bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 6: Vitamin D3 Repletion Improves Heart Failure Patient Quality of Life and Neurohormonal Indices
Authors: Moretti Heidi , Berry Bradley , Colucci Vince
Published: July 2021

Background:
Vitamin D deficiency has been associated with cardiovascular mortality and sudden cardiac death in heart failure patients. Vitamin D may influence parathyroid hormone, the renin-angiotensin axis, natriuretic peptide gene expression, cardiac contractility, and cardiopulmonary function. Heart Failure (HF) studies using vitamin D to date have typically not used adequate repletion doses.

Objectives:
The primary objectives of this research were to determine if vitamin D repletion over a six month period in New York Heart Association (NYHA) Class II-III HF patients would result in a change in neurohormonal markers, cardiopulmonary exercise parameters, circulating 25- hydroxyvitamin D, and quality of life.

Methods:
A randomized, double-blinded, placebo-controlled trial assessing adjunctive Vitamin D3 supplementation in the treatment of NYHA Class II-III HF patients was conducted. Patients received 10,000 International Units (IU) per day of vitamin D3 or placebo for 6 months. Inclusion Criteria: 1) 25-hydroxyvitamin D level ≤32 ng/ml 2) stable medical regimen for 3 months. Exclusion Criteria: 1) any clinically unstable medical disorder 2) supplementation of vitamin D3 or D2 of greater than or equal to 2,000 IU/day. Study endpoints were: 1) B-type Natriuretic Peptide (BNP), 2) cardiopulmonary exercise parameters using Shape HF, 3) 25-hydroxyvitamin D, 4) intact parathyroid hormone (PTH), and 5) quality of life with the Kansas City Cardiomyopathy Questionnaire (KCCQ). Statistical analysis included independent samples t-test and multivariate regression.

Results:
A total of 34 patients completed the study. When adjusted for baseline 25-hydroxyvitamin D, the difference between groups for BNP was significant ([[Unable to Display Character: ∆]]540 ±1928 pg/ml placebo vs [[Unable to Display Character: ∆]] 35 pg/ml ±1054 pg/ml treatment p=0.009). 25-hydroxyvitamin D was [[Unable to Display Character: ∆]]48.9 ±32 ng/ml treatment vs [[Unable to Display Character: ∆]]3.6 ± 9.4 ng/ml placebo, p<0.001 (mean 68 ng/ml treatment vs 23 ng/ml placebo). No toxicity was observed with treatment. PTH and exercise chronotropic response index trended towards improvement in the treatment group vs placebo group, respectively (([[Unable to Display Character: ∆]]-20 ±20 pg/ml vs [[Unable to Display Character: ∆]]7 ±54pg/ml (p=0.06)) and ([[Unable to Display Character: ∆]]0.13±0.26 versus [[Unable to Display Character: ∆]]-0.03 ± 0.23, p=0.12)). KCCQ quality of life total symptom ([[Unable to Display Character: ∆]]16 ±16 treatment vs [[Unable to Display Character: ∆]]-12 ±15 placebo, p< 0.001) and individual scores significantly improved from baseline in the treatment group.

Conclusions:
Preliminary results show that vitamin D3 treatment of 10,000 IU/day in heart failure patients is safe, results in adequate circulating 25-hydroxyvitamin D levels, and achieves improvement in surrogate endpoint markers of HF outcomes.
Abstract 11: Comparison of Patient Reported Angina with Provider Assigned Canadian Cardiovascular Society Angina Class Before and After Revascularization
Authors: Nassif Michael E , Cohen David J , Arnold Suzanne V , Qintar Mohammed , Farkouh Michael E , Fuster Valentin , Spertus John A
Published: July 2021

Background:
The Canadian Cardiovascular Society (CCS) classification system for angina is a critical determinant of revascularization appropriateness. A major limitation of CCS is that it rates patients’ symptoms from the perspective of providers, rather than patients themselves. Accordingly, we sought to evaluate the correlation of physician-assigned CCS class with patient-reported Seattle Angina Questionnaire (SAQ), before and after revascularization.

Methods:
Using data from the FREEDOM trial, which randomized 1900 patients from over 160 international sites to either PCI or CABG, CCS was reported by physicians and the SAQ was completed by patients prior to randomization and 1 year later. SAQ angina frequency (SAQ AF) scores were considered to correspond to CCS class per the following: SAF AF: 100=CCS 0, 61-99=CCS I, 31-60=CCS II, 0-30=CCS III/IV. Agreement between physician- and patient-reported angina categories was compared using chi square tests.

Results:
Among 1640 patients who had CCS and SAQ data at both baseline and 1-year, the mean age was 63.1 years, 71% were male, and 83% had 3-vessel coronary disease. Before revascularization, physicians correctly reported the burden of angina in 25.5% of patients and overestimated the burden of angina in 62.1%. Among 1194 patients who reported monthly or no angina, 229 (19.2%) were classified by their physicians as having CCS III/IV. In contrast, at follow-up, 71.2% of patients had their angina correctly estimated by their physicians and only 0.6% among the 1568 patients with monthly/no angina were assigned CCS III/IV by their physicians. Among the 28.8% misclassified by CCS at 1 year, 20.8% had less angina than reported by physicians and 8.0% had more (Figure; p=0.01). Findings were similar when the analysis was repeated in patients who were treated with PCI or CABG.

