the previously-treated sample, the estimated admission rate was 3.2% lower for DE compared to warfarin (88.3% vs. 91.5%, p=0.010) with sensitivity analysis confirming a lower admission rate for DE (91.1% vs. 93.8%, delta=2.7%, p=0.001). Among the treatment-naive sample, DE had a 1.2% lower admission rate compared to warfarin (95.2% vs. 96.3%, p=0.048). Sensitivity analysis confirmed a lower admission rate for DE (95.5% vs. 97.0%, delta=1.5%, p=0.001).

Conclusions:
While the vast majority of AF encounters initiated in the ED result in admission, encounters where patients were treated with DE as continuing or new therapy were less likely to be admitted compared to similar encounters where warfarin was administered.
Abstract 99: COPS( Chest Pain Observational Prospective Study)- An Inpatient Quality Improvement Analysis Of Chest Pain Management Between Teaching And Non- Teaching Teams
Authors: Singh Manmeet , Bajwa Muhammad R , Bolla Vema H , Kotak Kamal , Mills Paul
Published: July 2021

Background:
Chest pain (CP) accounts for 6 million ED visits and 50% of these are admitted for CP management. Nearly 70 % are not proven to have ACS. Challenge of CP diagnosis is thus associated with high economic burden.

Aim:
To evaluate the variation in CP management among teaching & non-teaching teams (NTT)

Methods:

Design:
Prospective Observational study Setting: Single center investigation at acute care hospital

Patients:
820 patients admitted with chief complaint CP to both teams from July -Nov 2011. 517 patients included in final analysis. Patients with more than one chief complaint& insufficient data were excluded. Patients identified through ED admit nurse registry on daily basis Assessment tools (AT): 5 AT described as length of hospital stay (LOS), readmission within 1 month(ROA), cardiology consult (ROC), intervention rates-non-invasive & invasive (ROI) & Co-morbid disease score based on number of co-morbid conditions (COMB) were used.

Results:
70 % had non-typical CP at presentation. 13 % with non-typical CP had ACS v/s 66 % with typical CP (p-<0.001). Mean LOS was same at 2.67±1.9 days in both teams. COMB score was 4.12± 1.5 v/s 3.91 ±1.5, p-0.16, showing that both teams had similar co-morbid conditions. ROA was also not different (11.3 %± 1.5 v/s 12.7 % ±1.3, p-0.23). ROI was 46 % and near significantly high in NTT (50.5%, p-0.07). ROC was higher in NTT (67% v/s 52%, P-0.002), but associated with ACS diagnosis (p-0.005, OR 2.78). ROI & ROC did not result in significant increase in the total LOS. Overall, higher ROC was observed with ACS (p-0.001, OR-8.017), males (p-0.007, OR-1.73) & cardiac history (p-0.001 OR-2.2). Increase ROI was seen with typical CP (p-0.028, OR 1.66), ROC (p-0.001, OR 8.6) and resulted decrease in ROA (p-0.02, OR 0.50). On sub analysis of ROI, only teaching teams remains associated with reduction in readmission (p-0.03, OR-0.27). COMB Score ≥5 was associated with ROA (O.R. =7.82, 95 % CI, p=<0.001).

Conclusion:
There was no statistical differences found in the length of stay and readmission’s between teams. Non teaching teams used more consult services & interventions but showed no difference in any quality markers. Interventions resulted in concomitant decrease in readmission among teaching teams only. If validated COMB score can be used as a readmission predictor tool. Future efforts should be made to recognize the judicious use of cardiology consult services in timely fashion for effective management of CP patients.
Abstract 128: Adherence to Generic vs. Brand Statins among Older Patients After Acute Myocardial Infarction
Authors: O'Brien Emily C , Peterson Eric D , McCoy Lisa A , Thomas Laine , Wang Tracy Y
Published: July 2021

Background:
Statins reduce mortality after acute myocardial infarction (MI), but up to half of patients discontinue statins within 1 year of starting therapy. Cost is one factor that may influence medication adherence, yet it is unknown whether use of generic vs. brand statin influences medication adherence.

