bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 55: Reducing Utilization of Cardiac Stress Testing in the Outpatient Primary Care Setting: a Clinical Prediction Rule
Authors: Widlansky Michael , Mayhorn Rodney , Hariman Sara , Gaglianello Nunzio , Call Shawn , Murguriah Karthik , Abide William P , Milosavljevic Staci , Ali Murtuza J
Published: March 2022

Background:
Utilization of stress testing with imaging has significantly increased over the past decade. A simple clinical decision rule to guide stress test ordering for diagnosis of diagnose ischemia in the primary care setting could significantly reduce unnecessary utilization and health care costs.

Methods:
We retrospectively identified 495 outpatients without coronary artery disease (CAD) referred from primary care clinics who underwent stress echocardiography at a single US institution from 2007-2009. Predictors of echocardiographic ischemia were determined by logistical regression. From the predictor variables, a simple clinical decision rule was derived. The rule stratified individuals into 2 groups: subjects who should proceed to stress testing (ST) and subjects who do not require a stress test (NST). A receiver-operator characteristic curve was constructed to determine the rule’s accuracy. Event-free (interim stroke, myocardial infarction, or death) survival between the ST and NST arms was compared by log rank test. The rule was validated in a set of 299 charts from a different US institution.

Results:
In the derivation cohort, 23 tests (4.6%) demonstrated echocardiographic evidence of ischemia. Univariate predictors included male sex (odds ratio (OR) 2.3), family history of early CAD (OR 2.1), any chest pain (OR 9.1), fatigue or shortness of breath (OR 2.04), and age > 50 years (OR 4.4). All variables were retained for the clinical decision rule. The rule selected 183 (37%) of subjects for NST while maintaining 100% sensitivity for ischemia (c-statistic 0.71, P<0.001). 24 adverse clinical events occurred during follow-up (median: 2.6 years). There were no significant differences in adverse outcomes between ST and NST groups (P=0.35). In the validation cohort, 60% of subjects were select for NST with no differences in event-free survival between groups (P=0.30).

Conclusion:
Our simple decision rule could significantly reduce the number of stress tests ordered by primary care physicians without compromising event-free survival. Further refinement and validation of this score in both retrospective and prospective studies is warranted.
Abstract 64: Short Term Health Status Outcomes And Preferences In Patients Undergoing Elective Transradial Coronary Intervention
Authors: Baklanov Dmitri , Tang Fengming , Safley David , Fuss Christine , Jones Philip , Spertus John
Published: March 2022

Background.
Transradial PCI (TRI) is associated with reduced rate of complications, as compared with traditional femoral access PCI (FPCI). Despite the safety advantages of TRI, virtually no data exist to compare patients’ perspectives and health status between TRI and FPCI.

Objective.
To compare the short-term health status outcomes of patients undergoing elective TRI and FPCI.

Methods.
We prospectively followed 424 patients between 10/11- 9/12 who underwent elective PCI at our institution. Vascular access was selected by the operators. Within 72 hours after PCI, all patients were contacted by phone and completed health status questionnaires administered by a nurse blinded to the vascular access site. The questionnaires utilized a 5 point Likert scale with health status, satisfaction and preferences domains. Data were linked to NCDR to obtain patient and procedural characteristics of the PCI. Continuous variables were compared using Student’s T-test and categorical variables were compared using chi-square or Fisher’s exact test. Propensity scores were used to adjust for the differences between the groups when comparing outcomes.

Results.
Out of 424 patients, 316 underwent FPCI and 108 had TRI. Baseline differences between the groups included prior CABG (FPCI 29.1% vs. TRI 8.3%, p<0.001), prior CHF (FPCI 15.8% vs TRI 4.6%, p=0.003), and left ventricular ejection fraction (FPCI 55.3 ± 13.4% vs. TRI 59.1 ± 10.6%, p=0.02). Intraprocedural bivalirudin use was more common in the FPCI group (35.1% vs. 12%, p<0.001). There were no peri-procedural deaths, strokes or myocardial infarction. There was no NCDR-defined bleeding in the TRI group as compared with a 1.3% rate in the FPCI group (p=NS). Same day discharge was more common for TRI patients (16.7% vs. 0.6%, p< 0.001). When asked which approach the patients would prefer if having another PCI, femoral access was favored by 44.8% of FPCI patients and radial access by 87.0% of those undergoing TRI (p< 0.001). After propensity adjustment for baseline characteristics, there was no significant difference in overall pain (“pain level 2/10 or less”, RR 1.07 (95% CI 0.80, 1.44)), satisfaction with angina control (“completely satisfied” RR 1.04 (95% CI 0.79, 1.39)), ability to immediately return to work (“satisfied” RR 1.11 (95% CI 0.75, 1.65)).

Conclusion.
When compared with patients undergoing elective PCI via femoral access, TRI patients had stronger preferences for the same vascular access and were more frequently discharged on the day of the procedure. After adjustment for baseline clinical characteristics, there was no significant difference in short-term health status outcomes between the groups. Further collection of observational and clinical trial data regarding the patients’ perspectives of TRI is needed.
Abstract 83: Association of Preoperative Anemia with Heart Failure Hospitalization and Mortality among Veterans Undergoing Cardioverter-Defibrillator
Authors: Schneider Preston M , Katz David F , Pelligrini Cara N , Heidenreich Paul A , Aleong Ryan G , Keung Edmund C , Massie Barry M , Varosy Paul D
Published: March 2022

Introduction:
Anemia is associated with worse outcomes in many medical conditions, including congestive heart failure. Whether anemia is associated with heart failure hospitalization or mortality among patients undergoing implantable cardioverter-defibrillator (ICD) implantation is unclear.