Conclusions:
In a large cohort of patients with stable coronary disease undergoing revascularization, clinicians often overestimated the amount of angina patients were having prior to revascularization but were significantly more accurate at follow-up. Given that importance placed on CCS for enrollment in clinical trials, or assigning appropriateness of revascularization in clinical practice, using patient-reported symptom burden as a more unbiased measure should be considered.
Abstract 118: Are Patients with Atherosclerotic Cardiovascular Disease Receiving Appropriate Lipid Management? Insights from the PALM Registry
Authors: Navar Ann M , Peterson Eric D , Li Shuang , Virani Salim S , Wilson Peter W , Robinson Jennifer G , Goldberg Anne C , Roger Veronique L , Elassal Joseph , Lee L. Veronica , Wang Tracy Y
Published: July 2021

Background:
Prior ATPIII lipid guidelines recommended statin therapy for patients with clinical ASCVD to achieve low density lipoprotein cholesterol (LDL-C) targets, while the 2013 ACC/AHA lipid guidelines recommend high-intensity statin therapy for all ASCVD patients. How closely these recommendations are followed in routine clinical practice is unknown.

Methods:
We evaluated statin use, intensity, and LDL-C values in 1,483 patients with ASCVD (coronary heart disease, cerebrovascular disease, and peripheral arterial disease) enrolled and seen serially at 62 geographically dispersed US cardiology and primary care clinics in the Patient and Provider Assessment of Lipid Management (PALM) Registry between May - September 2015. Factors associated with high intensity statin use (atorvastatin ≥40 mg or rosuvastatin ≥20 mg daily) and LDL-C <70 mg/dL were evaluated in multivariable logistic regression.

Results:
Of 1,483 ASCVD patients, 86.2% were on a statin, but only 31.4% were on a high-intensity statin. Overall, 64.0% had an LDL-C <100 mg/dL, but only 29.0% had an LDL-C <70 mg/dL. Factors associated with high-intensity statin use in multivariable regression were younger age (OR 0.74 per 10 year increase, p<0.001, 95% CI 0.66-0.83), male sex (OR 1.69, p<0.001, 95% CI, 1.32-2.16), cerebrovascular disease (OR 1.55, p=0.008, 95% CI 1.12-2.13), coronary heart disease (OR 2.42, p<0.001, 95% CI 1.67-3.50), and being seen by a cardiologist (OR 1.35, p =0.04, 95% CI 1.01-1.81). Factors associated with an increased likelihood of LDL-C<70 were male sex (OR 1.55, p=0.001, 95% CI 1.20-2.01), white (OR 1.62, p=0.03, 95% CI 1.04-2.5-, diabetes (OR 1.64, p<0.001, 95% CI 1.29-2.09) and being seen by a cardiologist (OR 1.94, p<0.001, 95% CI 1.41-2.67).

Discussion:
Substantial gaps in care remain for secondary prevention of ASCVD despite simplified recommendations. While the majority of patients with ASCVD in community practice are on a statin, only one-third are on high intensity statins and over two-thirds have LDL ≥70 mg/dL.
Abstract 13: Real-time Decision Support and Physician Feedback Optimizes Use of Vascular Closure Devices in High Bleed Risk Patients Undergoing Percutaneous Coronary Intervention
Authors: Han Christopher R , Strauss Craig E , Garberich Ross F , Chavez Ivan J , Henry Timothy D , Poulose Anil K
Published: July 2021

Background:
Bleeding complications following Percutaneous Coronary Interventions (PCI) occur in 2-6% of cases. Designed to provide rapid hemostasis, vascular closure devices (VCDs) have been found to have the largest benefit in high bleed risk cases but are utilized less often in these patients. Decision support tools and real-time feedback may impact physician practice patterns and increase utilization of VCDs in cases with high bleed risk.

Methods:
In May 2012, a real-time decision support tool was introduced to prospectively evaluate PCI bleed risk and stratify patients into high, intermediate, and low bleeding risk based on a validated model using data from the National Cardiovascular Data Registry. In January 2014, a group goal of 50% utilization of VCDs in high-bleed risk patients was set and weekly reports to individual interventional cardiologists performing PCI were provided. Group and individual physician practice patterns before and after the goal and real-time feedback were assessed.

Results:
From May 2012 to August 2015, 5,285 patients received PCI, including 1,399 (26.5%) who were classified as high bleed risk. Prior to the group utilization goal and real-time feedback being implemented, VCD use in high bleed risk patients was 40.3% (292 of 725) and utilization by individual provider ranged from 7.4% (5 of 68) to 83.1% (103 of 124) of cases. After implementation of the group utilization goal and real-time feedback, 74.2% (500 of 674) high bleed risk received VCDs and utilization by individual provider ranged from 61.4% (43 of 70) to 87.9% (87 of 99) of cases. Therefore, the physician group saw a relative increase of 84.1% in VCD utilization (40.3% vs. 74.2%; p<0.001). Additionally, among individual providers, VCD use significantly increased for 7 of 8 physicians (see figure) and the group practice variation in use of VCDs decreased (standard deviation of VCD utilization across physicians decreased from 22.9% to 8.7%, p=0.021).

Conclusions:
Implementation of real-time feedback and clearly defined group goals for the use of VCDs in high bleed risk cases significantly increased VCD use in patients known to have the greatest benefit. These interventions also reduced the variation in care for high bleed risk patients.
Abstract 140: Customizable Solution for Heart Failure (HF) Care Standardization and Optimization: HF Readmission Performance and Economic Value in the McLaren Flint Hospital Pilot
Authors: Chambers James , Meisner Susan , Ellegood Cheryl , Nahey Tara , Tsintzos Stelios I
Published: July 2021

Introduction:
Preventing readmissions after an index HF hospitalization, alongside other hospitalization types, has become a formal Medicare quality metric linked to payment penalties. Similar international incentives exist internationally; under different delivery systems and models, payment for the subsequent admission may be reduced (sometimes even eliminated), or, only the most costly event is paid. McLaren Flint, a teaching facility in the fully integrated McLaren Health Care (MHC) delivery system, concerned with their readmission rate, proactively implemented an integrated Medtronic HF solution as part of its strategic objective to deliver healthcare value measured by quality outcomes and cost. The program, now titled CONNECT-HF®, is customizable and deploys experts, sophisticated technologies, and Lean Sigma techniques to optimize and standardize care. Several improvement areas were identified. Targeted interventions (inpatient process optimizations, standardization of inpatient admission/discharge order sets, training) began implementation Oct 2014.

