bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P311: CAPTURE: Cardio-Pulmonary Tissue Repository
Authors: Cheema Faisal H , Schaefle Kenneth J , Magda Gabriela , Malik Nasir , Goldsmith Lyn , Umann Tianna M , Latif Farhana , Williams Matthew , Stewart Alan , Oz Mehmet , Naka Yoshifumi , Smith Craig R , Argenziano Michael
Published: July 2021

Background:
Cardiothoracic tissue is highly sought by researchers, yet repositories for such tissue are conspicuously absent in the U.S.A. This limits the availability of research-quality tissue specimens. Columbia University is one of the nation's busiest heart and lung transplant centers and has excellent access to such tissue.

Ca

rdio

p

ulmonary

T

iss

u

e

Re

pository (CAPTURE) aims to fill this existing resource gap by creating a large-scale cardiothoracic tissue repository.

Methods:
Since 1999 Columbia University has collected cardiothoracic tissue on an informal basis. This is now being transitioned into CAPTURE, a sophisticated tissue bank for the collection, preservation, and distribution of research-quality tissue specimens. A team is on call 24/7 to collect tissue samples and process them immediately by flash freezing, formalin or RNAlater. Samples are annotated with clinical data from the Patients' Advantage Cardiothoracic Surgery Clinical Research Project (PACTS-CR Project), labeled with bar codes, catalogued using PROGENY LIMS (a secure electronic tracking system), and stored in freezers protected by emergency back-up (
centralized storage and collection
). CAPTURE aims to expand into a strong network of regional hospitals that contribute and utilize tissues (
centralized storage and decentralized collection
), and then to transition into a specialized program of research excellence (SPORE), becoming an NIH/NHLBI partner and later a nationwide cardiopulmonary tissue repository (
decentralized storage and collection
).

Results:
Tissue has been obtained from over 700 patients over the last decade. By obtaining up to 35 samples from each heart explanted during orthotopic heart transplant and up to 10 samples per myocardial core taken during ventricular assist device (VAD) implantation, over 12,000 tissue samples are currently stored. Intra- and multicenter collaborations have utilized these tissues to conduct several different studies.

Conclusion:
Successful past experiences have shown the promise of maintaining even an informal bank of cardiothoracic tissue samples. By offering greatly expanded and sophisticated tissue banking facilities, we anticipate CAPTURE will accelerate basic science and translational research.
Abstract P312: Impact of Cardiovascular Disease Guideline Dissemination on Provider Knowlege: A Statewide Physician Survey
Authors: Heppe Daniel B , Bucher Bartelson Becki , Estacio Ray , Krantz Mori J
Published: July 2021

Objective:
We sought to evaluate the presence of a knowledge gap amongst Colorado providers in evidence-based treatment of modifiable CVD risk factors. We wished to identify provider characteristics associated with a larger knowledge gap and we hypothesized that direct dissemination of a CVD/stroke clinical practice guideline (CPG) might narrow the gap.

Methods and Analysis:
A baseline knowledge survey was distributed to licensed Colorado providers to ensure representation by specialty, provider type, region, population density and years in practice. The CPG was then distributed followed by a repeat knowledge survey to assess proportion reading the guideline and any change in an aggregate knowledge score. We evaluated associations between provider characteristics with CPG review. We then compared pre and post CPG knowledge scores among all respondents, those who read and did not read the guidance. The survey answers were also analyzed to identify specific content areas of CVD knowledge deficits

Findings:
Of 1415 licensed providers, 59% (830) completed the pre guideline survey, 46% (651) completed the post survey and 37% (523) completed both. The weighted mean of self reported CPG review was 51% (325 of 651, 95% CI 47-55) and was significantly higher amongst mid-level providers (63% vs 44%, p<0.001) than physicians and those in practice greater than 5 years (53% vs 40%, p=0.017). A knowledge deficit was identified in the area of ACE inhibitor use in CKD, post MI, and heart failure patients. Baseline knowledge score was 71% and improved minimally to 72.2% (p=0.038) among those who reviewed the CPG.

Conclusions:
A significant CVD knowledge gap exists among primary care providers in Colorado, particularly in the use of ACE inhibitors for specific compelling indications. Direct dissemination of our CPG to providers resulted in a high rate of review of the guidance. Midlevel providers and those in practice for > 5 years were more likely to read the CPG. Nonetheless, review of our CPG provided only a small but significant improvement in knowledge, highlighting the need for more robust dissemination and education strategies.
Abstract P319: Which Types of Hospitals Have Higher Readmission Rates for Heart Failure
Authors: Joynt Karen E , Jha Ashish K
Published: July 2021

Reducing readmissions is an important policy goal, and heart failure (HF) is the most common cause of both hospitalizations and readmissions in the Medicare program. Most proposed policy changes involve penalizing poorly-performing hospitals, yet we know little about what kinds of U.S. hospitals have high readmission rates, and therefore might be at particularly high risk of facing financial penalties. We created multivariable regression models using Medicare inpatient data from 2006-2007 to examine the relationship between hospital characteristics and 30-day all-cause readmission rates for patients with a primary discharge diagnosis of HF. Given that many pay-for-performance programs penalize poor performers based on categorical cutpoints, we also examined the likelihood that a hospital would be in the worst quartile or decile of readmission rates nationally. Among the 4,010 hospitals in our sample, critical access hospitals and small hospitals had significantly higher 30-day readmission rates than medium or large hospitals (
Table
). Hospitals not part of a system had higher readmission rates than hospitals that were members of systems, and both public hospitals and for-profit hospitals had higher readmission rates than private non-profit hospitals. These same hospitals were far more likely to perform in the bottom quartile or decile nationally (Table). Consequently, these hospitals will be at significantly higher risk of payment reductions if cut-points are used to target institutions for penalties. Given that some of the most resource-poor hospitals in the country are among the worst performers for HF readmissions, quality improvement efforts that rely on penalties and rewards may further widen the quality gap. Concerted efforts are needed to understand why these hospitals perform poorly, why the top hospitals perform well, and how best to design interventions to improve the quality of care for all HF patients, regardless of where they seek medical care.

