bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 181: A Qualitative Insight Into Self-management Experience Among Chinese Patients With Poorly Controlled Type 2 Diabetes
Authors: Cheng Li , Sit Janet
Published: July 2021

Background:
Data from the United Kingdom Prospective Diabetes Study showed that poorly controlled diabetes mellitus are significantly associated with increased risk of cardiovascular diseases (CVDs). Exploring self-management experience of patients with poorly controlled type 2 diabetes would be valuable for developing patient-centered care so as to achieve an optimal glycemic control and reduce the risk of developing CVDs.

Methods:
A qualitative enquiry was undertaken. Participants with poorly controlled type 2 diabetes were purposively selected, with the aim of including patients having a variety of characteristics and experiences concerning diabetes self-management. Content analysis was conducted with data from one-time interviews and field notes. Trustworthiness was supported through triangulation of data sources, recruitment of extreme cases, and the use of an audit trail.

Findings:
A total of 30 participants were interviewed (age: 55.57 ±10.09 years old, 67% of participants were male, HbA1c: 8.97± 2.18 %). The qualitative data revealed that patients with poorly controlled type 2 diabetes were more likely to violate healthy eating principle and skip glucose testing. They described the experiences of managing diabetes as emotionally, physically, and socially challenging. Their engagement towards diabetes self-management, although varied, could be categorized into: autonomous, routine, collaborated, delegated, and burdensome activities. Participants with poor self-management performance experienced multiple impediments, including poor health literacy, lack of intrinsic motivation and purposive reflection, and psychological distress. Poor performance can affect their sense of self-efficacy and attitude towards active participation, initiating a vicious circle.

Conclusions:
These findings add depth and complexity to interpretations of self-management activities from the perspective of patients with poorly controlled type 2 diabetes. Patient-centered intervention are needed to assist and motive patients to become effective partners in diabetes care and thereby reduce the risk of developing CVDs.
Abstract 188: Implementation of Choosing Wisely Recommendations for Stress-First Nuclear Myocardial Perfusion Imaging
Authors: Winchester David E , Jeffrey Randy , Schmalfuss Carsten , Wymer David C , Taasan Vicente , Wokhlu Anita
Published: July 2021

Introduction:
Current guidelines for myocardial perfusion imaging (MPI) encourage facilities to adopt patient-centered risk mitigation strategies such as individualized radiotracer dosing and stress-first imaging. Reducing radiation exposure is also a key recommendation of multiple societies participating in the Choosing Wisely campaign. The stated goal is for over 50% of studies to be performed with <9 millisieverts (mSv) of radiation exposure. We hypothesized that adoption of a stress-first/stress-only imaging protocol would substantially reduce the median radiation dose administered in our nuclear lab.

Methods:
We switched the standard imaging protocol at the Malcom Randall VA Medical Center nuclear cardiology laboratory from rest-stress to stress-rest. To achieve this, a physician was required to review the stress images at the time they were obtained to determine if further imaging was indicated. Estimated effective radiation doses (in mSv) were calculated based on the radiotracer activity administered (in millicuries) used industry standards techniques. We compared 2 cohorts of patients: rest-stress studies consecutively done between 7/17/17 and 11/12/17 and stress-first studies consecutively done between 11/13/17 and 5/17/17. As a balancing measure, we compared the rate of normal studies between the cohorts. A normal MPI was defined as no evidence of ischemia or infarction with a preserved ejection fraction.

Results:
In the stress-first cohort, the median dose was 2.8 millisieverts (mSv) compared with 14.1 mSv in the rest-stress cohort (80.1% reduction, p<0.0001). During the observed period, we estimate that 4,780 mSv of effective dose were avoided. In the rest-stress cohort, 424 studies were performed. In the stress-first cohort, 716 tests were performed, 423 stress only studies (59.1%) and 293 stress-rest studies (40.1%). The rate of normal studies in the stress-first cohort was not different from the rest-stress cohort (stress-first: 73.5%, (526/716) versus rest-stress: 71.7%, p=0.54, odds ratio 0.92, 95% CI 0.69-1.21) In the rest-stress cohort, 3 patients (1.0%) underwent coronary angiography and 2 patients (0.7%) underwent percutaneous coronary intervention (PCI). In the stress-first cohort 8 patients (1.1%) underwent coronary angiography and 2 patient (0.3%) underwent percutaneous coronary intervention (PCI).

Conclusion:
By switching from a rest-stress to a stress-first imaging protocol, we reduced the median radiation dose in our lab by 80%. We observed no change in the proportion of normal tests, suggesting no potential for harm with this strategy.
Abstract 190: Use of Intensive Glycemic Management in Older Adults With Diabetes. An Analysis From the Diabetes Collaborative Registry
Authors: Arnold Suzanne V , Lipska Kasia J , Wang Jingyan , Seman Leo , Mehta Sanjeev N , Kosiborod Mikhail
Published: July 2021

Background:
Older adults with diabetes are less likely to benefit and more likely to be harmed by intensive glucose control. Prior research has shown that many older adults continue to be intensively managed despite guidelines that recommend that treatment targets should be relaxed in these patients. As many new agents have been introduced with minimal risk of hypoglycemia, we examined contemporary data to understand to what extent older patients with diabetes are still intensively managed with agents that can cause hypoglycemia.

