bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P348: Prognostic Value of Exercise Capacity in Patients With Diabetes Mellitus
Authors: Qureshi Waqas T , Zaidan Mohammad , Alqarqaz Mohammad , Lanfear David , Khalid Fatima , Shamieh Mohamad , Yaghmour Bassam , Al-Mallah Mouaz H
Published: July 2021

Background:
Exercise capacity has been shown to predict outcomes in the general population. However, the prognostic value of Exercise capacity in patients with insulin dependent diabetes mellitus (IDDM) and non insulin dependent diabetes mellitus (NIDDM) has not been extensively evaluated.

Methods:
We included 10768 consecutive diabetic patients (3600 (33%) IDDM and 7168 NIDDM (67%)) who underwent exercise testing between 1991 and 2008. Baseline characteristics and exercise data were collected prospectively at the time of testing including Metabolic Equivalents (METS). The primary endpoint is all cause mortality confirmed by the social security death index.

Results:
Patents with IDDM were older, more often females (46% vs. 41%) with higher prevalence of hypertension (83% vs. 77%) and prior coronary disease (21% vs. 17%). Patients with NIDDM achieved more than 10 METS more often (36% vs. 30%, p<0.0001). After a median follow-up duration of 6.4 years (Range 1-18 years), 2143 patients (20%) died. Kaplan Meier survival curves are shown below. Using Multivariable Cox Hazard Proportional Analysis, IDDM (Hazard ratio 1.45, 95% CI 1.3 -1.6, p<0.0001 (in comaprison to NIDDM)) and METS achieved (HR 0.82, 95% CI 0.80-0.83, p<0.0001 per METS achieved) were associated with decreased survival.

Conclusions:
In this large cohort of diabetic patients, decreased Exercise capacity is independently associated with decreased survival over long follow-up duration.
Abstract P35: Mild or Improving Stroke is the Most Frequently Documented Reason for Not Giving rt-PA in Time-Eligible Acute Ischemic Stroke Patients: Findings From Get With the Guidelines-Stroke
Authors: Smith Eric E , Fonarow Gregg C , Reeves Mathew J , Cox Margueritte , Olson DaiWai , Hernandez Adrian F , Schwamm Lee H
Published: July 2021

Introduction:
Previous studies suggest that mild or improving stroke is a frequently cited reason for not giving IV rt-PA and that some of these patients have poor outcomes.

Methods:
We examined the frequency of rt-PA use and contraindications among acute ischemic stroke patients arriving ≤2 hrs in the Get With The Guidelines-Stroke Program.

Results:
Between 4/1/2003-9/29/2009 there were 98,708 patients who arrived directly to the hospital within 2 hours. Among these patients 26.4% received IV rt-PA, 30.9% did not receive rt-PA solely because of mild/improving stroke, 28.6% had other contraindications, and 14.1% had no documented contraindications. From 2003-2009 rtPA use increased, the proportions not given rtPA despite no documented contraindications decreased, and the proportions with mild/improving stroke or other contraindications were similar (Figure). The initial NIH Stroke Scale (NIHSS) was recorded in 62.1% with mild/improving stroke and 82.3% given rt-PA; 75% of mild/improving stroke patients had NIHSS <5 while 90% of IV rt-PA-treated patients had NIHSS ≥5. Short-term outcomes in patients with mild/improving stroke were not always good: 1.1% died, 0.7% were discharged to hospice, 10.3% to a skilled nursing facility and 15.1% to an inpatient rehabilitation facility.

Conclusion:
In this large national study, mild/improving stroke is the most common reason for not giving rt-PA to early arriving patients. More patients are excluded because of mild/improving stroke than are treated with rt-PA. When deciding whether to withhold thrombolysis in patients with mild/improving stroke, clinicians should consider the risk of poor outcomes in this population.
Abstract P359: Both High and Low Total Cholesterol Levels Are Associated With Poor Prognosis in Patients With Left Ventricular Systolic Dysfunction
Authors: Mathur Gaurav , Karalis Dean , Clark AL , Cleland JG
Published: July 2021

AIM
To assess the influence of total cholesterol level on prognosis in patients with left ventricular systolic dysfunction (LVSD).

METHODS
Patients presenting to a HF clinic (2000-2006) were screened. Those with LVSD were divided into 3 groups based on tertiles of total cholesterol level. All-cause mortality data was used for Kaplan-Meier curve and Cox regression analysis to assess the prognostic significance of total cholesterol level in these patients.

RESULTS
Of 2901 patients screened, 1342 had some degree of LVSD on echocardiogram, classified as mild (EF=41-50%; N = 478), moderate (EF=31-40%; N = 513), and severe (EF≤30%; N = 351). Median age was 72 (interquartile range 65-78) yrs, 71% (952 of 1342) were men. Mean follow-up was 37.6 months, during which 340 deaths occurred. Kaplan-Meier curves were generated for the 3 groups based on tertiles of serum cholesterol level (cut-off points 162 and 197 mg/dL) (Figure 1). Patients in the lower and upper tertiles had similar prognosis, which was significantly worse than the middle tertile (log rank=0.004). On multivariate analysis, age (p=0.001), ischemic etiology (p=0.003), NYHA class (p=0.001) and total cholesterol levels below 162 and above 197 mg/dL (p = 0.026) were independent predictors of poor prognosis in patients with LVSD. Though the 3 cholesterol groups were evenly matched for NYHA Class and severity of LVSD, NT pro-BNP levels were significantly higher in the lowest tertile group (p=0.005).