Hospital Characteristics
30-day readmission rate
P value
OR (95% CI) for worst quartile
P value
OR (95% CI) for worst decile
P value

Hospital Type
Critical Access
28.2%
<0.001
12.4 (7.2, 21.4)
<0.001
12.5 (4.3, 36.6)
<0.001

Small
27.1%
8.1 (4.9, 13.6)
<0.001
8.9 (3.1, 25.4)
<0.001

Medium
25.4%
3.0 (1.8, 4.8)
<0.001
2.4 (0.9, 6.6)
0.10

Large
24.2%
1.0
Ref
1.0
Ref

Hospital System
Non-member
26.5%
0.048
1.2 (1.0, 1.4)
0.02
1.5 (1.2, 1.9)
0.002

Member
26.0%
1.0
Ref
1.0
Ref

Ownership
For-profit
27.0%
<0.001
1.7 (1.3, 2.1)
<0.001
1.6 (1.1, 2.3)
0.007

Public
26.7%
1.3 (1.0. 1.5)
0.02
1.3 (1.0, 1.7)
0.03

Non-profit
25.7%
1.0
Ref
1.0
Ref
Abstract P32: Potential Underuse of Antidepressants in Post Stroke Depression: Data From the AVAIL Registry
Authors: El Husseini Nada , Laskowitz Daniel T , Guidon Amanda C , Olson DaiWai M , Zhao Xin , Pan Wenqin , Zimmer Louise O , Drew Laura A , Peterson Eric D , Goldstein Larry B , Bushnell Cheryl
Published: July 2021

Background:
Post-stroke depression is common, yet little is known about factors associated with antidepressant use in this population

Methods:
Data from the multicenter, prospective Adherence eValuation After Ischemic stroke-Longitudinal (AVAIL) registry was used to identify patients with post-stroke depression and to describe factors associated with antidepressant use. The analysis was performed after 3 months in 1751 ischemic stroke patients who had been admitted to 97 hospitals nationwide; 12 month follow-up was available for 1637 patients. The Get with the Guidelines-Stroke database was used to collect baseline data. Patients were classified as depressed based on a self-report scale (the Patient Health Questionnaire-8; score range 0 to 24, score ≥10 indicating depression). Frequencies were compared with Pearson X
2
and unadjusted ORs were calculated.

Results:
The prevalence of post stroke depression was similar at 3 and 12 months (19% [331/1751] vs 17% [280/1637], respectively, p=0.17). Regardless of depression status, antidepressant use was higher at 12 months (16% [287/1751] vs 20% [334/1637], p=0.002). Antidepressant use was also higher at 12 months in depressed patients (25% [84/331] vs 35% [98/280], p=0.009). The odds of antidepressant use at 3 months was higher in women than men (OR 1.6, 95% CI 1.2-2.1), Whites vs. Blacks (OR 1.7, 95% CI 1.1-2.8), in patients with vs. without cognitive deficits (OR 1.6, 95% CI 1.2-2.1) and in those with more severe disabilities (mRS≥3 vs. mRS<3, OR 1.7, 95% CI 1.3-2.3). Use did not vary with educational level, marital status, living situation, medication insurance coverage, or stroke recurrence. Similar trends were present at 12 months, except with higher use in those with recurrent stroke or TIA (OR 2.1, 95% CI 1.4-3.1).

Conclusion:
Three-quarters of depressed stroke patients at 3-months and nearly two-thirds at 12 months were not receiving antidepressants. Regardless of depression status, utilization of antidepressants after 3 and 12 months varied based on gender, race/ethnicity, cognitive status, disability level, and after 12-months, stroke recurrence. The reasons for the apparent underuse of antidepressants in patients with prevalent post-stroke depression require further study.
Abstract P326: Health Status and Frailty in Assisted Living and Nursing Home Residents
Authors: Kanwar Amrit , Lennon Ryan J , Ghanta Kalyan , Singh Mandeep , Roger Veronique L
Published: July 2021

Objectives:
To determine the prevalence and relationship of frailty and health status measures among residents of long-term care [nursing homes (NH) and assisted living (AL)] facilities.

Resident and methods:
Residents ≥ 65 years who are residents of NH and AL facilities at La Crosse county, Wisconsin, were assessed for frailty (gait speed, unintended weight loss, and grip strength), comorbidity (Charlson index), and quality of life (QOL) [Short Form (SF)-36].

Results:
Among 96 participants (57 from NH and 39 from AL), 78% were frail. The prevalence of frailty (77% vs. 79%), comorbidity (2.0 vs. 2.0), and poor health status did not differ between residents of NH and AL living facilities. Frail residents were older and had higher comorbidity index (2.0 vs. 0, p=0.02), including diabetes mellitus, hypertension, and heart failure. Frailty had the strongest correlation with the SF-36 Physical Component Score (r=-0.45), Figure. It exhibited weaker associations with comorbidity and the SF-36 Mental Component Score. Overall, SF-36 for physical component was lower among frail residents (33 vs. 48, p<0.001). Following adjustments by linear regression, compared to those without frailty, frail residents had lower adjusted quality of life scores.

