bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P324: Implications of ACC/AHA Cholesterol Guidelines on Statin Underutilization for Prevention of Cardiovascular Disease in Diabetes Mellitus among Several U.S. Networks of Community Health Centers
Authors: Akhabue Ehimare , Rittner Sarah S , Carroll Joseph E , Crawford Philip M , Dant Lydia , Laws Reesa , Leo Michael C , Puro Jon , Persell Stephen D
Published: July 2021

Introduction:
Little is known about statin underuse among diabetes (DM) patients cared for in community health centers (CHCs), which tend to serve socioeconomically disadvantaged populations. Implications of the recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines on preexisting gaps in statin treatment in this population are unclear.

Hypothesis:
Substantial statin underutilization will exist regardless of differences between guidelines.

Methods:
We included 32,440 adults (45% male, 63% non-white, 28% uninsured/Medicaid) with DM aged 40 to 75 years who received care within 16 CHC groups in eleven states in the Community Health Applied Research Network (CHARN) during 2013. Statin prescribing was analyzed as a function of concordance with the National Cholesterol Education Program Adult Treatment Panel (ATPIII) 2001 guideline and ACC/AHA 2013 guideline.

Results:
More patients were concordant with the ACC/AHA (52.8%) versus ATPIII (36.2%) guideline. Female gender was independently associated with lower concordance for both guidelines [OR 0.90 CI (0.85-0.94) and OR 0.84 CI (0.80-0.88) respectively]. Black race was associated with lower concordance with ATPIII but not ACC/AHA. Being insured, Asian/Pacific Islander or primarily Spanish speaking were associated with greater concordance for both guidelines. 35% (11526/32440) of the cohort were concordant with neither guideline (Figure), the majority (80%) having no statin prescribed. 28% (9168/32440) were concordant with ACC/AHA guidelines but not ATPIII guidelines. 8.5% of these patients had an LDL >160 despite having a medium or high intensity statin prescribed. 12% (3772/32440) were concordant with ATPIII but not ACC/AHA guidelines. Most of these patients had an LDL between 70-99 mg/dl with no or a low intensity statin prescribed.

Conclusions:
Opportunities exist to improve cholesterol management in DM patients in CHCs. Addressing care gaps could improve cardiovascular disease prevention in this high risk population.
Abstract P352: Associations Between Signs and Symptoms of Androgen Excess With Chronic Kidney Disease in Hispanic/Latina Women of Reproductive Age in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)
Authors: Meyer Michelle L , Sotres-Alvarez Daniela , Steiner Anne , Cousins Larry , Talavera Gregory A , Cai Jianwen , Daviglus Martha , Loehr Laura R
Published: July 2021

Background:
Androgen excess among women is characterized by high levels of testosterone and is a feature of polycystic ovary syndrome (PCOS), a common reproductive endocrine disorder in women. Evidence from animal and human studies show that androgens may promote renal dysfunction. The association between signs and symptoms of androgen excess and chronic kidney disease (CKD), however, has been relatively unexplored.

Methods:
HCHS/SOL is a community-based cohort study of 16,415 self-identified Hispanic/Latino adults from diverse backgrounds in the US, including 3,801 women age 18-44 years at visit 1 (2008-2011). This preliminary cross-sectional analysis describes results from 994 reproductive-aged women who attended the ongoing visit 2 (2014-2017) by Sept. 2016. Signs and symptoms of androgen excess included menstrual cycle length (>35 days or too irregular), self-reported PCOS, and oral contraceptive use to regulate menstrual cycles or acne. We also evaluated each component separately. CKD was defined as either a low estimated glomerular filtration rate (eGFR; <60 ml/min/1.73 m
2
) or albuminuria based on a urine albumin/creatinine ratio ≥30 mg/g. Estimates are adjusted for sampling design, site, age, Hispanic/Latina background, education, smoking status, and body mass index.

Results:
Among women reporting any sign or symptom of androgen excess (unweighted N=278), 9% reported cycles >35 days, 51% reported cycles too irregular, 49% reported oral contraceptive use to regulate cycles or acne, and 19% self-reported PCOS. Compared to women without any sign or symptom of androgen excess, women reporting a sign or symptom of androgen excess had a higher mean body mass index, waist circumference, albumin/creatinine ratio, and prevalence of hypertension and the metabolic syndrome. The prevalence of CKD (7%, 95% confidence interval (CI): 4-13%) was the same with or without signs and symptoms of androgen excess, and the association was not significant after adjusting for covariates (odds ratio (OR): 1.0; 95% CI: 0.4-2.1). When individual components were analyzed, women reporting cycles too irregular had higher odds of CKD (OR: 1.5; 95% CI: 0.6-3.7) compared to women reporting cycles of 24-35 days, although not statistically significant.

Conclusion:
Over a fourth of Hispanic/Latina women reported signs and symptoms of androgen excess. Overall, there were no statistically significant associations with CKD among women reporting signs and symptoms of androgen excess. Completion of visit 2 would allow us to draw a more robust conclusion and to further characterize these relationships.
Abstract P353: New Evidence on the Association of Physical Activity and Chronic Kidney Disease: ORISCAV-LUX Study
Authors: Alkerwi Ala’a , Sauvageot Nicolas , Stranges Saverio , Delagardelle Charles , Beissel Jean
Published: July 2021

Background:
Evidence on stages of renal impairment and related risk factors in Luxembourg adults is lacking. This study aimed to assess the prevalence of chronic kidney disease (CKD) and identify potential correlates among general population in Luxembourg, using the recent definition suggested by the Kidney Disease Improving Global Outcomes (KDIGO) guidelines.