Methods:
Among veterans enrolled in the Outcomes among Veterans with Implantable Defibrillators (OVID) registry between 2003 and 2009, 3,918 were identified as within 3 months of initial ICD implantation and having hemoglobin measured at the time of implantation. Baseline clinical characteristics and clinical outcomes were abstracted from the electronic medical record and social security death index. Association of anemia with heart failure hospitalization and mortality was examined using Cox proportional hazards regression.

Results:
The mean blood hemoglobin level was 13.7 grams per deciliter (g/dl), and 674 patients (17.5%) had anemia as defined by a blood hemoglobin level less than 12 g/dl. The rate of hospitalization for heart failure was 18.8 per 100 person-years, and mortality was 13.1 per 100 person-years for subjects with anemia at the time of implantation, compared with 9.2 per 100 person-years and 5.8 per 100 person-years, respectively, for those subjects with hemoglobin levels greater than 12 g/dl. After adjusting for potential confounding factors (including the baseline severity of heart failure, coronary disease, left ventricular ejection fraction, cardiac resynchronization therapy, chronic kidney disease, age, race, and other comorbidities), a hemoglobin of less than 12 g/dl at the time of implantation was associated with increased risk of both heart failure hospitalization (adjusted HR, 1.5; 95% CI, 1.3 - 1.8; P < 0.001) and mortality (adjusted HR, 1.7; 95% CI, 1.4 - 2.1; P < 0.001).

Conclusions:
Preoperative anemia is associated with an increased risk of both subsequent heart failure hospitalization and mortality among veterans undergoing ICD implantation even after controlling for comorbidities.
Abstract 90: Ten-year Trends in Mechanical Revascularization, Intra-Aortic Balloon Pump Use and In-Hospital Mortality in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock
Authors: Kolte Dhaval , Khera Sahil , Aronow Wilbert S , Palaniswamy Chandrasekar , Mujib Marjan , Sule Sachin , Peterson Stephen J , Frishman William H
Published: March 2022

Background:
Early mechanical revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock is associated with improved survival. The current guidelines also recommend (Class IIa) the use of intra-aortic balloon pump (IABP) in patients with cardiogenic shock. However, the evidence supporting this recommendation is controversial.

Objectives:
To examine the trends (2001-2010) in mechanical revascularization, IABP use and in-hospital mortality in patients with cardiogenic shock complicating AMI and to determine if IABP use is associated with improved in-hospital survival among these patients.

Methods:
We conducted a retrospective trend analysis of the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) database from 2001-2010. All patients ≥ 40 years of age with AMI and cardiogenic shock were identified using ICD-9-CM diagnosis codes. Trends in mechanical revascularization (PCI or CABG), IABP use and in-hospital mortality were analyzed. We used logistic regression analysis to determine the association between IABP use and in-hospital mortality.

Results:
From 2001-2010, among 6,670,347 patients aged ≥ 40 years admitted with AMI, 287,256 (4.3%) had cardiogenic shock. The proportion of patients with cardiogenic shock complicating AMI increased from 3.7% in 2001 to 5.1% in 2010 (P
trend
< 0.001). There was a significant increase in mechanical revascularization rates (49.7% in 2001 to 66.3% in 2010, P
trend
< 0.001) as well as IABP use (38.7% in 2001 to 47.8% in 2010, P
trend
< 0.001) in these patients over the 10-year period. The overall in-hospital mortality among patients with AMI and cardiogenic shock decreased from 48.6% in 2001 to 32.7% in 2010 (P
trend
< 0.001). When adjusted for demographics, cardiovascular risk factors and mechanical revascularization status, IABP use was associated with higher in-hospital mortality (adjusted OR 1.14, 95% CI 1.11-1.16, P<0.001). Similarly, in the subgroup of patients who underwent mechanical revascularization, in-hospital mortality was higher among those with IABP placement (adjusted OR 1.39, 95% CI 1.35-1.43, P <0.001).

Conclusion:
Mechanical revascularization rates in patients with cardiogenic shock complicating AMI have increased during the past decade. This is also associated with a decrease in in-hospital mortality during this period. IABP use has also increased over the past 10 years; however, IABP use is associated with higher in-hospital mortality among patients with AMI and cardiogenic shock.
Abstract 91: Temporal Trends in Patient Characteristics and Outcomes Among Medicare Beneficiaries Undergoing Primary Prevention Implantable Cardioverter-Defibrillator Placement in the United States: 2006-2010 Results from the NCDR
®
Authors: Borne Ryan T , Peterson Pamela N , Greenlee Robert , Heidenreich Paul A , Wang Yongfei , Curtis Jeptha , Tzou Wendy , Varosy Paul D , Masoudi Frederick A
Published: March 2022

Background:
Trends in the use and outcomes of ICDs in community practice settings are not well characterized. Our objective was to determine the temporal trends in characteristics and outcomes among patients undergoing primary prevention ICD therapy.

Methods:
We identified Medicare beneficiaries aged 65 years and older with an ejection fraction <35% undergoing ICD implantation for primary prevention between 2006 and 2010 in the NCDR ICD Registry™. Using a probabilistic method, eligible subjects were matched to Medicare claims data to capture outcomes using age, gender, admission date or procedure date, and hospital Medicare provider number. We tested the significance of trends in characteristics over time with χ2 tests for categorical variables and ANOVA for continuous variables. Standardized outcome rates were calculated adjusting for demographics and characteristics.