Conclusion:
Frailty was highly prevalent among residents of long-term care facilities and did not differ between NH and AL facilities. We noted significant correlations between frailty, comorbid conditions, and poor quality of life.
Abstract P327: Frail Older Adults at Risk for Loss of Independence following MI
Authors: Alexander Karen P , Reid Kimberly J , Chan Paul S , Gharachalou S. M , Peterson Eric D , Krumholz Harlan M , Rich Michael W , Weintraub William S , Spertus John A
Published: July 2021

Background:
One month following a myocardial infarction (MI), more than a third of older adults (age ≥65 years) are frail as demonstrated by slow gait speed (≤ 0.65 m/sec). The prognostic significance of frailty in a cardiovascular population in terms of future health states is unknown.

Methods:
The TRIUMPH longitudinal registry enrolled 1314 older adults (age ≥65 years) following an acute MI from 24 US centers. Gait speed (m/sec) was determined at one month (to allow for acute recovery) in 329 patients with in-home follow up. Using averages of 3 timed walks over 15-feet, patients were stratified by gait speed into 2 groups: slow (<0.65m/sec) and preserved (≥0.65m/sec). One year basic (mobility, self care) and instrumental activities of daily living (ADL) (phone, meds, travel, money), physical function score (SF12 PCS), quality of life (Seattle Angina Questionnaire (SAQ)), and mortality were assessed.

Results:
Slow gait speed was present in 38% (N=126) of older adults at 1 month. At 1 year, despite similar survival, frail adults were much more likely to need help with basic and instrumental (ADL), and had lower physical function and quality of life (QOL) compared to non-frail adults. (
table
) Slower gait speed remained a significant predictor of worse physical function at 1 year after adjustment for baseline physical function (p=0.013).

Conclusions:
Frailty is common in older adults following an MI, and those with frailty are at substantial risk for continued impairment over time. Understanding the mechanisms or reversibility of this vulnerable state would contribute to optimization of independence and quality of life among older adults with cardiovascular disease.

Frailty Post MI and 1 Year Outcomes

Frail (Gait <0.65m/sec)N=126
Not Frail (Gait ≥0.65m/sec)N=203
P value

Mobility ADL (% need help)
45
23
<0.001

Self-Care ADL (% need help)
11
4
<0.001

Instrumental ADLs (% need help)
36
19
0.003

Physical Function (PCS)
39.2 ± 12.0
47.2 ± 9.7
<0.001

SAQ Quality of Life (QOL)
88.0 ± 15.9
91.3 ± 12.1
0.061

Mortality (%)
5.6
4.5
NS
Abstract P349: Risk Factors for Rehospitalization for Syncope and for Long-Term Mortality in 325 Consecutive Patients Hospitalized for Syncope
Authors: sule sachin S , Palaniswamy Chandrasekar , Aronow Wilbert S , Peterson Stephen J , Ahn Chul , Adapa Sreedhar , Mudambi Lakshmi
Published: July 2021

Purpose:
To investigate in patients hospitalized for syncope risk factors for rehospitalization for syncope and long-term mortality.

Methods:
We investigated in 325 consecutive patients, mean age 66 ± 17 years, hospitalized for syncope risk factors for rehospitalization for syncope and long-term mortality. Mean follow-up was 27 ± 8 months.

Results:
Of 325 patients, 13 (4%) were rehospitalized for syncope, and 38 (12%) died. Stepwise logistic regression analysis showed significant independent prognostic factors for rehospitalization for syncope were glomerular filtration rate (GFR) (odds ratio 0.97; 95% CI, 0.95-0.995) diabetes (odds ratio 5.7; 95% CI, 1.6-20.4), atrial fibrillation (odds ratio 4.0; 95% CI, 1.0-15.6), and smoking (odds ratio 4.6 ; 95% CI, 1.3-16.8). Stepwise Cox regression analysis showed significant independent prognostic factors for mortality were GFR (hazard ratio (HR) 0.98 (95% CI, 0.97-0.99), diabetes ( HR 2.7; 95% CI = 1.4-5.2), coronary artery surgery (HR 2.9; 95% CI, 1.3-6.5), malignancy history ( HR 2.5; 95% CI, 1.2-5.2), narcotics use (HR 4.0; 95% CI, 1.7-9.8), smoking (HR 2.8; 95% CI, 1.4-5.5), and atrial fibrillation (HR 2.4; 95% CI, 1.0-5.4).

Conclusions:
In patients hospitalized for syncope, significant independent prognostic factors for rehospitalization for syncope were GFR, diabetes, atrial fibrillation, and smoking; significant independent prognostic factors for mortality were GFR, diabetes, coronary artery surgery, malignancy history, narcotics use, smoking, and atrial fibrillation.
Abstract P41: Predictive Models of Mortality After Stroke: A Systematic Review
Authors: Bernheim Susannah M , Bhat Kanchana , Savage Shantal , Phipps Michael , Drye Elizabeth , Ross Joseph S , Desai Mayur , Krumholz Harlan , Lichtman Judith H
Published: July 2021

Objectives:
Risk-standardized mortality is increasingly recognized as an important measure of hospital quality. We conducted a systematic review to identify models of morality after stroke developed to profile hospitals or predict patient mortality within 1 year of stroke hospitalization.

Methods:
We searched PubMed for English-language articles published since 1996. Articles were excluded if they were restricted to hemorrhagic strokes or transient ischemic attacks, did not report mortality within 1 year of the index stroke event, had fewer than 100 subjects, considered only a sub-group of patients based on a demographic or clinical characteristic (e.g. only diabetic patients), or used a composite outcome. The investigators independently reviewed all abstracts to select articles that met criteria and used a standardized instrument to abstract information.

