bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 120: Effectiveness of a Pharmacist Population Health Intervention for Sacubitril/valsartan in Systolic Heart Failure
Authors: Dorsch Michael P , Adie Sarah , Pogue Kristen T , Hanigan Sarah , Conway Monique , Koelling Todd M
Published: April 2019

Purpose:
Previous literature demonstrates higher prescribing rates by providers after contact with a pharmaceutical representative or after obtaining drug information from an external source. This study aims to evaluate the effectiveness of an Electronic Health Record (EHR), pharmacist-based, population health intervention on physician prescribing patterns of sacubitril/valsartan in patients at Michigan Medicine General Cardiology clinics.

Methods:
The institutional review board approved this prospective, cluster-randomized controlled study. Patients seen by providers at the General Cardiology clinics of Michigan Medicine between 3/21/2017 and 6/1/2018 were included. Twenty-seven cardiology providers were clustered based on specialty. Fourteen providers were included in the intervention group while 13 providers were included in the control group. Within each arm, study personnel prospectively screened patients by preliminarily filtering those with a diagnosis of systolic heart failure and a left ventricular ejection fraction (LVEF) of 40% or less. Practice-based guideline criteria were then used to determine final patient eligibility. Intervention notifications were sent by pharmacists to providers using the EHR inbox within two-weeks prior to the clinic visit. The primary endpoint for this study was the proportion of patients prescribed sacubitril/valsartan within three months following the appointment. Baseline demographic data was collected on intervention patients. Additionally, the reasons for ineligibility were collected on all patients.

Results:
A total of 1559 patients were included (intervention=763, control=796). Fifty-two patients met eligibility criteria for sacubitril/valsartan (intervention=16, control=36). Of eligible patients, two in the intervention group and one in the control group had sacubitril/valsartan initiated (12.5% vs. 2.8%, OR 5.0, 95% CI 0.42-59.7, p=0.22). Of the 14 interventions that were not accepted, there was a common provider and 79% of the messages were ignored. The main reasons for ineligibility were patients not taking a dose of angiotensin converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) equivalent to enalapril 10 mg twice daily (92.6%) or not currently taking an ACE inhibitor or ARB (5.1%).

Conclusion:
Few patients met practice-based guideline criteria which reflected a conservative approach to initiating sacubitril/valsartan and limited sacubitril/valsartan initiation. EHR inbox interventions may be limited since most of the messages were ignored. Future research should explore tools to aid in optimizing medication therapy for patients with systolic heart failure which may lead to more successful pharmacist-based, population health interventions for this patient population.
Abstract 130: Social Factors Influence Readmission Rates in Women with Acute Myocardial Infarction
Authors: Haddadin Faris I , Rzechorzek Wojciech , Sabharwal Basera , Yue Bing , Khandaker Mariam , Weininger David , De La Villa Pagán Ricardo , Munoz Estrella Alba , Lee Shawn , Ahsan Syed , Lemor Alejandro , Selby Allison , Tamis-Holland Jacqueline
Published: April 2019

Background:
Studies have shown that women with acute myocardial infarction (AMI) have a higher prevalence of unfavorable social variables than men and have a worse outcome. Less is known regarding the impact of these social variables on 30-day all-cause readmission after AMI.

Methods:
We analyzed adult patients with AMI enrolled in a Quality Improvement Program aimed to decrease 30-day all-cause readmission after AMI. We compared clinical and social variables by sex using Pearson Chi Squared and Cramer’s V test. Multivariate linear regression was used to measure adjusted odds for 30-day all-cause readmission by sex.

Results:
Among 173 patients included in our project, 54 (31.2%) were women. Table 1 depicts the clinical and social variables in women and men. Only 33.3% of women were married or had domestic partner and less than one fourth were employed. Nearly half of women needed help at home, and nearly half of women did not speak English as their first language. These variables were significantly different by sex. The 30-day all-cause readmission was higher in women than men (20.4% vs 7.6%, p=0.03). After adjusting for clinical and social variables this difference by sex in 30-day all-cause readmission was no longer noted (OR 1.1, 95% CI 0.33-3.74, p=0.86).

Conclusion:
Women with AMI are more likely than men to have unfavorable social factors that can impact recovery from AMI, and women have a higher 30-day all-cause readmission rate. The higher readmission rate in women appears to be influenced by these social factors. Healthcare interventions aimed at reducing 30-day all-cause readmission after AMI should focus on providing assistance for those requiring additional social support at home.
Abstract 137: Using an Electronic Clinical Support Tool to Improve Anticoagulation in Patients with Atrial Fibrillation/Flutter
Authors: Kampangkaew June , Nowalk Nathan , Hamzeh Ihab
Published: April 2019

Background:
It is estimated that atrial fibrillation (AF) impacts between 2.7 to 6.1 million American adults, and this is expected to double by 2050. The outpatient performance measures of the 2016 AHA/ACC Clinical Performance and Quality Measures include: Documentation of CHA2DS2-VASc Risk Score and anticoagulation (AC) prescription, when indicated. To address these outpatient measures, our team integrated a clinical support tool into our electronic medical record (EMR).

Objectives:
Our quality improvement project aimed to increase the percentage (or proportion) of patients with atrial fibrillation/flutter (AF) who were appropriately prescribed AC in an academic cardiology clinic. Our outcome measure was the frequency our tool was either: acknowledged, cancelled, or completed.