Methods:
We linked detailed in-hospital clinical data for 1,421 NSTEMI patients discharged on a statin in 2006 to Medicare Part D medication claims records to examine post-discharge medication use. We excluded brand statin fills for which there were no generic dose equivalents. One-year statin adherence was defined as the proportion of days covered (PDC). We examined the association of brand vs. generic statin prescription and one-year adherence after adjusting for demographics, clinical factors, pre-discharge lipid values, prior statin use, and copay amount.

Results:
Overall, 65.5% of statin fills were for brand named statins. There were few baseline differences in demographics and clinical factors among generic vs. brand users. Patient copay amounts for generic statins (median=$5; IQR 1 - 10) were lower than those for brand statins (median=25; IQR 3 - 35). The mean PDC over one year was similar for brand users (71.5%; SD 31.2) and generic users (68.9%; STD 35.2%; p=0.97; unadjusted OR 1.15 [95% CI 0.96, 1.37]). Adherence remained non-significantly different between generic and brand statin users after adjusting for demographics, clinical risk factors, lipid value, prior statin use, and copay amount (Figure). Copay amount was not significantly associated with PDC (Per $ increase: OR=0.99 [95% CI 0.97, 1.01]; p=0.23).

Conclusions:
In a cohort of older NSTEMI patients, we found no evidence that adherence to statins one year after hospital discharge was improved among patients prescribed generic statins vs. brand statins.
Abstract 144: Residual Cardiovascular Risk After Cardiac Rehabilitation
Authors: Verma Divya Ratan , Noon Shirely , Rose Taylor , Young Dawn , Khor Lillian
Published: July 2021

Background:
CAD is the leading cause of death and disability in US. Cardiac rehabilitation (CR) program is an important secondary-prevention intervention to reduce mortality, cardiovascular (CV) events, & disability. At start of CR program, patients undergo extensive risk assessment to guide risk reduction goals. However, the residual risk at CR completion is not well studied. We sought to investigate the residual modifiable risk factors of patients completing CR

Methods:
We retrospectively reviewed our center’s data on consecutive patients between October 2012 and November 2013 who were entered into the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) registry and identified those who completed the CR program. We calculated their residual risk using the newly released ACC/AHA’s ‘Pooled Cohort Equations CV Risk Calculator’ (ACC/AHA risk) and Framingham risk (FR) calculator

Results:
Out of 128 consecutive CR participants, 44 (34%) completed the program. Patient characteristics and risk assessment are summarized in table 1. As per AACVPR risk stratification algorithm, 37 (84%) of patients were intermediate to high risk. Compared to the start, at completion of CR program, there was a significant improvement in 6-minute walk distance (365±107 vs 484± 137, p<0.001), favorable reduction in total cholesterol, LDL-C, non-HDL-C (p<0.001) and metabolic syndrome (p=0.02). At time of completion, calculated 10 year CV risk using ACC/AHA risk calculator was still elevated (14±10%), while 64% of patients had elevated risk≥7.5% (mean 19.3±9%). FR estimation was low (9±4%). The two risk scores showed moderate correlation (Pearson’s r=0.6, p<0.001), but the ACC/AHA risk was significantly higher than the FR estimation (p<0.001). In multivariate linear regression model, waist circumference (WC) at discharge was significant modifiable independent predictor of ASCVD risk, while systolic BP showed a trend towards significance

Conclusion:
Successful completion of CR program is associated with improvement in CV risk profile. However, the residual CV risk remains elevated at time of CR completion and is driven by WC & systolic BP. Elevated WC from central adiposity is the main residual atherogenic CV risk factor post CR completion. Further research on significant WC reduction during CR is needed
Abstract 15: Frequency and Predictors of Inappropriate Aspirin Prescribing for Primary Prevention of Cardiovascular Disease: Insights from the NCDR® PINNACLE Registry.
Authors: Hira Ravi S , Kennedy Kevin F , Nambi Vijay , Jneid Hani , Alam Mahboob , Basra Sukhdeep S , Ho Michael , Deswal Anita , Ballantyne Christie M , Petersen Laura A , Virani Salim S
Published: July 2021