Findings:
Of the 1,794 articles identified during the initial search, only 20 met our inclusion criteria. We identified one article that developed a model for purposes of hospital comparison; this model focused on the predictive value of laboratory results. The remaining 19 articles developed models to predict patient-level mortality. All of the studies relied on chart data for their models. The studies varied in terms of case definition (10/20 included ischemic and hemorrhagic strokes), duration of follow-up, and the selection of covariates for inclusion in the models. The significance of included clinical covariates also varied across studies for age (significant in 12/18 models), diabetes/ hyperglycemia (4/15), prior stroke (4/14), hypertension (2/13), atrial fibrillation (4/12), and ischemic heart disease (2/12). Less than half (9/20) of the papers included a stroke severity measure in the model. Although the severity measure varied widely across studies, most (8/9) found severity to be significantly associated with mortality. Fewer than half of the studies included an external validation of their model.

Conclusions:
We identified 20 separate models to predict stroke mortality but these studies varied widely in characteristics and findings. Our search did not identify a validated hospital-level model that could be feasibly used to measure hospital quality on a national level.
Abstract P51: Aspiration Pneumonia is a Negative Predictor of Post-Stroke Level of Care: Findings From the UTHSC Houston Stroke Registry
Authors: Jones Nneka I , Harun Nusrat , Grotta James
Published: July 2021

Introduction:
Aspiration Pneumonia (AsPNA) in acute stroke patients can lead to a three-fold risk in mortality. Treatment of AsPNA requires increased acuity of hospital care for antibiotic therapy and respiratory management. This care is provided at all levels, including Inpatient Rehabilitation (IR), Skilled Nursing Facility (SNF) or Sub-acute Care (Sub). There are limited studies assessing the role of AsPNA as an independent predictor of post-stroke disposition.

Hypothesis:
Low NIHSS is a predictor of higher functional status. We assessed the hypothesis that absence of AsPNA predicts post-stroke disposition to a functional level similar to low NIHSS.

Methods:
All patients admitted to the UT Stroke Service between January 2004 and October 2009 were included. Stratification occurred for age>65, NIHSS and stroke risk factors. Using multivariate logistic regression, the data was analyzed for differences in post-stroke disposition among patients without aspiration pneumonia.

Results:
Home vs. Other Level of Care
Of 3390 patients, 1668 were discharged home, 1722 to another level of care. Patients without AsPNA are
5.3
times more likely to be discharged home (P = <.0001, OR 5.272, 95% CI 2.902 to 9.578). Patients with NIHSS < 8 are
15.1
times more likely to be discharged home.
IR vs. SNF
Of 1547 patients, 983 patients were discharged to IR, 564 to SNF. Patients without AsPNA are
8.6
times more likely to be discharged to IR (P = <.0001, OR 8.592, 95% CI 4.574 to 16.140). Patients with NIHSS < 8 are
3.4
times more likely to be discharged to IR.
SNF vs. Sub
Of 739 patients, 564 were discharged to SNF, 175 to Sub. Patients without AsPNA are
5.5
times more likely to be discharged to SNF (P = <.0001, OR 5.461, 95% CI 3.571 to 8.351). Patients with NIHSS < 8 are
2.6
times more likely to be discharged to SNF.

Conclusions:
The absence of AsPNA is an independent predictor of improved post-stroke disposition. Patients with AsPNA have an increased likelihood of post-acute stroke care at a lower functional level, with a correlation stronger than NIHSS. This study is limited by its retrospective nature and unmeasured psychosocial factors related to discharge. Prospective studies on dysphagia screening, dietary modification and respiratory management are needed.
Abstract P63: BRIDGE Clinic: A Novel Approach to the Hospital-to-Home Transition
Authors: Bumpus Sherry M , Smith Cydni , Kosteva Adam , Kline-Rogers Eva , Housholder-Hughes Susan , Mollo Lynette , Bord Cheryl , Merz Julie , Norville Janice , Leidal Adam , Figurel Jeanette , Eagle Kim A , Rubenfire Melvyn
Published: July 2021

Background:
Unplanned 30-day rehospitalization rates for AMI (19.9%) and CHF (24.4%) represent a huge health care burden for patients and providers. Delays in follow-up and lack of adherence to standardized guidelines, by providers and patients, contribute to these findings. The hospital-to-home transition is one area with the potential to effect changes in this complex problem. Specially trained outpatient cardiovascular nurse practitioners (NP) aim to “bridge” the transitional care gap in the Cardiovascular Medicine Bridge Program (BRIDGE). NPs, acting as an extension of the inpatient team, adjust treatments depending on patient status, educate patients, and ensure adherence to lifestyle and therapeutic guidelines.

Purpose:
To assess differences between patients who attended the BRIDGE clinic and those who did not.

Methods:
This was a retrospective study of all patients referred to BRIDGE, from June 2008 to February 2009. Univariate techniques were used to compare those who attended BRIDGE and those who did not, in terms of age, diagnoses, comorbidities, time to follow-up visit with a cardiologist, and unplanned readmission.

Results:
Of 359 patients, 239 (67%) attended BRIDGE, mean time from discharge to BRIDGE follow-up was 19.8 days. Mean age of attendees was 63.9, non-attendees M = 61.2, P = .110; 66.6% were male. Patients were more likely to attend BRIDGE if they had greater than two comorbidities (≤ 2 comorbidities 10.5% vs. > 2 comorbidities 18.3%, P = .046). Primary cardiac diagnoses accounted for 217 (60.6%) BRIDGE referrals (ACS 21.2%, CAD 13.7%, CHF 13.4%, other cardiac 12.3%); cardiac was a secondary diagnosis or complication for the remaining 39.4%. Mean days from discharge to first cardiology appointment was 73.0 for attendees and 53.6 for non-attendees, P = .018. BRIDGE attendees had significantly lower 30-day readmission and ED rates than those who did not attend (readmit: attend 8.7 % vs. not attend 21.7%, P = .001, ED visits: attend 13.5% vs. not attend 28.2%, P = .005).