Methods:
Baseline data was collected via retrospective chart review for patients with documented AF. With the assistance of information technology, we created a pop-up clinical tool in the EMR that recognized if the patient is prescribed AC and provided a semi-automated calculation of the CHA2DS2-VASc score. If the patient had CHA2DS2-VASc ≥ 2 and was not on AC, the tool prompted the physician to select either: a contraindication, refusal or prescribe AC. Before implementing the electronic tool, the cardiologists were educated on the new tool and made aware of future data collection.

Results:
Baseline data from April 2018 included 104 patients with AF, of which 57.7% were prescribed AC. The frequency of AC prescription for all AF over the next 3 months increased: 76% in May, 69% in June, 86% in July. For these 3 months, when the clinical decision tool was encountered: 69 - 72% of cardiologists cancelled, 11 - 22% acknowledged, and 9-17% used the tool.

Conclusion:
Our outcome measure to increase AC prescription was achieved following implementation of an electronic clinical tool even though the cardiologists often did not interact with the tool. Similar to prior literature on clinical support tools, the provider’s clinical proficiency plays a large role in use. The tool may have been successful by providing a clinical reminder about AC in these patients . Early results show sustainability in AC prescription. Our clinical tool is now being implemented into a primary care clinic and may have increased use in that setting.
Abstract 14: Secular Trends in Racial and Socioeconomic Status Disparities in the Rate of Coronary Revascularization Among Post-Menopausal Women Before and After 2005 for Acute Coronary Syndrome: The Women Health Initiative
Authors: Tertulien Tarryn , Breathett K , Cene C W , Corbie-Smith G , Nassir R , Allison M , Roberts M B , Manson J , Eaton C B
Published: April 2019

Background:
We looked at a large multi-racial, geographically diverse cohort of post-menopausal women to determine whether revascularization for either acute coronary syndrome (ACS) or coronary disease (CHD) differed by race and socioeconomic status when 2002 ACC/AHA guidelines secular trends are considered.

Methods:
Using data from the WHI, we evaluated the rate of revascularization among 20,262 post-menopausal women (2,181 were Black, 572 Hispanic, and 17,509 white). We chose 2005 as the cut-point for the secular trend as it usually takes 2-3 years for guidelines to be implemented. We used a Cox proportional hazards models with unadjusted, age-adjusted, and fully adjusted hazards ratios to examine revascularization disparities by race and SES.

Results:
Revascularization rates increased over the two decades studied but the racial disparities did not narrow. Black women with either ACS or CHD had significantly lower rates of revascularization pre and post 2005. Hispanic women with acute coronary syndrome or CHD had significantly lower rates of revascularization pre-2005 and a trend for lower rates post-2005. Black women with STEMI had trend towards lower rates of revascularization pre and post 2005 compared to their white counterparts. Hispanic women with STEMI have similar rates of revascularization pre-2005 and a trend towards lower rates of revascularization post-2005. Black women with NSTEMI trend towards a higher rate of revascularization pre-2005 and a trend towards a lower rate of revascularization post-2005. Hispanics with NSTEMI had a trend for higher revascularization pre-2005, and similar rates of revascularization post-2005. Low SES women with acute coronary syndrome or coronary heart disease had no difference in the rate of revascularization pre-2005 and significantly lower revascularization post-2005. Low SES with STEMI and NSTEMI had comparable rates of revascularization for both time periods when compared to their high SES counterparts.

Conclusions:
Black women with ACS or CHD had lower rates of revascularization, regardless of timing, compared to their white counterpart. Despite having similar rates of coronary events, low SES women had lower rates of revascularization in the post 2005 period when compared to their high SES counterpart.
Abstract 150: Early Administration of Ticagrelor in Patients with Non-ST Segment Elevation Myocardial Infarction is Associated with Improved Survival
Authors: Mazzone Steven , Chua Rhys F , Besser Stephanie A , Nathan Sandeep , Shah Atman P , Liao James K , Tabit Corey E
Published: April 2019

Background:
Dual antiplatelet therapy (aspirin plus clopidogrel/ticagrelor - DAPT) is a mainstay treatment for NSTEMI. However, studies suggest that early administration of clopidogrel may not confer significant benefit over later administration. As the time to peak plasma concentration is much shorter for ticagrelor (1-2 hours) vs. clopidogrel (8-12 hours), we hypothesized that earlier administration of ticagrelor may confer survival benefit over later administration.

Methods:
Patients treated for NSTEMI at our center using DAPT, January 2012 through May 2017, between 18 and 90 years old, were retrospectively identified. Patients who left the hospital against medical advice, were discharged to hospice, or were already treated with DAPT or an anticoagulant at the time of presentation were excluded. Patients who received ticagrelor ≤ 2 hours from arrival were matched with similar patients who received ticagrelor > 2 hours from arrival using 30 clinical and demographic variables. Patients who received clopidogrel were matched similarly. We then compared survival for 500 days using a log rank test.

Results:
349 patients met the inclusion criteria. Of these, 18 received ticagrelor within 2 hours and 41 received clopidogrel within 2 hours. These were matched with 18 and 41 control patients, respectively, who received ticagrelor/clopidogrel > 2 hours from arrival. As shown in Figure 1a, patients who received ticagrelor ≤ 2 hours from arrival had significantly lower 500-day mortality than patients who received ticagrelor > 2 hours from arrival (0.0% vs. 27.7%; p=0.017). There was no difference in mortality between the early and late clopidogrel groups (Figure 1b).