CONCLUSION
In patients with LVSD, both high and low cholesterol levels are associated with poor prognosis. Low cholesterol may be a marker of severity of disease and cardiac cachexia in patients with LVSD, accounting for their poor prognosis.
Abstract P360: Temporal Variability in the ECG Manifestations of Cardiac Sarcoidosis
Authors: Shah Aman M , Beegle Scott , Torosoff Mikhail
Published: July 2021

BACKGROUND:
Temporal variability in ECG manifestations of cardiac sarcoidosis in patients with documented extra-cardiac sarcoidosis has not been previously reported.

METHODS:
Six or more 12-lead ECGs were reviewed for each of 8 patients (6 females, 6 African Americans, 38-63 years old) with documented extra-cardiac sarcoidosis. Analyzed ECGs were obtained at intervals no longer than 12 months apart. PR and QT intervals and QRS duration were measured in each ECG lead and averaged for three consecutive beats per lead. The presence of PVCs, AV block, RBBB, and/or QT prolongation was recorded. Between ECG variability was analyzed with ANOVA for continuous data and chi-square analysis for categorical data.

RESULTS:
Significant variability in ECG indicators of sarcoidosis activity, concurrent with clinical impression of sarcoidosis exacerbation, was detected in seven of eight patients. Most common were new QT prolongation (94%, p=0.031) and PR interval increase (87.5% of the analyzed ECGs, p=0.029). Concordant variability was noted for both in between visit and in between lead comparisons of PR duration, QT/QTc intervals, and QRS duration (p<0.0001 in 5 patients; p<0.001 in 2 patients). No PVCs were documented on the analyzed ECGs.

CONCLUSION:
ECG abnormalities diagnostic of cardiac sarcoidosis have high temporal variability which parallels clinical impression of extra-cardiac disease activity. A 12-lead ECG is warranted at each visit in patients with documented extra-cardiac sarcoidosis. At the same time, 12-lead ECGs are probably not sufficiently sensitive to detect arrhythmias and/or PVCs in patients with documented extra-cardiac sarcoidosis.
Abstract P52: Absence of Dysphagia is a Stronger Predictor of Favorable Discharge Disposition than Stroke Severity: Insights from the UTHSC Houston Stroke Registry
Authors: Jones Nneka I , Harun Nusrat , Noser Elizabeth , Grotta James
Published: July 2021

Introduction:
Dysphagia is one of the most common post-stroke complications. The use of feeding tubes to provide nutrition requires increased acuity of care for management, which affects costs. This care is provided at all levels, including Inpatient Rehabilitation (IR), Skilled Nursing Facility (SNF) or Sub-acute (Sub). There are limited studies of the role of dysphagia as a predictor of post-stroke disposition.

Hypothesis:
Low NIHSS is a predictor of higher function. We assessed the hypothesis that the absence of tube feeds as an indicator of dysphagia is a predictor of post-stroke disposition to a similar functional level.

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 to determine if differences in post-stroke disposition were present among patients not receiving tube feeds as an indicator of dysphagia.

Results:
Home vs. Other Level of Care
Of 3389 patients, 1668 were discharged home, 1721 to another level of care. Patients without tube feeds are
14.6
times more likely to be discharged home (P = <.0001, OR 14.66, 95% CI 8.05 to 26.69) Patients with NIHSS < 8 are
10.9
times more likely to be discharged home.
IR vs. SNF
Of 1546 patients, 983 were discharged to acute IR, 563 to SNF. Patients without tube feeds are
6.1
times more likely to be discharged to IR (P = <.0001, OR 6.118, 95% CI 4.34 to 8.63). Patients with NIHSS < 8 are
2.5
times more likely to be discharged to IR.
SNF vs. Sub
Of 738 patients, 563 were discharged to SNF, 175 to Sub. Patients without tube feeds are
3
times more likely to be discharged to SNF (P = <.0001, OR 2.999, 95% CI 2.048 to 4.390). Patients with NIHSS < 8 are
2
times more likely to be discharged to SNF.

Conclusions:
The absence of tube feeds as an indicator of dysphagia is a predictor of improved post-stroke disposition, with a correlation stronger than NIHSS. This study is limited by its retrospective nature and unmeasured psychosocial factors related to discharge. Prospective studies should focus on early diagnosis, therapeutic intervention and caregiver involvement in dysphagia education to improve outcomes and decrease the cost of post-stroke care.
Abstract P60: The Effect of Angiotensin Receptor Blocker/Calcium Channel Blocker Single Pill Combination Therapy on Adherence to Antihypertensive Treatment
Authors: Zeng Feng , Andrews Laquesha , Patel Bimal V
Published: July 2021

Objective:
To evaluate the impact of ARB/CCB single pill combination therapy on adherence to antihypertensive (AHY) treatment.

Methods:
A retrospective data analysis was performed using pharmacy claims data from a national pharmacy benefit management company. The study included patients who were newly initiated on ARB/CCB treatment between 01/01/2007 and 08/31/2008, age ≥18 years, and continuously enrolled in the same health plan for 6 months prior to and 13 months after starting ARB/CCB treatment. Patients who started either valsartan and amlodipine or amlodipine and olmesartan medoxomil ARB/CCB single pill combinations were assigned to the single pill combination (SPC) group. The ARB/CCB free combination (FC) group included patients who used a combination of single-agent ARB and CCB treatment. Outcome variables were persistence, defined as time to discontinuation of therapy, and adherence, defined as proportion of days covered (PDC) ≥0.80. Propensity score weighted multivariable regression models were used to estimate the impact of combination pill therapy. Covariates included age, gender, baseline comorbidities, insurance type, geographic region, copayment, and history of other AHY use.