Conclusion:
Individuals who attended the BRIDGE clinic had fewer unplanned readmissions, when compared to patients who did not take advantage of this opportunity. These preliminary findings suggest that this strategy can improve efficiency of acute cardiac care in the US.
Abstract P76: Effect of Patient Activation on Self-Management Behaviors in Heart Failure
Authors: Shively Martha , Gardetto Nancy , Kodiath Mary , Kelly Ann , Smith Tom
Published: July 2021

Background
Disease management and chronic care models have evidenced success with heart failure (HF) patients but have not fully explored patients' engagement/activation in self- care.

Objective
Determine efficacy of a patient activation intervention (Heart PACT Program) compared to usual care on activation and self-care management in HF.

Methods
This study was a 4-year, randomized, 2-group, repeated-measures design (baseline, 3 months, and 6 months). Following consent, 84 patients were stratified by activation level and randomly assigned to usual care (n = 41), or usual care plus the activation intervention (n = 43). The primary outcome variables were patient activation using the Patient Activation Measure (PAM) (Hibbard et al., 2005), and self-care using the Self-Care for Heart Failure Index (SCHFI) (Riegel et al., 2004) and the Medical Outcomes Study (MOS) Specific Adherence Scale. The intervention consisted of individual meetings and phone call follow-up over 6 months based on the patient's level of activation: stage 1 or 2 (low activation), stage 3 (medium), or stage 4 (high) as assessed by the patient's self-report PAM score and brief interview. The leaders collaborated with patients to improve activation and self-management of HF: adhering to medications; monitoring weight, blood pressure, and symptoms; and implementing health behavior goals.

Findings
Participants were primarily male (99%), Caucasian (77%), and classified as NYHA III (52%). The mean age was 66 years (SD 11). The majority (71%) of participants reported 3 or more comorbid conditions. The intervention group compared to the usual care group showed a significant increase in activation/PAM scores from baseline to 6 months (significant group by time interaction linear contrast, F=16.90, p=.02). Although the baseline MOS mean was lower in the intervention group, results revealed a significant group by time effect (F=9.16, p = .001) with the intervention group improving more over time. There were no significant group by time interactions for the SCHFI.

Conclusion
Patient activation can be improved through targeted intervention. The patient activation model has the potential to change approaches to tailored patient education for self-management in heart failure.
Abstract 12: Determinants of Health-Related Quality of Life after Percutaneous Coronary Intervention or Bypass Surgery: Insights from the SYNTAX Trial
Authors: Arnold Suzanne V , Magnuson Elizabeth A , Wang Kaijun , Serruys Patrick W , Kappetein A P , Mohr Friedrich W , Cohen David J
Published: July 2021

Background:
Patients with multivessel or left main CAD treated with CABG have a small but significant improvement in angina as compared to those treated with PCI. However, there is uncertainty as to the mechanism of greater angina relief with CABG and whether the greater need for repeat revascularization in PCI patients could account for this treatment difference.

Methods:
In the SYNTAX trial, 1800 patients with three-vessel or left main CAD were randomized to CABG (n=897) or PCI with paclitaxel-eluting stents (n=903). Health-related quality of life was assessed at baseline, 1, 6, and 12 months using the Seattle Angina Questionnaire and the SF-36 General Health Survey. Longitudinal random effect growth curve models were used to examine the association between patient-related factors, treatment-related factors, clinical outcomes, and follow-up health status.

Results:
Older age, male sex, and absence of angina at baseline were associated with less angina at 12 months, whereas completeness of revascularization was not. The need for repeat revascularization was associated with worse angina frequency scores in both treatment groups, with differences in PCI patients of 7.8 points at 6 months (p<0.001) and 2.9 points at 12 months (p=0.07) and in CABG patients of 16.4 points at 6 months (p<0.001) and 9.1 points at 12 months (p<0.001). Among patients who did not require repeat revascularization, the effect of CABG vs. PCI on 12-month angina frequency scores was 1.6 points–nearly identical to the overall benefit in the intention-to-treat analysis.

Conclusions:
Patients with multivessel or left main CAD who required repeat revascularization had substantially worse angina and overall health status during follow-up. However, this factor explained little of the treatment benefit observed with CABG over PCI in the overall population, suggesting that some of the anti-anginal benefit of CABG may result from mechanisms unrelated to relief of myocardial ischemia. In addition, there was a substantial difference in the magnitude of association between repeat revascularization and anginal status in patients treated with CABG as compared with PCI, suggesting that this endpoint should play a limited role in any direct comparison of the two treatment strategies.
Abstract P116: Valuing Improvement in Value-Based Purchasing
Authors: Borden William B , Blustein Jan
Published: July 2021

Background
Medicare will soon implement hospital value-based purchasing (VBP) nationwide, with a scoring system that values both achievement (absolute performance on measures) and improvement (performance increase over time). Yet the way that improvement is defined in one VBP proposal gives less credit to initial low performers than initial high performers. Since initial low performers are disproportionately hospitals in socioeconomically disadvantaged areas, these institutions stand to lose under that proposal. We suggest a simple change to the VBP scoring proposal that awards equal credit for equal improvement, and test the impact of that modification on hospital scores in areas of locational advantage and disadvantage.

Methods
The Medicare 2007 Report to Congress proposed scoring methodology uses a fixed achievement scale for all hospitals and a variable improvement scale unique to each hospital, with the highest score determining the final blended score. We modified the formula to create a fixed improvement scale, mirroring the achievement scale. Using 2005-2008 CMS composite process measure performance for acute myocardial infarction (AMI) and heart failure (HF), we calculated hospital scores using both the original and modified approaches. The most and least locationally advantaged hospitals were compared across 5 locational dimensions: poverty, unemployment, physician shortage, high school graduates, and college graduates.