Conclusion:
In the ticagrelor era, early administration of DAPT with ticagrelor (within 2 hours of arrival) may be associated with improved mortality in patients with NSTEMI, an effect not seen with clopidogrel. Larger studies investigating the impact of door to DAPT time in patients with NSTEMI are needed.
Abstract 153: Predictors of Aspirin Nonadherence in Adults with Prior Myocardial Infarction
Authors: Mehta Aayushi A , Parikh Puja B
Published: April 2019

Background:
Medication nonadherence is an alarming public health concern due to its effect on both individual treatment success and overall health care costs. In this study, we sought to identify the predictors of aspirin nonadherence in adults with prior myocardial infarction (MI).

Methods:
The 2017 Centers for Disease Control’s Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of 2,173 adults with prior MI who had reported the presence or absence of regular aspirin use. Demographic and clinical history were recorded and compared in individuals reporting the presence versus absence of aspirin adherence (defined as self-reported regular use of aspirin).

Results:
Among 2,173 adults with prior MI, 1623 (74.7%) reported adherence to aspirin while 550 (25.3%) reported aspirin nonadherence. Adults with aspirin nonadherence were younger, and more likely to be female (50.2% vs. 40.8%, p<0.001), Black (16.3% vs. 12.1%, p<0.001), and of Hispanic ethnicity (21.0% vs. 10.0%, p<0.001). They were also less likely to have health insurance (92.1% vs. 95.2%, p=0.007) or own a home (62.6% vs. 72.3%, p<0.001), and had lower annual incomes. Adults with aspirin nonadherence were noted to have less frequent medical checkups and lower rates of multiple comorbidities including diabetes mellitus (33.9% vs. 39.9%, p=0.012), hypertension (72.8% vs. 78.0%, p=0.013), hyperlipidemia (61.7% vs. 70.3%, p<0.001), and obesity (39.4% vs. 41.9%, p=0.013). In multivariate analysis, independent predictors of aspirin nonadherence in this population included female sex (adjusted odds ratio (OR) [95% confidence interval]) = 1.45 [1.14-1.83], Black race (1.64 [1.19-2.26]), Hispanic ethnicity (2.27 [1.61-3.21]), current employment (1.74 [1.28-2.36]), and absence of homeowner status (0.71 [0.55-0.93]).

Conclusion:
In this observational contemporary study of adults with prior MI, predictors of aspirin nonadherence include female sex, Black race, Hispanic ethnicity, employment status, and homeowner status. Appropriately identifying demographics of patients that may have barriers to adherence, especially at the time of initial medication recommendations, may help physicians to identify those at heightened risk for future nonadherence, thus allowing for timely and targeted educational and social work interventions to achieve treatment success through improved health outcomes and lower health care costs.
Abstract 154: True Outcome Determination After In-Hospital Cardiac Arrest
Authors: Miller Art , Thomas Kathie , Myers Gary
Published: April 2019

Background/Objectives: A commonly reported measure for a successful resuscitation from in-hospital cardiac arrest is survival to discharge. But what does that really tell us? In the continuation of a previous study looking at whether hospital bed size impacted survival, we wanted to look even further to identify the true condition of those patients at discharge who survived, and their discharge destinations after an in-hospital cardiac arrest.

Methods:
By using data for the years 2013-2017 from Get With the Guidelines-Resuscitation for 75-199 & 300-399 bed hospitals in the AHA Midwest Affiliate, we compared survival to discharge destination & cerebral performance category, (CPC score), for patients who survived with and without shockable rhythms. All patients were included in a risk adjusted formula.

Results:
Although survival rates in the 75-199 bed hospitals were always higher, CPC scores were almost always lower for the 300-399 bed facilities indicating a better neurological outcome. Discharge destinations varied but in almost every case, the majority were sent to other healthcare facilities, (extended care, skilled nursing, rehab). A large percentage were discharged home however, verifying again that many patients survived with normal to nearly normal neurologic status. We also discovered that nearly 1 in 4 patients had no CPC score documented at discharge.

Conclusions:
After analyzing hospitals with 75-199 & 300-399 beds, the data showed higher rates of survival to discharge in the smaller hospitals however, neurologic outcomes were better at larger facilities. This led us to conclude that survival rate alone may not be the most appropriate measure of a successful resuscitation. CPC score at discharge is another key component that should be included. Discharge destination can also be considered as an indicator of the patient’s condition. Additionally, hospitals should evaluate their process for documenting neurologic status at discharge and whether there are omissions in the medical record or an abstracting oversight in Get With the Guidelines-Resuscitation by not including a CPC score.
Abstract 158: A Learning Health System Approach to Reduce Time to Treatment for Out of Hospital Cardiac Arrest
Authors: Coulter-Thompson Emilee , Neumar Robert , Friedman Charles , Shields Theresa , Platt Jodyn , Satterfield Kate , Nallamothu Brahmajee
Published: April 2019

Background:
Rapid treatment is critical to improve survival from out-of-hospital cardiac arrest (OHCA) and is directly affected by bystanders’ abilities to immediately recognize cardiac arrest, call 911, and provide early CPR and/or Automated External Defibrillation (AED). Given the critical element of early bystander interventions, we chose to use a learning health system (LHS) approach to reduce time-to-first-treatment for OHCA. In a LHS, a community of diverse stakeholders embark on continuous, data-driven learning to improve best practices and health outcomes.