Results:
The final sample contained 2,312 patients in the ARB/CCB FC group and 2,213 patients in the ARB/CCB SPC group. After adjustment for differences in baseline characteristics, a Cox proportional hazards model showed that patients in the SPC group were 24% less likely to discontinue ARB/CCB therapy as compared to patients in the FC group (HR 0.76, 95% CI 0.73-0.79, p<0.0001). A logistic model showed that patients in the SPC pill group had a 90% greater odds of being adherent compared to patients in the FC group (OR 1.90, 95% CI 1.75-2.08, p<0.0001). In both models, higher copayment (copayment $50 and above) was associated with poorer persistence and adherence in comparison to patients who faced copayment $0-$5: HR=1.15, p<0.001 and OR=0.67, p<0.0001.

Conclusion:
Patients using single pill combination ARB/CCB therapy were more likely to be persistent and adherent to treatment as compared to patients taking free combination therapy.
Abstract P62: Efficacy of Ezetimibe 2.5 Milligrams Utilizing a Novel Tablet Splitting Strategy
Authors: Baruch Lawrence , Gupta Bhanu , Haynos Ann , Agarwal Sanjay , Johnson Swapna , Kelly-Johnson Katelyn , Eng Calvin
Published: July 2021

Background:
Ezetimibe's excellent tolerability and approximately 20% LDL lowering effect have made it the most commonly prescribed 2
nd
line lipid lowering agent after statins. Ezetimibe is available only in a 10 mg form, either as a stand-alone tablet or in combination with simvastatin as ezetimibe/simvastatin (Vytorin). During clinical development, a wide range of ezetimibe doses were evaluated, including 0.25, 1, and 5 mg. A 2.5 mg dose of ezetimibe was never evaluated. Prospective and retrospective studies have demonstrated that splitting a 10 mg ezetimibe tablet, which provides approximately 5 mg of ezetimibe, is clinically equivalent to a whole 10 mg tablet. On the basis of these results, along with others that demonstrated 1 mg of ezetimibe significantly lowered LDL by approximately 13 to 15%, we prospectively randomized patients to either a simvastatin 20 mg tablet or an ezetimibe/simvastatin 10/80 tablet (10 mg ezetimibe plus 80 mg simvastatin) split into 4 to yield an estimated daily dose of ezetimibe 2.5 mg and simvastatin 20 mg. The efficacy of the two strategies on lipid parameters was compared. We selected ezetimibe/simvastatin 10/80 as a means of obtaining 2.5 mg of ezetimibe, as this tablet size can be readily split into 4 relatively equal parts with a commercially available tablet splitter.

Study design:
Thirty three subjects were randomized to either simvastatin 20 mg or an ezetimibe/simvastatin 10/80 tablet divided into 4. Lipid panels were collected at baseline and after 6 weeks of therapy.

Results:
Twenty nine of the 33 subjects successfully completed the study.

Conclusion:
From a comparative effectiveness perspective, ezetimibe 2.5 mg, delivered by splitting an ezetimibe/simvastatin10/80 tablet into 4, provides the greatest value and delivers LDL lowering comparable to full dose ezetimibe 10 mg. This novel tablet splitting strategy may be applicable to other medications and provide significant additional cost-reduction.

Lipid Value (mg/dL)

ES 2.5/20
*
(n=14)

Simvastatin 20 (n=15)
P (between groups)

% change from baseline (p
**
)

% change from baseline (p
**
)

Low density lipoprotein

-44.7 ± 19.0% (<.001)
-27.1 ± 22.4% (<.001)
0.03

High density lipoprotein

-5.1 ± 7.4% (<.05)
-0.7 ± 9.3% (ns)
0.17

Triglycerides

-23.3 ± 3.8% (<.01)
-11.9 ± 6.0% (.03)
0.18

Total cholesterol

-34.2 ± 13.0% (<.001)
-19.9 ± 14.6% (<.001)
0.001

Data is expressed as mean ± SD.

*

ES: Ezetimibe/simvastatin 10/80 tablet split into 4 parts, supplying ezetimibe 2.5 and simvastatin 20.

**

P-value for the change in the lipid parameter from the baseline value.
Abstract P65: Outpatient Atrial Fibrillation Ablation on Therapeutic Warfarin - Safety, Efficacy, and Cost Savings
Authors: Giudici Michael C , Paul Deborah L , Sloane Caroline , Press Gisela , Petersen Ashley , Garrison Ashley , Schrumpf Phillip E
Published: July 2021

Introduction:
Catheter ablation for atrial fibrillation (PVI) is being performed with increasing frequency. This time and labor-intensive procedure is under increasing scrutiny as we look for means to decrease costs of delivering care. Performing these procedures on therapeutic warfarin could shorten hospital stays, eliminate costly low-molecular weight heparin (LMW) use, and decrease procedural heparin administration which could reduce hemorrhage from access sites.

Methods:
Over a six-year period, 180 patients, 138 M/42 F, mean age 43 yr (18-77 yr), underwent PVI for persistent - 99 pts., and paroxysmal - 81 pts. atrial fibrillation. Mean INR was 2.2 (1.5 - 4.2). Procedures were performed with standard radiofrequency (RF) catheters - 132, Cryoablation - 27, and Ablation Frontiers RF - 21. Procedural time, fluoroscopy time, hospital stays, outcomes, and complications were tracked.