Results
The least advantaged hospitals demonstrated greater absolute improvement over time. The original formula yielded higher blended scores for the most locationally advantaged hospitals for 4/5 dimensions in AMI and 2/5 for HF. After implementing the modified formula, differences on blended scores between hospitals in the most and least advantaged areas existed in 3/5 dimensions in AMI and 1/5 dimensions for HF.

Conclusions
Compared to a proposed VBP formula, use of a modified formula that reflects the principle of “equal credit for equal improvement,” resulted in a relatively equitable distribution of blended payment scores. This modification could be incorporated into Medicare's hospital VBP program, allowing hospitals in both socioeconomically advantaged and disadvantaged areas to succeed.
Abstract P124: Perceived Stress in Acute Myocardial Infarction: Associations with Long-Term Health Status Outcomes
Authors: Arnold Suzanne V , Smolderen Kim G , Buchanan Donna M , Li Yan , Spertus John A
Published: July 2021

Background:
Chronic stress is associated with adverse prognosis in cardiovascular disease, but little is known about its link with health status. We studied the association between chronic stress and health status following acute myocardial infarction (AMI).

Methods:
In the 24 center US TRIUMPH registry, 4204 AMI patients completed the Perceived Stress Scale-4 (scores range 0-16) during hospitalization. Moderate/high stress over the prior month was defined as scores in the top 2 quintiles (scores=6-16). Patients were assessed at 1 year for disease-specific health status with the Seattle Angina Questionnaire (SAQ) and for generic health status with a Visual Analog Scale (VAS) and the SF-12. Multivariable logistic regression evaluated the independent association between moderate/high stress and poor health status (defined as SAQ angina frequency <100; SAQ physical limitations <75; SAQ QOL <75; VAS <65; SF-12 physical <35; and SF-12 mental <45).

Results:
After extensive adjustment for demographic, socio-economic and clinical characteristics (including depressive symptoms), AMI patients with moderate/high stress had a greater likelihood of angina and poor disease-specific and generic health status (Figure; p<0.01 for all).

Conclusion:
Moderate/high stress at the time of an AMI is associated with poor post-AMI health status, even after adjustment for important confounders. Future studies need to examine whether stress mediates observed racial and socio-economic disparities, and whether novel interventions targeting chronic stress can improve post-AMI health status.
Abstract P139: Rates of Low Output Failure After Cardiac Surgery Cannot Be Explained Solely by Preoperative Characteristics
Authors: Likosky Donald S , Baribeau Yvon R , Brown Jeremiah R , Westbrook Benjamin M , Dacey Lawrence J , Frumiento Carmine , Sisto Donato , DiScipio Anthony W , Helm Robert E , Leavitt Bruce J , Clough Robert A , Kramer Robert S , Sardella Gerald L , Groom Robert C , Malenka David J , Ross Cathy S , Olmstead Elaine M ,   Northern New England Cardiovascular Disease StudyGroup
Published: July 2021

Background:
Post-operative low output failure (LOF) is an important contributor to morbidity and mortality during coronary artery bypass grafting (CABG) surgery, and may result from poor myocardial protection. We hypothesized that rates of LOF would vary across surgeons, in part attributed to their myocardial protective strategy.

Methods:
We identified 11,838 patients undergoing non-emergent, isolated CABG surgery utilizing cardiopulmonary bypass (CPB) at 8 centers in northern New England from 2001-2009. Our cohort included patients with preoperative ejection fractions 40+% and patients operated on by surgeons who performed 80+ CABG procedures during the time period. Patients with preoperative balloon pumps were excluded. LOF was defined as the need for an intra- or post-operative balloon pump, or return to CPB or 2+ inotropes at 48 hours. Predicted rates of LOF were estimated using logistic regression.

Results:
Case volume varied across surgeons (range: 80-766, median: 344). Overall rate of LOF was 5.3% (return to CPB: 3.2%, balloon pump: 1.8%, inotrope usage: 1.3%). While predicted risk of LOF did not differ across surgeons, p=0.381, observed rates varied from 1.1% to 15.6%, p=0.003 (Figure). Post-operative outcomes, including death (ptrend=0.03) or stroke (ptrend =0.02), significantly increased across surgical LOF strata (low: <2%, medium: 3-9%, high: 10+%).

Conclusions
There was a 14-fold variability in rates of LOF across surgeons among patients with ejection fractions 40+%. This variability could not be explained by patient case mix. Future work should focus on understanding the relationship between myocardial protective strategy and risk of LOF.
Abstract P14: Increased Prescription of Dual Antiplatelet Therapy Following CHARISMA and ACTIVE-W
Authors: Goldsweig Andrew M , Chan Paul , Tang Fengming , Fang Margaret , Cohen David J , Chen Jersey
Published: July 2021

Introduction:
The CHARISMA trial for chronic cardiovascular disease (CVD) and the ACTIVE-W trial for atrial fibrillation (AF) demonstrated benefits of dual antiplatelet therapy with aspirin and clopidogrel (A+C) versus aspirin alone. We hypothesized that these trials caused increased prescription of A+C in clinical practice.

Methods:
We queried the ACC's PINNACLE Program for patients meeting inclusion criteria of the CHARISMA trial (CVD defined as CAD, angina, stroke/TIA, or PVD; excluded AF or PCI patients) or the ACTIVE-W trial (chronic AF, not prescribed warfarin). We determined the proportion of patients prescribed A+C therapy by quarter 9/08-12/09. A Poisson model was established for A+C prescription by patient-quarter.