Methods:
We established an OHCA learning community (LC) comprised of multidisciplinary representatives of the chain of survival in Michigan’s Washtenaw-Livingston county medical control authority region (a two-county entity, population 555,278, that coordinates emergency medical services). The LC aimed to accelerate the shared identification of priority areas for investigation and to facilitate more rapid implementation of innovative interventions to reduce OHCA response time.

Results:
We held two LC meetings. Using an approach that included facilitated discussion, 65 diverse stakeholders (OHCA survivors, 911 dispatchers, first responders, physicians) identified the following 4 themes as critical to improving time-to-first-treatment: 1) Improve bystander response; 2) Increase OHCA public awareness; 3) Reduce time-to-treatment and improve data collection for key process measures (time of cardiac arrest, time to first chest compression, time to AED); and 4) Improve post-cardiac arrest systems of care. The LC was supported by examination of standardized processes and infrastructure in a learning cycle (see graphic). These LC findings are being deployed in the Washtenaw-Livingston region to enhance OHCA data collection and increase bystander engagement; e.g. by establishing a system to review 911 calls to accurately assess times and identify systematic barriers to rapid treatment.

Conclusions:
The LHS approach and multi-stakeholder LC has led to the identification of community-owned key priority areas within a local context for OHCA. We believe this approach will accelerate the implementation and adoption of new data collection methods and innovative practices that will facilitate continuous learning and improvement.
Abstract 165: Challenges to Self-Management of Heart Failure Among Homeless Individuals: A Qualitative Study
Authors: Pendyal Akshay , Rosenthal Marjorie S , Keene Danya
Published: April 2019

Background:
Outpatient heart failure (HF) care involves intensive self-management (SM). Effective HF SM is associated with improved HF outcomes. Homelessness poses challenges to successful SM of many chronic diseases. Possessing a greater understanding of the barriers faced by homeless patients with HF, from the perspective of these patients, may lead to improved care of this vulnerable and under-studied population.

Methods:
We conducted open-ended, semi-structured interviews with HF patients with a history of current or prior homelessness within the past year. Data were analyzed using a grounded theory approach. The purpose of the interviews was to understand the ways in which homelessness may impede successful SM of HF and engagement with the healthcare system.

Results:
Face-to-face interviews with 15 patients, 9 (60%) of whom were homeless at the time of interview, revealed a combination of influences on patients’ SM of HF. Major themes included instability and lack of ontological security, the need to make difficult tradeoffs, and the experience of stigma in the healthcare setting. While patients frequently reported instability as a reason for poor HF SM, instability itself proved to be a complex phenomenon with myriad manifestations. Patients reported that instability posed a barrier to the formation of medication, weight, and dietary routines, but also forced them to engage in short-term—rather than long-term—thinking surrounding HF as a chronic condition. Patients described having to make tradeoffs in HF SM; examples included choosing between attending HF clinic visits versus securing shelter, or prioritizing medications for comorbid conditions over those for HF. For some patients, homelessness served as a source of stigma, which resulted in perceived inequitable or inadequate care in both the inpatient and outpatient settings, and thus discouraged continued engagement with clinicians.

Conclusion:
Anticipatory guidance tailored toward the unique challenges faced by homeless individuals with HF may help to attenuate their difficulties with successful SM, but is likely insufficient. HF providers, too, must be made aware of the practical aspects of managing HF in the setting of homelessness. The vulnerability of this population necessitates creative approaches on the part of HF providers, including simplifying medication regimes and engaging in non-stigmatizing discourse.
Abstract 169: A Retrospective Cardiovascular Disease Registry to Inform Community Prevention
Authors: Pursell Irion W , Ford Jessica , Lee Elizabeth , Moore Lauren , Mao Yuxuan , Washington Ty , Sears Sam , Mounsey Paul
Published: April 2019

Background:
Cardiovascular disease (CVD) registries are essential to planning, implementation, and evaluation of clinical and public health practice. Registries primarily enroll patients seeking medical care and poor, socially isolated and medically underserved populations are not well represented, distorting the magnitude of the problem and mischaracterizing victims. Lincoln Project investigators contend a retrospective CVD victim registry, created from a well-documented cohort of all-cause Out of Hospital Premature Death (OHPND) victims, dominated by cardiovascular deaths, will accurately identify, describe and locate CVD victims and drive intervention strategies targeting CVD risk factors in the community.

Objective:
To establish a comprehensive retrospective CVD registry from a cohort of OHPND victims in rural Eastern North Carolina.

Methods:
All deaths (12,665) for 2014 from 29 counties in Eastern North Carolina (Population 1.5M) were electronically filtered. 1122 cases of OHPND (18-74 years old, natural causes, that died out of the hospital) were identified. Cancer deaths were excluded. Medical records from clinical providers, Emergency Medical Services (EMS) and the Medical Examiner (ME) were procured. Cases were mapped using victim’s residence address and matched with Census data to determine socioeconomic status. All available medical records and reports of OHPND victims were reviewed by a group of 3 cardiologists to determine inclusion in CVD registry per internally designed protocol.

Results:
Death registration data was acquired for all 1122 OHPND subjects. Medical provider records were available for 71.9% (807/1122) of victims; we captured EMS records on the date of death for 67.2% (755) of victims and all EMS encounter data for three years prior to death on 89.2% (I1001)of decedents. Report of Medical Examiner was available on all (39%) ME cases. No medical records were available for 124 subjects. Of 998 OHPND subjects with available medical records, 659 (66%) met the criteria for inclusion in CVD registry. Of CVD registrants, 66.1% (435/659) had coronary artery disease, 72% (475) hypertension, and 55.2% (364) had diabetes mellitus. Heart failure accounted for 19.3% (127) of registry deaths; resuscitation was attempted on 27.9% (184) of victims, no ROSC was recorded in cases where ressucitation was attempted. GPS mapping of residence addresses shows CVD victims cluster in low socioeconomic areas.