Hypothesis:
The program would result to reductions in 30-day readmits and positive financial impact to McLaren.

Methods:
We conducted before/after comparisons of readmit rates after “index” HF events, comparing Jan-Mar 2015 rates with the ones from the 3-month period before (Oct-Dec 2014). To adjust for seasonality, rates were also compared to the respective period the year before (Jan-Mar 2014).

Results:
During Jan-Mar 2015, 14 readmits followed 90 index HF hospitalizations vs. 29 readmits after 112 “indexes” over Oct-Dec 2014. This leads to a reduction from 25.9% to 15.6% (RR 39.93%). Jan-Mar 2014 equivalent rate was 21.05% leading to a RR of 26.11% in that comparison. These put McLaren Flint on track to outperform the current 22.7% national rate, the 23.86% previous performance and potentially eliminate the penalty contribution of HF. Potential savings model out to over
$154K
vs the actual penalty in FY2015 (
44.6%
of total).

Conclusions:
HF care pathway standardization and optimization can yield significant improvement on HF 30-day readmit rates, saving costs.
Abstract 144: Development of a Risk Score for Predicting Hypertension in Women with a History of Gestational Diabetes Mellitus
Authors: Carey James , Wenger Julia , Huynh Jennifer , Thadhani Ravi , Bentley-Lewis Rhonda
Published: July 2021

Introduction:
Gestational diabetes mellitus (GDM) is associated with increased maternal cardiovascular disease (CVD) risk manifest as hypertension subsequent to pregnancy. The impacts of dysglycemia and race/ethnicity on hypertension risk have been examined; however, the study of putative risk factors has been limited.

Hypothesis:
We hypothesize that GDM and gestational dysglycemia are sufficiently predictive of hypertension subsequent to pregnancy and that a risk score based on degree of dysglycemia can be used to identify at-risk patients.

Methods:
We examined a cohort of 23,223 women who presented for prenatal care to the Massachusetts General Hospital Obstetrical Department between September 1998 and January 2007. We selected women, ages 18 to 40 years, free of CVD or pre-GDM, with complete glycemic and demographic data who delivered a singleton, live birth. Each woman’s initial pregnancy was selected in order to not violate the independence assumption. The population was stratified by incident hypertension subsequent to pregnancy. Logistic regression models (with and without stepwise selection) were used to identify significant maternal risk factors based on their predictive performance. Finally, the risk prediction score was developed from β-coefficients in multivariable Weibull models.

Results:
The study sample comprised of 11,161 women, 547 (4.9%) of whom developed hypertension during 4.2 years (median) follow-up. Significant predictors of hypertension included age, body mass index, systolic and diastolic blood pressures, parity, dysglycemia, and race/ethnicity. These factors were used to develop a risk score for subsequent hypertension risk. The final risk score achieved a c-statistic of 0.76, indicating moderate discriminative ability (Figure 1).

Conclusions:
We developed a risk score that may be used to identify patients with an elevated risk of hypertension subsequent to a pregnancy complicated by dysglycemia. Further external validation is warranted to determine clinical effectiveness.
Abstract 157: Gender Differences in the Ambulatory Treatment of Hypertension in Patients with Heart Failure
Authors: Garcia Rachel A , Piatetsky Yana , Scheidler Matthew , Norton Mary-Alice , Philbin Edward F , Torosoff Mikhail
Published: July 2021

Background:
We investigated gender-specific differences in treatment of hypertension (HTN), and how they may affect outcomes in congestive heart failure (CHF) patients.

Methods:
Records of 194 (100 male, 94 female) unselected consecutive patients with HTN enrolled in the CHF clinic were reviewed. Left ventricular ejection fraction (LVEF) was compared to LVEF at time of enrollment in the clinic. The average interval between the two echocardiograms was 30 months.

Results:
ANOVA, chi-square, and logistic regression analyses demonstrated that men were more likely than women to have baseline LVEF ≤35%, (50% vs. 36%, p=0.108), coronary artery disease (63% vs. 43%, p=0.004), diabetes mellitus (p=0.095), and be ever smokers (66% vs. 40%, p<0.0001). Factors such as age, peripheral vascular disease, hyperlipidemia, serum K+, creatinine clearance, body mass index, and heart rate were similar in both genders.

Optimal BP control noted during the most recent visit was more often achieved in men (59% vs. 46%, p=0.002). Remarkably, during follow up, more men experienced decline in LV dysfunction (29% vs. 18%, p=0.081), women were more likely to have no change in LVEF (51% vs 34%, p=0.081), and men were only slightly more likely to show improvement (37% vs. 31%, p=0.081).

There was no gender difference in utilization of angiotensin converting enzyme inhibitors (ACE), beta blockers (BB), or aldosterone receptor antagonists (ARA). Women were more likely to be treated with angiotensin receptor blockers (ARBs, p=0.054) and men were more likely to be on diuretics (57% vs. 43%, p=0.069).