Results:
A total of 117,100 patients were included in the analysis. Between 2006 and 2010, small but significant increases were observed in the prevalence of hypertension, diabetes, and NYHA Class III symptoms, and decreases in the prevalence of ischemic heart disease and NYHA Class IV symptoms (Table 1). There was minimal change in age, gender, and race of patients receiving ICDs over the study period; fewer single lead and more biventricular devices were used over time. Risk-standardized six-month re-hospitalization and complication rates decreased and risk-standardized six-month all-cause mortality was stable over the study period (Table 1).

Conclusions:
Modest changes in patient characteristics undergoing primary prevention ICD implantation were observed between 2006 and 2010. There have simultaneously been significant improvements in outcomes after accounting for these patient trends, suggesting the possibility that there have been improvements in care of this patient population.
Abstract 13: The PCI Choice Decision Aid for Stable Angina: A Randomized Trial.
Authors: Coylewright Megan , Dick Sara , Shepel Kathy , Zmolek Becky , Askelin Jason , Branda Megan , Inselman Jonathan , Shah Nilay , Hess Erik P , LeBlanc Annie , Montori Victor M , Ting Henry H
Published: March 2022

Background:
Although percutaneous coronary intervention (PCI) has not been shown to reduce the risk of death and myocardial infarction (MI) for stable coronary artery disease (CAD), many patients believe that PCI is a life-saving procedure. PCI for stable CAD is known to improve patients’ quality of life more rapidly than medications alone. We conducted a randomized trial to assess the impact of a decision aid (DA) compared to usual care (UC) for the treatment of stable CAD when there is a choice between PCI and optimal medical therapy (OMT).

Methods:
The PCI Choice trial was a prospective, randomized trial comparing the effects of DA versus UC. The DA was designed with a user-centered approach for an in-visit consultation, involving patients and clinicians throughout the development process. The final DA included information on myocardial infarction (MI), death and quality of life outcomes for PCI with OMT vs. OMT alone in the treatment of stable angina, stratified by angina type. Risks of procedure, bleeding, stent thrombosis, and need for future procedures were also depicted. The primary outcome was patient knowledge, measured by pre- and post-visit surveys. Additional outcomes included decisional conflict, patient satisfaction, preferred decision making style, and treatment decision.

Results:
A total of 110 patients were enrolled; mean age was 68.3 years and 26% of patients were women. At baseline, most patients had CCS Class I/II angina and were on a mean of two anti-anginal medications (2.3, SD 1.2). Knowledge increased among patients receiving DA compared to UC (63% vs. 44% p=0.0003). Specific knowledge about the impact of PCI for stable angina on death and MI was higher in both groups compared to prior studies (54% DA, 46% UC, p=0.45; 12% prior). Patient satisfaction was significantly higher in the DA group vs. UC (72% vs 40%, p=0.004). Decisional conflict was greater than in non-procedural DA trials, and was not different between the two arms (p=.43). Following exposure to DA, patients’ preference for sharing decision making tended to change more with DA (55% to 65%) than with UC (56% to 59%). While the proportion of patients choosing PCI over OMT was nearly half in both groups, there were fewer patients that remained undecided with DA (18% vs. 4%; p=0.14 overall difference).

Conclusions:
Exposure to a DA for the choice of PCI vs. optimal medical therapy in stable CAD improved patient knowledge and satisfaction and decreased uncertainty, without reducing the rate of PCI. Use of the DA in a larger patient population may further delineate impact on outcomes such as treatment choice, geographic variation and cost.
Abstract 131: Ranolazine Improves Cardiovascular Outcomes and Healthcare Utilization: A Comparative Effective Analysis with Traditional Antianginal Medications
Authors: Page Robert L , Ghushchyan Vahram , Allen Richard R , Hartsfield Cindy , Koch Bruce R , Nair Kavita V
Published: March 2022

Introduction:
Real-world comparative studies evaluating traditional with newer antianginal medications in chronic stable angina (CSA) on cardiovascular (CV) outcomes and healthcare utilization are limited.

Methods:
Medical and pharmacy claims from 2008-2012 were analyzed using a large commercial database. Patients with a CSA diagnosis receiving ranolazine, beta blocker (BB), calcium channel blocker (CCB), or long-acting nitrates (nitrates) were identified and followed for 12 months after a change in antianginal therapy. Patients on traditional antianginal medication: BB, CCB, and nitrates were required to have concurrent sublingual nitroglycerin. Therapy change was defined as adding or switching to another traditional antianginal or ranolazine to identify patients who had failed prior therapy. Four groups were identified (BB, CCB, nitrates, or ranolazine users) and matched for age,gender, baseline Charlson Comorbidity Index (CCI), acute coronary syndrome,hypertension, diabetes, heart failure, hyperlipidemia, diabetes related complications, and cardiovascular healthcare costs. Rates for percutaneous intervention (PCI) and coronary bypass graft (CABG) at 30, 60, 90, 180 and 360 days, as well as, annual number of CV-related outpatient visits, emergency room (ER) visits, and inpatient admissions post therapy change were compared between groups.