Conclusion:
A CVD registry, created from a data-rich cohort of OHPND victims, will identify high-risk communities and illuminate common antecedents and modifiable CVD risk factors. Intensive community preventative health care efforts can be initiated to minimize the undue burden of CVD on rural populations.
Abstract 173: Predictors of Medication Noncompliance in Patients with an Acute Myocardial Infarction
Authors: Sabharwal Basera , Haddadin Faris , Rzechorzek Wojciech , Khandaker Mariam , Weininger David , Yue Bing , De La Villa Ricardo , Lee Shawn , Ahsan Syed , Lemor Alejandro , Selby Allison , Tamis-Holland Jacqueline
Published: April 2019

Background:
Aspirin, P2Y12 inhibitors, Statins, Angiotensin-Converting-Enzyme Inhibitor/Angiotensin II Receptor Blockers and Beta Blockers improve outcomes for patients with an Acute Myocardial Infarction (AMI). Despite this, some patients remain noncompliant with medications. We investigated potential predictors of medication noncompliance in patients with an AMI.

Method:
We examined adult patients with an AMI enrolled in a quality improvement program (QIP). Patients discharged prior to enrollment or those discharged to skilled nursing facilities were excluded. The primary outcome was medication noncompliance at the first follow up visit - defined as not taking at least 1 of the medications listed above. Multivariate logistic regression was used to identify risk factors for noncompliance.

Results:
Among 173 patients enrolled in the QIP, 119 patients (Mean age 64 +/- 1 year; 32% Females) had data regarding their follow-up office visit, of which 32% of patients were noncompliant. Table 1 lists the univariate and multivariate predictors of noncompliance. Among 25 clinical and socio-demographic variables examined, we found that needing help with medical care, or being a primary care giver to others were each associated with a roughly 5 fold higher risk of medication noncompliance.

Conclusion:
A significant number of patients with an AMI are noncompliant with their medications. Social support programs should focus efforts on providing patients with the help needed at home to ensure compliance with care.
Abstract 179: Cardiac Resynchronization Therapy among Cancer Patients in the United States: Results from National Inpatient Sample
Authors: Saxena Anshul , Rubens Muni , Das Sankalp , Bhatt Chintan , Ramamoorthy Venkataraghavan , Cavalcante Ludimila , Veledar Emir
Published: April 2019

Background:
Studies have shown that implantation of cardiac resynchronization therapy (CRT) devices could reduce morbidity and mortality in heart failure patients. Aims of this study are to examine the temporal trends and outcomes in CRT device implanted cancer survivors.

Method:
This study was a retrospective analysis of Nationwide Inpatient Sample during the period 2005-2014. Patients ≥18 years and who underwent CRT device implantation were included in the study. CCS codes 11-44 were used to identify cancer survivors. The International Classification of Diseases-9th Revision-Clinical Modification (ICD-9-CM) primary procedure codes 00.50 and 00.51 were used to identify patients with device implantation. Association between cancer diagnosis and in-hospital mortality and complications were determined using multivariable analyses.

Result:
During 2005 to 2014, a total of 392,758 inpatient CRT implantations were performed in the United States. Nearly 8.3% of these procedures were performed among patients with history of cancer. Number of procedures among cancer survivors decreased from 3127 in 2005 to 2115 in 2015. However, proportion of cancer patients undergoing CRT implantations increased from 6.8% in 2005 to 10.3% in 2014 (relative increase: 51.4%,
P
<0.001). Overall in-hospital mortality was higher among cancer survivors (odds ratio (OR) 1.44, 95% confidence interval (95% CI) 1.01-2.10), compared to patients without a history of cancer. In addition, pericardial complications (OR 3.11, 95% CI 1.15-8.44), and vascular complications (OR 2.53, 95% CI 1.43-3.56) were observed more among cancer survivors.

Discussion:
Our study found that proportion of CRT implantations among cancer survivors increased from 6.8% to 10.3% during the study period. In addition, CRT implantations among cancer survivors were associated higher in-hospital complications. Strategies like prehabilitation and close collaboration between cardiologists and oncologists could improve outcome and general well-being of cancer survivors undergoing CRT implantations.
Abstract 182: Adverse Pregnancy Outcomes and Cardiovascular Disease in the Mother: The Women’s Health Initiative (WHI)
Authors: Sondergaard Marc Meller , Hlatky Mark , Stefanick Marcia L. , Vittinghoff Eric , Nah Gregory , Howard Barbara , Allison Matthew , Shadyab Aladdin H. , Van Horn Linda , Gemmill Alison , Park Ki , Salmoirago-Blotcher Elena , E. Manson JoAnn , Sealy-Jefferson Shawnita , Valdiviezo Carolina , Sattari Maryam , Parikh Nisha I.
Published: April 2019

Background:
Adverse pregnancy outcomes (APOs) occur in up to 15% of all pregnancies, and are associated with an increased risk of long-term atherosclerotic cardiovascular disease (ASCVD) in the mother. However, it is unclear if this association is independent of standard ASCVD risk factors or is present in multiethnic populations with adjudicated CVD events.