Results:
127 of 180 pts. were discharged the day of procedure (OP) from the outpatient unit, 51 pts. stayed one night post-procedure (IP), 2 patients stayed 4 days, one for pulmonary treatment and one for CVA. Mean procedural length was 3.3 hours, mean fluoro time was 52 min. Mean time from hospital admit to discharge was 17.3 hr. Mean time from procedure end to discharge was 11.0 hr. 77% of pts. were free from AF on follow-up on no meds or “pill-in-the-pocket”. 6 complications occurred - 1 phrenic nerve paralysis (resolved), 2 CVAs (one was 72 hrs post PVI), 1 perforation/tamponade, 1 groin bleed requiring evacuation, 1 PV stenosis. There was no difference in outcome for patients discharged OP vs IP. Cost savings by continuing warfarin were LMW = $205/dose X 6 doses - $1230/pt. Cost savings by same day discharge = $1330/day.

Conclusions:
PVI can be safely performed as an outpatient procedure on therapeutic warfarin with good clinical outcomes. Significant cost savings can be realized from OP PVI from reduced staff, medication, and facilities utilization.
Abstract P80: Initial and 12 Month Outcomes After Percutaneous Coronary Intervention in Australian Private Hospitals; Results From a National Multi-Centre Registry
Authors: Eccleston David , Holt Geoff , Horrigan Mark ,   Heart Care Group Investigators
Published: July 2021

Background:
Several large multi-centre registries have evaluated outcomes after percutaneous coronary intervention (PCI) in the USA, however there is little data regarding the outcomes of patients in Australian Private hospitals. The aim of this study was to report the initial results of a new multi-centre registry.

Methods:
We prospectively enrolled consecutive patients (n=951) undergoing PCI to 1179 lesions at 6 Australian private hospitals from November 2008 to February 2010. Baseline patient/procedural data and in-hospital and 30 day and 12 month outcomes were recorded on case report forms. Data is stored electronically in the department of Epidemiology at Monash University.

Results:
The mean age ± SD was 67 ± 12 years. Females comprised 29.7 % (282/951), diabetics 26.6% (252/951), 33% (313/951) were obese (BMI>30) and 19% (181/951) had acute coronary syndromes. At least one DES was used in 64% of PCI (755/1179). In patients not taking Warfarin, 99.4% were taking aspirin and 98.8% clopidogrel at discharge. At 12 months, 10% (96/951) had undergone further revascularisation by PCI or CABG however only 1.1% (11/951) required target vessel revascularisation.

Conclusion:
A prospective, multicentre registry providing outcomes after PCI in private hospitals is feasible. Australian practice and in-hospital outcomes after PCI are consistent with those reported in American/European registries. One year follow up data will be presented.

Outcomes at discharge
(%)

PCI Success
99.4

Death- Overall - Patients without pre-procedural shock
0.0

0.0

Myocardial infarction
2.4

Stroke
0.0

Urgent/ Early Target vessel revascularisation
0.6
Abstract P84: The Impact of a Potential Nationwide Comprehensive Smoking Ban on Acute Myocardial Infarction Hospitalizations
Authors: Al-Mallah Mouaz H , Khawaja Owais , Alqaisi Fadi , Nerenz David , Weaver W Douglas
Published: July 2021

Introduction:
Smoking is a well established risk factor for acute myocardial infarction (AMI). The potential impact of a nationwide comprehensive smoking ban (CSB) legislation on the incidence of AMI hospital admissions is not known. The aim of this analysis is to determine the impact of a nationwide CSB legislation on the incidence of AMI hospitalizations.

Methods:
We contacted the department of health at states with no CSB law for information on the total number of AMI discharges (ICD-9-CM 410), length of stay and charges in dollars for 2007. Expected decrease in the number of AMI in the year following a potential implementation of a nationwide CSB was calculated by multiplying the current number of AMI by the pooled relative risk reduction (RRR) obtained from a recent published meta analysis (RR 0.89).

Results:
In 2007, 37 States had CSB laws. There were 169,043 AMI hospitalizations in states without CSB. A nationwide smoking ban would result in 18,596 less AMI hospitalizations in the year following such a ban. This is associated with more than 92 million dollars in direct cost savings.

Conclusion:
A nationwide CSB legislation would result in significant reduction in the number of AMI hospitalizations. This is associated with significant cost saving. Further studies are needed to evaluate the impact of CSB on admission from other disease states.
Abstract P85: Are Myocardial Bridges Associated With Increased Risk of Death or Myocardial Infarction?
Authors: Al-Mallah Mouaz H , Kassem Kamal , Khawaja Owais , Song Thomas , Poopat Chad , Pantelic Milan , Nour Khaled
Published: July 2021

Background:
Myocardial bridging (MB) is frequently seen on coronary CT angiography (CCTA). However, there has been conflicting data on the prognostic value of MB. The aim of this analysis is to determine the prognostic value of MB in patients without obstructive coronary artery disease (CAD) (<50 diameter stenosis).

Methods:
We included patients with no known prior coronary artery disease (CAD) who underwent CCTA for various clincial reasons. Patients with obstructive CAD on CCTA were excluded. The study cohort was followed for all cause mortality or myocardial infarction (MI) (median follow-up 1.7 years). Group comparisons were made between patients with patients with or without MB.