Methods:
Analyses were based on data from 1361 adult participants aged 18-69 years, enrolled in the Observation of Cardiovascular Risk Factors in Luxembourg (ORISCAV-LUX) study, 2007-2008. Descriptive and multivariable logistic regression analyses were performed to identify demographic, socio-economic, clinical and behavioral factors associated with CKD, defined as single estimated glomerular filtration rate (eGFR) measure <60 ml/min/1.73m
2
and/or urinary albumin creatinine ratio (ACR)>30mg/g.

Results:
Overall, 6.3% had CKD, including 4.4% and 0.7% presented with moderate and severe macroalbuminuria respectively, and 0.1% had kidney failure (eGFR
<
15 mL/min/1.73 m
2
). CKD risk increased significantly with age; the odds ratio increased more than two folds among subjects aged 50-69 years, with no sex-specific difference. CKD was higher among subjects with primary education. Hypertension and diabetes were associated with more than 3-fold and 4-fold higher risk of CKD [adjusted odd ratio (95%CI): 3.11 (1.76, 5.52); P<0.001] and [adjusted odd ratio (95%CI): 4.69 (2.35, 9.36), P<0.001] respectively. Increased physical activity measured as total MET-hour/week was independently associated with a lower odd of CKD (P=0.035).

Conclusion:
The prevalence estimate of CKD in Luxembourg may represent a neglected public health issue, stressing the benefit of early detection of CKD, particularly in subjects with hypertension, diabetes, lipid disorders and obesity. Promoting physical activity among these high-risk subjects should be considered to prevent CKD. These measures altogether could defray costs related to eventual complications and decrease risk of associated cardiovascular events.
Abstract P368: Carotid Intima-Medial Thickness is Associated with Silent Brain Infarctions: The Atherosclerosis Risk in Communities Study
Authors: Caughey Melissa C , Qiao Ye , Gottesman Rebecca F , Mosley Thomas H , Windham Beverly Gwen , Wasserman Bruce A
Published: July 2021

Background:
Carotid intima-medial thickness (IMT) is an indicator of subclinical atherosclerosis and medial hypertrophy, and is easily quantified by ultrasonography. Although carotid IMT has been associated with systemic cardiovascular disease, its relation to silent brain infarctions (SBI) is not well established. The etiology of SBI is multifactorial; likely causes include atherosclerotic and thrombotic obstructions, microthrombi, and lipohyalinosis. Because arterial IMT reflects both atherogenesis and hypertensive remodeling, we hypothesized that elevated carotid IMT would be associated with SBI.

Methods:
The Atherosclerosis Risk in Communities (ARIC) study is an observational cohort of 15,792 black and white participants from 4 US communities. At visit 3 (1993-1995) a subset of stroke-free study participants (N=1,346) was screened by brain MRI and carotid ultrasound. IMT was averaged bilaterally, from 12 posterior wall measurements along a 1 cm segment of the distal common carotid artery up to the bifurcation. Consistent with European Society of Cardiology recommendations, IMT > 0.9 mm was considered elevated. Asymptomatic brain lesions ≥3 mm in diameter were considered SBI. Prevalence ratios (PRs) for number of SBI lesions associated with elevated IMT were analyzed using Poisson regression, adjusted for age, race-center, sex, current smoking, hypertension, diabetes, and hyperlipidemia. Model fit was ascertained by the deviance to degree of freedom ratio.

Results:
Of 1,346 individuals, 170 (13%) were classified with elevated IMT. Mean IMT was 1.0 ± 0.2 mm vs. 0.7 ± 0.1 mm for those with and without elevated IMT. Study participants with elevated IMT were more often male (49% vs. 38%; p=0.006), black (60% vs. 46%; p=0.0007), and older (64 vs. 62 years; p=0.0001); with a greater prevalence of both hypertension (65% vs. 42%; p<0.0001) and diabetes (27% vs. 13%; p<0.0001). SBI were detected in 157 individuals with a collective total of 247 lesions. A total of 30 (18%) participants with elevated IMT had at least one SBI lesion, compared to 127 (11%) with normal IMT (p=0.009). Elevated IMT was associated with 70% greater number of SBI lesions (PR=1.7; 95% CI: 1.3 - 2.3; p=0.0008). After adjustment for cardiovascular risk factors, elevated IMT remained associated with a 40% greater SBI count (PR= 1.4; 95% CI: 1.0 - 1.9; p=0.05).

Conclusions:
Although elevated IMT is often classified by a conservative 0.9 mm cut-point, it is a continuum, with advanced wall thickening (>1.5 mm) recognized as plaque. In this analysis from the ARIC Study, asymptomatic individuals classified with elevated IMT had mild wall thickening (mean IMT = 1.0 mm), which nonetheless was associated with greater number of SBI lesions. This association remains robust after adjustment for cardiovascular risk factors.
Abstract P370: Risk Factors for Progression of Coronary Artery Calcification in Patients with Chronic Kidney Disease
Authors: Bundy Joshua D , Appel Lawrence J , Budoff Matthew , Chen Jing , Go Alan S , Grunwald Juan E , Kallem Radhakrishna R , Mohler Emile R , Post Wendy S , Reilly Muredach P , Ricardo Ana C , Rosas Sylvia E , Yang Wei , Zhang Xiaoming , He Jiang
Published: July 2021

Introduction:
Coronary artery calcification (CAC) is prevalent among patients with chronic kidney disease (CKD) and predicts the risk of cardiovascular disease (CVD). Risk factors for the progression of CAC in patients with CKD have not been well studied.