Background:
Aspirin use is recommended in patients with cardiovascular disease (CVD) for secondary prevention. However, among men and women without CVD and low 10 year coronary heart disease (CHD) risk, aspirin use for primary prevention has not been shown to reduce CVD death or all-cause death. In low risk patients, the risks of gastrointestinal bleeding and hemorrhagic strokes associated with aspirin use outweigh any potential atheroprotective benefit. As per the American Heart Association (AHA) guidelines on Primary Prevention of CVD and Stroke in 2002 and U.S. Preventive Services Task Force (USPSTF) recommendations from 2009, use of aspirin is considered appropriate in patients with > 6% 10 year Framingham CHD risk and inappropriate in patients with 10 year risk < 6%. We studied the frequency and predictors of inappropriate aspirin prescribing for primary prevention in a large national registry.

Methods:
Within the NCDR Practice Innovation and Clinical Excellence (PINNACLE) Registry, we identified 267,957 patients without CVD (coronary heart disease, peripheral arterial disease or ischemic stroke) or atrial fibrillation receiving aspirin for primary prevention. Of these, Framingham Risk Score (FRS) could be calculated in 68,808 patients. We assessed the frequency of inappropriate aspirin prescribing for primary prevention (aspirin prescribing in those with FRS <6%). Using hierarchical regression models, we also assessed the extent of practice-level variation using the median rate ratio (MRR). MRR is interpreted as the likelihood that 2 random practices would differ in treating identical patients with aspirin inappropriately.

Results:
Inappropriate aspirin prescribing rate was 32.8 % (22601/68808) in the overall cohort. Mean FRS in the inappropriate aspirin group was 3.6 versus 16.2 in the appropriate group (p<0.001). Significant variation was noted between practices in the Northeast, Midwest, South and West with inappropriate aspirin prescribing rates ranging from 31.5% to 34.4% (p<0.0001). There was practice-level variation in inappropriate prescribing (range 17.9-52.4%, median rate 33.5%, interquartile range 28.6-37.7%) for practices; adjusted MRR 1.19 [95% CI 1.14 to 1.23]. Results remained consistent after excluding 14,097 patients with diabetes (inappropriate aspirin use rate = 38.2%, median rate 37.6%, interquartile range 32.5-43.8%; adjusted MRR 1.17 [95% CI 1.13- 1.21]).

Conclusion:
Inappropriate aspirin prescribing occurs in approximately one third of patients receiving aspirin for primary prevention. There is modest but significant practice-level variation. Our findings identify opportunities to improve evidence-based aspirin prescribing in primary CVD prevention.
Abstract 151: Outcomes Associated With Prophylactic Amiodarone Protocol in Patients Undergoing Cardiac Surgery: A Single Center Experience
Authors: Atreya Auras R , Arora Sonali , Garb Jane , Rousou John , Lindenauer Peter , Lotfi Amir
Published: July 2021

Background:
The incidence of post-operative atrial fibrillation (POAF) in patients undergoing cardiac surgery is approximately 25-40% and has significant consequences. One large randomized control trial demonstrated that the use of amiodarone prophylaxis decreases the incidence of POAF. To improve the quality of care for cardiac surgery patients and improve outcomes, an amiodarone prophylaxis protocol was implemented at our institution in July 2007. The protocol consisted of administering intravenous amiodarone (150 mg) after surgery, in patients without contraindications, followed by a week of 400 mg of oral amiodarone twice a day and 200 mg daily for one more week. In order to encourage utilization, an order care set was created in the electronic medical record system. We studied the effect of this intervention on practice and clinical outcomes.

Methods:
We included all patients ≥ 18 years of age without pre-existing atrial fibrillation, undergoing cardiac surgery in 5-year periods before and after the implementation of the amiodarone prophylaxis protocol in July 2007. Data were obtained from the Society of Thoracic Surgery (STS) National Database. The primary outcome was the rate of utilization of amiodarone and secondary outcomes were incidence of STS-defined POAF, stroke, myocardial infarction (MI) and 30-day mortality. Outcomes in the January 2002 to July 2007 time-period were compared with those in the September 2007 to June 2012 time-period.