Methods:
We examined A1c and treatment data in adults ≥75 years with type 2 diabetes from 151 US outpatient sites in DCR. Patients were categorized as poor control (A1c >9%), moderate control (A1c >8-9%), conservative control (A1c 7-8%), tight control/low-risk agents (A1c <7% on meds with low risk for hypoglycemia), and tight control/high-risk agents (A1c <7% on insulin, sulfonylureas, or meglitinides). Adults with A1c <7% on no glucose-lowering medications were excluded. We used hierarchical logistic regression to examine patient and site factors associated with tight control/high-risk agents vs. conservative control or tight control/low-risk agents.

Results:
Among 30,696 older adults with diabetes, 5,596 (18%) had moderate or poor control, 9,227 (30%) conservative control, 7,893 (26%) tight control/low-risk agents, and 7,980 (26%) tight control/high-risk agents (Fig. A). Older age, male sex, heart failure, chronic kidney disease, and coronary artery disease were each independently associated with a greater odds of tight control/high-risk agents (Fig. B). After adjusting for patient factors, there were no differences among practice specialties (endocrinology, primary care, cardiology) in how aggressively patients were managed.

Conclusion:
Despite greater availability of agents that do not cause hypoglycemia, a quarter of older adults with type 2 diabetes are tightly controlled with high-risk medications. These results suggest potential overtreatment of a substantial proportion of patients. Efforts are needed to provide more specific guidance on how to safely treat older adults with diabetes (both through targeting treatment with low-risk agents and through de-escalation of glucose control) and then to efficiently translate that guidance into busy clinical practice.
Abstract 191: Trends in Hospitalization and Readmission of Patients With Syncope: An Analysis Using State Inpatient and Emergency Department Databases
Authors: Anderson Timothy S , Thombley Robert L , Lin Grace A
Published: July 2021

Background:
Syncope accounts for 1% of US emergency department (ED) visits. Because the etiology of syncope is often benign, diagnostic testing for syncope can be low yield and routine hospitalization has not been shown to improve outcomes. Thus, professional society guidelines from cardiology and emergency medicine have advocated shifting priorities in the decision to hospitalize patients from a focus on determining the etiology of syncope to stratifying the need for hospitalization by patients’ cardiac risk. Changes in utilization and clinical outcomes as a result of this paradigm shifts are not known. Thus, our objective was to characterize longitudinal changes in hospitalization and readmission rates of patients presenting to the ED with syncope.

Methods:
Using linked State Inpatient and Emergency Department Databases from the Agency for Healthcare Research and Quality, we conducted a retrospective study of all ED visits in 12 geographically diverse states in 2009 and 2013. First, we calculated annual incidence rates of syncope ED visits and subsequent hospitalizations. We then calculated 30-day ED revisit and hospital readmission rates for the subset of 3 states with readmission identifiers. Differences between years were estimated using mixed effect regression modeling adjusted for patient clinical and demographic characteristics and hospital random effects.

Results:
We identified 471,379 ED visits for syncope in 2009 and 535,521 ED visits in 2013. The annual incidence of syncope ED visits increased by 11.4% from 697 to 777 visits per 100,000 persons. Rates of subsequent hospitalization decreased from 41.2% in 2009 to 29.0% in 2013 (Adjusted Odds Ratio [AOR] 0.50; 95% CI [0.47-0.52]). Though age was the strongest predictor of hospitalization, hospitalization rates decreased across all age groups, (7.2% to 4.7% for patients ages 18-25, p<.0001, and 66.6% to 52.3% for patients age ≥85, p<.0001). The 30-day ED revisit rate following an index syncope ED visit decreased for patients discharged from the ED during the index visit (14.2% in 2009 to 13.7% in 2013; AOR 0.96 [95% CI 0.93-0.98]) and did not significantly change for patients admitted during the index visit (16.0% in 2009 to 16.5% in 2013; AOR 1.01 [95% CI 0.98-1.05]). The 30-day readmission rate decreased for patients discharged from the ED during the index visit (4.3% in 2009 to 3.9% in 2013, p<.0001) and did not significantly change for patients admitted during the index visit (9.7% in 2009 to 9.5% in 2013, p=.19).

Conclusions:
Although the incidence of ED visits for syncope increased from 2009 to 2013, hospitalization rates for declined by 25% without an adverse effect on ED revisits or hospital readmissions.
Abstract 193: Supplement Usage and the Relationship Between Education and Socioeconomic Status: Is Counseling Intervention Needed?
Authors: Gowda Ramita , Iyengar Rupa L , Maceda Cynara , McLaughlin Mary Ann
Published: July 2021

Introduction:
Multivitamin (MVI) intake is seen in more than one third of American population. Each form of MVI differs in content and quantity of nutrients. Approximately 1 billion people around the world suffer from the deficiency of Vitamin D (Vit-D). Vit-D is necessary for a range of important cellular functions including the maintenance of calcium metabolism and normal muscle function. Current American College of Physician guidelines suggest a daily intake of 1,500 to 2,000 IU/day for adults for Vit-D less than 30ng/ml. There are no current guidelines for MVI usage. The aim of this study to understand the differences in supplement use among varying education levels.

Methods:
We evaluated 1,013 participants in the World Trade Center-CHEST Program from January 2011 to June 2014. Education level and supplement use for both MVI and Vit-D were self-reported in the questionnaire. Education levels were separated into 4 categories in regard to higher education: (1) None=Less than 12 years/High School/GED, (2) Some=Some college, no degree/associates degree, (3) College =Bachelor’s degree, (4) Graduate=Advanced degree (Masters’ and/or Doctorate Degrees) Chi-square analysis, independent t-test, and ANOVA analyses were performed in SAS 9.4.