Hypothesis:
We assessed the hypothesis that several established and novel CVD risk factors are associated with progression of CAC among patients with CKD.

Methods:
In a random subsample of 1,123 participants from the Chronic Renal Insufficiency Cohort (CRIC) Study, CAC was measured at baseline and the follow-up visit using electron beam computed tomography (CT) or multidetector CT. CAC progression was defined as an increase of Agatston score ≥100 units during follow-up. Multiple logistic regression and mixed-effects regression models were used to assess risk factors for progression of CAC.

Results:
Over an average of 3-year follow-up, 332 (29.6%) participants developed CAC progression. After adjusting for age, sex, race, clinical site, total cholesterol, HDL-cholesterol, systolic blood pressure, antihypertensive treatment, diabetes, and current smoking in the multivariable models, history of CVD (odds ratio [OR] 1.53, 95% CI 1.09-2.15, p=0.02), lipid-lowering treatment (OR 1.81, 95% CI 1.28-2.55, p<0.001), higher serum phosphate (OR 1.37, 95% CI 1.17-1.61, p<0.001), hemoglobin A1c (OR 1.32, 95% CI 1.10-1.58, p=0.002), and cystatin C (OR 1.24, 95% CI 1.06-1.45, p=0.007), and lower estimated-glomerular filtration rate (eGFR) (OR 1.32, 95% CI 1.10-1.56, p=0.002) were associated with CAC progression. In addition, lower physical activity, lipid-lowering treatment, body-mass index, LDL-cholesterol, lower serum calcium, phosphate, total parathyroid hormone, fibrinogen, interleukin-6, tumor necrosis factor-α, fibroblast growth factor-23, lower eGFR, cystatin C, and 24-hour urine albumin were associated with square root transformed change in CAC score from baseline in multiple-adjusted models. These findings persisted after additional adjustment for baseline CAC score.

Conclusions:
In conclusion, these data suggest that reduced kidney function, calcium and phosphate metabolic disorders and inflammation, in addition to established CVD risk factors, might play a role in CAC progression among patients with CKD.
Abstract P371: Race Disparities in the Contribution of Lipid Profiles to Ankle-Brachial Index: Lifecourse Evidence from the Bogalusa Heart Study
Authors: Fernandez Camilo , Zheng Liqiang , Guo Yajun , Barshop Rupert , Harville Emily , Chen Wei , Bazzano Lydia
Published: July 2021

Background:
Ankle-brachial index (ABI) is a practical non-invasive estimation of the burden of atherosclerosis on the vascular system. Although cholesterol is known to affect ABI as part of the disease process, information is limited on the contribution of longitudinal measures of cholesterol on the decline of ABI over time.

Hypothesis:
Race (black-white)—specific differences exist in cumulative burden effects of cholesterol, measured from childhood to adulthood, on ABI decline in young adults.

Methods:
We examined 497 adult participants of the Bogalusa Heart Study (72.8% white, 43.1% men, age 32-51 years), who had at least 3 measurements of cardiovascular (CV) risk factors since childhood (average follow-up 33.5 years). ABI was obtained in two separate instances: baseline (2001-2002) and follow-up (2007-2010), and its change was computed as the mean difference, divided by the time (years), between the two instances. The long-term cumulative burden of each risk factor was calculated as the total area under the curve (AUCt). Measurements of cholesterol and other CV risk factors in childhood, adulthood and AUCt were standardized to z-scores prior to regression analyses.

Results:
ABI significantly decreased (1.09±0.09 vs 1.03±0.09, p<0.01) after a mean follow-up of 6.8 years. There were no significant differences in annual ABI decline between male and female (p=0.56) / black and white (p=0.18) participants. In multivariable linear regression analyses, after adjustment for sex, lipid-lowering medications, smoking status, body mass index, systolic blood pressure and baseline ABI, significant predictors of annual ABI decline in white participants were: childhood total cholesterol (TC) (β= -0.11, p<0.01), low-density lipoprotein cholesterol (LDL-C; β= -0.10; p<0.01), and non-high-density lipoprotein cholesterol (non-HDL-C; β= -0.10, p<0.01), as well as the AUCt of TC (β= -0.09; p=0.02) and non-HDL-C (β= -0.08, p=0.04). The AUCt of HDL-C was the only significant predictor in black participants (β= 0.16, p=0.04).

Conclusions:
These findings suggest that the impact of cholesterol levels on future adult ABI decline starts in childhood, and follows a cumulative detrimental pattern throughout the lifespan in a race-dependent fashion. Further, this information may aid in the development of strategies to improve prevention, diagnosis and treatment of vascular disease by race group
Abstract P378: Association Between an Ideal Cardiovascular Health (ICH) Profile and Coronary Artery Calcium (CAC) in South Asians: Implications for the Role of Lifestyle Factors in the Prevention of Cardiovascular Disease in a Minority Population.
Authors: Mehta Akhil
Published: July 2021