Results:
From January 2002 to June 2012, 5473 patients underwent cardiac surgery. The mean age was 66 years, 69% were male and 93% were Caucasian. In the September 2007 to June 2012 time-period, 54% of patients (1303 of 2405) received amiodarone as compared to 11% of patients (330 of 3068) in the January 2002 to July 2007 time-period (p<0.01). The STS-defined incidence of POAF decreased in the September 2007 to June 2012 time-period as compared to the January 2002 to July 2007 time-period [36% (861 of 2405) vs. 38% (1178 of 3068), p= 0.04]. The incidence of stroke [4% (93 of 2405) vs. 6% (103 of 1696), p<0.01] and peri-operative MI [4% (90 of 2405) vs. 12% (378 of 3068), p<0.01] decreased as well but there was no change in 30 day mortality [2% (55 of 2405) vs. 2% (78 of 3068), p = 0.55].

Conclusions:
Implementation of an amiodarone prophylaxis protocol order care set was associated with greater utilization of amiodarone. It was also associated with a modest decrease in the incidence of STS-defined POAF, stroke and MI but was not associated with a change in 30-day mortality in patients undergoing cardiac surgery. Further studies are needed to study the cost-effectiveness and risk-benefit analysis of routine amiodarone as prophylaxis.
Abstract 160: Ethnic differences in the Relationship of theECG QRS Interval to Findings on Cardiac Magnetic Resonance Imaging
Authors: Garcia Daniel , Macedo Francisco Y , Nascimento Rhanderson , Viles-Gonzalez Juan , Hendel Robert
Published: July 2021

Background:
QRS prolongation is associated with increased risk of ventricular arrhythmias and cardiac death. Studies have suggested its association with areas of scarring fibrotic tissue on the myocardium from infarction and non-ischemic fibrosis and arrhythmogenesis identified by late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR). Group ethnicity might play role on fibrotic tissue and cardiac conduction. We aimed to evaluate the QRS interval among white, Hispanic and black population by LGE CMR.

Methods:
Forty-two patients with CMR performed for different purposes were divided by white, Hispanic and black ethnicity and stratified by age, male gender, heart failure (HF), coronary artery disease (CAD), left ventricle ejection fraction (LVEF) on CMR and presence of any segmental LGE. We then stratified each ethnicity group by the presence or not of LGE and analyzed the QRS interval.

Results:
Baseline characteristics were similar among all three groups detailed LVEF were 51%, 42% and 52% for white, black and Hispanic patients, respectively (p=0.07). There was no difference of QRS interval in patients with or without any segmental LGE in white and black population. Hispanic patients with LGE presented with significant prolongation of QRS interval when LGE was present (91 vs. 128; p=0.002).

Conclusion:
This is the first analysis of ECG QRS interval among different ethnicities with similar baseline characteristics and preserved cardiac function by LGE on CMR. We have demonstrated that LGE on CMR is associated with a prolonged QRS interval only in a Hispanic population.
Abstract 181: Patterns of Waveform and Energy Use in Defibrillation for Cardiac Arrest: Insights from the Get With The Guidelines-Resuscitation Registry
Authors: Schneider Preston M , Liu Wenhui , Grunwald Gary K , Chan Paul S , Nallamothu Brahmajee K , Sasson Comilla , Varosy Paul D , Turakhia Mintu P , Ho P Michael , Bradley Steven M
Published: July 2021

Background:
Early defibrillation for termination of life-threatening arrhythmias is key to survival of cardiac arrest. Biphasic waveform defibrillation has been suggested as superior to monophasic waveform defibrillation, but little is known about trends in defibrillation waveform and energy used for in-hospital cardiac arrest.

