bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 210: Utilization of ACTION Registry® - GWTG™ Report Data to Decrease Gender Disparity in Facility's Time to PCI ≤ 90 Minutes
Authors: Castelblanco Francisco , Triplett Dana , Arviso-Green Rosemary
Published: July 2021

Door to Percutaneous Coronary Intervention (PCI) time is a standard benchmark that is closely analyzed and reviewed in most PCI centers. Studies have established that gender bias exists in healthcare. The facility utilized the ACTION Registry® - GWTG™ 2009 annual report data to discern that females received a PCI within 90 minutes 92% of the time as compared to males receiving PCI within 90 minutes 97% of the time. The 5% gender difference illustrated a possible disparity in care that was converted into an opportunity for improvement. The hospital’s Acute Coronary Syndrome team reviews ACTION Registry® - GWTG™ data on a quarterly basis and employed a three prong approach to decrease the disparity. The team utilized case reviews, physician education, and staff education. The case reviews illustrated that the females who had not met the PCI within 90 minutes measurement were atypical presentations. The atypical presentations included “flu-like” symptoms, ear pain, hyperglycemia, and other uncommon signs and symptoms. The physician and staff education focused on awareness of the disparity and understanding atypical presentations in females. The nursing staff and physicians received education in the form of case reviews and quarterly tracking and reporting of the measure. The results became evident beginning with the 2010 Quarter 3 data, whereupon females received a PCI within 90 minutes 100% of the time. The case reviews and education have become part of the monthly Acute Coronary Syndrome and the Emergency Department monthly agendas. The female PCI within 90 minutes has been 100% for the last four quarters. The utilization of reliable data from the ACTION Registry® - GWTG™ registry enabled the facility to bring awareness to a disparity but more importantly to employ the data as a basis for a long term quality improvement project. The project has been replicated by various teams to examine several other measures. The project has led to several other process improvement projects that include utilization of the ACTION Registry® - GWTG™ data to improve regional Door to PCI times, Door to ECG times, and discharge medication measurements.
Abstract 220: Longer Door to Balloon Time: Effect of Chronic Kidney Disease on Each Step Leading to PCI
Authors: Morrone Doralisa , Xu Xin , Aguiar Ruth , Murphy Dan , Bowen James , DiSabatino Angela , Weintraub William S , Jurkovitz Claudine
Published: July 2021

Purpose:
Primary percutaneous coronary intervention (PCI) is a time-sensitive process. In high risk populations this time could be longer and affect the reperfusion results. The aim of this study was to examine the door-to-balloon time in patients with chronic kidney disease (CKD) and determine the influence of CKD at each step leading to PCI.

Methods:
We conducted a retrospective study of patients admitted at an academic medical center for suspicion of acute coronary syndrome from 2004 to 2011. ICD9 codes were used to identify patients with myocardial infarction (MI) and comorbidities. CKD was defined using an estimated glomerular filtration rate (GFR) <60 mL/min/1.73 m
2
. ST segment elevation (STEMI) status was ascertained at hospital admission. In our hospital, date-times of each step (diagnostic ECG, alert for potential MI) are monitored. Non-parametric tests were used to compare time intervals according to GFR. Because the door-to-balloon time is right skewed, we log transformed time and modeled it as gamma distributed using a generalized estimating equation (GEE) to examine its association with CKD, after adjusting for age, gender, race, hypertension, congestive heart failure, and diabetes.

Results:
Our study population included 712 patients with STEMI, of whom 138 (19.4%) had CKD (see table). Door-to-balloon time was longer in patients with GFR <30. Likewise diagnostic ECG-to-MI alert time was longer in patients with GFR <30 whereas MI alert-to-balloon time was not different between those with and without CKD. Results from the GEE showed that GFR<30 was an independent predictor of door-to-balloon time.