The goal of this study was to evaluate cross sectionally the association between an ideal cardiovascular risk factor (IRF) profile and the presence and severity of subclinical atherosclerosis measured in the form of coronary artery calcium (CAC) at the El Camino Hospital South Asian Heart Center. We included 515 participants of South Asian origin with no prior history of cardiovascular disease aged 36 to 88 years who underwent CAC measurement. The 2010 Task Force of the American Heart Association (AHA) cutoffs were used to define ideal level of smoking, physical activity, diet, blood pressure, glucose, cholesterol levels, and body mass index (BMI). Participants were categorized according their number of IRFs: 0 to 1 (n = 45, 8.7%), 2 (n = 103, 20%), 3 (n = 144, 28%), 4 (n = 128, 24.9%), 5 (n = 70, 13.6%), and 6 to 7 (n = 25, 4.8%). Compared to individuals with 0 to 1 IRFs, the odds ratio of participants with 6 to 7 IRFs presenting with a CAC >0 was 0.16 (95% CI 0.04-0.69). Moving forward, participants were also categorized according to their number of ideal lifestyle factors (BMI, physical activity, smoking status, and healthy diet) and clinical factors (blood pressure, total cholesterol, and blood sugar). Compared to individuals with 0 ideal lifestyle factors, the odds ratio of participants with all 4 ideal lifestyle factors presenting with a CAC >0 was .12 (95% CI .03-.50). Amongst the individual ideal lifestyle factors though, only non-smoking status, 0.47 (95% CI 0.30-.75), and a BMI <23 kg/m^2, 0.60 (95% CI 0.38-.95), conferred a statistically significant protective effect from having a non-zero CAC score. In contrast, compared to those with 0 ideal clinical factors, the odds ratio of participants with all 3 ideal clinical factors presenting with a CAC >0 was .16 (95% CI .06-.44). That said, amongst the individual ideal clinical factors, normal BP produced the strongest protective effect from having a non-zero CAC score, 0.37 (95% CI 0.25-.57), followed by total cholesterol <200 mg/dL, 0.69 (95% CI 0.44-.90), and blood glucose <100 mg/dL, 0.69 (95% CI 0.47-.90).
Abstract 112: 12-Month Healthcare Utilization and Expenditures in Medicare Advantage Patients With Mitral Regurgitation From the Medical Outcomes Research for Effectiveness and Economics Registry
Authors: Cork David , Kottenmeier Emilie , Mollenkopf Sarah , Gunnarsson Candace , Verta Patrick , Mehta Hirsch
Published: July 2021

Background:
Mitral Regurgitation (MR) is associated with significant health care costs. This study aims to quantify the financial healthcare burden of Medicare Advantage (MA) patients across all MR patients from the Medical Outcomes Research for Effectiveness and Economics (MORE2) Registry.

Methods:
MA patients with a minimum of 1 inpatient or 2 outpatient claims for MR from 2008-2014 were reviewed. The index date was defined as a first inpatient claim or second outpatient claim. A 6-month pre-period (baseline) and 6-month post (washout) after index was used to define baseline etiology and severity. Three MR cohorts were defined: (1) Functional MR (FMR) was defined by the presence of heart failure during washout; (2) Degenerative MR (DMR) was defined by presence of chordal rupture or the absence of both heart failure and ischemia; and (3) Uncharacterized MR (UMR) was defined by patients otherwise not meeting the criteria for FMR or DMR. sMR was defined by a history of MR surgery, a diagnosis of atrial fibrillation or pulmonary hypertension, chordal rupture (DMR only), or record of two or more echocardiograms (per clinical guidelines) during washout. Demographics, comorbidities, healthcare utilization, and all-cause expenditures were summarized.

Results:
Of the 164,682 MA patients with MR who met inclusion criteria, 70,452 (43%) had FMR, 51,399 (31%) had DMR, and 42,831 (26%) had UMR. Average age (SD) was similar across cohorts: 74 (7.95), 72 (8.46), and 74 (7.45) years for FMR, DMR, and UMR, respectively. Proportion of severe patients and Charlson Comorbidity Index (CCI) indicates that the FMR cohort was “sicker” as compared to the others: FMR (41,325 [59% of 70,452]; CCI 4.56), DMR (16,169 [32% of 51,399]; CCI 1.67), and UMR (16,131 [38% of 42,831]; CCI 2.80). 2,079 patients (1.26% of total 164,682) received mitral valve surgery at index or washout with the highest occurrence in FMR patients (1,663), followed by UMR (327) and DMR (89). When comparing across the MR cohorts, the FMR cohort had higher rates of hospital admission, but length of stay was similar between cohorts (FMR [19.9%, 4-days], DMR [9.4%, 4-days], and UMR [13.6%, 3-days]). FMR had the highest annual all-cause healthcare costs (SD) ($22,569, [$59,876]), followed by UMR ($14,735 [$32,070]) and DMR ($10,485 [$23,934]).