Results:
MVI usage was lowest among those with the lowest education (None group) at 7.97%. compared to the other education levels: 44.93% (Some group), 31.64% (College group) and 15.46% (Graduate group). There was significant relationship in terms of MVI usage between the lowest education level (None group) and the other education levels (
p
=0.0214). Among those taking Vit-D, the lowest usage was also seen in the lowest education level, at 9.65%, compared to ‘Some’ at 41.67%, ‘College’ at 31.14% and ‘Graduate’ at 17.54%. There was a trend towards significance in Vit-D usage among those with the lowest education levels (None) compared with the other education groups (
p
=0.0773).

Conclusion:
There is no established data to suggest multivitamin use is directly associated with chronic illnesses such as increased cardiovascular risks, cancer and pulmonary disease. It has been established that hypovitaminosis D is associated with increased risk for hypertension and other cardiovascular diseases. Vitamin D supplementation is recommended to mitigate these risks. Those with higher education levels are more likely to take supplements possibly because of their increased health literacy. Patients with lower education levels may benefit from counseling of vitamin supplementation usage, MVI and especially in Vit-D as it has shown to have health benefits.
Abstract 213: Prevalence and Regression of Left Ventricular Hypertrophy by Sokolow-lyon and Cornell Electrocardiogram Voltage Criteria After Transcatheter Aortic Valve Replacement
Authors: Zhang Robert , Jou Stephanie , de la Rosa Angelo , El-Hajjar Mohammad , Nappi Anthony , Delago Augustin , Steckman David , Torosoff Mikhail
Published: July 2021

Background and Hypothesis:
Left Ventricular Hypertrophy (LVH) due to critical aortic stenosis is expected in TAVR patients. ECG markers of LVH were associated with a significant increase in all-cause mortality in a large prospective study (ARIC) of the general, middle-aged population. However, the sensitivity of LVH by ECG voltage criteria in patients with severe aortic valve stenosis undergoing trans-catheter aortic valve replacement (TAVR) has not yet been studied. The regression of LVH by ECG voltage criteria after TAVR also has not been evaluated.

Methods:
A retrospective chart review was conducted in 388 consecutive TAVR patients (57.7% females, transfemoral approach in 59.3%, 77.9% with Sapien valve) without ventricular-paced rhythm. ECG data was collected and analyzed by Sokolow-Lyon and Cornell Voltage criteria. Results were compared to transthoracic echocardiogram. Analyses of variation, correlation, chi-square, and logistic regression were used. The study was approved by the institutional IRB.

Results:
Pre-TAVR LVH by echocardiographic criteria was present in all patients. Sokolow-Lyon and Cornell criteria for LVH were present and concordant in 15% of patients; and in 53% of patients, neither ECG criteria was suggestive for LVH. Concordance between these two citeria was poor, with 37% of patients had LVH only by Cornell and 25% only by Sokolow-Lyon criteria (p<0.0001). One hundred forty one of 388 patients had follow up ECG’s at least 6 months (9.0+/-12.8 months) post-TAVR, with 13% no longer indicating LVH by Sokolow-Lyon criteria (p=0.005). Post-TAVR LVH by SL criteria was more likely in women (83 vs. 17%, p=0.015). Other co-morbidities and demographic variables were not predictive of LVH regression by ECG criteria.

Conclusion:
The presence of LVH by Sokolow-Lyon and Cornell ECG voltage criteria poorly correlates with the presence of LVH in critical aortic stenosis patients undergoing TAVR. Despite significant variability in pre-TAVR LVH manifestation by traditional ECG criteria, LVH regression by ECG criteria may be observed fairly soon after TAVR. Additional research is needed to clarify clinical implications and long-term outcomes associated with post-TAVR LVH regression.
Abstract 215: GenderDisparities in Health Care Expenditure Among Patients With MI and Depression: ResultsFrom the Medical Expenditure Panel Survey 2014
Authors: Veledar Emir , Saxena Anshul , Okunrintemi Victor , Valero-Elizondo Javier
Published: July 2021

Introduction:
Previous studies have linked depression and cardiovascular diseases, however gender differences in cost of hospitalization and care associated with events related to depression and myocardial infarction (MI) is not studied in detail. We utilized data from 2014 Medical Expenditure Panel Survey (MEPS) to evaluate national estimates of such costs.

Hypothesis:
Proportion of depression and MI and corresponding healthcare expenditures are high in general population and differ between genders. Also, payments are appropriated differently between payers.

Methods:
Participants from 2014 MEPS with events attributed to MI and/ or depression were included in this study. Mean (95% CI) event related cost, and total cost of health care was calculated using survey methods. Expenditure and utilization cost was grouped as related to ambulatory, emergency room, inpatient, home visits and medications. By source, payments were grouped as paid by family, MEDICARE, MEDICAID, private insurance, VA, Tricare and other.