Results:
A total of 8008 patients were identified with 2002 patients in each antianginal matched group. The majority (63-65%) were male with a mean age of 66 years and a CCI of 2.89-3.01. The Table summarizes the annual rate per 1000 for CV outcomes. Compared to other antianginal therapies, ranolazine consistently exhibited lower PCI and CABG rates at all time periods following therapy change. Compared to BB, CCB,and nitrates,ranolazine had a 21% (p=0.004), 4% (p=0.578), and 23% (p<0.0001) lower mean number of annual CV inpatient admissions; and 15% (p<0.0001), 4% (p=0.224), and 13% (p<0.0001) lower mean number of annual CV outpatient visits,respectively.Ranolazine had a 17-21% lower mean annual number of CV ER visits compared to the other antianginal groups (p=0.073,p=0.079, p=0.106,respectively).

Conclusion:
Ranolazine improves CV outcomes and lowers healthcare utilization compared to traditional antianginal therapies.
Abstract 136: Recidivism to Uncontrolled Blood Pressure in Patients with Previously Controlled Hypertension
Authors: Sandhu Amneet , Ho Michael , Asche Steve , Magid David , Margolis Karen , Sperl-Hillen JoAnn , Rush Bill , Price David W. , Ekstrom Heidi , Tavel Heather , Godlevsky Olga , O'Connor Patrick J.
Published: March 2022

Objectives:
Control of hypertension has improved nationally with focus on identifying and treating elevated blood pressures (BP) to guideline recommended levels. However, once BP control is achieved, the frequency in which BP falls out of control and the factors associated with BP recidivism is unknown. The objective of this study is to examine rates and predictors of blood pressure recidivism in adults with controlled hypertension.

Study Design:
A retrospective cohort study in two large, integrated health care systems in Minnesota and Colorado.

Methods:
Patients with a prior diagnosis of hypertension based on a combination of ICD-9 codes, receipt of anti-hypertensive medications and/or elevated blood pressure readings were eligible to be included. We defined controlled hypertension as normotensive blood pressure (BP) readings (less than 140/90 mmHg or less than 130/80 mmHg if coexistent diabetes or chronic kidney disease present) at 2 consecutive primary care visits. Following these visits among patients with controlled BP, we followed patients for BP recidivism defined by the mean of the last 2 blood pressure readings greater than 140/90 mm Hg or 130/80 mm Hg for those with diabetes or chronic kidney disease during a mean follow-up period of 13.2 months .

Results:
A total of 22,275 patients with controlled hypertension were included in this study. The proportion of patients with hypertension recidivism was 16.4%. A linear increase in blood pressure recidivism was noted with time between the index visit and last observed blood pressure reading. Major predictors of recidivism included female gender (OR 1.14, p = 0.02), history of diabetes (OR 2.32, p < 0.001) and black race (OR 1.37, p = 0.02). Age 50-64 displayed a protective effect against recidivism (OR 0.80, p = 0.02).

Conclusions:
Hypertensive recidivism occurs in a significant portion of patients with controlled hypertension. Patient factors associated with recidivism include age, race and prior history of diabetes among other characteristics. Strategies to minimize hypertension recidivism have significant potential to improve overall levels of blood pressure control and hypertension related quality measures from a health care systems perspective.
Abstract 139: A Novel Taxonomy for Acute Myocardial Infarction in Young Women
Authors: Spatz Erica S , Curry Leslie , Gross Cary P , Masoudi Frederick A , Dryer Rachel , Bueno Hector , Lampropulos Julianna F , Chaudhry Sarwat I , Zhou Shengfan , D'Onofrio Gail , Spertus John A , Safdar Basmah , Lansky Alexandra J , Krumholz Harlan M
Published: March 2022

Background:
In young women, the mechanism of injury in AMI is heterogeneous. Current classification schemes may not accommodate the breadth of phenotypic presentations in this population.

Methods:
We aimed to develop a new taxonomy for young women with AMI based on a random sample of patients enrolled in VIRGO, a multinational cohort study of young (≤55y) AMI patients. All met criteria for AMI with elevations of cardiac biomarkers and either chest pain or ECG changes. Five physicians abstracted data from the medical record using a structured instrument. Chart review focused on domains hypothesized to be relevant to clinical care and prognosis: clinical symptoms (e.g., chest pain, trigger, abruptness); clinical substrate for supply-demand mismatch (criteria defined in the abstraction instrument); underlying mechanism (assigned with probable/definite certainty); angiographic findings, (e.g., culprit artery); LV systolic function; and troponin elevation. We classified AMI phenotypes as Type I (plaque rupture/thrombus), Type II (supply-demand mismatch) or Type 4b (stent thrombosis), based on the 3
rd
Universal Definition. Using a systematic, empirical approach we developed a taxonomy by: (1) investigating heterogeneity within the current classification system, and (2) grouping patients with similar clinical characteristics into distinct classes, iteratively evaluating face validity with cardiologists.

Results:
According to the 3
rd
Universal Definition, patients (n=598, 69% female; mean age 47y) were classified as: Type 1: 504 (84%); Type 2: 39 (7%); Type 4b: 2 (<1%). Among these types, we identified few specific clinical entities of AMI, e.g., embolism, n=2; vasospasm, n=3; takotsubo, n=4. An additional 54 (9%) patients had no identifiable mechanism and were unable to be classified; of these 51 were women. Iterative grouping of patients by clinical presentation yielded 5 phenotypes (Table).