Results:
A total of 715 patients were included in this analysis of which 68 patients had MB (10%). 73% of the bridges were in the mid LAD and 22% had bridging in the distal LAD. 48% of the study cohort had normal coronaries, while 52% had evidence of non obstructive CAD. There were no differences in the baseline characteristics, symptomatic status or prevalence of non obstructive CAD between the two groups (all p>0.5). After a median follow-up duration of 1.7 years, 23 patients died and 10 patients experienced myocardial infarction. There were no statistically significant differences in the rate of death/MI between the two groups (figure). Using multivariable Cox regression, the presence of MB was not associated with increased risk for death/MI (Adjusted HR 0.4, 95% confidence interval 0.1 -2.8, p=0.34)

Conclusions:
In patients with non-obstructive CAD, MB is not associated with increased risk for all cause death or MI.
Abstract P86: Cost-Effectiveness of Enhanced External Counterpulsation in Reducing Hospital Costs in Refractory Angina Patients
Authors: Lawson William E , Hui John C , Kennard Elizabeth D , Kelsey Sheryl F , Linnemeier Georgiann C
Published: July 2021

Background:
Repeat hospitalizations represent significant direct costs of care in patients (pts) with refractory angina. Enhanced external counterpulsation (EECP) is effective in treating coronary pts with disabling angina, who are not candidates for revascularization, and have limited treatment options. This study evaluated the cost savings in hospitalizations using EECP therapy.

Methods:
Annual EECP hospitalization cost savings/pt was calculated by the product of estimated hospitalization and physician charge based on a sample-size weighted average of Healthcare Cost and Utilization Project Nationwide Inpt Sample database and the reduction of hospitalizations/year after subtracting the cost of EECP. Pre- and post- EECP hospitalization rates were derived using data from the International EECP Pt Registry. The prevalence of refractory angina in the US in 2008 was estimated from the AHA Heart Disease and Stroke Statistics, heartstats.org, and the Incidence and Prevalence Database.

Results:
The annual pre-EECP treatment hospitalization rate for 1,015 refractory angina pts with 95% in Canadian Cardiovascular Society (CCS) functional class III and IV was 1.85 /pt/year. 92% of these pts had prior PCI or CABG with multivessel coronary disease and were no longer candidates for revascularization. EECP therapy was effective in reducing the proportion of CCS class III and IV pts to 21% at 1-year follow-up. Post-EECP 23% of the pts were hospitalized with a mean of 1.4 ± 1.0 hospitalizations in the 1 year after EECP. The post-EECP hospitalization rate was 0.63/pt/year, giving a hospitalization rate reduction of 1.22/pt/year. The average hospitalization and physician charge in the US was $17,995, and the average EECP treatment cost was $4,880, yielding an annual cost savings/pt of $17,025. Estimates of total savings were calculated by the product of cost savings/pt and the low and high estimates of the incidence of refractory angina (low: 422,000 pts; high: 1,273,000 pts). This calculation translated the total annual hospitalization cost savings as a potential 7.185 billion to 21.673 billion dollars.

Conclusions:
Appropriate use of EECP in refractory angina pts could result in a substantial decrease in hospital costs at an attractive cost-effectiveness.
Abstract P90: Cardiovascular and Economic Outcomes Following Initiation of Atorvastatin versus Simvastatin in an Employed Population Stratified by Cardiovascular Risk
Authors: Simpson Ross , Signorovitch James , Ramakrishnan Karthik , Ivanova Jasmina , Birnbaum Howard , Kuznik Andreas
Published: July 2021

OBJECTIVE:
To compare initiation with atorvastatin versus simvastatin among higher- and lower-risk employees in terms of subsequent risk of cardiovascular (CV) events and direct and indirect costs from the employer perspective.

METHODS:
Employees initiating atorvastatin or simvastatin were identified from a claims database (1999-2006) spanning 23 large, self-insured employers and stratified as 1) high-risk employees with prior CV events, diabetes or renal disorders and 2) low-to-intermediate-risk employees without these conditions. Propensity score matching was used to adjust for baseline differences between the atorvastatin and simvastatin cohorts, and two-year outcomes were compared between matched cohorts. Indirect costs included disability payments and medically-related absenteeism. Atorvastatin and simvastatin drug costs were imputed with recent prices to account for availability of generic simvastatin.

RESULTS:
Among 4,167 matched pairs of high-risk employees, initiation with atorvastatin vs. simvastatin was associated with similar rates of subsequent CV events (17.6 vs. 18.4%, P=0.37), higher direct medical costs ($17,590 vs. $17,377, P=0.002), similar indirect costs ($4,830 vs. $4,989, P=0.29) and higher total costs by $54 ($22,420 vs. $22,366, P=0.034). The majority of high-risk employees (62%) received low initial statin doses (atorvastatin ≤ 10 mg or simvastatin ≤ 20 mg). Among 9,326 matched pairs of low-to-intermediate risk employees, initiation with atorvastatin vs. simvastatin was associated with a lower rate of CV events (3.1 vs. 3.7%, p=0.030), lower direct medical costs ($8,400 vs. $8,436, P<0.001), similar indirect costs ($2,781 vs. $2,807; P=0.12) and lower total costs by $61 ($11,181 vs. $11,243, P<0.001).

CONCLUSIONS:
Among high-risk patients, initiation with atorvastatin vs. simvastatin was associated with no significant difference in CV events and higher total costs to employers. Among low-to-intermediate risk patients, initiation with atorvastatin vs. simvastatin was associated with fewer CV events and net cost savings to employers. Formulary policies reserving atorvastatin for higher-risk patients may not be beneficial from the employer perspective.
Abstract P94: Rural-Urban Utilization of Echocardiography: Analysis of Veterans Administration Data
Authors: Okrah Kingston , Vaughan-Sarrazin Mary , Kaboli Peter , Cram Peter
Published: July 2021

BACKGROUND:
Patients residing in rural areas may have reduced access to many medical services. This is a particular concern for highly regionalized delivery systems such as VA Healthcare System. We examine echocardiography (echo) utilization among veterans residing in urban and rural regions of the US.