Results:
There were 23486 participants in the study, representing 242,628,543 individuals in the US who were 20 years or above. Total health expenditure in 2014 among these was $1.5 trillion (Males: $696,940,498,022; Females: $837,486,094,699) with $27,937,582,549 attributed to depression (Males: $10,991,761,342; Females: $16,945,821,207) and $51,142,260,003 to MI (Males: $40,676,887,518; Females: $10,465,372,485). There were around 6,174,408 (2.5%) and 27,269,837 (11.2%) events associated with MI and depression respectively. Approximately 901,762 individuals reported both events. Among males, MI was 4,189,696 (3.6%) and among females, 1,984,711 (1.6%). Depression was reported 8,755,276 (7.5%) among males and 18,514,560 (14.6%) among females. Among females who were depressed, 2.3% reported MI, and 1.4% among those who were not depressed. Among males who were depressed, 5.4% reported MI and 3.4% among those who were not depressed. Among depressed males, AMI hospitalization was 0.31% whereas among depressed females, AMI hospitalization was 0.24%.

Conclusion:
Among both depressed and non-depressed populations, males had significantly higher proportion of MI and hospitalizations related to AMI when compared to females. But, out of total MI costs for males, less than 1% cost was accrued by depressed; whereas, of total MI cost for females, 9.6% of cost was accrued by depressed females showing gender based disparities in healthcare cost and utilization. With Medicare paying between 78%-83% of all MI costs, treating depression can result in significant savings.
Abstract 228: National Prevalence of Substance Use Disorders Among Hospitalized Heart Failure Patients
Authors: Snow Sarah C , Fonarow Gregg C , Ladapo Joseph A , Washington Donna L , Hoggatt Katherine , Ziaeian Boback
Published: July 2021

Background:
Several cardiotoxic substances contribute to the development of heart failure (HF). The burden of comorbid substance use disorders (SUD) among patients with HF is under-characterized.

Objectives:
To describe the national burden of comorbid SUD (tobacco, alcohol, or drug use disorders) among hospitalized HF patients in the U.S.

Methods:
We used data from the 2014 National Inpatient Sample to calculate the proportion of hospitalizations for a primary HF admission with tobacco, alcohol, or drug use disorder diagnoses, accounting for demographic factors. Drug use disorder analysis was further sub-divided into specific illicit substance categories.

Results:
There were a total of 989,080 HF hospitalizations of which 35.3% (n=348,995) had a documented SUD. Tobacco use disorder (TUD) was most common (n= 327,220, 33.1%) followed by drug use disorder (DUD) (n=34,600, 3.5%) and alcohol use disorder (AUD) (n=34,285, 3.5%). Female sex was associated with less TUD (OR 0.59; 95% CI, 0.58-0.60), AUD (OR 0.23; 95% CI, 0.22-0.25) or DUD (OR 0.58; 95% CI 0.55-0.62). Tobacco, alcohol, cocaine, and opioid use disorders were highest among HF patients age 45 to 55, while cannabis and amphetamine use was highest in those <45 years. Native American race (versus White) was associated with increased risk of AUD (OR 1.67; 95% CI 1.27-2.20). Black race was associated with increased risk of AUD (OR 1.09; 95% CI 1.02-1.16) or DUD (OR 1.63; 95% CI 1.53-1.74). Medicaid insurance (versus Medicare) was associated with greater TUD (OR 1.27; 95% CI 1.23-1.32), AUD (OR 1.74; 95% CI 1.62-1.87), and DUD (OR 2.15; 95% CI 2.01-2.30). Decreasing quartiles of median household income were associated with increasing SUD.

Conclusions:
Comorbid SUD disproportionately affects certain HF populations, including men, younger age groups, lower SES patients, and race/ethnic minorities. Further research on interventions to improve prevention and treatment of SUD among hospitalized HF patients are needed given the high rates of SUD in this population. Systematically screening hospitalized HF patients for SUD may reveal opportunities for treatment and secondary prevention.
Abstract 233: Blood Pressure and Pulse Pressure Differences in Elderly versus Young Patients
Authors: Shofu Abimbola , Hujier Fares , Omar Bassam A , Awan G. Mustafa , Malozzi Christopher
Published: July 2021

Background:
Systolic blood pressure and pulse pressure tend to increase with age in the general population, with increase in cardiovascular risk. Whether this holds in treated hypertensive patients remains unknown.

Methods:
Encounters from a university-based cardiology clinic with broad referral base were analyzed for blood pressure (BP), pulse pressure (PP), and lipids by age in patients with hypertension as a diagnosis. Differences between groups were compared using 2-tailed student t-test.

Results:
200 encounters were analyzed: 42% (84) were ≥ 60 years old (average 68 ± 8; elderly); 58% (116) were < 60 years old (average 48 ± 9; young). Systolic BP (SBP) and pulse pressure (PP) were 134 ± 20 mmHg and 55 ± 18 mmHg in elderly compared with 128 ± 18 mmHg and 42 ± 13 mmHg in young, respectively (P < 0.05). Total cholesterol and LDL were 166 ± 35 mg/dL and 92 ± 32 mg/dL in elderly compared with 171 ± 48 mg/dL and 95 ± 38 mg/dL in young, respectively (P = NS).