Methods:
Participants in the Women’s Health Initiative were asked to complete a retrospective survey in 2017 about APOs, [gestational diabetes, birthweight < 5 pounds, birth weight > 9 pounds, delivery > 3 weeks pre-term, and hypertensive disorder of pregnancy (gestational hypertension or preeclampsia)]. Cox models were used to assess the hazard for developing incident ASCVD (defined as adjudicated stroke, myocardial infarction, peripheral artery disease, coronary revascularization). Follow up began at the baseline study exam. Hazard ratios were assessed using the Cox model. Two primary models were employed for each individual APO: 1) univariate, and 2) adjusted for the baseline ASCVD risk factors of age, smoking, use of cholesterol lowering drugs, hypertension and diabetes.

Results:
The 50,679 respondents were 89.1% White, 5.2% Black, 2.4% Hispanic, 2.1% Asian-Pacific Islander, and 1.2% Other race. There were 12,499 (25%) women who reported an APO: 1041 (2.1%) had gestational diabetes, 6282 (12.4%) had low birth weight, 2970 (5.9%) had high birth weight, 7365 (14.5%) had a premature birth, and 3238 (6.4%) had preeclampsia or gestational hypertension. Over 1,020,899 person-years of follow up, 3569 (7.0%) adjudicated CVD events occurred. In univariate models, each APO was associated with ASCVD (Figure). In multivariable models adjusting for standard risk factors, all APOs were associated with a significantly increased risk of CVD (Figure), with the exception of high birth weight. There was no significant effect modification by race on these associations.

Conclusion:
Adverse pregnancy outcomes were associated with increased risk of late ASCVD in a multiethnic population of post-menopausal women, independent of ASCVD risk factors. Associations between APO and ASCVD were consistent across racial groups. APOs should be considered in CVD risk assessment in women.
Abstract 190: A Systematic Alarm Management Pilot to Reduce Alarm Fatigue at a Tertiary Care Center
Authors: Venkateswaran Ramkumar V , Kreitzman Kevin , Fraai Michael , Brosseau Elizabeth , Preston Lisa , Scirica Benjamin M
Published: April 2019

Background:
While alarms on hospital telemetry units are vital to patient safety, alarm fatigue is a well-established and potentially dangerous consequence. Our goal was to implement an alarm management pilot to systematically determine how to safely reduce alarm burden.

Methods:
The Brigham and Women’s Hospital Monitoring Steering Committee (BWH MSC) studied the effect of alarm fatigue from March to November 2014 in a multiweek, phased pilot (Figure 1). The intervention groups were two medical/surgical stepdown units (group 1) and three cardiac stepdown units (group 2). The control group was a combination of two medical/surgical units and one cardiac stepdown unit. Various interventions were performed in a stepwise and cumulative manner. Electrodes were switched on a daily basis. The high heart rate (HR) alarm threshold was increased from 120 to 130 beats per minute (bpm) and the low HR threshold was decreased from 50 to 45 bpm. Duplicate alarms (e.g. “tachy” alarm same as high HR parameter alarm) and non-actionable alarms (e.g. “couplets”) were switched to messages (non-audible). Alarm data was pulled and analyzed on a weekly basis.

Results:
At baseline, there was wide fluctuation in alarms monitored/week across all three groups; however, the peak alarm unit averaged roughly 400 audible, unique alarms/bed/day. Heart rate alarms decreased by 54% after phase 2 in group 1 and 48% after phase 2 in group 2 (Figure 1). Audible alarms were reduced in phase 3 and 4, most notably by making non-actionable alarms inaudible (34% decrease in phase 3 in group 1, 64% decrease in phase 4 in group 2). Electrode alarms appeared to be mildly reduced in phase 1 and 2 (4-24%), however, these findings were not consistent in phase 3 and 4.

Conclusions:
Alarm type and burden varied widely across time and hospital units, making it difficult to generalize interventions. However, based on the pilot results, the BWH MSC implemented the following changes across all telemetry units: 1) high HR limit and low HR limits were made more permissive as above, and 2) duplicate and non-actionable alarms were made non-audible. The latter intervention was thought to provide the greatest impact based on our experience. While this pilot represented a systematic approach to reduce alarm burden, ongoing efforts to safely improve alarm burden are warranted.
Abstract 194: The Effect of Obstructive Sleep Apnea on the Outcomes of Patients with Supraventricular Tachycardia
Authors: Weininger David , Ochoa Roberto C , Rodriguez Mario , Setareh-Shenas Saman , De La Villa Ricardo , Manguba Alexander , Rzechorzek Wojciech
Published: April 2019

Background:
The obesity epidemic has become a major public health issue with repercussion through all the spectrum of cardiovascular disease. Obesity-associated pathologies like obstructive sleep apnea (OSA) have also emerged. There have been some studies associating OSA with cardiovascular disease, but the impact on outcomes is largely unknown.

Purpose:
evaluate the impact of OSA after adjustment for obesity on the outcomes of patients with supraventricular tachycardia (SVT).

Methods:
A retrospective analysis using the 2014 Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) was performed. Patients between the ages of 18 and 65 with a primary diagnosis of SVT as well as secondary diagnosis of OSA. The primary outcome was in-hospital mortality. The secondary outcomes were length of stay, cardiogenic shock, use of mechanical ventilation, acute kidney injury requiring dialysis (AKID), cost of stay, rate of direct current cardioversion (DCCV), rate of ablation, hemorrhage requiring transfusion (HRT), cardiac arrest and heart failure (HF) exacerbation. Multivariate regression analyses after adjustment for age, race, insurance, hospital location and obesity was done. Analysis was performed using Stata 15 IC.