Conclusion:
Patients with severe CKD have a longer door-to-balloon time than patients without CKD. This difference seems to be due to a longer time-interval between the time the diagnostic ECG is made and the time the MI alert is called. This delay in initiating PCI could be related to the misleading ECG (left ventricular hypertrophy, electrolyte and conduction abnormalities) frequently found in patients with CKD.
Abstract 23:
N
-Terminal Fragment of the Prohormone Brain-Type Natriuretic Peptide (NT-proBNP) vs. BNP for Predicting Heart Failure in Patients with Stable Coronary Artery Disease: the Heart and Soul Study.
Authors: Mishra Rakesh K , Regan Mathilda , Wu Alan H , Whooley Mary A
Published: July 2021

Background
The B-type natriuretic peptide (brain natriuretic peptide [BNP] and its amino terminal pro-BNP [NT-proBNP]) are powerful predictors of adverse cardiovascular outcomes, including heart failure (HF), in patients with coronary artery disease (CAD). However, their relative prognostic utility remains uncertain. We compared the ability of NT-proBNP and BNP to predict HF hospitalizations in patients with stable CAD.

Methods
We studied the relative prognostic utility of NT-proBNP and BNP in 983 participants with stable CAD from the Heart and Soul Study. The primary outcome was time to HF hospitalization.

Results
During an average of 6.7 ± 3.0 years follow-up, there were 173 hospitalizations for HF. NT-proBNP and BNP levels were strongly correlated with one another (r=0.87; p<0.001). In demographically-adjusted models, HF hospitalization was predicted similarly by NT-proBNP (HR per 1-SD increase in log-transformed level: 3.1; 95% C.I. 2.7 - 3.7; p<0.001) and BNP (HR per 1-SD increase in log-transformed level: 3.0; 95% C.I. 2.5 - 3.6; p<0.001). This finding persisted after adjustment for traditional coronary risk factors, history of HF, left ventricular (LV) systolic and diastolic function and LV mass index, with NT-proBNP (HR per 1-SD increase in log-transformed level: 3.4; 95% C.I. 2.5 - 4.5; p<0.001) and BNP (HR per 1-SD increase in log-transformed level: 3.0; 95% C.I. 2.3 - 3.8; p<0.001) continuing to predict the primary outcome similarly. Moreover, in fully adjusted ROC analyses, NT-proBNP (AUC 0.87) and BNP (AUC 0.86; p=0.19 for comparison) performed similarly for predicting HF hospitalization.

Conclusions
NT-proBNP and BNP are secreted in equimolar amounts and perform similarly for predicting HF hospitalization in patients with stable CAD. This suggests that their relative prognostic utility is not affected by differences in their biological half-lives,
in vitro
stability and mechanisms of clearance.
Abstract 258: Incidence and Predictors of Cardiac Arrest in Cerebrovascular Diseases
Authors: Moradiya Yogesh , Modi Sneha , Akten Sine , Becker Christopher , Patel Sameer , Gropen Toby
Published: July 2021

Background and purpose:
Large scale studies of cardiac arrest in hospitalized patients with cerebrovascular accident (CVA) are lacking. We sought to describe the incidence, demographics and hospital characteristics of cardiac arrest in CVA. Additionally, we aimed to indentify predictors of cardiac arrest in patients with CVA.

Methods:
We analyzed the data from the Nationwide Inpatient Sample (NIS) of Healthcare Cost and Utilization Project for years 2005-2009. NIS is a discharge level 20% stratified sample of all non-federal hospitals in the US. We used International Classification of Diseases-9 (ICD-9) codes to select cases of CVA. Comparisons were made by using χ2 and student-t tests. Multivariate logistic regression was used to identify independent predictors of cardiac arrest.

Results:
We included 672,161 cases of CVA [ischemic stroke: 58.2%, transient ischemic attack (TIA):28.2%, intracerebral hemorrhage (ICH): 9.7%, and subarachnoid hemorrhage (SAH): 3.9%] in our analysis. Of these, 3,154 (0.467%) also had cardiac arrest. Compared to ischemic stroke (0.413%), incidence of cardiac arrest was higher in ICH (1.221%) and SAH (2.523%) and was lower in TIA (0.038%). Patients with cardiac arrest were younger (mean age±SD: 67.8±16.4 vs. 70.5±15.7 years, p<0.001) and were less likely of female gender (51.8% vs. 55.7%, p<0.001). There was a significant difference in the incidence of cardiac arrest between various ethnic groups (Caucasian: 0.415% vs. African-American: 0.563% vs. Hispanic: 0.633% vs. Asian/Pacific Islander: 0.722%, p<0.001). Compared to the rest, patients in lowest income quartile had higher incidence of cardiac arrest (0.526% vs. 0.437%, p<0.001). Significant differences based on the hospital characteristics were as follows: 1. Bedsize: small (0.349%) vs. medium (0.443%) vs. large (0.498%), p<0.001; 2. Location: rural (0.354%) vs. urban (0.485%), p<0.001; 3. Academic status: teaching (0.553%) vs. non-teaching (0.403%), p<0.001; and 4. Region: northeast (0.399%) vs. midwest (0.403%) vs. south (0.489%) vs. west (0.553%), p<0.001. In multivariate analysis, factors associated with cardiac arrest are shown in the table.