Methods:
Within Get With The Guidelines-Resuscitation, a national registry of in-hospital cardiac arrest, we identified subjects over age 18 with an in-hospital cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia between 2005 and 2012. We restricted the study cohort to this time period, as defibrillation waveform and energy were not captured prior to 2005. We examined calendar year trends in defibrillation waveform and energy of first defibrillation attempt using the chi-square test.

Results:
A total of 22,108 patients from 504 facilities were identified. In 2005, in which there were 2898 in-hospital cardiac arrest cases, 1911 (66%) events were treated with biphasic defibrillation and 987 (34%) with monophasic defibrillation. By 2012, nearly all (97% [1460/1502]) events were treated with biphasic defibrillation; p for trend < 0.0001 (see Figure). For biphasic defibrillation, the predominant energy used for first defibrillation attempt was 200 J (55.91% of events) with 150 J being the next most common (18.21% of events) with a trend toward more frequent use of 200 J (p < 0.0001).

Conclusion:
Biphasic defibrillation at 200 J is now the predominant waveform and energy used for initial defibrillation during in-hospital cardiac arrest. Additional work is needed to determine if a rise in use of biphasic defibrillation is improving outcomes.
Abstract 204: Emergency Department Visits for Heart Failure and Subsequent Hospitalization or Observation Unit Admission
Authors: Blecker Saul , Ladapo Joseph , Doran Kelly , Goldfeld Keith , Katz Stuart
Published: July 2021

Background:
Although the majority of hospitalizations for heart failure (HF) originate in the emergency department (ED), many of these patients might be adequately treated and released in the ED or managed for a short period in an observation unit. Both ED and observation management have been shown to reduce costs and avoid the penalties related to rehospitalization. The purpose of this study was to examine trends in ED visits for HF and disposition following these visits. Because of increasing policy pressure to reduce rehospitalization for HF, we hypothesized that the number of HF patients hospitalized by ED providers decreased over time with a concurrent increase in admissions to the observation unit. We further hypothesized that the overall number of ED visits for HF decreased as a result of improved therapy for HF the last two decades.

Methods:
We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) to estimate rates and characteristics of ED visits for HF between 2002 and 2010. The primary outcome was the discharge disposition from the ED. Regression models were fit to estimate trends and predictors of hospitalization and admission to an observation unit.

Results:
The number of ED visits for HF remained stable over the period, from 914,739 in 2002 to 848,634 in 2010 (annual change -0.7%; 95% CI -3.7% - +2.5%). Of these visits, 74.2% led to hospitalization while 3.1% led to observation unit admission (Figure). The likelihood of hospitalization did not change during the period (adjusted prevalence ratio (aPR) 1.00; 95% CI 0.99-1.01 for each additional year) while admission to observation increased annually (aPR 1.11; 95% CI 1.00-1.23). We observed significant regional differences: as compared to other regions, patients in the Northeast were more likely to be hospitalized (aPR 1.15; 95% CI 1.07-1.22) but less likely to be admitted to an observation unit (aPR 0.43; 95% CI 0.19-1.02).

Conclusions:
The number of ED visits for HF has remained stable in the last decade. Although observation unit admissions increased during this period, they constituted a relatively small number of dispositions and did not appear to attenuate the substantial number of ED visits that resulted in hospitalization. Opportunities may exist to reduce hospitalizations by increasing short term management of HF in the observation unit.
Abstract 218: Do Weekends Influence Time to Treat?
Authors: Langabeer James R , Alqusairi Diaa , DelliFraine Jami , Segrest Wendy , Henry Timothy ,   Dallas Caruth Scientific Advisory Board
Published: July 2021

In emergency cardiovascular care, time to treat is a key system goal to improve patient outcomes. In patients experiencing ST-elevation myocardial infarction (STEMI), reducing delays requires continuous quality improvement at PCI hospitals to reduce door to balloon (D2B) times. Yet, many of the hospital operational processes are not well situated to accommodate variability in patient presentation patterns. In this study, we questioned whether the day of week influences time to treat, since this could have an effect on hospital staffing, personnel mix, and resource utilization. We analyzed the entire population of 1,247 STEMI patients that presented in all of the PCI facilities in Dallas County Texas during a 24-month period (2010-2012), to assess relationships between arrival patterns and treatment delays. Specifically, we examined the differences in D2B times of patients presenting on weekends versus weekdays. To control for confounding factors, we developed a robust generalized linear model (GLM) regression and relied on estimated marginal means analyses to assess the impact of weekday vs. weekend on hospital D2B, and controlled for a variety of confounding factors.