Results:
We identified 80,583 patients meeting CHARISMA criteria and 20,245 patients meeting ACTIVE-W criteria. Prescription of A+C therapy for CVD patients meeting CHARISMA criteria increased during the study period from 15.3% to 25.1% (p<0.001). Prescription of A+C therapy for AF patients meeting ACTIVE-W criteria increased from 3.0% to 4.0% (p=0.029). In both groups, most of the increase occurred after Q2 2009, when ACTIVE-W was published. In the Poisson model, after adjustment for age, sex, and insurance status, the increased prescription rate ratios were 1.0736 (1.0644-1.0829, p<0.0001) for CVD patients and 1.0390 (0.9927-1.0875, p=0.1001) for AF patients; after separate adjustment for comorbidities, the rate ratios were 1.0811 (1.0719-1.0903, p<0.0001) and 1.0747 (1.0238-1.1232, p=0.0014) respectively.

Conclusion:
Following CHARISMA and ACTIVE-W, clinicians have increased prescription of AsC therapy for patients with CVD or AF.
Abstract P149: Standardization of Emergency Responses in the Cardiovascular Intensive Care Unit
Authors: Booth Aubrie G , Burns Kathleen M , Byrd Jeannie M , Krokosky Kirk D , Miller Leanna R , Wagner Chad E , McPherson John A
Published: July 2021

Background:
An unexpected medical crisis may impair normal decision-making processes and clinical practices. If handled inappropriately, the management of emergency situations can present risks to patient safety and potentially worsen patient outcomes.

Aim:
In order to improve patient safety and quality of care, our Cardiovascular Intensive Care Unit (CVICU) developed and implemented standardized emergency response (SER) protocols for medical and surgical emergencies.

Methods:
We completed a literature review and, through surveys of CVICU staff, an assessment of our current practice and identified gaps in our process. Identified gaps included: (1) excessive staff at the bedside; (2) lack of noise discipline; (3) lack of a clearly defined role for each healthcare provider involved; (4) lack of a clearly identified code leader; and (5) ineffective communication throughout the response. We used these identified gaps to help create specific objectives for this initiative. With key CVICU stakeholders, we created a SER model and staff education plan. In order to measure the efficacy of our standardization initiative, we also created a debriefing tool to be used after each response. All CVICU staff successfully completed the SER education and training. This training included a video, a slide presentation, a skills check-off, and an assessment quiz. The SER protocol was implemented after all staff members completed their training

Results:
Since the implementation of the SER protocol, we have reviewed nine emergency response events with the debriefing tool. In 5 of the 9 events (56%), CVICU staff noted improvements in all of the following: (1) timely physician response; (2) clear leader identification; (3) team communication; and (4) performance of appropriate roles by team members. Avoidance of non-essential staff was improved in 7 of 9 (78%) events, and noise control was improved in 6 of 9 (67%) events.

Conclusions:
Assessment of performance gaps in emergency response facilitated the development of an effective SER protocol. Implementation of an SER resulted in improvement of most identified gaps in our facility, as measured by a debriefing tool. An SER protocol with systematic debriefing may positively impact crisis management in the CVICU.
Abstract P151: Diagnostic Yield of Elective Cardiac Catheterization After an Abnormal Stress Test: A Quality Initiative Study
Authors: Raju Manjunath G , Sidini Srikar , Gardiner Joseph , Vedre Ameeth , Abela George S
Published: July 2021

Background:
Guidelines for triaging patients for cardiac catheterization recommend a risk assessment and noninvasive testing. We determined patterns of noninvasive testing and the diagnostic yield of catheterization among patients with suspected coronary artery disease in our outpatient clinical center at Michigan State University.

Methods:
We conducted a retrospective cohort study of 133 consecutive patients who underwent elective cardiac catheterization from July 2008 through August 2010. Demographic characteristics, risk factors, symptoms and the results of noninvasive testing were correlated with the presence of obstructive coronary artery disease, which was defined as 50% or more of coronary artery stenosis.

Results:
The median age was 62 years with 71% men. Risk factors included diabetes 39%; hypertension 77 %; prior CAD 44% and dyslipidemia 79 %. Angina/chest pain was present in 62 % and atrial fibrillation in 7%. Patients with prior CAD receiving percutaneous coronary intervention were 34 % (20/58) as compared to 27% (20/75) without prior CAD. Noninvasive testing was performed in 78 % (104/133) of the patients. Among patients undergoing heart catheterization 53% (71/133) had obstructive coronary artery disease. A total of 97 patients had an abnormal stress test and 52% (50/97) had obstructive CAD. Associations with obstructive coronary artery disease were: male sex (odds ratio [OR], 1.51; 95% confidence interval [CI], 0.71, 3.19), older age (OR per 5-year increment, 1.21; 95% CI, 1.03, 1.42), presence of diabetes (OR= 1.51; 95% CI, 0.75, 3.06), and presence of dyslipidemia (OR=1.42; 95% CI, 0.62 to 3.29).

Conclusions:
Patients with a positive result on a noninvasive test were more likely to have obstructive coronary artery disease than those who did not undergo any testing but this did not achieve significance (52% vs. 48%; P=.76). A larger patient group may be required to confirm this observation. However, improved strategies for risk stratification could help increase the diagnostic yield of cardiac catheterization in routine clinical practice.
Abstract P164: Reduction of Heart Failure Readmissions Through an Enhanced Internal Medicine Residency Curriculum
Authors: Chandrasekaran Mercy P , Barry Janice , White Barbra , Eryazici Paula L , Danciu Sorin C
Published: July 2021

Background:
Heart failure (HF) carries a significant economic burden and hospitalizations account for 70% of the total costs of heart failure. Rehospitalizations are particularly costly and potentially avoidable. As part of the National Initiative for Alliance of Independent Academic Medical Centers, we aimed to decrease the HF readmissions by 5% through enhancements in the Internal Medicine Residency Curriculum.

Methods:
Between 7/10-2/11, we implemented a HF lecture series, multidisciplinary rounds, article and case reviews. Cardiac Rehabilitation, Information Systems, HF Team, Case Managers/Social Work and Nursing staff collaborated to develop better documentation and discharge protocols. To determine the impact of our intervention, the change in 30-day readmission and pre and post questionnaire about HF knowledge/attitudes were statistically analyzed.