Conclusion:
This is one of the largest studies to describe the predictors of cardiac arrest in CVA. The patients with ICH and SAH are at significantly higher risk of cardiac arrest. The association of hospital characteristics and the incidence of cardiac arrest warrants further exploration into the contributing factors. The patients with higher risk profile as per the predictor model should warrant closer monitoring.
Abstract 266: Are Outpatient Cardiologists Asking about Peripheral Artery Disease Clinical Symptoms in Low and High Risk Patients in accordance with ACC/AHA Guidelines?
Authors: Patel Ankitkumar K , Kabadi Rajesh M , Sharma Rajani , Schmidt Rita , Iliadis Elias
Published: July 2021

Background:
Lower extremity peripheral artery disease (PAD) is a common syndrome that afflicts many individuals and leads to significant morbidity. The American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for the Management of Peripheral Artery Disease (PAD) (JACC, 2006) outlines four clinical symptoms (claudication, walking impairment, exertional leg complaints and poorly healing wounds) that should be asked to at risk patients. Outpatient cardiology practices often take care of individuals at risk for PAD and have the opportunity to screen and improve quality of medical care in accordance with professional guidelines.

Methods:
A group of 367 outpatients seen in a large academic cardiology practice from September 2011 underwent chart review. Risk factors for PAD that were assessed include history of smoking, hypertension, diabetes, hyperlipidemia, homocysteine levels, and CRP. Those that had three or more risk factors or a previous diagnosis of known PAD were classified as high risk and those with less than 2 risk factors were classified as low risk. Documentation of whether clinical symptoms were asked was obtained from outpatient chart. Fisher exact test was utilized for statistical analysis.

Results:
Fifty-seven percent (N=208) of our population were classified as high risk for PAD and forty-three percent (N=158) were low risk. Table 1 below shows assessment of clinical symptoms in high and low risk patients.

Conclusions:
Though both high risk and low risk PAD patients are assessed at equivalent rates for clinical symptoms, the vast majority of patients overall are underassessed. Lack of knowledge of clinical symptoms can lead to underscreening of PAD and thus undertreatment. Increasing clinical symptom screening in the outpatient cardiology setting can lead to quality improvement and adherence to ACC/AHA Guidelines.
Abstract 276: Obesity Even Without Co-morbidity Harbors more Cardiovascular Structural and Functional Abnormalities than what you think! Time for Early CV Screening!
Authors: El Shahawy Mahfouz , Entcheva Miglena
Published: July 2021

Purpose:
To determine the extent of structural and functional cardiovascular (CV) abnormalities in asymptomatic obese subjects with and without untreated comorbidities.

Methods:
We evaluated 2174 consecutive asymptomatic subjects, age 25 to 80, who presented to our Cardiovascular Disease (CVD) Assessment Center for CVD risk evaluation, utilizing Early CVD Risk Score [ECVDRS]. ECVDRS, also known as Rasmussen Risk Score (RRS), consists of 10 non-invasive tests: large (C1) and small artery (C2) stiffness, blood pressure (BP) at rest and post mild exercise (PME), carotid intima media thickness (CIMT), abdominal aorta and left ventricular ultrasound, retinal photography, microalbuminuria, ECG, and pro-BNP. Fasting lipid panel and blood sugar were measured for each subject. Obesity was assessed using waist circumference measurement (> 35 inches for female and 40 inches for male). Co morbidities were defined as BP>140/90mmHg, LDL>130mg/dl, HDL<40 mg/dl for male and <50 mg/dl for female, TrG>150mg/dl, and FBS>100mg/dl.