There was a statistically significant difference in the D2B times between patients who arrived at the hospital on weekends (75 minutes) compared to those who arrived on weekdays (65 minutes) (KW=48.9; df=1; p<.001). Seventy two percent of patients who arrived on weekends or holidays achieved a D2B time of <90 minutes, compared to 79.5% for those who arrived on weekdays. GLM regression results confirmed that arriving on weekends or holidays is associated with statistically significantly higher D2B time (p=0.000), controlling for confounding variables (gender, age, presence of heart failure, cardiac arrest, shock at first medical contact, EMS transportation, and cardiac cath lab activation by EMS). Based on these findings, we recommend careful evaluation and update of hospital activation protocols and staffing policies for weekends.
Abstract 22: Impact Of Drug Policy On Regional Trends In Ezetimibe Use
Authors: Lu Lingyun , Krumholz Harlan , Tu Jack , Ko Dennis , Ross Joseph , Jackevicius Cynthia
Published: July 2021

Background:
Ezetimibe use has gradually but steadily increased in Canada during the past decade even with the absence of outcomes evidence. Among the 4 most populated provinces in Canada, there is a gradient in the restrictiveness of ezetimibe in the public-funded formularies (most strict to least strict: British Columbia (BC), Alberta (AB), Quebec (QC) and Ontario (ON)). We examined ezetimibe use trends in these 4 provinces in the period before and after the ENHANCE trial, which was published in January 2008 to better understand the association between use and formulary restrictiveness.

Methods:
We conducted a population-level observational cohort study using the data collected by IMS Health Canada’s CompuScript Audit® from June 1, 2003 to December 31, 2012. The main outcome measure was monthly ezetimibe expenditures, which were used as a proxy for the total number of prescriptions. The differences in ezetimibe-associated expenditures between the 4 provinces were tested using a linear regression model with interaction effects for province and time.

Results:
The monthly population standardized ezetimibe-associated costs increased in different patterns in the 4 provinces over the past decade. From June 2003 to December 2012, BC had the lowest monthly increasing rate from $ 261 to $21,926 ($190/100,000 population/month), ON had the most rapid monthly increase from $223 to $ 74,030 ($ 647/100,000 population/month) and QC from $ 130 to $ 59,690 ($522/100,000 population/month) and AB from $ 356 to $ 37604 ($327/100,000 population/month) were in between. (P<0.001) The cost for ezetimibe appeared to increase steadily in QC over the study period. In contrast, the increasing rate began declining in BC, AB and ON at the time point which coincided with the publication of ENHANCE.

Conclusions:
Distinct patterns of ezetimibe use emerged within the 4 biggest provinces in Canada, which was associated with the restrictiveness of their publicly-funded drug formularies. Without the support of clinical outcomes evidence, ezetimibe remains commonly used in the provinces with least strict formularies (QC and ON). In contrast, the use of ezetimibe seemed to plateau post-ENHANCE in BC and AB, which have more restrictive formularies. The strictness of the drug formulary appears to be influencing ezetimibe prescribing in Canada.
Abstract 243: Regional System to Optimize First Medical Contact to Balloon times for Primary PCI in STEMI Penalized by New AHA Guidelines
Authors: Khandhar Sameer J , Macpherson Nicholas , Martin-Gill Chris , Munshi Laishiya , Mulukutla Suresh , Marroquin Oscar , Lee Joon S , Toma Catalin
Published: July 2021

INTRO:
The AHA Mission Lifeline recommends an EMS first medical contact (FMC) to balloon time of 90 minutes for patients STEMI when presenting directly to a percutaneous coronary intervention (PCI) hospital but 120 minutes for those requiring transfer from a non-PCI hospital. We examine the impact of direct air medical transport from the scene to a PCI center of rural patients without access to a local PCI capable hospital versus EMS transport to and subsequent transfer from a non-PCI hospital.