Conclusions:
In patients with HTN enrolled in the HF clinic, male gender was associated with increased cardiovascular comorbidities and lower LVEF at baseline. Despite improved blood pressure control and similar utilization of evidence-based therapy, men experienced more decline in LVEF, had LV systolic function that was less likely to remain unchanged, and were only slightly more likely to demonstrate improvement of LVEF compared to women. This study suggests a potential gender-related pharmacodynamic difference in response to guideline therapy, or perhaps the manifestation of an already described gender difference of adaptation to chronic elevated after load.
Abstract 163: High Burden of Valvulopathy in Heart Failure: A Moving Target
Authors: Agunanne Enoch , Abbas Aamer , Mukherjee Debabrata
Published: July 2021

Background:
The lifetime risk of developing Heart Failure (HF) is 20% for Americans ≥40 years of age. In the United States, greater than 650,000 new HF cases are diagnosed annually. About 5.1 million persons in the United States have clinically manifest HF. Additionally, HF has high absolute mortality rates of approximately 50% within 5 years of diagnosis. HF carries substantial health and economic burden. It is the primary diagnosis in >1 million hospitalizations annually. Patients hospitalized for HF are at high risk for all-cause re hospitalization. The total cost of HF care in the United States exceeds $30 billion annually.

Objective:
The study objective was to investigate the prevalence of valvular heart disease among patients hospitalized for HF in a largely Hispanic population.

Methods:
This is a retrospective study with aims inclusive of: analyzing the hospitalization and 4 months, 6 months, 2 year- re-hospitalization rates of HF in University Medical Center between Oct 2010 and Oct 2013; evaluating the association between valvular heart disease and hospitalizations for HF. Inclusion criteria were: admission/re hospitalizations with HF (with reduced, preserved and borderline EF). Echocardiographic determination of at least moderate valvular disease was utilized in this study as significant. Exclusion criteria were: patients lost to follow-up, death in hospital, transfer to another acute care facility, and discharge against medical advice. Demographics were also collected.

Results:
Hospitalizations involving 195 patients (120 men and 75 women) were randomly analyzed. The racial spread showed 77.4% (151 of 195) Hispanics and 22.6% (44 of 195) non-Hispanics. Out of the 195 index hospitalizations, the 4 month, 6 months and 2 years rehospitalization visits were 17.4% (34 of 195), 22.5% (44 of 195) and 38.5% (75 of 195) respectively. The prevalence of significant valvular heart disease was 45.9% (90 of 195), while the prevalence of no valvular heart disease was 54.1% (105 of 195) (p < 0.05).

Conclusion:
Multiple, prior studies have shown that valvular heart diseases have a comparatively low association with clinical Heart Failure. This study raises a valid point that in some population groups (the Hispanic), the burden of valvular heart disease may be greater than has been published in other groups. This calls for more studies, and has lots of potential implications in Heart Failure management.
Abstract 202: Predictors of Percutaneous Endoscopic Gastrostomy in Intracerebral Hemorrhage
Authors: Blatsioris Ashley D , Moser Elizabeth A , Stevenson Alec , Carter Ravan J , Ofner Susan , Hulin Abigail L , O’Neill Darren P , Cohen-Gadol Aaron A , Leipzig Thomas J , Williams Linda S , Mackey Jason
Published: July 2021

Introduction:
Intracerebral hemorrhage (ICH) patients often require percutaneous endoscopic gastrostomy (PEG) placement. Previous studies identifying predictors of PEG placement in ICH have been small and have not accounted for specific clinical findings on validated stroke severity scores. We sought to determine early predictors of PEG placement in a large cohort of ICH patients.

Methods:
We retrospectively identified all primary ICH cases by ICD-9 code at our two academic centers from 2009-2011. All cases were physician-reviewed. Patients who were made comfort care only, transferred to hospice, or died within 72 hours of presentation were excluded. Demographic data, stroke characteristics including clinical severity scores, processes of care, and outcomes were ascertained. We also constructed an abbreviated four-item NIHSS composite score, which included level of consciousness (item 1a), facial palsy (4), best language (9), and dysarthria (10). Variables with p-values <0.25 in the univariate were considered for regression analysis. Linearity of the logit was assessed for continuous variables.

Results:
Of the 610 subjects with primary ICH, 519 met inclusion criteria and 89 (17.1%) underwent PEG placement. Median time from presentation to PEG placement was 11.8 days. Univariate predictors of PEG placement are shown in the Table. In the best multivariate logistic regression model we found younger age (OR 0.99 (0.97, 1.00), p=0.04), higher four-item NIHSS composite score (OR 1.15 (1.05, 1.26), p=0.003), lower initial GCS (OR 0.91 (0.85, 0.97), p=0.003), and greater ICH volume (OR 2.97 (1.11, 7.97) for highest quintile vs. lowest, p=0.02) were independently associated with PEG placement. This model achieved an area under the curve of 0.78 with a good fit.

Conclusions:
We identified several independent early predictors of PEG placement in ICH. Early identification of ICH patients who will require PEG placement could result in reduced resource utilization, quicker initiation of rehabilitation, shorter hospital length of stay, and reduction of preventable complications. Prospective studies are required to determine optimal patient selection and timing for PEG placement.
Abstract 220: Missed Opportunity for Medical Emergency Team Activation in Pediatric In-Hospital Cardiac Arrest
Authors: Jayaram Natalie , Chan Maya L , Tang Fengming , Chan Paul S
Published: July 2021

Background:
Prior studies of Medical Emergency Teams (METs) in pediatric hospitals have shown inconsistent results in terms of their ability to improve outcomes. Whether the variable success is due to differential utilization of METs among hospitals is unknown.

Methods:
Within the Get With The Guidelines-Resuscitation Registry (GWTG-R), we identified children (age <18 years) with an in-hospital cardiac arrest (IHCA) on the general inpatient or telemetry floors from 2007 to 2014. In cases of IHCA where MET evaluation did not occur, we examined the frequency of “missed” opportunities for activation of the MET based upon the presence of one or more abnormal vital signs. We also examined the variability in utilization of the MET among those hospitals with at least ten cases of IHCA.