METHODS:
We used VA administrative data to identify patients receiving care at the VA from 1999-2007. Patients were included during any year that they were engaged in care at the VA, defined by having at least 2 primary care visits during the year (“VA users”). For each year, we identified echos performed on VA users using CPT or ICD-9 codes. We classified each veteran as living in an urban, rural or highly rural region using the RUCA classification system. We compared demographics, comorbidity, and echo utilization rates per 1000 VA users among veterans living in each of the 3 regions using bivariate methods. We used logistic regression models to compare echo utilization for veterans residing in rural and highly rural areas with urban veterans serving as the reference while adjusting for patient demographics, comorbidity, and clustering of patients within 23 veteran integrated networks.

RESULTS:
Echo recipients residing in highly rural areas were older than residents in rural and urban areas (67.3 yrs vs. 66.7 yrs vs. 66.6 yrs), and more likely to be white, (76.5% vs. 73.6% vs. 59.4%). Unadjusted echo utilization was significantly higher for residents of urban areas compared to rural areas, but similar to highly rural areas (64.0 echos per 1000 per year for urban vs. 59.2 for rural vs. 63.7 for highly rural). In regression models however, we found that veterans living in rural and highly rural areas were slightly more likely to receive echos compared to veterans living in urban areas after adjusting for patient demographics and comorbidity (OR 1.03 95% CI 1.03-1.04 for rural and OR 1.13 95% CI 1.12-1.14 for isolated rural).

CONCLUSION:
We found no evidence that veterans residing in rural and highly rural regions of the U.S. had reduced utilization of echocardiography after adjusting for patient demographics and comorbidity. These findings suggest that the regionalization of the VA delivery system does not limit the performance of echocardiography for rural veterans.
Abstract 2: Effect of a Decision Aid on Patient Knowledge, Patient Satisfaction, Safety, and Resource Use in Emergency Department Patients Presenting with Chest Pain: A Randomized Trial
Authors: Hess Erik , Knoedler Meghan A , Kline Jeffrey A , Shah Nilay D , Breslin Maggie , Branda Megan E , Pencille Laurie J , Asplin Brent R , Nestler David M , Sadosty Annie T , Ting Henry H , Montori Victor M
Published: July 2021

Objectives:
Patient involvement in the choice of whether to undergo emergency department observation unit (EDOU) admission and cardiac stress testing or follow-up with a physician could increase knowledge, increase satisfaction, and safely decrease resource use. We test this hypothesis in a randomized trial.

Methods:
We developed and tested Chest Pain Choice, a decision aid that communicates the pre-test probability of an acute coronary syndrome (ACS) within 45 days and makes management options (EDOU admission and stress testing or 24-72 hr follow-up with a physician) explicit to the patient. Patients with a primary complaint of chest pain and no known coronary artery disease who were being considered for EDOU admission were eligible. Patient-clinician pairs were randomized to intervention (decision aid plus risk estimate) or usual care (no decision aid, no risk estimate). We used patient surveys and 30-day phone follow-up to assess the primary outcome (patient knowledge regarding their short-term risk for ACS), patient satisfaction, safety (delayed or missed ACS defined as acute myocardial infarction, ventricular arrhythmia, cardiogenic shock, or cardiac/unknown death), and resource use. Analysis was by intention to treat.

Results:
The 205 patients had the following characteristics: mean age (SD) 54.7 (11.8), 59% female, 36% history of HTN and 10% history of diabetes. Compared with usual care patients (n=104), patients receiving the decision aid (n=101) less frequently decided to be admitted to the EDOU for cardiac stress testing (58% vs 77%, absolute difference = 19%, 95% CI 6, 31), had a lower rate of stress testing (74% vs 90%, absolute difference = 16%, 95% CI 6, 26), greater knowledge of their exact pre-test probability of ACS (25% vs 1%, absolute difference = 24%, 95% CI 15, 33) and reported greater satisfaction with the decision-making process (strongly agree: 61% vs 40%, absolute difference = 21%, 95% CI 7, 33). There were no cases of delayed or missed ACS in either arm.

Conclusion:
Use of a decision aid in ED chest pain patients increased knowledge, increased satisfaction, and safely decreased resource use. In an era of health care reform, shared decision-making is a promising approach that may both increase patient engagement and decrease resource use.Funding(This research has received full or partial funding support from the American Heart Association, National Center)
Abstract P1: Limitations of Self-Reported Readmission Data After Acute Myocardial Infarction: Insights from the TRIUMPH Registry
Authors: Jones Philip G , Salisbury Adam C , Decker Carole , Krumholz Harlan M , Spertus John A
Published: July 2021

Background:
Self-reported readmission rates are frequently reported in the medical literature, yet the validity of these data is controversial. Few studies describe the accuracy of self-report of readmission following an AMI in comparison with physician-adjudicated data.

Methods:
We studied 4,340 AMI patients enrolled in the 24-US center TRIUMPH registry. Patients were interviewed at 1, 6 and 12 months after their AMI, and were asked to report all hospitalizations since their last contact, including the hospital name, date and reason. After obtaining consent from the patient and each hospital, all hospitalization records within the first year after the patient's index MI were requested and adjudicated by a physician panel. Accuracy of patients’ report of hospitalization and reason for admission (sensitivity, specificity) were assessed.

Results:
Of 4,340 patients, 3,633 (84%) completed follow-up interviews, reporting a total of 2,016 readmissions. Of these, hospital records were successfully obtained on 1,373. Record review revealed that 501 (36%) were not actual rehospitalizations (e.g., emergency department only, outpatient visits, admissions prior to study enrollment). Interestingly, when obtaining hospital records, we identified another 394 readmissions that were not reported by patients. Sensitivity of self-reported reason for admission was modest to poor for cardiac-cause rehospitalization, AMI and percutaneous coronary intervention (Table).