Conclusions:
MR in the Medicare Advantage population is associated with a substantial health care burden, with FMR patients having the highest cost and utilization patterns. This population should, therefore, have access to innovative treatment options that relieve symptoms and reduce economic burden.
Abstract 115: Results of a Twelve Month Randomized Trial of an Internet Based Lifestyle Intervention in High Cardio Metabolic Risk Individuals: The Baptist Employee Healthy Heart Study (BEHHS)
Authors: Aneni Ehimen , Arias Lara , Post Janisse , Ali Shozab S , Osondu Chukwuemeka U , Saxena Anshul , Agatston Arthur S , Katzen Barry , Feldman Theodore , Nasir Khurram
Published: July 2021

Background:
Web-based platforms have been proposed as tools to facilitate lifestyle improvement, however, their efficacy in individuals with high cardiometabolic risk has not been adequately tested. The Baptist Employee Healthy Heart Study (BEHHS) was designed to assess the addition of a personalized, interactive, web-based, lifestyle-management program to the existing health-expertise web platform available to BHSF employees with metabolic syndrome (METS) or type 2 diabetes (DM2)

Methods:
In this 1:1 randomized, non-blinded trial, the intervention arm was provided access to a web-based personalized and interactive lifestyle program that provided targeted and personalized dietary, weight management and physical activity counseling. The intervention was in addition to access to an online wellness program, a non-interactive website that provided information on healthy diet and physical activity. The control group only had access to the online wellness program. At baseline, each participant had their demographic data collected via questionnaire. At each study visit (baseline, 4 months and 12 months) participants completed questionnaires on lifestyle indices such as diet and physical activity, had their weight, height, waist circumference, body fat (by plethysmography) and blood pressure measured. Laboratory testing was done for traditional lipids and glucose at each visit.

Results:
Of the 182 participants that were randomized, 163 (82 in the intervention arm and 81 in the control arm) completed the baseline survey and had complete laboratory data at baseline. Loss to follow-up was 12% at 4 months 34% at 12 months. As shown the table, intention to treat analysis using both single imputation (last observation carried forward) and multiple imputation techniques showed no difference in BMI, other measures of adiposity, blood pressure, lipids, physical activity and diet scores. When analyses were restricted to completers alone, no significant change in the results were observed.

Conclusion:
The addition of web-based, personalized lifestyle program to an already existing lifestyle educational platform did not significantly impact healthy lifestyle promotion and cardiometabolic risk in employees with MetS or DM2.
Abstract 120: Persistence in Antihypertensive Therapy - The Chicago Heart Association Detection Project Industry Study
Authors: Schiman Cuiping , Liu Lei , Shih Ya-Chen Tina , Zhao Lihui , Daviglus Martha , Liu Kiang , Fries James , Garside Daniel , Vu Thanh-Huyen , Stamler Jeremiah , Lloyd-Jones Donald , Allen Norrina
Published: July 2021

Introduction:
There is limited evidence on the long-term persistence of antihypertensive therapy.

Methods:
We linked Medicare Part D Event data (2006 - 2012) for participants of the Chicago Heart Association Detection Project Industry Study (1967 - 1972) who were diagnosed with essential hypertension and had at least one drug (any drug) event (N = 5,578). Antihypertensive medications and therapeutic classes were identified using the Medi-Span Electronic Drug File v2. The adherence rate was defined by the proportion of days covered (PDC) in 6-month intervals from the first fill of antihypertensive medication and was calculated separately for each therapeutic class. Additionally, to identify adherence patterns as the number of medications an individual used increased, we calculated adherence rates for time intervals after each subsequent medication was filled. Fractional response generalized linear models were used to identify predictors of the adherence patterns.

Results:
At 6 months from the first fill, the median adherence rate was 0.72 and the mean was 0.56. Roughly 30% of the individuals in the sample did not fill any antihypertensive medication for the duration of the study. Adherence rates declined substantially over time, but the largest drop occurred within the first 12 months. Compared to individuals with a high school degree or less, individuals with more than a high school degree were on average 8.6% more adherent (p-value <0.001); however, they experienced similar drops in adherence rates over the 6-year duration. Similarly, the adherence patterns were parallel for white and non-white individuals over the study duration although white individuals had higher adherence rates. Moreover, as the number of medications prescribed increased, the overall adherence rates declined at an increasing rate. For example, average adherence rates decreased by 5.2% (p-value <0.001) as the number of medications increased from one to two and by 8.3% (p-value <0.001) as the number of medications increased from two to three.

Conclusion:
Adherence to antihypertensive therapy decreased significantly over time and with greater medication burden. Interventions are needed to improve persistence in antihypertensive therapy, particularly among those taking multiple medications.
Abstract 123: Revascularization Rate and Associated Costs Among Patients With Stable Ischemic Heart Disease Initiating Ranolazine versus Traditional Antianginals
Authors: Meyer Nicole , Tran Oth , Hartsfield Cindy , Nguyen Linda , Kazi Dhruv , Koch Bruce
Published: July 2021

Background:
Real-world data are limited on resource utilization for revascularization procedures and associated healthcare costs for patients treated with ranolazine versus traditional antianginals.

Objective:
Describe frequency and costs of revascularization procedures among patients with stable ischemic heart disease (SIHD) initiating ranolazine versus traditional antianginals.

Methods:
Using Marketscan claims databases between 1/1/07-6/30/15, we identified adult patients with one of the following qualifying diagnosis codes: angina (stable or unstable), myocardial infarction, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) who initiated ranolazine or a traditional antianginal (beta-blocker [BB], calcium channel blocker [CCB], or long-acting nitrate [LAN]) as second or third line therapy. To be included, patients had to be continuously enrolled for ≥12 months prior to and after the date of qualifying antianginal prescription. Inverse probability weighting based on propensity score was employed to balance the ranolazine and traditional antianginals cohorts on patient clinical characteristics. Outcomes of interest were frequency and total cost of revascularization procedures (PCI or CABG) over a 12-month follow-up.