Results:
Of 215 children from 23 hospitals sustaining an IHCA, 48 (22.3%) had a preceding MET evaluation. Children with MET evaluation prior to IHCA were older (6.8 ± 6.5 vs. 3.1 ± 4.7, p < 0.001) and were more likely to have metabolic/electrolyte abnormalities (9/48 [18.8%] vs. 9/167 [5.4%], p=0.006), sepsis (8/48 [16.7%] vs. 8/167 [4.8%], p=0.01), or malignancy (11/48 [22.9%] vs. 9/167 [5.4%], p<0.001) at the time of their IHCA. Hospital utilization of the MET varied substantially (median 20%; inter-quartile range [IQR]: 3.4%-29.8%; range: 0%-36.4%). Among patients who did not have a MET called prior to their IHCA, 78/141 (55.3%) had at least one abnormal vital sign that should have triggered a MET.

Conclusion:
In a large, national registry, we found that the majority of pediatric IHCA cases are not preceded by a MET evaluation despite meeting criteria that should have triggered a MET. Improved utilization of the MET by all hospitals could lead to fewer pediatric IHCA and improved outcomes following pediatric IHCA.
Abstract 253: The Association of Socioeconomic Status With Elevation of N-terminal Pro-b-type Natriuretic Peptide
Authors: Vart Priya , Matsushita Kunihiro , Selvin Elizabeth , Crews Deidra C , Ndumele Chiadi E , Ballantyne Christie M , Heiss Gerardo , Szklo Moyses , Coresh Josef
Published: July 2021

Background:
The association between socioeconomic status (SES) and clinical cardiovascular disease (CVD) is well established. However, the association between SES and subclinical cardiac overload is unclear. We examined the association of SES with N-terminal pro-B-type natriuretic peptide (NT-pro-BNP), a marker of cardiac overload, in a population without prevalent clinical CVD (coronary disease, stroke, and heart failure hospitalization).

Methods:
In a cross-sectional study of 11,026 ARIC Study participants without prevalent clinical CVD at visit 2 (1990-1992), we assessed whether education level (high school (high)) and household income (<$12,000 (low), $12,000 - $24,999 (medium) and ≥ $25,000 (high): $1 in 1991 = ~$1.75 in 2015) were associated with elevated NT-pro-BNP (≥400 pg/ml) in logistic regression models. Given that disproportionately high number of blacks belong to low SES and levels of NT-proBNP might vary by race, we tested SES-race interaction and stratified analyses by race.

Results:
After accounting for potential confounders, those with low education and income levels demonstrated higher odds of having elevated NT-proBNP compared to those with high education and income, although statistical significance was observed only for income. In race-stratified analysis, association of low education and income with NT-pro-BNP did not appear to differ between blacks and whites (p-interaction with income=0.99 or with education=0.52). When using NT-pro-BNP as a continuous dependent variable, both, low income and education showed a significant association with higher NT-proBNP levels compared to those with high income and education, respectively.

Conclusions:
Low SES (particularly low income) was associated with elevated level of NT-pro-BNP. Targeting low SES individuals might be helpful in early identification of high risk population for cardiac overload.
Abstract 259: The Effects of Depression on BRIDGE Patients
Authors: Carolan Jacob , Sylvester Rachel , Costin Nathaniel , McMahon Colin , Bradford Morgan , Montgomery Daniel , Kline-Rogers Eva , Eagle Kim A , Bumpus Sherry
Published: July 2021

Background:
Depression creates additional barriers to receiving transitional care. Bridging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner-delivered cardiac transitional care program. We sought to determine if, 1) there was a difference in readmission rates of BRIDGE patients with depression (PWD) and those without depression (PWOD), and 2) if BRIDGE attendance lowered 30-day readmission rates in PWD.

Methods:
Retrospective data was abstracted for all patients referred to BRIDGE (June ’08 - Dec ’14). Readmission rates of PWD and PWOD were compared in both BRIDGE attenders and non-attenders.

Results:
Of 2446 patients, 577 (23.6%) had a history of depression. PWD were significantly younger (62.82 ± 14.04 v 66.17 ± 14.88, p<0.001), more likely to be female (55.6% v 39.1%, p<0.001), and less likely to attend their BRIDGE appointment (67.1% v 72.1%, p=0.010) than PWOD. Among BRIDGE attendees, PWD had significantly higher 60, 90, and 180 day readmission rates than PWOD (Table 1). Although 30 day readmissions were lower in PWD who attended BRIDGE, compared to PWD who did not attend BRIDGE, these results were not significant (10.5% v 12.6%, p=0.505), and this trend was not seen in 60, 90, and 180 day readmission rates.

Conclusions:
PWD are less likely to attend BRIDGE appointments and more likely to be readmitted. These results suggest that special attention needs to be given to PWD upon hospital discharge to ensure that proper transitional care is received and readmissions are avoided.
Implantation in Coronary Circulation Induces Morphofunctional Transformation of Radial Grafts From Muscular to Elastomuscular
Authors: Gaudino Mario , Prati Francesco , Caradonna Eugenio , Trani Carlo , Burzotta Francesco , Schiavoni Giovanni , Glieca Franco , Possati Gianfederico
Published: July 2021

Background—

The purpose of this research was to investigate the in vivo morphofunctional changes induced in the radial artery (RA) by its use as coronary artery bypass conduit by comparing the morphological features and vasoreactivity of the native RA versus the coronary RA graft in the same patient.