Results:
7,690 patients with a primary diagnosis of SVT and secondary diagnosis of OSA were identified. 67% of this population were female and mean age was 65 years. Patients with OSA and SVT had decreased odds of death (OR 0.53 p<0.001) as well as decreased odds of HRT (OR 0.59 p< 0.001) and development of cardiogenic shock (OR 0.51 p=0.03). Also, a non-statically significant trend towards increased AKID (OR 1.11 p=0.71), along with decreased odds of cardiac arrest (OR 0.80 p= 0.34) and stroke (OR 0.82 p=0.72) was seen. There was also increased rate of heart failure exacerbation (OR 1.42 p<0.001) in patients with OSA hospitalized for SVT. Risk of cardiac arrest (OR 0.80 p=0.34) and stroke (OR 0.82 p=0.72) exhibit a non-statically significant decreased in odds. Length of stay was showed to be less (1.3 days p<0.001) in the OSA group cohort.

Conclusion:
Prior studies have showed decreased mortality in OSA patients with acute myocardial infarction. This retrospective analysis demonstrated that patients with OSA had decreased mortality when hospitalized for SVT. Nevertheless, patients had increased risk of HF exacerbation. Further studies are needed to clarify the full extent of this relationship.
Abstract 198: Lifetime Clinical Benefit of Folic Acid Therapy for Primary Prevention of Stroke in Patients with Hypertension - Projection Based on the CSPPT
Authors: Zhang Zugui , Zhang TianTian , Lin Tengfei , Wang Yang , Wang Binyan , Qin Xianhui , Xie Feng , Huo Yong , Wang Xiaobin , Jiang Jie
Published: April 2019

Background:
The CSPPT (China Stroke Primary Prevention Trial) demonstrated a significant risk reduction of first stroke in hypertensive patients treated with EPFA (enalapril plus folic acid) compared to those with enalapril alone, but the life time clinical benefit associated with the use of EPFA is unknown. In this study, we evaluated and quantified the net lifetime clinical benefit of EPFA vs. enalapril alone via assessing stroke-fee life expectancy.

Methods:
By establishing adjusted models for competing risks and an age-based time scale using data from 19, 053 participants of the CSPPT, we estimated lifetime incremental stroke-free life expectancy for EPFA vs. enalapril alone.

Results:
Compared with enalapril alone, lifetime EPFA treatment projected a mean stroke-free survival gain of 1.75 months, with an interquartile range months from 0.96 to 4.06 months and the maximum gain up to 12.95 months (
Table 1
). Subgroup analysis showed greater gain in stroke-free survival in younger male patients, and those with lower baseline folate levels, higher systolic blood pressure, higher total cholesterol and blood glucose, and with methylenetetrahydrofolate reductase (MTHFR) C677T CT or TT genotype; the net benefit of stroke-free life expectancy varies from 3.5 months to 5.3 months among subgroup (
Figure 1
).

Conclusions:
Our analyses projected that compared with enalapril alone, enalapril plus folic acid treatment in patients with hypertension is associated with a modest gain in lifetime stroke-free life expectancy. Younger male patients and those with lower baseline folate levels, and higher systolic blood pressure, total cholesterol and blood glucose, and the MTHFR C677T CT or TT genotype are expected to benefit most from the treatment.
Abstract 203: Radial versus Femoral Approach for Percutaneous Coronary Intervention in Patients with Cardiogenic Shock: A Systematic Review and Meta-analysis
Authors: Alreshq Rabah , Yager Neil
Published: April 2019

Background:
The transradial approach (TRA) has become increasingly adopted in clinical practice, given its potential advantages over the transfemoral approach (TFA). Despite cardiogenic shock (CS) being the leading cause of mortality in patients hospitalized with acute myocardial infarction, most studies comparing the two approaches have excluded patients with CS.

Objectives:
Our study sought to compare the clinical outcomes between the TRA and TFA in patients with CS undergoing percutaneous coronary intervention (PCI).

Methods:
We performed an updated systematic review and meta-analysis of published studies that investigated the outcomes of TRA versus TFA for PCI in patients with CS. A comprehensive literature search of PUBMED, EMBASE, and Cochrane databases was conducted in November 2018. The primary endpoints were: major adverse cardiac events (MACE), all-cause mortality, and major bleeding at 30-days of follow-up. Relative risk (RR) and 95% confidence interval (CI) was calculated using the Mantel-Haenszel method.

Results:
A total of 6 studies involving 7817 patients with CS were included in the meta-analysis, of which 2237 underwent PCI by TRA (29%) and 5580 underwent PCI by TFA (71%). Compared to TFA, TRA was associated with significant reduction in MACE (RR 0.68, 95% CI 0.63 to 0.73; 6698 participants; 4 studies)
(figure 1A)
, all-cause mortality (RR 0.63, 95% CI 0.55 to 0.73; 6910 participants; 5 studies)
(figure 1B)
, major bleeding (RR 0.44, 95% CI 0.33 to 0.60; 7080 participants; 6 studies)
(figure 1C)
, and access site related complications (RR 0.12, 95% CI 0.04 to 0.34; 505 participants; 4 studies). There was no difference between the 2 approaches in blood transfusion requirement (RR 0.55, 95% CI 0.29 to 1.04; 7268 participants; 5 studies).