Results:
Analysis included 19,574 patients initiating ranolazine (mean age 67 years; 59.2% male), 23,206 initiating BB (67 years; 57.7% male), 26,225 initiating CCB (67 years; 59.0% male), and 39,736 patients initiating LAN (67 years; 59.1% male). Overall, patients initiating CCB had the lowest rate of revascularization. Fewer ranolazine patients had revascularization procedures than BB and LAN patients. (Table). Ranolazine patients also had fewer hospitalizations with revascularization procedures and shorter length of stay than BB and LAN patients. Healthcare costs associated with revascularization were lower among ranolazine patients ($2933) than among BB ($4465) and LAN ($3609) patients (p<0.001), but similar to CCB patients ($2753, p=0.29).

Conclusions:
Frequency of revascularization procedures and associated healthcare costs were lower among patients with SIHD initiating ranolazine compared to patients initiating BB or LAN as antianginal therapy, and comparable to patients initiating CCBs.
Abstract 141: Why Did My Patient Die? Deaths Following Coronary Angioplasty
Authors: Lawson William E , Wilbert Lisa , Avino Nancy , Griffel Martin , Parikh Puja , Callias Patricia , Chen On , Pyo Robert
Published: July 2021

Objective:
To examine causes of death not captured by current risk factor adjustment following coronary angioplasty.

Background:
NYS tracks and reports in-hospital/30-day deaths during or following all PCIs as observed and risk adjusted rates. The decline in observed mortality [OMR] has been credited as due to public reporting improving care, but also as care denial. Whether risk adjustment influences selection and captures mortality risk is controversial.

Procedure:
NYS uses a multivariate risk factor equation to determine the risk adjusted rate. Adverse predictors include: Odds ratio: F_1.65, unstable_7.97, low EF_1.47 - 6.72, pre procedural MI_2.49- 8.03, chronic lung disease_2.04- 2.87, heart failure_1.87, PVD_1.87, renal failure_2.08-4.4, CAD extent_1.4. Emergent cases are higher risk than elective cases. At Stony Brook UH all PCI mortalities are reviewed to assess factors contributing to death. 4 yrs of deaths [unclassified preprocedure risks, major comorbidities contributing to death] are reported. Pts excluded from the NYS data base were excluded.

Results:
45 Patients died post PCI. Pre procedure risk factors not included as adjustments but that were felt to effect survival: severe aortic stenosis 13/45, coagulopathy 8/45, severe anemia 6/45, CTS turn downs 6/45, cancer not in remission 4/45, active systemic infection 4/45, post cardiac arrest not in coma 2/45, respiratory failure, active GI bleed, end stage liver disease [each 1/45]. PCI complications with adverse outcomes: coronary dissection 2/45, perforation 4/45, pericardial tamponade 4/45. Unsuccessful PCI 10/45 and need for IABP/Impella support 26/45 were associated with adverse outcomes. Post PCI diagnoses associated with mortality: CVA, hypoxic encephalopathy, intractable seizures 9/45, new diagnosis of cancer 2/45, sepsis 6/45 and pneumonia 4/45, persistent shock 16/45 and multi organ failure 12/45, malignant arrhythmias and PEA 12/45, anemia & GI bleeding 14/45, contrast induced nephropathy/AKI 13/45, lower extremity ischemia/bleeding 5/45, mechanical complications of MI 3/45. The decision to make the pt DNR/DNI 18/45 or comfort care/hospice 15/45 impacted on delivery of care and the likelihood of survival, particularly if only rescinded for the PCI.

Conclusions:
Coronary PCI may be life saving. However, procedural urgency may limit knowledge of and optimization of risks. When possible, a more holistic discussion with the pt and family, giving careful consideration to the risks and benefits of angioplasty, goals of therapy and limitations of care should take place pre procedure. It is also important to be able to identify and aggressively treat the post procedure complications commonly associated with mortality.
Abstract 15: The Use of Handheld Focused Cardiac Ultrasound (FoCUS) for EF Assessment at Parkland Memorial Hospital: A Quality Improvement Initiative With Novel Applications for Clinical Outcomes
Authors: Raza Samreen , Vigen Rebecca , Matulevicius Susan
Published: July 2021

Background:
Focused cardiac ultrasound (FCU) has been used to answer clinical questions. Chemotherapy-related cardiotoxicity (CRR) is an entity that requires serial echocardiography. It is unknown whether FCU can be used to screen for CRR using advanced practice providers (APPs). The goal of this study is to determine if FCU can be used to reliably evaluate left ventricular ejection fraction (EF) by an APP to assess for CRR.

Methods:
The study was conducted at the Echo lab and the Oncology clinic. An Oncology APP was trained on the use of FCU and EF analysis. The APP was trained to obtained standard 2D views for EF assessment and on EF interpretation. The EF assessment was compared to sonographer echocardiogram on the same day. EF was assessed by a cardiologist and this was deemed to be the gold standard. The studies were all analyzed by two separate blinded cardiologists and the degree of correlation was analyzed. Linear regression modeling to analyze correlation between EF interpretation between all blinded observers and Bland Altman analysis was performed. Image quality was evaluated for all FCU images by a single blinded cardiologist and segmental endocardial border delineation was scored.

Results:
A total of 91 patients were scanned in Phase I of the study. The correlation coefficient between cardiologists was r=0.93. The correlation between cardiologist and APP were r=0.79 and 0.76 respectively. For the images obtained by the APP, the correlation between the APP and cardiologists were =0.83 and re=0.78. The correlation between APP and EF gold standard was r=0.77. The correlation between experienced cardiologists interpreting the FCU images was r=0.87. All images were determined to be interpretable.