Methods and Results—

Ten years after surgery, 10 patients were submitted to intravascular ultrasound examination of the RA graft of the controlateral (in situ) RA and of the internal thoracic artery (ITA) graft and to vasoactive challenges with acetylcholine and serotonin. Quantitative angiographic assessment showed that the mean diameter of the RA coronary grafts was significantly larger than that of the in situ RA and of the ITA (2.89±0.40 mm RA grafts, 2.14±0.52 mm in situ RA, 2.25±0.53 mm ITA grafts;
P
<0.001). The in situ RA demonstrated a typical muscular architecture, whereas RA coronary grafts showed a clear reduction of the thickness of the medial layer and had a less well-defined muscular component of the media with interposition of elastic tissue. Serotonin endovascular infusion elicited a strong spastic reaction in in situ RAs; the same challenge induced only moderate constriction in RA and ITA coronary grafts.

Conclusions—

Implantation in the coronary circulation leads to major anatomic and vasoreactive modifications of the RAs that tend to lose the morphofunctional features of a muscular conduit and assume those of an elastomuscular artery, such as the ITA.
Arterial Versus Venous Bypass Grafts in Patients With In-Stent Restenosis
Authors: Gaudino Mario , Cellini Carlo , Pragliola Claudio , Trani Carlo , Burzotta Francesco , Schiavoni Giovanni , Nasso Giuseppe , Possati Gianfederico
Published: July 2021

Background—

In patients who develop in-stent restenosis, successful revascularization can be difficult to achieve using percutaneous methods. This study was designed to verify the surgical results in this setting and to evaluate the potential beneficial role of arterial bypass conduits.

Methods and Results—

Sixty consecutive coronary artery bypass patients with previous in-stent restenosis and 60 control cases were randomly assigned to receive an arterial conduit (either right internal thoracic or radial artery; study group) or a great saphenous vein graft (control group) on the first obtuse marginal artery to complete the surgical revascularization procedure. At a mean follow-up of 52±11 months, patients were reassessed clinically and by angiography. Freedom from clinical and instrumental evidence of ischemia recurrence was found in 19 of 60 subjects in the study group versus 45 of 60 in the control series (
P
=0.01). The results of the arterial grafts were excellent in both the study and control groups (right internal thoracic artery patency rate, 19 of 20 for both, and radial artery patency rate, 20 of 20 versus 19 of 20;
P
=0.99). Saphenous vein grafts showed lower patency rate than arterial grafts in both series and had extremely high failure rate in the study group (patency rate, 10 of 20 in the study group versus 18 of 20 in the control group;
P
=0.001). Use of venous graft was an independent predictor of failure in the study group, whereas hypercholesterolemia was associated with graft failure in both series.

Conclusions—

Venous grafts have an high incidence of failure among cases who previously developed in-stent restenosis, whereas the use of arterial conduits can improve the angiographic and clinical results. Arterial grafts should probably be the first surgical choice in this patient population.
Relation Between Mild Renal Dysfunction and Outcomes After Coronary Artery Bypass Grafting
Authors: Zakeri Rosita , Freemantle Nick , Barnett Vivian , Lipkin Graham W. , Bonser Robert S. , Graham Timothy R. , Rooney Stephen J. , Wilson Ian C. , Cramb Robert , Keogh Bruce E. , Pagano Domenico
Published: July 2021

Background—

Risk stratification algorithms for coronary artery bypass grafting (CABG) do not include a weighting for preoperative mild renal impairment defined as a serum creatinine 130 to 199 μmol/L (1.47 to 2.25 mg/dL), which may impact mortality and morbidity after CABG.

Methods and Results—

We reviewed prospectively collected data between 1997 and 2004 on 4403 consecutive patients undergoing first-time isolated CABG with a preoperative serum creatinine <200 μmol/L (2.26 mg/dL)] in a single institution. The in-hospital mortality was 2.5% (112 of 4403), the need for new dialysis/hemofiltration was 1.3% (57 of 4403), and the stroke rate was 2.5% (108 of 4403). There were 458 patients with a serum creatinine 130 to 199 μmol/L or 1.47 to 2.25 mg/dL (mild renal dysfunction group) and 3945 patients with a serum creatinine <130 μmol/L (<1.47 mg/dL). Operative mortality was higher in the mild renal dysfunction group (2.1% versus 6.1%;
P
<0.001) and increased with increasing preoperative serum creatinine level. New dialysis/hemofiltration (0.8%versus 5.2%;
P
<0.001) and postoperative stroke (2.2% versus 5.0%;
P
<0.01) were also more common in the patients with mild renal impairment. Multivariate analysis adjusting for known risk factors confirmed preoperative mild renal impairment (creatinine 130 to 199 μmol/L or 1.47 to 2.25 mg/dL; odd ratio, 1.91; 95% CI, 1.18 to 3.03;
P
=0.007) or glomerular filtration rate estimates <60 mL/min per 1.73 m
2
, derived using the Cockroft-Gault formula, (odds ratio, 1.98; 95% CI, 1.16 to 3.48;
P
=0.015) as independent predictors of in-hospital mortality. Preoperative mild renal dysfunction adversely affected the 3-year survival probability after CABG (93% versus 81%;
P
<0.001).

Conclusions—

Mild renal dysfunction is an important predictor of outcome in terms of in-hospital mortality, morbidity, and midterm survival in patients undergoing CABG.
Myocyte Volume and Function in Response to Osmotic Stress
Authors: Mizutani Shinichi , Prasad Sandip M. , Sellitto Angela D. , Schuessler Richard B. , Damiano Ralph J. , Lawton Jennifer S.
Published: July 2021

Background—

Hypothermic hyperkalemic cardioplegia results in significant myocyte swelling and impaired contractility. These detrimental effects may be eliminated by the addition of an adenosine triphosphate-sensitive potassium (K
ATP
) channel opener. This study evaluated the hypothesis that a K
ATP
channel opener (diazoxide) would benefit volume homeostasis by limiting volume and subsequent contractility changes during osmotic stress.