Results:
Among the subjects screened 949(44%) met criteria for obesity, 458(48%) were not receiving any CV medications and were divided in two groups: A 100 subjects (22%) with no comorbidities (CM): 68 (68%) female and 32(32%) male; and group B - 358 subjects (78%) with CM: 199(56%) female and 159(44%) male. The presence of CVD abnormalities among the subjects in the different groups is shown in Picture 1.

Conclusions:
1. Obesity is very prevalent disease in Sarasota County-close to 50% in our study. 2. Co morbidity superimposed on obesity did alter significantly the incidence of abnormal C2 and BP rise PME, while there was only slight increase in the incidence of CIMT abnormalities.3. Based on our data early evaluation for structural and functional cardiovascular abnormalities in obese subjects will help risk stratification and appropriate therapeutic intervention to delay or overt future catastrophic events
Abstract 304: The Outcomes of Pre-Procedural Angiotensin Converting Enzyme Inhibitor Therapy in patients undergoing Percutaneous Coronary Intervention
Authors: Bandeali Salman J , Kayani Waleed T , Lee Vei-Vei , Elayda MacArthur , Nambi Vijay , Jneid Hani , Alam Mahboob , Wilson James M , Birnbaum Yochai , Ballantyne Christie M , Virani Salim S
Published: July 2021

Background:
Post-procedural outcomes associated with the use of angiotensin converting enzyme inhibitors (ACEI) in patients undergoing percutaneous coronary intervention (PCI) have not been studied. We aimed to determine the association between ACEI use and adverse cardiovascular/ renal outcomes in these patients.

Methods:
We performed retrospective analysis of 15,485 consecutive patients who underwent percutaneous coronary intervention from January 1, 2000 to June 30, 2011. Primary outcome was the incidence of major adverse events (MAE) defined as a composite of mortality, post PCI renal dysfunction, myocardial infarction, and stroke during index hospitalization for PCI. Secondary outcome was the incidence of aforementioned components of MAE analyzed separately. Logistic regression and multivariate analyses were performed.

Results:
Of the patients undergoing PCI, 6,600 (43%) received pre-PCI ACEI and 8,885 (57%) did not. Patients on ACEI were more likely to be older (64.6 ± 10.9 years vs. 63.6 ± 12.1 years; p<0.0001), have diabetes (41% vs. 26%; p<0.0001), prior renal insufficiency (19% vs. 15%; p<0.0001) and ejection fraction less than 35% (9.6% vs. 7%; p<0.0001). There were no significant associations between pre-operative ACEI use and primary and secondary outcomes (table).

Conclusion:
Pre-operative ACEI use is not associated with major adverse events in patients undergoing PCI.
Key Words:
angiotensin converting enzyme inhibitor; percutaneous coronary intervention
Abstract 321: A Validated Model to Identify Patients at High Risk for 30-Day Readmission After Percutaneous Coronary Intervention
Authors: Wasfy Jason H , Rosenfield Kenneth , Shivapour Daniel , Zelevinsky Katya , Sakhuja Rahul , Spertus John A , Moore Stephanie A , Mauri Laura , Normand Sharon-Lise , Yeh Robert
Published: July 2021

Background:
The Affordable Care Act (ACA) creates incentives within Medicare for hospitals that minimize readmissions shortly after discharge. Percutaneous coronary intervention (PCI) has among the highest rates of 30-day all-cause readmission. We developed and validated a prediction model to assist clinicians in identifying patients at high risk for 30-day readmission after discharge for PCI.

Methods:
We included all PCI admissions in non-federal hospitals in Massachusetts between October 1, 2005 and September 30, 2008. Readmissions within 30-days of discharge were identified via linkage with Massachusetts inpatient claims files. Within a 2/3 random sample, we developed 2 separate multivariable models to predict all-cause 30-day readmission, one incorporating only variables known prior to cardiac catheterization (Pre-PCI model), and a second incorporating variables known at discharge, including PCI-related complications and discharge disposition (Discharge model). In order to facilitate clinical use of the model via a web-based application, less influential variables were eliminated via stepwise selection, while retaining 95% of the predicted variability in the complete models. Models were validated within the remaining 1/3 sample, and model discrimination and calibration were assessed. Readmissions for staged PCIs were not considered as a readmission.