Conclusions:
There was good correlation between cardiologists with respect to EF analysis. There was also good correlation between APP and cardiologists for EF analysis. Image quality from FCU was found to be good and acceptable for interpretation. This study demonstrates it is feasible to train an APP on obtaining images for EF analysis and they can be trained on EF interpretation with good correlation with experienced echocardiographers. We will evaluate outcomes associated with its use including delays to chemotherapy imposed by traditional echocardiography, cost to the health care system and patient-reported outcomes.
Abstract 161: Rapid-Cycle Development of Decision Support Tools for Patients With Symptomatic Aortic Stenosis
Authors: Knoepke Christopher , Ingle PIlar , Carroll Adam , Allen Larry , Jenkins Amy , Carroll John , Gama Kristy , Doermann Byrd Katherine , Valle Javier , Matlock Daniel
Published: July 2021

Background:
Therapy for aortic stenosis (AS) is quickly evolving, with treatment options expanded by transcatheter aortic valve replacement (TAVR). The complexity of information patients need to make value-concordant decisions highlights the need for accessible, acceptable, and unbiased decision aids (DAs) for patients considering AS treatment.

Methods:
Using a rapid-development process adapted from our team’s earlier work creating DAs for ICD and LVAD candidates, and guided by International Patient Decision Aid Standards (IPDAS), we created decision support materials for AS patients. This process included simultaneous 1) qualitative assessments of decision support needs & experience among TAVR recipients, 2) alpha testing iterative versions of paper DAs with patients to assess for accessibility & bias, and 3) assessment of clinical accuracy and usability of DAs with clinicians through individual feedback and expert panel consensus (Figure 1).

Results:
Over a 14 month period, we created two paper and two video DAs (corresponding to high or non-operative surgical risk), including input from interviews with 17 patients and 3 caregivers, 6 clinician reviews, and 4 expert panel assessments. Patient/caregiver feedback included DA usability and when it should be introduced into the clinical process. Clinician feedback focused on expected valve durability, procedural risks, and clinical accuracy. While most patients and clinicians expressed enthusiasm about TAVR, they described subpopulations of AS patients for whom the decision of whether to accept TAVR should be weighed within the context of clinical uncertainty about expected benefits (i.e. patients with prohibitive surgical risk and multi-comorbid conditions) or valve durability (i.e. surgery candidates). The DAs are currently available on the American College of Cardiology’s patient-facing CardioSmart website.

Conclusion:
AS treatment options are technically complex and have patient-centered trade-offs. Developing and adapting patient decision aids for AS can improve the decision making process. This development process offers lessons for improving shared decision making for evolving therapies for other life-threatening disease.
Abstract 201: Travel Distance Among Publicly Insured Infants With Operable Congenital Heart Disease
Authors: Woo Joyce , Anderson Brett R , Gruenstein Daniel , Chua Kao-Ping
Published: July 2021

Background:
Infants with congenital heart disease (CHD) often require surgery within the first year of life, but may live far from congenital heart centers (CHCs) that can perform these surgeries. While some advocate for regionalization of care, others are concerned with impacts on travel distance and access. Using national Medicaid claims data, we determined the magnitude and predictors of nationwide travel distances between the homes of infants with operable CHD and the nearest CHCs.

Methods:
Our primary data source was the 2012 Medicaid Analytic eXtract claims data from 46 states and the District of Columbia. We identified 120 CHCs from the 2012 Congenital Cardiology Today directory, which is published annually in collaboration with the American College of Cardiology. Our sample included infants <365 days old with a 2012 claim containing one of 13 ICD-9-CM diagnostic codes for CHD requiring surgery in the first year of life (e.g. pulmonary atresia). We calculated straight-line distance between centroids of each patient’s ZIP code and the ZIP code of the nearest CHC. To determine predictors of travel distance, we performed a linear regression of log-transformed distance as a function of age, gender, race/ethnicity, urban/rural status, and mean adjusted gross income by ZIP code (mAGI).

Results:
Our sample included 11,868 children. Of these, 228 patients did not have a CHC within their state. Mean travel distance was 50.3 (SD 86.8) miles with a median of 25.6 (IQR 7.6-72.9) miles. In our sample, 53% lived within 30 miles of a CHC, but 15.3% lived greater than 100 miles away. Race, mAGI, and urban/rural status were independently associated with travel distance. On average, minorities lived closer to CHCs compared to white patients, with the exception of American Indian and Alaskan natives. Individuals in the poorest and urban ZIP codes lived closer to CHCs compared individuals in wealthier and rural ZIP codes (Table 1).

Conclusion:
Regionalization of CHD care could increase travel distances and impose access barriers. Our study informs the regionalization debate by estimating the prevalence and characteristics of infant CHD patients who may have high travel distances. Future research should use quasi-experimental approaches to ascertain the relationship between travel distance, access, and outcomes among CHD patients.
Abstract 207: Assessing the Clinical Value of Frailty as a Prognostic Indicator to Aid Decision-Making in Cardiac Surgery
Authors: Wilson-Pease Emma , Kephart George , Gainer Ryan , Moorhouse Paige , Hassan Ansar , Hirsch Greg
Published: July 2021

Background:
In North America, octogenarians are the fastest growing demographic. Chronological age of a patient is not always the same as their biological age, and their biological status can vary from robust to frail. Frail patients are predisposed to falls, institutionalization, hospitalization, and mortality. In the realm of cardiac surgery, there is little research examining frailty as a prognostic factor for cardiac surgical intervention.