Methods and Results—

Isolated rabbit ventricular myocyte volume and contractility were evaluated using video microscopy and field stimulation after exposure to osmotic stress at 37°C. Myocytes were exposed to Tyrode’s physiological solution for 20 minutes and test solution for 20 minutes, and then reexposed to Tyrode’s for 20 minutes. Test solutions included control Tyrode’s (1T) and osmotically altered Tyrode’s (2.6T, 0.9T, and 0.6T) solutions with or without the K
ATP
channel opener diazoxide. Severe osmotic stress (2.6T and 0.6T) resulted in significant cell shrinkage and swelling, respectively. This was unchanged by the addition of diazoxide. Mild hyposmotic stress (0.9T) resulted in significant cell swelling that was eliminated by the addition of diazoxide. Cell swelling was associated with reduced contractility.

Conclusions—

Cell swelling, but not shrinkage, was detrimental to myocyte contractility. Diazoxide eliminated volume change due to mild hyposmotic stress, similar to that previously noted with hyperkalemic cardioplegia, but did not alter volume change secondary to severe osmotic stress.
Myocardial Recovery Using Ventricular Assist Devices
Authors: Simon Marc A. , Kormos Robert L. , Murali Srinivas , Nair Pradeep , Heffernan Michael , Gorcsan John , Winowich Stephen , McNamara Dennis M.
Published: July 2021

Background—

Ventricular assist devices (VADs) are important bridges to cardiac transplantation. VAD support may also function as a bridge to ventricular recovery (BTR); however, clinical predictors of recovery and long-term outcomes remain uncertain. We examined the prevalence, characteristics, and outcomes of BTR subjects in a large single center series.

Methods and Results—

We implanted VADs in 154 adults at the University of Pittsburgh from 1996 through 2003. Of these implants, 10 were BTR. This included 2/80 (2.5%) ischemic patients (supported 42 and 61 days, respectively). Both subjects had surgical revascularization, required perioperative left VAD support, and were alive and transplant-free at follow up (232 and 1319 days, respectively). A larger percentage of nonischemic patients underwent BTR (8/74, 11%; age 30±14; 88% female; left ventricular ejection fraction 18±6%; supported 112±76 days). Three had myocarditis, 4 had post-partum cardiomyopathy (PPCM), and 1 had idiopathic cardiomyopathy. Five received biventricular support. After explantation, ventricular function declined in 2 PPCM patients who then required transplantation. Ventricular recovery in the 6 nonischemic patients surviving transplant-free was maintained (left ventricular ejection fraction 54±5%; follow-up 1.5±0.9 years). Overall, 8 of 10 BTR patients are alive and free of transplant (follow-up 1.6±1.1 years).

Conclusions—

In a large single center series, BTR was evident in 11% of nonischemic patients, and the need for biventricular support did not preclude recovery. For most BTR subjects presenting with acute inflammatory cardiomyopathy, ventricular recovery was maintained long-term. VAD support as BTR should be considered in the care of acute myocarditis and PPCM.
Tissue-Engineered Myocardial Patch Derived From Extracellular Matrix Provides Regional Mechanical Function
Authors: Kochupura Paul V. , Azeloglu Evren U. , Kelly Damon J. , Doronin Sergey V. , Badylak Stephen F. , Krukenkamp Irvin B. , Cohen Ira S. , Gaudette Glenn R.
Published: July 2021

Background—

Extracellular matrix (ECM), a tissue-engineered scaffold, recently demonstrated cardiomyocyte population after myocardial implantation. Surgical restoration of myocardium frequently uses Dacron as a myocardial patch. We hypothesized that an ECM-derived myocardial patch would provide a mechanical benefit not seen with Dacron.

Methods and Results—

Using a canine model, a full thickness defect in the right ventricle was repaired with either Dacron or ECM. A third group had no surgery and determined baseline RV function. Eight weeks later, global systolic function was assessed by the preload recruitable stroke work relationship. Regional systolic function was measured by systolic area contraction (SAC), calculated by high density mechanical mapping. Tau was used to assess global diastolic function. Recoil rate and diastolic shear were used as measures of regional diastolic function. After functional data acquisition, tissue was fixed for histological evaluation. Global systolic and diastolic functions were similar at baseline and after ECM and Dacron implantation. Regional systolic function was greater in the ECM group compared with the Dacron group (SAC: 4.1±0.9% versus −1.8±1.1,
P
<0.05). Regional diastolic function was also greater in the ECM group (recoil rate (° sec
−1
): −44±7 versus −17±2, ECM versus Dacron;
P
<0.05). Immunohistochemical analysis revealed cardiomyocytes in the ECM implant region, a finding not seen with Dacron.

Conclusion—

At 8 weeks, an ECM-derived tissue-engineered myocardial patch provides regional mechanical function, likely related to cardiomyocyte population. These results are in sharp contrast to Dacron, a commonly used myocardial patch.
Mitral Annulus Flattens in Ischemic Mitral Regurgitation: Geometric Differences Between Inferior and Anterior Myocardial Infarction
Authors: Watanabe Nozomi , Ogasawara Yasuo , Yamaura Yasuko , Wada Nozomi , Kawamoto Takahiro , Toyota Eiji , Akasaka Takashi , Yoshida Kiyoshi
Published: July 2021

Background—

New surgical strategies to restore the saddle shape of the mitral annulus are expected to increase annuloplasty effectiveness. Preoperative and postoperative configuration of the curved annulus, however, is difficult to quantify with 2-dimensional echocardiography. We sought to investigate the geometric deformity in the mitral annulus in ischemic mitral regurgitation (MR), comparing inferior and anterior myocardial infarction (MI) with the use of a custom quantitation software system with transthoracic 3-dimensional echocardiography.