Conclusions:
We identified several limitations of self-reported readmission rates in this multi-center AMI cohort. Emergency department and outpatient visits were frequently reported as hospital admissions, nearly 400 hospitalizations were not reported to study personnel at the time of the follow-up interview, and accuracy of patient-reported reason for admission was modest at best. These data underscore the importance of verifying self-reported follow-up outcomes data.

Accuracy of Patient Self-Reported Reason for Admission

Adjudicated Reason for Admission
Sensitivity
Specificity

Any cardiac
37%
88%

AMI
43%
94%

PCI
66%
93%
Abstract P100: An Interactive, Training-Based Data Audit Approach Improves Subsequent Data Validation in a Large State-Based Registry
Authors: Coe Laura J , O'Neill June , Kunches Laureen , Reinhalter Nancy , Schwamm Lee H
Published: July 2021

Objective:
We sought to determine whether an interactive, training-based approach to data validation would effectively reduce data element discrepancy rates in subsequent years.

Methods:
Fifty-eight Massachusetts hospitals participate in the Coverdell Stroke Registry and collect data on stroke-care processes using national definitions. From 2007 to 2009 auditors visited selected sites annually to assess data accuracy. Initial data element selection was based on performance measure inclusion. Subsequent audits focused on new data elements and those with frequent errors. Full-day site visits included: re-abstraction of approximately 10 charts and discussion with hospital staff to clarify discrepancies. Emphasis was on teaching to promote data quality improvement. Written feedback was sent to the coordinators following each visit. Variable-level discrepancy rates were calculated as the number of errors for a given variable over the total number of cases reviewed system-wide. A “low” discrepancy rate of < 5% was the goal. Discrepancy rates of > 20% were considered “high”.

Results:
From 2007 through 2009, a total of 78 stroke registry variables were audited in more than 1,300 patient records during 147 unique hospital visits. The mean variable-level discrepancy rate decreased significantly from 11% in 2007 to 5% in 2008 (p = 0.006) and remained at 5% in 2009. Evidence of decline in the “high” discrepancy rate elements were of particular interest as they became the focus of various training opportunities, including the audit visits. The percentage of variables with a “high” range of errors significantly declined from 20% (10 of 51) in 2007 to 3% (1 of 36) in 2008 to 0% (0 of 46) in 2009 (2007 vs. 2009; p-value = 0.001).

Conclusion:
The on-site audits proved to be teachable moments for hospital staff resulting in highly effective and valuable one-on-one training. Commonly identified errors were also highlighted at periodic Registry trainings, and subsequent revisions to the data collection tool and reference guides may also have facilitated improvement. While various approaches to assess data reliability exist, using the chart audit as a vehicle for abstractor training was effective in improving discrepancy rates. Further research is warranted.
Abstract P107: Comparing Perceptions of Chronic Heart Failure Patients' Health Status Prior to Hospitalization by Patients and Their Family Caregiver/Significant Others
Authors: Quinn Jill R , Tucker Rebecca , Chen Leway , Brasch Judith , Smith Joyce A , Chen Ding-Geng
Published: July 2021

PURPOSE:
Little is known if family caregivers/significant others (FC/SOs) have similar or different perceptions of the patients' health status. FC/SO perception may influence care decisions and affect patient outcomes. The purpose of this study was to compare chronic HF patients' and FC/SOs' perception of the patients' health status prior to hospitalization and relationship to time to seek care.

METHODS:
Participants were 144 hospitalized chronic HF patients and 144 FC/SOs recruited to complete the Kansas City Cardiomyopathy Questionnaire (KCCQ). The questionnaire was administered to both patients and their FC/SOs during the patients' hospitalization to measure perceptions of the patients' health status 2 weeks before hospitalization. The KCCQ is a validated questionnaire that quantifies physical limitation, symptoms, social limitation, self-efficacy, and QOL for patients with HF; lower scores meaning worse perceived health status. The questionnaire with modified wording was used for FC/SOs to respond about their perceptions of the patients' health status and reliability was evaluated. Patient participants were primarily white males with a mean age of 66.2 (SD=15.3). Mean LVEF was 33.3 % (SD=18.3). The FC/SO participants were primarily family members and white females; mean age of 58.2 years (SD=14.3).

RESULTS:
Paired t-test correlation analysis revealed the responses from patients and FC/SOs as significant (p<.001) and highly correlated on their perceptions of the patient’s physical limitation (
r
=.63), symptom frequency (
r
=.68), symptom burden (
r
=.61), social limitation (
r
=.59); and moderately correlated on perceptions of QOL (
r
=.38), self-efficacy (
r
=.38), and symptom stability (
r
=.44).Cronbach's alphas for patient KCCQ and FC/SO KCCQ were .91 and .90, respectively. Overall health status summary scores were highly correlated (
r
=.70) but the patients' overall score was significantly inversely related to days to hospitalization (
B
=−.031,
p
=.01).

CONCLUSIONS:
The health status of chronic HF patients is perceived similarly by both patients and FC/SOs as poor and is associated with longer time to seek care. Further research is needed to understand how these perceptions influence decision making to seek appropriate and timely care.
Abstract P108: Assessing Utility of Drug-Eluting Stents in Coronary Patients Aged 85 Years and Older
Authors: Forman Daniel E , Vasaiwala Samip , Silbaugh Traecy S , Lovett Ann , Normand Sharon-Lise T , Mauri Laura
Published: July 2021

Background:
Very old (VO) adults (≥85 years) are intrinsically susceptible to coronary heart disease (CHD) and are often treated with coronary stents. While current evidence supports use of drug-eluting stents (DES), generalizability to VO remains controversial, especially given high age-associated bleeding risks from long-term dual antiplatelet therapy.