Results:
The pre test questionnaire showed: 1) Residents felt more confident in treating/ counseling patients with HF and were not as confident in identifying precipitants of readmissions or applying core measures. 2) Most residents felt the key factors to preventing readmissions were close post-discharge follow up and patient education. Post intervention questionnaire showed: 1) More residents were confident about the core measures, quality indicators, appropriate documentation of HF. 2) More residents were satisfied with the Internal Medicine Residency Curriculum. The average HF readmission rate reduced from 24.6% to 20.9% between 7/10-11/10 (above goal).

January - August 2010 (Before Intervention)
September - November 2010 (After Intervention)

All HF Admissions
1178
464

All HF Readmissions
292 (24.8 %)
103 (22.2%)

Primary HF Admissions
167
63

Primary HF Readmissions
40 (24.0%)
12 (19.0%)

Statistical comparison of All HF
p=0.483, OR 1.339, 95% CI 0.656-2.727

Statistical comparison of Primary HF
p=0.276, OR 1.155 95% CI 0.895-1.491

Conclusions:
A 6-month resident-oriented multidisciplinary intervention improved patient care, documentation, and resident understanding of HF syndrome. This led to promising trends towards a significant decrease in 30-day HF readmissions. Further improvement in outcomes should be evident at the completion of 12-month follow-up.
Abstract P202: Do Cardiac Hemodynamic Differences in Patients with Acute ST-Elevation Myocardial Infarction Contribute to Gender Differences in Outcomes?
Authors: Dreyer Rachel , Tavella Rosanna , Hoffmann Bernadette , Pati Purendra , Beltrame John , Arstall Margaret , Zeitz Christopher
Published: July 2021

Aim:
Previous studies demonstrate higher 30-day all-cause mortality and re-infarction amongst women with ST-elevation myocardial infarction (STEMI). This study examines if gender differences exist in cardiac hemodynamic parameters assessed during an acute STEMI.

Methods:
The clinical, angiographic and hemodynamic features of 470 consecutive patients undergoing emergency primary percutaneous coronary intervention for an acute STEMI were evaluated with respect to gender. Patients routinely underwent right heart catheterization using a Swan-Ganz catheter, during the emergency reperfusion therapy procedure. Infarct size was estimated by evaluating the peak creatinine kinase (CK) levels.

Results:
The 135 STEMI female patients were significantly older than males (69±13 vs. 60±12 years, P <0.001) so subsequent analyses were age-adjusted. The findings are summarized below (*p < 0.05, **p<0.001 compared with men). Multivariate logistic regression analysis revealed that pulmonary capillary wedge pressure (PCWP) was the strongest independent predictor of 30-day death and re-infarction (Odds Ratio for PCWP = 1.06 (95% CI = 1.01 - 1.12, p = 0.019).

Conclusion:
Women with an acute STEMI have a higher 30-day cardiac event rate despite similar extent of coronary artery disease, infarct size and site. However they do have higher left ventricular filling pressures, which is consistent with their poorer outcomes. The mechanism/s of this hemodynamic difference requires further investigation.

Clinical and Hemodynamic Features of STEMI patients (Expressed as Mean ± SD or frequency data)

Men (n = 335)
Women (n =135)

Acute Anterior STEMI on ECG
128 (41%)
53 (40%)

Peak Creatine Kinase
2309±5894 IU
1455±1797 IU

Multi-vessel disease on angiography
168 (51%)
61 (49%)

Initial Heart Rate
80±22 bpm
79±25 bpm

Initial systolic blood pressure
137±29 mmHg
145±99 mmHg

Pulmonary capillary wedge pressure
16±7 mmHg
20±7 mmHg*

Arterial oxygen saturation
97±4.5%
97±2.9%

Mixed venous oxygen saturation
70±9%
67±10%

30 Day All cause Mortality/Re-Infarction
14 (4%)
15 (11%)*
Abstract P232: Influence of Individualized Risk Prediction and Patient Preferences on Selection of Prasugrel Versus Clopidogrel at the Time of Percutaneous Coronary Intervention for an Acute Coronary Syndrome
Authors: Salisbury Adam C , Wang Kaijun , Cohen David J , Li Yan , Spertus John A
Published: July 2021

Introduction:
Given the need to weigh prevention of ischemia against bleeding risk with prasugrel vs. clopidogrel at the time of PCI for an acute coronary syndrome (ACS), we developed risk models for both outcomes from TRITON-TIMI 38. We then applied these models to each TRITON patient and examined how preferences for outcomes could influence thienopyridine selection.

Methods:
We built separate multivariable regression models for ischemia (cardiac death, MI, stroke) and bleeding (TIMI major/minor) from 12,579 patients in TRITON-TIMI 38 with no history of stroke or TIA. For each patient, we calculated the probability of ischemic and bleeding events with prasugrel vs. clopidogrel and the associated benefit:risk ratio (predicted difference in ischemic events/predicted difference in bleeding). We then examined the impact of alternative outcome weights - benefit:risk preference thresholds - on individualized decision making.

Results:
Based on individualized risk predictions, the majority of ACS patients treated with PCI (66%) may choose prasugrel when preventing ischemia is considered equally important as avoiding bleeding (Figure), but this proportion varied from 32% to 80% when the benefit:risk preference threshold was varied from 3 (reflecting a 3-times greater preference for avoiding bleeding) to 0.25 (reflecting a 4-times greater preference for avoiding ischemia).

Conclusions:
Based on empirical analyses, the expected absolute benefits and risks of prasugrel vs. clopidogrel depend highly on patient characteristics and preferences. Presenting individualized predictions of benefits and risks with competing treatments may improve shared decision making.