Purpose:
The objective of the current study is to explore whether frailty provides additional information as a risk factor regarding patient prognosis over and above that of the comprehensive risk analysis scale, EuroSCORE II, used to determine suitability for cardiac surgery.

Methods:
This non-interventional study uses hospital patient files and questionnaire interviews, which assesses the patient’s frailty using the Frailty Assessment for Care-Planning Tool (FACT). From the documented EuroSCORE II from patient files, predictive modeling was used to consider frailty as a prognostic indicator for three adverse outcomes, discharge to an institution, major adverse cardiac events (MACE), and all-cause mortality + MACE. Furthermore, the sensitivity and specificity of the FACT will be evaluated using the area under the ROC curve for significant models.

Results:
Prognostic models determined that AUROC values provide improved prediction for two adverse outcomes, MACE and all-cause mortality + MACE. Using a cumulative score that involves all four domains (usual mobility, daily tasks, social function, and memory), higher discrimination with good calibration is achieved.

Conclusions:
Certain aspects of frailty, as measured by the FACT, have clinical value as prognostic indicators. These models are the first, to our knowledge, to investigate the relationship between the EuroSCORE II and MACE +/- all-cause mortality using the FACT. Traditional risk assessment scores such as the EuroSCORE II will benefit from having frailty included as a risk factor.

Implications:
This study will assist in educating future heart surgery patients about their possible risks by predicting adverse outcomes with better predictive ability. It is hoped that patients who possess more knowledge about their personal risks will be able to make more informed decisions about their surgery. Strategies to address and reduce frailty by increasing mobility and cognitive function and reducing nutritional deficiencies could use this information to inform future work.
Abstract 23: Lower Heart Rate Variability Associated With Incident Coronary Heart Disease and Death in Post-Menopausal Women
Authors: Mohamed Ahmed S , Qureshi Reema , Allison Matthew A , Manson JoAnn E , Roberts Mary , Eaton Charles
Published: July 2021

Rationale:
Lower heart rate variability (HRV) has been associated with increased all-cause mortality and adverse cardiovascular events including sudden death. The role of HRV in post-menopausal women is understudied. Therefore, we tested the hypothesis of a significant association between HRV and incident coronary heart disease (CHD) and CHD death in post-menopausal women.

Methods:
This is an analysis of prospective data collected during the Women’s Health Initiative (WHI) clinical trials. A total of 57,061 post-menopausal women were included. HRV was quantified using two variables; standard deviation of all normal-to-normal RR intervals (SDNN, milliseconds), and the root mean square of successive differences in normal-to-normal RR intervals (RMSSD, milliseconds). We used Cox proportional hazards models to test the association between HRV and incident CHD, hard CHD (including myocardial infarction and fatal CHD), and total CHD death. We controlled for age, race, alcohol use, physical activity, depression, BMI, smoking, diabetes, hypertension, lipid disorders, and family history of CHD.

Results:
The results are as highlighted for incident and hard CHD in table 1 and for CHD death in table 2. There were statistically significant associations between lower HRV (as a continuous variable and as quartiles) and higher levels of incident CHD.

Conclusion:
In post-menopausal women, lower HRV was associated with a modestly higher, but statistically significant, risk for incident cardiovascular events, including fatal and non-fatal myocardial infarction. Factors associated with lower HRV and cardiac autonomic impairment may be candidates for reducing CHD risk, such as better glycemic control and improved physical activity.
Abstract 232: Medication Cost Savings Using an On-line Drug Discount Program
Authors: Munigala Satish , Brandon Margaret , Goff Zackary D , Sagall Richard , Hauptman Paul J
Published: July 2021

Objective:
To evaluate the frequency of drug discount card utilization and to estimate cost savings associated with heart failure (HF) medication prescriptions.

Methods:
We conducted a retrospective study of all HF prescriptions filled through the NeedyMeds.org drug discount card program nationwide, from January 2009 to December 2016. We evaluated the frequency of drug discount card prescriptions (across pharmacy types, pharmacy location, by prescriber specialty and by drug class) and calculated cost savings (average per drug discount card and total program dollars saved) for entire study period and for each year (from 2009 to 2016).

Findings:
A total of 381,347 prescriptions for medications that can be used for HF with drug discount cards were identified during the study period (83.7% at national, 5.7% at regional and 9.8% at local pharmacies). Most prescriptions were filled at urban locations (89.1% in urban clusters, 7.6% in urbanized areas) and in ZIP-codes with lower median household income (65.5%). Angiotensin-converting enzyme inhibitors and selected angiotensin receptor blockers were the most prescribed drugs with discount cards (44.1%) followed by beta blockers (27.5%), diuretics (21.5%), and mineralocorticoid receptor agonists (3.9%). The number of HF prescriptions with drug discount cards increased from 2577 in 2009 to 64,750 in 2016. Increase in the number of prescriptions was also noted for all drug classes from 2009 to 2016. Overall 224,049 prescriptions for HF medications (59% of the total) benefited from the program resulting in total savings of $4,739,204 with a median cost saving of $9.30 (41.5%) per prescription.

Conclusion:
Use of a drug discount program resulted in cost savings on HF prescription medications (approximately $9 in savings per prescription) compared to the original cost charged by pharmacies. While these drug assistance programs may reduce financial burden, continued efforts should be made to improve adherence to medications and for better outcomes.