Methods:
We identified all VO CHD patients who received stents between April 1, 2003 and September 30, 2006 at all non-federal hospitals in Massachusetts (MA) (N=1619), and completed 2-year follow-up on the entire cohort. Patients were classified as DES-treated if stents were all drug-eluting and BMS-treated if stents were all bare-metal (those receiving DES and BMS were excluded). Mortality rates were determined from vital statistics records. New myocardial infarction (MI) and subsequent bleeding (requiring hospitalization) were determined using ICD-9 codes. Repeat target vessel revascularization (TVR) was determined from the MA database. Risk-adjusted cumulative incidence was estimated using propensity score matching based on 57 clinical, procedural, hospital, and insurance variables.

Results:
During the study period, 1145 and 474 VO patients received DES and BMS respectively. Unadjusted 2-year mortality rates were 23.8% vs. 35.0% (DES vs. BMS, p<0.0001). Risk-adjusted (propensity score matching [665 DES:343 BMS]) 2-year DES vs. BMS rates were 25.4% vs. 32.4% (hazard ratio [HR] 0.69, 95% confidence interval [CI] 0.51, 0.93; p=0.01) for mortality and 9.8 vs.16.9% (HR 0.51, 95% CI 0.35, 0.76; p=0.001) for MI. Risk-adjusted 2-year rates of bleeding (13.6% vs. 12.5%, HR 1.08, 95% CI 0.73, 1.59; p=0.72) and TVR (5.7% vs. 8.7%, HR 0.62, 95% CI 0.38, 1.02; p=0.06) were similar in patients treated with DES vs. BMS.

Conclusions:
In a large, unrestricted, state dataset of VO CHD patients with mandated follow-up, DES were associated with reduced 2-year mortality and MI compared with a matched BMS subset, without an increased hazard of bleeding.
Abstract P126: Risk Factor Profiles of South Asians with Cerebrovascular Disease: Findings from a Community-Based Prevalence Study in Semiurban Pakistan
Authors: Ahmed Bilal , Itrat Ahmed , Khan Maria , Kamal Ayeesha
Published: July 2021

Background
There is a paucity of population based data about the coexistent prevalence of risk factors for stroke in South Asians.

Methods
In this cross sectional survey performed in an urban slum, individuals 35 years of age or older were invited for participation through simple random sample drawn from baseline census data. For each participant a systematic history and examination was performed to confirm the following risk factors: Diabetes, Hypertension, Obesity, Tobacco Use, Coronary Artery Disease, Family History of Coronary Artery Disease and/or Stroke. Cerebrovascular events (stroke and TIA) were verified by a vascular neurologist. We report the association of risk factor groups and the presence of contemporaneous cerebrovascular event (CVE).

Results
Five hundred and forty five individuals (49.4% females 269 out of 545) participated in the study. Cerebrovascular event (Stroke and /or TIA) were found in “21.8% (119 out of 545)” individuals. Obesity was found to be the predominant risk factor, occurring in “56.9% (310 out of 545)”, followed by total hypertension “52.1% (284 out of 545)” and tobacco use respectively “39% (213 out of 545)”. There were “63.3% (345 out of 545) individuals with two or more risk factors, with the majority of these being women (54.6%). CVE increased in percentage with quantitative increase in risk factors, with 13% of CVE in individuals with no risk factors to 85.7% CVE among those with 5 risk factors. The combination of Hypertension, Diabetes, Obesity and cigarette smoking conferred the highest odds at 4.9 (p=0.039).

Conclusion
A systematic screening within South Asians with cerebrovascular disease will uncover multiple preventable risk factors.
Abstract P131: Importance of Algorithm-Consistent Warfarin Dosing in the Quality of Anticoagulation Control in Atrial Fibrillation: A Multilevel Analysis
Authors: Van Spall Harriette G C , Nieuwlaat Robby , Wallentin Lars , Yusuf Salim , Ezekowitz Michael D , Yang Sean , Kabali Conrad , Reilly Paul A , Connolly Stuart J
Published: July 2021

Background:
The quality of anticoagulation control in AF patients on warfarin varies between countries, but the reasons are unclear. We determined the effect of algorithm-based warfarin dosing on anticoagulation control after adjusting for patient, center, and country characteristics.

Patients:
RE-LY trial patients with AF on warfarin. Centers with >5 patients on warfarin were included.

Design:
We tracked INR measurements and warfarin doses in patients. Dose adjustments were considered algorithm-consistent if they were within 5% of the recommendation made in the RE-LY warfarin nomogram. We developed a multilevel linear regression model with patients (1st level) nested in centers (2nd level), and centers nested in countries (3rd level), and examined the effect of algorithm-consistent dosing on Time in Therapeutic Range (TTR) of the INR.

Results:
A total of 4577 patients (62% male) from 402 centers and 40 countries were included. Considerable regional variation in mean TTR was found, ranging from 54 ± 22% in East Asian countries to 73 ± 15% in North European countries. The degree of algorithm-consistent warfarin dosing correlated with mean country TTR (r
2
=0.6) (Fig.). After adjusting for patient, center, and country variables, algorithm-consistent warfarin dosing was found to strongly predict TTR; a 1% increase in consistency with algorithm-based dosing increased mean TTR by 0.67% [0.61-0.73%, p<0.001].

Conclusion:
Algorithm-consistent warfarin dosing is predictive of anticoagulation control after adjusting for patient, center, and country factors. There is potential to improve the quality of anticoagulation control by simple algorithm-based warfarin dosing.