Conclusion:
Elderly patients remain at very elevated risk for atherosclerotic cardiovascular events, with mounting healthcare costs. Efforts to improve cardiac risk factors in this vulnerable group are of paramount importance. Higher SBP and PP in the elderly compared to young patients likely reflects increased arterial stiffness, resulting in a wider pulse pressures. Lack of compliance with medications is unlikely since these patients had insurance and their total cholesterol and LDL levels were adequately controlled with medications, not significantly different compared to young patients. White-coat-hypertension is another potential explanation in the elderly. A trend towards higher use of nonsteroidal anti-inflammatory agents (NSAIDs) due to more prevalent arthritis in the elderly may have contributed to the blood pressure difference. Whether prescribing non-NSAID medications would improve compliance with exercise, weight loss, and blood pressure control in elderly patients is subject of further studies.
Abstract 239: The Effect of an Interdisciplinary Simulation Training Program on Translational Outcomes for In-Hospital Cardiopulmonary Arrests
Authors: Hunninghake John , Reis Justin , Delaney Heather , Borgman Matthew , Trevino Raquel , Matos Renee
Published: July 2021

Purpose:
High-quality cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest (IHCA) is the primary component influencing return of circulation (ROSC) and survival to hospital discharge, but few hospitals regularly track these metrics. Other studies have demonstrated significant improvements in survival after IHCA events following implementation of a dedicated code team training program. Therefore, we developed a unique curriculum for a Code Team Training (CTT) course, and evaluated its post-implementation effect on CPR quality and post-IHCA patient outcomes at our institution.

Methods:
CPR quality data was prospectively collected for quality improvement purposes once our institution had that capability, with 12-months pre-CTT and 21 months post-CTT. Pre-CTT data shaped the elements of the four-hour CTT course that included didactics, small group sessions, and high-fidelity simulation exercises. A total of 456 multi-professional code team members were trained in 22 courses. Data collection included CPR quality and translational outcomes for events where CPR was performed, except the ED. CodeNet® software was used for CPR quality measures, cardiac rhythm, defibrillation metrics, use of continuous waveform capnography, and pauses in compressions. Target metrics for CPR quality were based on 2015 AHA guidelines. Key translational outcomes measures included event location, ROSC, and survival to hospital discharge.

Results:
CPR quality was obtained from 140 of 230 (61%) in- and out-of-hospital pulseless adult cardiac arrest events over 33 months (50 [36%] before CTT and 90 [64%] following the first course). There was no significant difference between groups in terms of event location within the hospital nor initial event rhythm. A total of 116,908 chest compressions were evaluated. Median compressions in target rate improved from 32% before CTT to 49% after CTT (p<0.05). When accounting for target rate and depth, the median compressions rate improved to 38% post-CTT compared to 31% pre-CTT (p<0.05). While compression depth had a non-statistically significant decline (90.8% pre-CTT and 83.4% post-CTT), mean rate and median rate-in-target improved from 119.99 +/- 15.6 cpm and 32.4% pre-CTT to 113.7 +/- 16.1 cpm and 48.6% post-CTT (p<0.05). The rate of ROSC improved from 60% (30 of 50) to 78% (70 of 90) after implementation of CTT (p=0.003), excluding IHCA in the ED. Index IHCA survival rate for our institution improved from 26% to 33% before and after CTT [p-value NS], which far surpasses the national average (23.8%).

Conclusions:
After the initiation of a CTT course that targets key code team member personnel, CPR quality significantly improved, which was associated with an increase in ROSC and a trend towards increased survival for in-hospital cardiac arrest patients.
Abstract 245: Assessing Patient Knowledge and Satisfaction Following Stroke Video Education
Authors: Tisel Sarah , Rieman Abigail , Hodges Matthew , Gwathmey Kelly
Published: July 2021

Objective:
To create a stroke education video and study its impact in stroke clinic with regards to patient satisfaction and knowledge acquisition.

Background:
Excellent medical care includes providing patient education, but most clinics do not emphasize this. We are exploring the use of video education in the stroke clinic, as this patient population may particularly benefit from secondary stroke prevention teaching.

Methods:
Ischemic stroke patients coming for routine hospital follow-up were enrolled and randomized to either watch an educational stroke video or receive standard care. Patients were stratified by education level, with one group having completed high school or less, and the other having completed any post high school training. Both groups took a pre- and post-visit knowledge test as well as a post-visit satisfaction survey. We hypothesized that knowledge acquisition, judged by improvement in test score, and satisfaction scores would both be greater in the video group. Test scores were expected to positively correlate with satisfaction.

Results:
Forty patients were enrolled to date. Preliminary data demonstrated patients were positive (n=15) or neutral (n=5) about the video. Both groups were highly satisfied with their visit, and a two-tailed t-test demonstrated no difference in satisfaction between groups (p=0.89). A linear regression showed a trend for the highly educated patients in the video group having improved test scores after the visit (p=0.069). Further enrollment of patients is needed to better assess this. In both groups, there was a correlation between post-test scores and satisfaction scores (R=0.37, p=0.03).

Conclusions:
Based on this preliminary data, stroke patients enjoy video education in clinic. However, as patients in both groups were highly satisfied, it remains unclear whether video education increases overall satisfaction. Highly educated patients may bennefit from video education, but further enrollment will clarify this. A positive correlation between post-visit test score and satisfaction indicates that clinics should prioritize patient education.
Abstract 252: Regional Variations in Access to Care Among U.S. Veterans With Cardiovascular Disease
Authors: Srivastava Pallavi , Shroyer A. Laurie , Templeton Rebecca , Butler Javed , Parikh Puja B
Published: July 2021

Background:
It is unclear whether access to health care for veterans with cardiovascular disease (CVD) vary among U.S. regions. This study sought to determine the extent of regional variations in access to medical care in a cohort of U.S. veterans with CVD.