METHODS:
A regional STEMI transport system was developed in 2012 for western Pennsylvania between non-PCI capable hospitals, local EMS agencies, and UPMC Presbyterian Hospital. This system was designed to improve transfer times and one component of this was to allow local EMS companies to activate the cath lab directly. In this program, an emergency helicopter meets the EMS and allows for direct transport of the patient to PCI hospital, bypassing the local ED. We compared reperfusion times in consecutive patients brought directly to the PCI center versus patients taken by EMS to a local ED first in 2012-2013. Patients were then matched based on distance from PCI center.

RESULTS:
A total of 22 patients were brought directly to the PCI center and 32 patients were taken by local EMS to their local non-PCI hospital followed by helicopter transport for primary PCI. Median FMC to balloon times for patients taken directly from the scene to PCI center was 22 minutes less (113 vs 135 minutes, p=0.0006) than when first taken to a local ED. There was no difference in PCI arrival to balloon times (26 vs 20 minutes, p=0.128) and breakdown of median times listed in table 1. The average linear flight distance between groups was 37 vs 41 miles (p=0.2123).

CONCLUSIONS:
In this regional system, transport of rural patients with STEMI directly to a PCI center improves FMC to balloon times when compared to patients taken to a local non-PCI hospital first. Despite shortening reperfusion times with implementation of this system, some of these patients would fall out of the recommended AHA guidelines because they are considered to present directly to the PCI hospital. Further investigation on the benefits of direct transport of rural patients to a PCI center is warranted and whether the AHA recommended FMC to balloon time needs adjustment in this scenario.
Abstract 249: Economic Outcomes for Patients with Acute Coronary Syndrome Managed with Percutaneous Coronary Intervention and Receiving Prasugrel or Ticagrelor: A Retrospective US Hospital Database Analysis
Authors: Molife Cliff , Frech-Tamas Feride , Effron Mark B , DeKoven Mitch , Karkare Swapna , Zhu Yajun E , Larmore Cynthia , Lu Jingsong , Lee Won C , Mc Collam Patrick , Marrett Elizabeth , Vetrovec George W
Published: July 2021

Objectives:
To compare all-cause healthcare resource utilization and costs with prasugrel (pras) vs. ticagrelor (ticag) with real world data in patients (pts) with ACS managed with PCI.

Methods:
The IMS Patient-Centric Data Warehouse was used to identify ACS-PCI pts ≥18 years with an in-hospital claim for pras or ticag (index date) between 8/1/11 and 4/30/13. The baseline period began on 1/1/08 with the follow-up period spanning until 7/29/13. The two drug groups were propensity-matched (PM) based upon demographic and clinical characteristics. Three cohorts were pre-defined and analyzed: ACS-PCI (primary cohort), ACS-PCI without prior TIA or stroke (label cohort), and ACS-PCI patients without prior TIA or stroke and if age ≥75 years required evidence of diabetes or prior MI (core cohort). Hospital specific cost:charge ratios were used to determine costs and adjusted to 2013 US dollars. Total costs were the sum of medical costs, including lab and diagnostic tests, and pharmacy costs during hospitalization. Generalized estimating equations were used to evaluate PM-adjusted differences in length of stay (LOS) and costs. Costs are reported on a per patient basis. Resource utilization and costs were assessed during index hospitalization, 30 and 90 days post-discharge.

Results:
16,098 pts were in the primary cohort (pras: 13,134 [82%] and ticag: 2,964 [18%]). Compared to ticag pts, pras pts were younger, more likely men, and less likely to have cardiovascular or bleeding risk factors (P<0.05). In all 3 cohorts, unadjusted data showed that PCI characteristics (stent type, number of stents and vessels) were similar between pras and ticag, but ticag patients tended to have higher use of lab and diagnostic tests compared to pras during index hospitalization. For the index hospitalization, the unadjusted CCU/ICU and post-PCI LOS were shorter for pras vs. ticag, but overall LOS was not significantly different after adjustment. PM-adjusted mean all-cause total, medical, and pharmacy costs are presented in the table.