Discussion:
Nearly 1 in 10 young AMI patients are not captured by the current classification system; most are women. Moreover, there is wide heterogeneity in clinical presentation and extent of CAD among Type II AMI. A novel taxonomy may improve the complete classification of young women with AMI.
Abstract 140: Characteristics and risk factors in patients completing and not completing a cardiac rehabilitation program at the University of Utah during its first year of participation with the American Association of Cardiovascular and Pulmonary Rehabilitation’s (AACVPR) Cardiac Rehabilitation Registry
Authors: Springer Jennifer , Verma Div , Noon Shirley , Rose Taylor , Young Dawn , Khor Lillian
Published: March 2022

Introduction:
Cardiac Rehabilitation (CR) is a multi-disciplinary secondary prevention program associated with decreased rates of re-infarction, cardiac and overall mortality in post myocardial infarction (MI) patients. Despite clear benefits, only 14-35% of MI survivors participate nationwide. Aim of this study was to describe the characteristics in CR eligible patients post MI, post percutaneous or surgical revascularization, post valvular, transplant or left ventricular assist device (LVAD) surgery who completed and did not complete CR.

METHODS:
Using reporting functions of the AACVPR, Society of Thoracic Surgery, and National Cardiovascular Data Registry, data was extracted for patients who attended at least one CR session from January to November 2013. Paired t-tests and multivariate regression were run to compare patients who did and did not complete CR. Additionally, data was compared to the registry’s nation-wide cohort of 20,671 patients from 607 CR programs.

RESULTS:
In 2013, 1550 patients (67% male, 33% female) were discharged from our institution with one of the above diagnoses, 700 (45%) were eligible for and referred to CR, of those referred 302 (43%) lived within a 40-mile radius of our program, only 128 (42%) enrolled in CR and 44 (15%) of those eligible completed CR. Of those enrolled in CR, mean age was 62 years; 76% male and 24% female. Travel distance to CR was the most significant predictor of enrollment and completion of CR. Characteristics of those completing and not completing CR are outlined in the table below. In addition to travel distance, independent predictors of program completion are age (65 v 59, p 0.02, OR 1.05) and metabolic syndrome (36% v 17%, p 0.03, OR 3.08). There was minimal difference between genders (data not shown), after completion of CR both had significant improvement in lipid profiles and exercise tolerance. When compared to national AACVPR registry, our data is overall similar except for lower smoking rates.

CONCLUSION:
Although our enrollment is higher than reported averages, less than half of eligible patients enroll in and completed CR. Distance to CR is a significant limiting factor. For our secondary prevention program to be affective, further investigation on increasing accessibility to CR and alternate ways of delivering CR will need to be piloted.
Abstract 152: Factors Associated With Enrollment In Cardiac Rehabilitation: A Single-center Experience
Authors: Boyden Thomas F , Jiang Qingmei , Gracik Theresa , Rubenfire Melvyn
Published: March 2022

Introduction:
Cardiac rehabilitation (CR) is a vital component of secondary prevention shown to reduce mortality and improve quality of life. Despite this, referral to CR is low compared to other secondary prevention measures and enrollment of those referred is variable. We examined factors that are associated with enrollment to better understand ways in which participation in CR can be improved.

Methods:
Using data from the CR Center at the University of Michigan Health System, we analyzed 2012 patients who were referred to CR from January 1, 2008 to June 1, 2013. We systematically performed forward, step-wise multiple logistic regression to determine the best model for predicting acceptance of referral to CR. The outcome variable of interest was enrollment in CR if referred to CR.

Results:
Of the 2012 patients referred to CR, 1334 patients (66.3%) attended at least one session of CR. While there were no differences in age, gender or race between the two cohorts, there were several differences in baseline characteristics between those who enrolled vs. those who did not enroll. Those who enrolled in CR were more likely to be married (74.5% vs. 61.4%, P<0.0001), employed (54.2% vs. 29.8%, P<0.0001), insured (99.6% vs. 96.3%, P<0.0001), and have two or more co-morbidities (51.5% vs. 41.7%, P <0.0001). In the multiple logistic regression model, factors associated with enrollment (in descending order) were private insurance vs. none (OR=10.8; 95% CI 2.17-53.28, P=0.004), coronary artery bypass grafting vs. MI/ACS (OR= 3.42; 95% CI 1.68-6.99, P=0.0007), referral from cardiac surgery vs. cardiology (OR 3.15; 95% CI 1,43-6.95, P=0.004), outpatient vs. inpatient referral (OR=2.1, 95% CI 1.5 -2.9 , P=0.0001), unemployed (OR=1.55; 95% CI 1.09-2.2, P=0.01), and married (OR=1.41, 95% CI 1.04-1.92, P=0.01).

Conclusion:
Several patient and system-level factors are associated with enrollment in CR for those who were referred to CR at a single institution. These patient and organizational level variables represent opportunities for targeted interventions to improve CR utilization.
Abstract 153: Stress Testing Following PCI in the VA Health Care System: Insights from the VA CART Program
Authors: Bradley Steven M , Hess Edward , Winchester David E , Sussman Jeremy , Aggarwal Vikas , Maddox Thomas M , Baron Anna E , Rumsfeld John S , Ho P. Michael
Published: March 2022

Background:
Use of stress testing following percutaneous coronary intervention (PCI) is common in community practice with 60% of patients undergoing stress testing within 24 months of PCI. Rates of stress testing following PCI within integrated and salaried healthcare systems like the VA are unknown.

Methods:
Using national data from the VA Clinical Assessment Reporting and Tracking (CART) Program, we evaluated all VA patients who had PCI from October 2007-September 2011. We assessed the proportion of patients undergoing stress testing, stress test type, and timing of stress testing in the 2 years following PCI. To be consistent with prior studies, we excluded stress tests performed within 60 days of PCI as these may reflect assessment of residual ischemia in anticipation of staged procedures. Timing of follow-up stress testing was determined from 30-day incremental windows of follow-up.