Methods:
The 2016 Centers for Disease Control Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of veterans with cardiovascular disease. Participants were classified based on four U.S. regions: (1) Northeast, (2) Midwest, (3) South, and (4) West. Presence of CVD was noted with a single affirmative response to the following questions: “Has a health care professional ever told you that you had any of the following:” (1) a heart attack or myocardial infarction, (2) angina or coronary heart disease, (3) a stroke? Demographic data, baseline medical history, and access to care for veterans of each U.S. region were compared.

Results:
Among the 13,835 veterans with CVD, 18.3% were from the Northeast, while 23.5%, 37.1%, and 21.0% were from the Midwest, South, and West respectively. Veterans from South were more likely to be younger (21.4% vs 18.5% in the Northeast vs 18.6% in the Midwest vs 19.1% in the West, p=0.0018) and Black (9.7% vs 2% in the Northeast vs 3.3% in the Midwest vs 1.9% in the West, p<.0001). Veterans from West had the highest proportion of females (4.9% vs 3.8% in the Northeast vs 3.5% in the Midwest vs 4.8% in the South) and Hispanics (4.3% vs 2.3% in the Northeast vs 1.2% in the Midwest vs 1.7 in the South, p<.0001). Veterans from West were more likely to be college educated and have higher annual income compared to their counterparts. Veterans from South had highest rates of depressive disorder (20.5% vs 18.1% in the Northeast vs 18.4% in the Midwest vs 19.3% in the West, p=0.0318) were more likely to be smokers (16.4% vs 14.8% in the Northeast vs 15.4% in the Midwest vs 13.2% in the West, p<.0001), obese (34.4% vs 32.8% in the Northeast vs 34.3% in the Midwest vs 29.7% in the West, p<.0001) and had lowest rates of physical activity (62.3% vs 66.7% in the Northeast vs 66.3% in the Midwest vs 69.6% in the West, p<.0001 ). Rates of medical checkup within the past year (91.7% vs 89.5% vs 91.4% vs 86.6%, p<0.0001) differed significantly among the Northeast, Midwest, South, and West respectively. On multivariate analysis, West region (OR 0.39, 95% CI 0.22 - 0.70) was independently associated with lower rates of medical checkup within the past year compared to the Northeast.

Conclusions:
In this observational study involving U.S. veterans with CVD, West region was independently associated with lower rates of medical checkup within the past year. Further large-scale studies examining the prevalence of impaired access to care in U.S. veterans with CVD are warranted.
Abstract 255: Weight Management in Peripheral Artery Disease: Insight From the PORTRAIT Registry
Authors: Peri-Okonny Poghni A , Patel Krishna , Gosch Kensey , Buchannan Donna , Stone Naancy , Smoleren Kim
Published: July 2021

Introduction:
Obesity or body mass index (BMI) ≥ 30 is a risk factor for atherosclerosis. The 2011 AHA/ACCF secondary prevention guidelines recommend weight measurement at every visit and targeting BMI in normal range in management of patients with atherosclerotic diseases like peripheral arterial disease (PAD). However, no studies have prospectively examine obesity management in a vascular specialty setting and whether patients with PAD successfully address this risk factor are lacking.

Methods:
Participants from the 16-center PORTRAIT registry presenting with new or worsening PAD symptoms to a vascular clinic were included in this analysis. BMIs were calculated for all patients (kg/m
2
) and categorized as normal (18.4 -24.9), overweight (25 -29.9), and obese (≥ 30). Referral rates for weight/diet counseling during the initial PAD visit were assessed and site variability for weight/diet counseling rates among obese/overweight participants was estimated using median odds ratios (MOR).Weight information was collected at 1 year through interviews and rates of successful weight loss ≥5 were calculated. A hierarchical multivariable logistic regression with a random effect for site was used to assess predictors of ≥5 % weight loss at 1 year.

Results:
Among 1275 enrollees, we excluded 273 participants without documented BMI. The prevalence of obesity among those with documented BMI was 37% (n=370). Obese participants were more likely to have sleep apnea, hypertension, coronary disease and diabetes but less likely to be active smokers compared to those with normal weight. The prevalence of weight/diet counselling among normal, overweight and obese participants were 8.7%, 12.0%, 20.5% (p-value < 0.001) respectively. Weight loss of ≥ 5% occurred in 93(30.2%) of obese participants. Predictors of ≥ 5% weight loss at 12 months included male, coronary disease, diabetes, and country. There was significant variability in the utilization of weight/diet counselling across participating sites (MOR =2.8 (1.8 - 6.0), Fig).

Conclusion:
Only 1 in 5 obese patients were offered weight/diet counseling and 30% achieved weight loss of ≥ 5%. There was marked site variability in the use of weight management in these patients. This suggests an opportunity for improvement in addressing this important cardiovascular risk factor.
Abstract 270: Prediction of Health-Related Quality of Life at 12 Months From Baseline Modifiable Factors in Patients With Heart Failure
Authors: Heo Seongkum , Kim Jinshil , Moser Debra K , Lennie Terry A , Fischer Mary , Ounpraseuth Songthip , Walsh Mary
Published: July 2021

Introduction:
Patients with heart failure (HF) report that good health-related quality of life (HRQOL) is more valuable than longer survival, and improvement in HRQOL after discharge has been associated with lower rates of hospitalization. However, HRQOL in patients with HF is remarkably poorer than that in patients with other chronic diseases. To improve HRQOL effectively, it is critical to examine comprehensive modifiable predictors. However, to our knowledge, this has not been examined in patients with HF.