Results:
Of 36060 PCI patients surviving to discharge, 3760 (10.4%) were readmitted within 30 days. In the pre-PCI model, significant independent predictors of readmission included history of heart failure as well as heart failure status at time of PCI, gender, chronic lung disease, worse renal function, insurance status, admission status, previous CABG, peripheral vascular disease, presence of cardiogenic shock, and age. Additional predictors of readmission in the discharge model included length of stay, bleeding or vascular complications, use of drug-eluting stents, previous PCI, diabetes status, race, discharge location, and beta blocker being prescribed at discharge (Figure 1). Model discrimination was moderate for the pre-PCI model (C statistic = 0.67) and not substantially improved by the addition of post-PCI variables (C statistic = 0.69). Both models were well-calibrated within the validation dataset (Hosmer-Lemeshow goodness of fit P = NS for both).

Conclusions:
These validated models, developed in a large and broadly generalizable population, can be used to identify patients at high risk for readmission after PCI. Such a model could be used to target high risk patients for interventions to prevent readmission.
Abstract 323: Mean Arterial Pressure predicts Heart Failure Morbidity in a predominantly Minority Cohort
Authors: Odiete Oghenerukevwe , Wariboko Minaba , Okafor Chimalum , Nwazue Victor , Adebiyi Oluwafisayo , Taylor Kimberli , Sawyer Douglas , Okafor Henry
Published: July 2021

Background:
Hypertension is a well-established risk factor for the development of heart failure (HF), however some studies have suggested that higher systolic blood pressure (SBP) in patients with HF is associated with better survival. It is unclear how this applies to morbidity in HF with preserved ejection fraction (HFpEF) versus HF with reduced EF (HFrEF). We sought to examine this using the more physiologic measure of perfusion pressure - mean arterial pressure (MAP).

Methods:
The study data was derived from the Meharry HF registry at Nashville General Hospital, which is comprised of patient care data from January 2006 to December 2008. The population consists of 72% African-American, 19% Caucasian. 321 medical records were analyzed and 29.5% had a LVEF<40% (HFrEF) and 37.5% had a LVEF>40% (HFpEF). MAP categories used includes, MAP<80, MAP ≥80<110 and MAP>110. Outcomes were assessed using a univariate and multivariate analysis, and were defined as number of HF readmissions (HFA), emergency room (ER) visits, and non-HF readmissions (nHFA). Further analysis was performed using t-test and one-way ANOVA.

Results:
The HFrEF group had a significantly higher MAP and lower nHFA (p<0.0001; P<0.01) respectively, when compared to HFpEF. Also, there was a trend towards a lower HFA and ER visit in those with HFrEF. In this group, increasing MAP up to 100, was associated with a decreased rate of HFA and ER visits. In the HFpEF group, MAP greater than 110 was associated with an increased rate of HFA (p<0.035).

Conclusions:
Our study suggests that in a predominantly-minority cohort of HF patients, MAP can be used to predict long-term morbidity. Patients with HFrEF did better with MAP close to 100 while MAP less than 110 was associated with better outcomes in the HFpEF group. Confirmation of these findings in larger prospective studies will provide clinicians additional objective and cost-effective bedside tool in improving HF outcomes.
Abstract 33: The Nationwide Survey of Quality of life, Burnout and Depression among Japanese Neurosurgeons and Neurologists, J-ASPECT Study
Authors: Nishimura Kunihiro , Takegami Misa , Nakamura Fumiaki , Miyamoto Tomonori , Nakagawara Jyoji , Ogasawara Kuniaki , Ono Junichi , Shiokawa Yoshiaki , Aruga Toru , Miyachi Shigeru , Nagata Izumi , Toyoda Kazunori , Matsuda Shinya , Kitaoka Kazuyo , Mori Hisae , Iihara Koji
Published: July 2021

Background:
Burnout is a syndrome of emotional exhaustion and depersonalization that leads to decreased effectiveness at work. A limited amount of information exists about the relationship between specific demographic and practice characteristics with burnout among neurosurgeons and neurologists and no previous survey were conducted for Japanese physicians. The objective of this study is to determine the incidence of burnout among Japanese neurosurgeons and neurologists and evaluate personal and professional characteristics associated with their burnout.