Results:
Overall, 7,145 of 21,635 patients (33.0%) had a stress test performed within 2 years of PCI. The vast majority of stress tests following PCI were performed with nuclear imaging (80.8%). Treadmill stress ECG without imaging represented 15.2% of stress tests and stress echo 3.9%. Patients undergoing stress testing in follow-up were younger (63.4 vs 65.7 years, P<.001) and less likely to have comorbid congestive heart failure (21.8% vs 25.1%, P<.001) or chronic obstructive pulmonary disease (23.2% vs 25.5%, P<.001). In 30-day incremental windows of follow-up, first stress tests were most commonly performed in the 60-90 days following PCI (Figure).

Conclusions:
About 1 in 3 patients had a stress test performed in the 2 years following PCI in the VA. This rate is nearly half that reported from prior studies of community practice. Further study is needed to understand if this represents underuse of stress testing in VA or overuse in fee-for-service care.
Abstract 155: Improving ST-Elevation Myocardial Infarction Care with Site-specific Reperfusion Goals for Interfacility Transfers
Authors: Burt David R , Zarzar Rochelle , Mullvain Richard
Published: March 2022

Introduction:
Optimizing interfacility transfer of STEMI patients for emergent PCI remains a challenge due to difficulty calculating a customized time goal for transfer from a single non-PCI to PCI center (known as a “STEMI conduit”). Here we propose a simple formula to calculate conduit-specific interfacility STEMI transfer goals, allowing hospitals to assess and optimize their performance.

Hypothesis:
Optimal time for individual STEMI transfers within a STEMI conduit can be reliably calculated with the formula (V1+ V2 + 60 minutes). In this formula, V1 is the optimal EMS response time to the transferring facility (in minutes) and V2 is the interfacility (door-to-door) transfer time (in minutes). V1 and V2 are site-specific and vary across STEMI conduits. The additional 60 minutes represents the sum of the goal Door to Decision, EMS Scene Turn-around, and PCI Door to Reperfusion times. The goal times for these individual parameters are based on established expectations or national best practices and remain constant for all STEMI conduits. Using this formula, the expected facility-to-facility transfer time [F2F(expected)] can be calculated and this value can then be compared to actual performance [F2F(observed)] with the ratio of observed/expected performance. A ratio close to 1 suggests the transfer occurred in a realistic yet optimized time frame.

Methods:
Interfacility STEMI transfers occurring within five STEMI conduits over four years were evaluated retrospectively. A performance goal was determined for each conduit using the formula [F2F(expected) = V1 + V2 + 60 minutes] and a ratio of F2F(observed /expected) was calculated for each transfer.

Results:
The figure demonstrates the F2F ratio ranges and means for transfers within each conduit. Four of five conduits exhibit mean ratios close to 1, indicating that the calculated expected performance is representative of what is optimized and sustainable within that conduit. The remaining conduit has a mean ratio of 0.81 indicating observed performance better than predicted.

Conclusion:
The proposed formula [F2F(expected) = V1 + V2 + 60 minutes] can be used to accurately calculate interfacility transfer goals for STEMI conduits and can thereby serve as a marker for quality improvement, enabling hospitals to monitor and optimize STEMI transfer performance.
Abstract 16: Low Rates of Implantable Cardioverter-Defibrillator Use Among Medicare Patients with Low Ejection Fraction After Myocardial Infarction
Authors: Pokorney Sean , Miller Amy L , Chen Anita Y , Thomas Laine , Fonarow Gregg C , de Lemos James A , Al-Khatib Sana M , Peterson Eric D , Wang Tracy Y
Published: March 2022

Objective:
Implantable cardioverter-defibrillators (ICDs) are a proven life-saving therapy for patients with low ejection fraction (EF) due to ischemic cardiomyopathy. Because ICDs are not recommended within 40 days of an acute myocardial infarction (MI), ICD consideration is potentially susceptible to errors of omission during the transition of care post-MI. This study examines ICD implantation rates within 1 year post-discharge among MI patients with low EF.

Methods:
We identified Medicare patients with an EF ≤ 35% after an acute MI, treated at 441 ACTION Registry-GWTG hospitals between January 2007 and September 2010, excluding patients with prior ICD implantation. Using Medicare data, we examined the incidence of ICD implantation among survivors at 1 year post-discharge. A multivariable Cox model, stratified by discharging hospital, was used to determine patient characteristics associated with receiving an ICD within 1 year, accounting for death as a competing risk.

Results:
Among 10,318 MI patients with EF ≤ 35%, 7,842 (76%) were alive at 1 year post-MI, of which 700 patients (8.9%) received an ICD in that year. The variation in 1-year ICD implantation rate by discharging hospital was significant (p=0.02), with the 90th percentile sites implanting 2.7 times more devices than the 10th percentile sites (8% vs. 3%). Patients that received an ICD were younger (median 74 vs. 77 years), more likely to be male (69% vs. 53%) and to have had a larger infarct (median peak troponin 80 vs. 51 times upper limit of normal) or ventricular tachycardia/fibrillation during the MI hospitalization (25% vs. 22%), but were less likely to have end stage renal disease (7% vs. 14%) than patients who did not receive an ICD (p<0.001 for all). Patients who saw a cardiologist within 2 weeks of discharge were more likely to receive an ICD at 1 year than patients who did not (12% vs. 8%, p<0.001). In the multivariable model, the factors significantly associated with ICD implantation within 1 year post-MI are shown in the Figure.