Conclusion:
Economic outcomes of ACS-PCI pts receiving pras were similar to ticag for the primary population with significant savings in total and medical costs for pts without prior TIA or stroke. These data indicate that ticag has no economic advantage compared with pras in routine clinical practice.
Abstract 281: Diabetes in India: Insights from PINNACLE India Outpatient Registry
Authors: Risch Samantha A , Glusenkamp Nathan T , Kerkar Prafulla , Kumar Ganesh , Oetgen William J
Published: July 2021

Background:
India may have the largest diabetes (DM) population in the world. Indians have high genetic susceptibility and a low threshold for risk factors. Prevention, delay through lifestyle intervention or drug therapy has proven effective in all ethnic groups. Thus surveillance of vulnerable populations through a cardiovascular (CV) registry can assist in targeting opportunities for intervention.

Methods:
PINNACLE India is the first CV data collection and reporting program in India. Data are collected by transmission from paper scanners and an electronic data collection tool. Patients are followed longitudinally if they return to a data collecting site.

Results:
DM is documented in 14.5% of patients and 17.1% of encounters. Mean glucose was 125 mg/dL and 28.4% of values fell above 130 mg/dL. Among HbA1c values, 88.7% were high. For documented DMs, mean total cholesterol was 137.6 mg/dL, LDL was 87.8 mg/dL, HDL was 32.3 mg/dL and triglycerides were 133.7 mg/dL.

Conclusion:
Cholesterol is well managed among diagnosed DMs.
Blood sugar is not well managed and indicates a significant number of undiagnosed DMs.

DM appears underdocumented, underdiagnosed, and sub-optimally managed in the registry population. In the US, an estimated 7 million DMs are undiagnosed.

A similar or higher proportion is likely in India. Reducing risk of CV disease requires prevention for non-DMs and management of those diagnosed.
Data suggest a focus on DM diagnosis and management as opposed to lipid control for already diagnosed DMs.
Abstract 311: Risk Factor Profile and Outcome in Young Adults Presenting With Acute Myocardial Infarction Compared to Older Adults.
Authors: Indramohan Venmathi , Hajjali Raef , Akosah Kwame
Published: July 2021

Background:
Management of acute myocardial infarction has improved but preventing the first myocardial infarction in the first place continues to be a challenge. Guidelines for prevention have focused on ‘one-size-fits-all’ approach. With the nation’s changing trends in risk factor profile (Diabetes mellitus, obesity and tobacco use), we aimed to examine the risk factor profile for young adults (<50 years) suffering acute myocardial infarction (AMI) and compared to older adults (>50 years).

Methods:
The Nationwide Inpatient Sample (NIS), a part of the Healthcare Cost and Utilization project (HCUP) is the largest publicly available inpatient database designed to provide information on patients discharged from United States community hospitals. Using the NIS database from 2008 to 2010, 374,173 adults with AMI were identified.

Results:
Younger adults had a significantly higher incidence of smoking (51% vs. 18.8%; P< 0.001) and obesity (17.3% vs. 9.9%; P<0.001). The rate of hypertension was similar in both groups.

Younger adults were more likely to present with ST elevation myocardial infarction (42 % vs. 27%) and undergo percutaneous revascularization (62% vs. 41%) as compared to older adults.

In-hospital mortality was lower in younger adults presenting with AMI (1.7 % vs. 6.2%) as expected.

Conclusion:
1). Acute MI in the young adult is more likely to present as STEMI.

2). Young adults are more likely to be obese and use tobacco.

3). The results suggest that there is opportunity to improve AMI in the young by focusing on modifiable risk factors.

4). The lower short term mortality may imply that young adults with MI are beset with greater or long standing burden for complications.