Purpose:
To examine baseline psychosocial, behavioral, and physical predictors of HRQOL at 12 months in patients with HF.

Methods:
We collected data on HRQOL at 12 months using the Minnesota Living with Heart Failure Questionnaire and other data at baseline from 94 patients with HF (mean age 58 ± 14 years). We collected data on all psychosocial variables, one behavioral variable, and one physical variable using questionnaires: depressive symptoms (Patient Health Questionnaire), perceived control (Control Attitudes Scale-Revised), social support (Multidimensional Scale of Perceived Social Support), self-care management (Self-care management subscale of the Self-Care of Heart Failure Index), and HF symptoms (Symptom Status Questionnaire-HF). We assessed one physical factor (New York Heart Association [NYHA] functional class) using in-depth interview. We assessed two behavioral factors using objective measures: medication adherence (Micro-Electro-Mechanical Systems) and sodium intake (24-hour urine). Covariates were age and comorbidity. Multiple regression analysis was used to address the purpose.

Results:
After controlling for covariates, among multidimensional psychosocial, behavioral, and physical variables, 3 modifiable factors (medication adherence [p = .001], HF symptoms [p = .011], and NYHA functional class [p < .001]) significantly predicted 12-month HRQOL (F = 11.853, R
2
= .59, p < .001).

Conclusion:
The findings of this study demonstrate multidimensional, modifiable predictors that interventions can target to improve HRQOL. Clinicians and researchers can target improvement in self-care, HF symptoms, and NYHA functional class to improve HRQOL, and, in turn, to reduce hospitalization rates.
Abstract 273: The Evolving Use of Cardiac CT to Inform Defining Quality in Imaging
Authors: Zhang Ming , Earls James , Choi Brian G , Zeman Robert K , Choi Andrew D
Published: July 2021

Introduction:
Cardiac computed tomography (CT) has emerged as a diagnostic technique beyond the evaluation of outpatient stable chest pain; however, as quality in imaging has only recently been defined by the American Heart Association, understanding the changing utilization of CT use may inform application of these standards. This study aims to characterize changes in cardiac CT utilization and for chest pain, assess the impact on downstream invasive testing over a 3 year time period.

Methods:
439 consecutive patients from July 2013 through June 2016 who had cardiac CT performed at an urban academic medical center were evaluated. Patient demographics and cardiac CT indications were reviewed from electronic medical records and archived cardiac CT reports. Cardiac CT indication categories included calcium scoring, outpatient chest pain, inpatient chest pain, electrophysiology applications, transcatheter aortic valve replacement (TAVR) and other. For patients who had cardiac CT for outpatient or inpatient chest pain, all records were reviewed to assess for further invasive cardiac catheterization. The studies were divided into three academic years.

Results:
The average age of patients undergoing cardiac CT was 60 ± 14 years, 64% were male and 55% were white. Overall, there was a 34% increase in the utilization of Cardiac CT across the study period. There was a significant rise in CT for inpatient chest pain from 2% (2/123) to 14% (26/187; p=0.0002) from year one to year three of the study period. In addition there was a significant rise in CT for TAVR planning from 7% (8/123) in year one to 14% (26/187; p=0.04) in year three. The proportion of patients undergoing evaluation for outpatient chest pain and calcium scoring was relatively unchanged from year one to year three. There was a decrease in cardiac CT for electrophysiology applications from 33% (41/123) to 15% (28/187) from year one to year three (p=0.0001). Among patients who had cardiac CT for either inpatient or outpatient chest pain, 23% (29/123) patients had previous equivocal stress testing. Only 3 of these pts required further cardiac catheterization potentially preventing 90% (26/29)of patients from undergoing invasive cardiac catheterization.

Conclusion:
Cardiac CT utilization is rising for inpatient chest pain and for TAVR planning. For 90% of the patients undergoing evaluation for chest pain, and 90% of patients with equivocal stress testing, cardiac CT potentially prevented need for further downstream invasive testing. This hypothesis-generating data has potential implications that may inform application of quality standards for TAVR and chest pain imaging. Further research is needed to disseminate the effect of cardiac CT on patient outcomes in this cohort.
Abstract 278: Trends in Prescribing Patterns for Patients Hospitalized With Heart Failure With Preserved Ejection Fraction Before and After Clinical Trial Presentation
Authors: Brophy Todd J , Wu Jingjing , Kelly Jacob P , DeVore Adam D , Hammill Bradley G , Peterson Eric D , Pitt Bertram , Yancy Clyde W , Fonarow Gregg C , Hernandez Adrian F
Published: July 2021

Background:
There are limited treatment options for patients with HFpEF, with guidelines focusing on diuresis and management of associated cardiovascular conditions. In the TOPCAT trial, treatment with spironolactone in patients with HFpEF compared to placebo did not significantly decrease the incidence of the composite primary outcome, but the incidence of heart failure (HF) hospitalization was significantly lower. The impact of the TOPCAT results on mineralocorticoid antagonists (MRA) prescribing rates is unknown. We analyzed discharge prescribing rates of MRAs in the Get With The Guidelines-Heart Failure (GWTG-HF) registry to assess for practice changes following dissemination of TOPCAT results in 2013.