Methods and Results—

We performed real-time 3-dimensional echocardiography in 23 patients with ischemic MR attributable to inferior MI or anterior MI and in 10 controls. Three-dimensional data were cropped into 18 radial planes, and we manually marked the annulus in mid systole. Three-dimensional annular images were reconstructed, and annular circumferences, areas, and heights were quantified. Annulus was significantly more dilated and flattened in ischemic MR than in controls and was further deformed in anterior MI as compared with inferior MI (control: circumference 9.9±0.7 cm, area 9.6±0.5 cm
2
, height 5.0±0.7 mm; inferior MI: circumference 11.5±1.2 cm [
P
<0.01 compared with control], area 11.4±2.0 cm
2
[
P
<0.05 compared with control], height 3.5±1.6 mm [
P
<0.05 compared with control]; anterior MI: circumference 14.2±2.4 cm [
P
<0.0001 compared with control,
P
<0.05 compared with inferior MI], area 13.7±2.8 cm
2
]
P
<0.01 compared with control,
P
<0.05 compared with inferior MI], height 1.7±1.5 mm [
P
<0.0001 compared with control,
P
<0.05 compared with inferior MI]).

Conclusions—

Mitral annulus flattens in ischemic MR. Deformity of the mitral annulus was greater in anterior MI group than in the inferior MI group.
How to Guide Stent-Graft Implantation in Type B Aortic Dissection?
Authors: Koschyk Dietmar H. , Nienaber Christoph A. , Knap Malgorzata , Hofmann Thomas , Kodolitsch Yskert V. , Skriabina Valeria , Ismail Mohammed , Franzen Olaf , C. Rehders Tim , Dieckmann Christoph , Lund Gunnar , Reichenspurner Hermann , Meinertz Thomas
Published: July 2021

Background—

Despite growing interest in stent-graft implantation for type-B aortic dissection, there are no established recommendations to prepare and perform an implantation procedure.

Methods and Results—

We directly compared angiography (ANGIO), transesophageal echocardiography (TEE), and intravascular ultrasound (IVUS) intraprocedually before and after placement of 48 stent grafts in 42 consecutive patients (12 women, 61±11 years of age) with acute and chronic type-B aortic dissection for both usefulness and capability to guide aortic stent-graft implantation. Both IVUS and TEE are superior to ANGIO to identify multiple entries (52 and 43 versus 34;
P
<0.005 each), to diagnose false-lumen slow flow after stent-graft implantation (32 and 31 versus 24;
P
<0.005 each) and to detect incomplete stent apposition (18 and 16 versus 8;
P
<0.005 each). In comparison with ANGIO, guide wire position over the entire length of the aorta was documented more frequently by TEE and IVUS (40 and 42 versus 25;
P
<0.001 each). In 4 patients with abdominal extension of the dissection, only IVUS was able to accurately identify the false lumen over the entire length of the diseased aorta. TEE was superior to IVUS and ANGIO in the detection of endoleaks (5 versus 0 and 1;
P
<0.05 each). Intraprocedural ANGIO, TEE, and IVUS had been performed without complications in all patients.

Conclusions—

TEE in conjunction with ANGIO appears to be advantageous and adds incremental information to safely guide stent-graft placement in type-B aortic dissection. Additional use of IVUS was found to be helpful in patients with complex anatomy and abdominal extension of the dissection.
Aortic Valve Replacement and Concomitant Mitral Valve Regurgitation in the Elderly
Authors: Barreiro Christopher J. , Patel Nishant D. , Fitton Torin P. , Williams Jason A. , Bonde Pramod N. , Chan Vincent , Alejo Diane E. , Gott Vincent L. , Baumgartner William A.
Published: July 2021

Background—

The impact of mitral regurgitation (MR) on elderly patients (≥70 years) undergoing isolated aortic valve replacement (AVR) is not clearly defined. This study investigates the long-term effects of preoperative, moderate MR on survival and functional outcome in elderly AVR patients.

Methods and Results—

A retrospective review identified 408 consecutive elderly patients who underwent isolated AVR from January 1983 to February 2004. The pathologic etiology of MR was determined on preoperative echocardiogram, and patients were stratified into no/mild MR (Group I; n =338) versus moderate MR (Group II; n =70). Follow-up was 95.1% complete. Functional outcome was evaluated using the Short Form-12 questionnaire. On univariate analysis, Groups I and II differed in incidence of previous myocardial infarction (13.9% versus 28.6%;
P
=0.004), hyperlipidemia (18.7% versus 33.3%;
P
=0.009), and congestive heart failure (50.0% versus 70.0%;
P
=0.002). On multivariate analysis, moderate MR was an independent risk factor impacting long-term survival (
P
=0.04). Actuarial survival at 1, 5, and 10 years for Group I was 93.8%, 73.3%, and 40.1% versus 92.3%, 58.2%, and 14.6% for Group II (
P
=0.04). Available postoperative echocardiograms for Group II (n =37) demonstrated improvement in MR in 81.8% of functional MR patients. However, MR persisted or worsened in 65.4% of patients with intrinsic mitral valve disease (myxomatous, calcific, or ischemic MR). Functional outcomes showed 77% of Group I versus 78.6% of Group II rated their health as good to excellent post-AVR.

Conclusions—

Moderate MR is an independent risk factor impacting long-term survival in elderly patients undergoing AVR. Therefore, patients with intrinsic mitral valve disease should be considered for concomitant MV surgery.