Conclusions:
In US clinical practice, fewer than 1 in 10 Medicare patients with an EF ≤ 35% received an ICD within 1 year of an MI. This gap cannot be fully explained by EF recovery. Barriers to ICD implantation included sociodemographic and clinical factors, and they may be modified by transition of care practices.
Abstract 168: Effectiveness of Case-Based Education on Clinical Decision-Making in ACS
Authors: Larkin Amy , LaCouture Michael , Bates Eric R
Published: March 2022

Introduction:
Due to emerging clinical evidence and the availability of new therapies, professional societies continue to update guidelines that direct the management of patients with acute coronary syndromes (ACS). Evolving therapies and guidelines create clinical confusion. Confusion in ACS management has been self-identified by healthcare professionals (HCPs) as an area of clinical concern. Knowledge gaps were addressed by constructing a case-based educational intervention to improve physician’s ability to make appropriate evidence- and guidelines-based clinical decisions for patients with non-ST elevation myocardial infarction (NSTEMI).

Methods:
The continuing medical education (CME) activity was developed as an online case-based text activity modeled after the interactive grand rounds approach where clinicians make clinical decisions about treatment for a patient. The activity targeted primary care physicians (PCPs) and cardiologists who manage patients experiencing an ACS and focused on application of guideline recommendations. The effects of education were assessed using a linked pre-/post-assessment study design that separated learners into 3 categories: improved (incorrect pre, correct post), reinforced (correct pre and post), and unaffected (incorrect post).

Results:
755 PCPs and 255 cardiologist completed both the pre- and post-assessment survey with a large overall effect size of 1.229 (
P
=0.0001) and 0.808 (
P=
0.0005), respectively. PCPs Correct responses on post-assessment questions ranged between 18% and 164% higher after CME completion. A summary of the pre- compared with post-assessment scoring indicates the scoring distribution curve shifted to the right. While only 86 of 755 (11%) participants answered all 4 questions correctly on the pre-assessment, 451 (60%) answered them all correctly on the post-assessment. Between 17% and 53% of participants showed improvement in understanding individual learning concepts as demonstrated by selecting correct answers to case-based questions. Cardiologists Correct responses on post-assessment questions ranged between 3% and 134% higher after CME completion. A summary of the pre- compared with post-assessment scoring indicates the scoring distribution curve shifted to the right. While only 51 of 255 (20%) participants answered all 4 questions correctly on the pre-assessment, 176 (69%) answered them all correctly on the post-assessment. Between 6% and 55% of participants showed improvement in understanding individual learning concepts as demonstrated by selecting correct answers to case-based questions.

Conclusion:
Online case-based CME activities modeled after the interactive grand rounds approach prompted changes in clinical knowledge, showing that when effectively constructed, online CME is an effective tool to improve clinical application of guidelines and clinical decision-making.
Abstract 172: Patients' Experiences from Symptom Onset to Initial Treatment for Atrial Fibrillation
Authors: McCabe Pamela J , Rhudy Lori , DeVon Holli
Published: March 2022

Background:
The prevalence of atrial fibrillation (AF) is expected to increase 2.5-fold by 2050. As a result, there will be a greater demand for clinicians to provide patient education regarding the nature of AF and its management. Early self-management education is critical to provide patients with knowledge and skills they need to recognize AF, control its progression, and reduce associated complications of stroke and heart failure. Greater understanding of patients’ experiences from symptom onset through initial treatment for AF is needed to guide development of patient centered interventions to promote early effective self-management.

Purpose:
To describe patients’ experiences from symptom onset through initial treatment of AF.

Methods:
A descriptive qualitative design was used. Twenty females and 21 males at a Midwest academic medical center were interviewed using open-ended questions to explore their experiences from symptom onset through the initial treatment for AF. Data were analyzed using qualitative content analysis.

Results:
Participants’ mean age was 64.3 SD = 10.1 years. Themes emerging from data were: 1) understanding the meaning of symptoms 2) learning about AF 3) emotional response and 4) feeling cared for by healthcare providers. Participants were unacquainted with AF and took cues from providers’ responses to appraise their symptoms and diagnosis. Fear and uncertainty were reduced when providers initiated prompt treatment. Receiving clear, comprehensive information about AF was appreciated by participants and described as a factor in feeling cared for by providers.

Conclusions:
Providers’ played a critical role in reducing patients' emotional distress and helping them to develop an accurate understanding of AF symptoms and treatment. This study provides new insight into participant experiences from symptom onset through initial treatment of AF which may inform development of patient centered interventions to promote early effective AF self-management.
Abstract 178: Females with Cardiac Comorbidities Have Worse Outcome Compared to Males Presenting with Unexplained Syncope: An ACAP-SELF Dataset Analysis
Authors: Pratap Balaji , Bastawrose Joseph , Gurram Adilaxmi , Panneerselvam Narmadha , Lingannan Archana , Kalamkar Prachi , Patel Dipen , Verzosa Joanna , Shahanoor Ziasmin , Umali Tad , Pamidimukala Chaithanya , Pierce Matthew , Aziz Emad F , Herzog Eyal
Published: March 2022

Background:
The ACAP program consists of strategies for implementing ACC/AHA guidelines for various cardiac disorders, one of which is the SELF pathway, which covers the spectrum of care from presentation to discharge in patients with syncope. Patients are stratified according to SELF-1 (Short period, Early onset, Loss of consciousness, Full recovery) and SELF-2 criteria (Structural heart disease, abnormal ECG, arrhythmia).