Conclusions:
Our meta-analysis demonstrates that the TRA is safe and feasible in patients with CS undergoing PCI, and it is associated with lower MACE, all-cause mortality, major bleeding and access site related complications in comparison to the TFA.
Abstract 210: Rates of Drug Switching and Discontinuation among Nonvalvular Atrial Fibrillation Elderly Patients Treated with Direct Oral Anticoagulants in the US
Authors: Baker Christine L , Dhamane Amol D , Rajpura Jigar , Mardekian Jack , Dina Oluwaseyi , Russ Cristina , Rosenblatt Lisa , Lingohr-Smith Melissa , Lin Jay
Published: April 2019

Background:
While many studies have demonstrated the efficacy of direct-acting oral anticoagulants (DOACs) for stroke risk reduction among nonvalvular atrial fibrillation (NVAF) patients, there is little information regarding drug switching and discontinuation patterns in real-world settings, particularly in older adults. Thus, we evaluated rates of switching and discontinuation among elderly NVAF patients who initiated any of the three most commonly prescribed DOACs in the US.

Methods:
Patients ≥65 years who initiated apixaban, rivaroxaban or dabigatran (index event/date) were identified from the Humana database (1/1/2013-9/30/2017) and grouped into cohorts by index DOAC. Patients were required to have an NVAF diagnosis and continuous health plan enrollment for ≥12 months prior to the index date and ≥3 months during the follow-up period after the index date. Percentages of patients in each study cohort who switched to any other DOAC or warfarin or discontinued their index DOAC were evaluated. Multivariable Cox regression analyses were carried out to evaluate the impact of index DOAC treatments on the likelihood of switching or discontinuation while controlling for differences in patient characteristics.

Results:
Of the final study population (n=38,250), 56% initiated apixaban (n=21,376; mean age: 78.6 years), 37% rivaroxaban (n=14,277; mean age: 77.4 years), and 7% dabigatran (n=2,597; mean age: 77.0 years). During follow-up, the switching rate was lowest for patients treated with apixaban at 5.2%, followed by patients treated with rivaroxaban (10.6%), and patients treated with dabigatran (16.9%, p<0.001 across the 3 cohorts). Patients treated with apixaban also had the lowest discontinuation rate (63.2% vs. 68.7% vs. 71.7%, p<0.001). After controlling for patient differences, those treated with rivaroxaban and dabigatran had significantly greater likelihood of switching treatment than patients treated with apixaban (Figure A). Also, rivaroxaban and dabigatran treated patients were significantly more likely to discontinue DOAC treatment (Figure B).

Conclusion:
Of the DOACs evaluated in this real-world study, apixaban was associated with the lowest rates of switching and discontinuation among elderly NVAF patients.
Abstract 229: Atrial Fibrillation Effect on the Outcomes and Prognosis of Myocarditis, a Report From the National Inpatient Sample of 2016
Authors: Haddadin Faris I , Munoz Estrella Alba , Bandyopadhyay Dhrubajyoti , Haddadin Suhail , Beidoun Hassan , Modi Vivek , Herzog Eyal
Published: April 2019

Background:
Myocarditis of different etiologies can either present with different types of already existing arrhythmias or be the cause of subsequent arrhythmias. Literature have shown that both scenarios hold worse prognosis and outcomes.

Methods:
We conducted a retrospective cohort study based on the 2016 National Inpatient Sample of adults (>18 years) hospitalized for acute myocarditis of any kind as the primary admitting diagnosis and atrial fibrillation (AF) as a secondary concomitant diagnosis based on ICD-10 codes. All-cause mortality was our primary outcome while length of stay, in-hospital arrhythmia of any kind requiring DCCV, acute respiratory failure, the rate of endotracheal intubation, ICD device insertion and VAD placement during the same hospital stay were our secondary outcomes. We used multivariate regression adjusted for age, sex, race, history of coronary artery disease, history of congestive heart failure, Charlson comorbidity index, hospital region, size and teaching status. STATA-15 was used for statistical analysis.

Results:
In 2016, there were 8,110 admissions for myocarditis (37.9% females), out of whom 315 (3.9%) had concomitant AF. Mean age was 40y (39.5y without AF, 59y with AF). Our results, table 1, showed that myocarditis with AF significantly increased all-cause mortality (6.3% [20 of 315] vs 1.6% [130 of 7,760], OR 8.28, p <0.001), had higher rate of in-hospital arrhythmia of any kind requiring DCCV (7.9% [25 of 315] vs 1.7% [130 of 7,760], OR 4.88, p=0.017), were more likely to have undergone ICD device placement (6.4% [20 of 315] vs 0.76% [60 of 7,760], OR 14.31, p=0.016) and VAD placement (6.3% [20 of 315] vs 0.77% [60 of 7,760], OR 11.35, p=0.001). However, there was no significant difference in the length of stay (7.9 days vs 5.1 days, Coef. 2.12 [-0.23-4.46], p=0.077), the rate of acute respiratory failure (17.4% [55 of 315] vs 9% [700 of 7,760], OR 1.39, p=0.403) or the rate of endotracheal intubation (9.5% [30 of 315] vs 3.8% [300 of 7,760], OR 2.21, p=0.143).

Conclusion:
Atrial fibrillation appears to be an independent risk factor for higher all-cause mortality rate in myocarditis and is also associated with higher rate of ICD device and VAD implantation during the same hospital stay. Thus, patients with AF who are hospitalized for myocarditis mostly have worse in-hospital outcomes.