Methods:
All patients recorded in GWTG-HF with LVEF ≥ 50% and discharged between January 2009 and December 2016 were included in the study. Data were summarized by calendar year quarters (Q). The TOPCAT trial results were first presented in November 2013, so patients were dichotomized into those discharged before TOPCAT (2009Q1 through 2013Q3) and those after TOPCAT (2013Q4 through 2016Q4). Discharge prescribing rates for MRAs, beta blockers, ACE inhibitors, and ARBs were assessed for overall trends and change in prescribing rates after 2013Q3 by segmented regression.

Results:
Of 142,201 HFpEF patients included in the study, 18,581 (13.1%) were prescribed a MRA at discharge. Throughout the study period, MRA prescribing steadily increased (2009Q1 = 11.3%; 2016Q4 = 14.8%), without significant change in overall trend following announcement of TOPCAT results (p=0.17) (Figure 1). Discharge prescribing rates were largely stable for beta blockers but with a statistically significant change in trend after TOPCAT (2009Q1 = 82.8%; 2016Q4 = 80.5%; p < 0.0001), while prescribing rates for ACE/ARB decreased significantly throughout the study period without change in trend following TOPCAT (2009Q1 = 74.7%; 2016Q4 = 53.7%; p = 0.58).

Conclusions:
The prescribing rates for MRAs in HFpEF at hospital discharge modestly increased over time, with little discernible influence of TOPCAT. These findings suggest there

has been gradual, modest MRA adoption in the absence of other therapeutic options and highlight the need for further trials on the efficacy and safety of MRAs in HFpEF.
Abstract 281: Contemporary Epidemiology of Atrial Fibrillation Among Medicare Beneficiaries, 2004-2013
Authors: Parker Joshua , Khera Rohan , Pandey Ambarish , Cheeran Daniel , Ayers Colby , Das Sandeep R , Link Mark S , de Lemos James A , Berry Jarett D
Published: July 2021

Background:
Atrial fibrillation (AF) is the most common dysrhythmia in clinical practice, and is a significant contributor to morbidity and mortality. Prior reports have projected a large increase in AF burden over time. A contemporary assessment of epidemiology is needed to assess if an emphasis of prevention strategies over the last decade has been effective in alleviating this risk.

Methods:
We used a 5% national sample of all Medicare beneficiaries in the US from 2002 through 2013 to construct a longitudinal cohort of 2.3 million fee-for-service Medicare beneficiaries administratively followed for ≥2 years using claims data. Trends in incident and prevalent AF were assessed for 2004 through 2013. Using ICD-9 codes, encounters with AF were identified from inpatient, outpatient, and physician claims. AF during the first 2 years of entry into the cohort was defined as pre-existing AF. Incident AF was defined as having either 1 inpatient claim with a diagnosis of AF or 2 outpatient or physician claims with AF. Calendar-year prevalence comprised pre-existing and incident AF for the respective years as well as those with incident AF in preceding years. Age-adjusted time trends were assessed using Poisson regression.

Results:
Between 2002 and 2013, 219,570 patients had incident AF. At incidence, mean age was 79 years, 55% were women, and 92% and 5% were white and black, respectively. Age-adjusted AF incidence decreased by 0.4/1000 per year between 2004 (20/1000) and 2013 (17/1000). While incidence declined for white men and women (P<.05), it has remained unchanged for black men and women (Figure). Proportion of incident events in the outpatient setting increased from 26% to 40%. One-year mortality was 9%, and remained unchanged throughout the study period. Over this period, the overall prevalence of AF decreased by 0.9/1000 per year (p<.05), however, there was a relative increase in AF prevalence among black men.

Conclusions:
Between years 2004 and 2013, the overall incidence and prevalence of AF among a 5% sample of Medicare beneficiaries stabilized. There were, however, differences across racial groups, with a slight decline in incidence among white men and women, which was not observed in black men and women.
Abstract 33: Industry Payments to Cardiologists by Sub-specialty: An Analysis of 2016 Open Payments Data
Authors: Annapureddy Amarnath , Murugiah Karthik , Minges Karl , Curtis Jeptha
Published: July 2021

Background:
The Sunshine Act mandates that medical product manufacturers disclose payments and other transfers of value made to physicians or teaching hospitals. There is a lack of data characterizing payments received by cardiologists by sub-specialty.

Methods:
Using data from Open Payments Program for the year 2016 we aggregated payments made to individual cardiologists and analyzed the characteristics and distribution of payments by specialty - general cardiologists (GC), electrophysiologists (EP) and interventional cardiologists (IC). We calculated the Gini index, a measure of income dispersion in a group (index ‘0’ means payments are equally distributed; ‘1’ means one person received all payments).

Results:
A total of $1,598,677,844 was paid to 25,310 cardiologists in 2016, representing 84% of practicing cardiologists. The median annual aggregate value of payment was $2,245 for EP, $357 for GC and $1,143 for IC (p<0.05); the median number of payments was 35 for EP, 11 for GC and 35 for IC (p<0.05). The Gini index was 0.92 for GC, 0.80 for EP and 0.84 for IC. The products associated with the highest payment amounts were Xarelto (10%), Eliquis (7%) and Entresto (7%). The food and beverage category represented 88% of the total number of payments, but it constituted only 14% of the total amount.

Conclusion:
There is variation in payments among the three cardiology specialties, with EP receiving the highest median number and value of payments. Future analyses are needed to determine if payments are associated with changes in practice patterns.