Methods:
3044 patients were prospectively followed for syncope. They were divided into 4 groups: Group A (SELF +/+) who met both SELF 1 and 2 criteria, Group B (SELF +/-) who met SELF-1 criteria but not SELF-2, Group C (SELF -/+) who met SELF-2 criteria alone and Group D (SELF -/-) who met neither criteria. These groups were further separated into males and females. The primary endpoint was composite of readmission for syncope, myocardial infarction, stroke or death. Follow-up was 5 years.

Results:
Females were older than males (69+/-21 years), had more hypertension (65% vs. 63%) and syncopal episodes (18% vs. 16%). Males were more likely to be diabetic (25% vs. 24%), have coronary artery disease (21% vs. 16%; p=0.001), heart failure (11% vs. 9%) and smoking (65% vs. 42%; p<0.001). Regardless of sex, Group A patients had worse outcomes (p=0.25) while Group D patients had better outcome with far fewer events (p=0.06). In Group B patients, males were noted to have worse outcome while in Group C, females were noted to have significantly worse long-term outcome.

Conclusions:
The SELF-pathway for patients with syncope helps identify at-risk subgroups in our patient population. Females with SELF-2 criteria (Structural heart disease, abnormal ECG, arrhythmia) had significantly worse long-term outcome compared to males regardless of manner of syncopal presentation.
Abstract 180: Use of Hospital Teams Tasked to Reduce Readmissions in the VA
Authors: Sahay Anju , Heidenreich Paul
Published: March 2022

Objective:
The Department of Veterans Affairs (VA) joined the American College of Cardiology and the Institute for Health Care Improvement’s in their Hospital To Home (H2H) initiative. This initiative attempts to improve the transition of care following discharge for patients with acute myocardial infarction and Heart Failure. The Chronic Heart Failure (CHF) Quality Enhancement Research Initiative (QUERI) worked with providers at each VA hospital to encourage facility enrollment. Ultimately, 86 VA facilities enrolled. The purpose of this study was to determine the extent of existing quality improvement projects in place at each of the 86 enrolled facilities.

Method:
Contacts at each of the 86 VA facilities enrolled in H2H were asked to complete a web-based survey. This survey focused on each facility’s QI efforts that were currently in place for all their heart failure patients. We had a 93% (n=80) response rate from these facilities.

Results:
Findings showed that QI national initiatives that the VA facilities joined included H2H (76%), Re-Engineered Discharge (RED) Project (11%), Transitional Care Model (10%) and other local or regional collaboratives (31%). Of note, 81% (n=65) of the facilities had QI teams devoted to reducing preventable readmissions for patients with heart failure. These QI teams included a variety of staff: 89% included physicians, 83% included nurses, 74% included advanced practice nurses or physician assistants, 74% included QI/quality management staff, 63% included pharmacists, and 57% included senior management of the hospital.

Conclusions:
Many VA facilities have teams devoted to preventing
r
eadmissions for heart failure. These teams almost always include physicians in addition to managers and other providers. Facilities often participate in multiple national initiatives to improve their goal of reducing readmissions.
Abstract 186: Quality of Cardiovascular Care in Patients Subjected to Inappropriate Myocardial Perfusion Imaging
Authors: Winchester David E , Kitchen Andrew , Brandt John , Bradley Steven M , Dusaj Raman S , Shaw Leslee J , Beyth Rebecca J
Published: March 2022

Background:
Approximately 10-20% of myocardial perfusion imaging (MPI) is performed for inappropriate indications. Established metrics of quality outpatient care for coronary artery disease (CAD), hypertension, and diabetes mellitus (DM) have similar, or worse, failure rates. The extent to which inappropriate use of MPI is associated with failure to achieve quality care metrics has not been investigated.

Methods:
We conducted a cross-sectional investigation of MPI performed on outpatients at a single VA medical center between December 2010 and July 2011. Data were gathered from documentation of the visit when the MPI test was ordered, including metrics of quality care for outpatient management of hypertension, DM, CAD, and smoking. Goals of care were selected from established metrics of quality outpatient care. We also assessed whether the clinician documented a plan to bring the metrics to goal.

Results:
516 MPI patients were included, 52 (10.1%) inappropriate (I) and 464 (89.9%) appropriate or uncertain (A/U). Hypertension (82.2%), DM (41.3%), CAD (41.1%), and tobacco use (23.1%) were common. No significant differences between A/U and I cases were observed for CAD quality metrics (aspirin use, p=0.22; beta-blocker use, p>0.99; statin use, p>0.99; lipids at goal, p=0.20). While hemoglobin A1c levels were significantly lower for I cases (6.6% versus 7.5% for A/U cases, p=0.04), no difference was observed in the percent of patients at goal (62.5% for I versus 46.3% for A/U, odds ratio [OR] 2.90, 95% confidence interval [CI] 0.55-15.27, p=0.258). Blood pressure at goal (p=0.36) was not different. Use of tobacco was not different between the two groups (23.2% versus 15.7%, p=0.29), and neither was the proportion without tobacco cessation planning (0.65% versus 3.9%, p=0.08) Overall achievement of quality metrics was poor but similar to other reports of these metrics (CAD 44.8%, DM 47.9%, hypertension 73.1%, smoking 77.5%). Most clinicians documented a reason for not achieving, or a plan to achieve the metrics (CAD 95.3%, DM 68.2%, hypertension 90.8%, smoking 99.0%).

Conclusion:
Overall, the inappropriate use of MPI is not associated with failure to achieve established metrics of quality outpatient care. On the contrary, most clinicians demonstrate awareness of these care deficiencies by documenting either a reason for not achieving, or a plan of care to achieve quality care metrics