Methods:
Members of the Japanese Neurosurgical Society and Japanese Society of Neurology were sent an anonymous, cross-sectional survey in March 2011. The survey evaluated demographic variables, practice characteristics, career satisfaction, burnout, and quality of life (QOL). Burnout and QOL were measured using validated instruments, Maslash Burnout Inventory and SF-36, respectively.

Results:
Of total 10741 neurosurgeons and neurologists excluding three prefectures in the Tohoku earthquake area, 2724(25.3%) returned surveys. Responders had been in practice 21.9 years, worked 65.9 hours per week, and were on duty 2.95 nights/month and on call 2.02 nights/ week (mean values). Overall, 47.6% of responders were burned out, 58% screened positive for mild symptoms of depression, 27.1% showed sever depressive symptoms. Overall, 27.8 % had a mental QOL score > 1 standard deviation below the population norm and 58% screened positive for mild symptoms of depression, 26.6% showed sever depressive symptoms. Factors associated with burnout included longer working time(OR=1.24/10hour increase,95%CI 1.17-1.31),number of patients(OR =1.08,95%CI 1.03-1.13),number of t-PA treatments(OR=1.17, 95%CI 1.07-1.28), number of on duty nights per month (OR=1.08,95%CI 1.05-1.11),number of on call nights per week (OR=1.08,95%CI 1.05-1.21), more time spending for stroke care (OR=1.09, 95%CI 1.01-1.17). Factors protective for burnout included sleep hours (OR=0.77/1hr increase, 95%CI 0.69-0.85), high income (OR=0.81/60K US $ increase, 0.74-0.88) and year of experience (OR= 0.75, 95%CI 0.68-0.81). After the stepwise selections, sleeping hours, working time, number of on duty nights, high income, number of patients remained in the final prediction model.

Conclusion:
Burnout is common among Japanese neurosurgeons and neurologists. One hour increase of sleeping time reduced the 23% of burnout risk and high income level was also protective for burnout. Additional prospective research is needed to confirm this relationship to prevent the burnout and promote the mental health of Japanese neurosurgeons and neurologists.
Abstract 36: Nuisance Bleeding after Percutaneous Coronary Intervention
Authors: Amin Amit P , Bach Richard G , Chhatriwalla Adnan K , Bachuwar Alok , Gosch Kensey , Salisbury Adam C , Decker Carole , Cohen David J , Spertus John A
Published: July 2021

Introduction:
TIMI Major and Minor bleeding, reflecting large bleeds of >5 and >3g/dl, respectively, are routinely tracked as outcomes of PCI. Lesser degrees of bleeding, called ‘nuisance’ bleeding (NB), can occur as a result of chronic dual antiplatelet therapy (DAPT). NB has never been reported in clinical trials of PCI or DAPT. The frequency of patient-reported NB after PCI and its association with patients’ quality of life (QOL) is therefore unknown.

Methods:
We assessed the incidence of NB in a 9-center prospective PCI registry, the PRISM study, at 1 and 6 months after the index PCI. NB was defined by patients who responded positively, via telephone interviews, to the following question: ‘Since leaving the hospital after your heart procedure have you had easy bleeding?” QOL was assessed with the EuroQOL-5D visual analogue scale (EQ5D VAS) score (range 0-100, higher = better). Hierarchical linear regression models was used to assess the association of NB at 6 months with QOL (EQ5D VAS) at 6 months, after adjustment for socio-demographic and clinical factors (age, gender, race, insurance status, warfarin use, atrial fibrillation and baseline EQ5D VAS score).

Results:
Among 2,630 patients enrolled in the PRISM trial, NB occurred in 1085 (41.25%) at 6 months. Compliance with DAPT was 98.6% at 1 month and 93.3% at 6 months, precluding an assessment of its association with NB. NB was associated with a significant decrement in QOL, even after adjusting for baseline EQ5D-VAS score and other confounders (EQ5D VAS estimate -1.41, 95%CI -2.79 to -0.03, P-value 0.045, Figure)

Conclusions:
In this multicenter study of PCI, we found NB to be very common and to be independently associated with worse QOL. These results suggest that NB should be quantified in future outcomes studies and interventions to minimize its occurrence should be explored.
Abstract 39: Clinical Outcomes Of Octogenerians Requiring Urgent Cardiac Catheterization: Percutaneous Intervention versus Medical Therapy.
Authors: Parikh Analkumar , Mazimba Sula , Pena Esteban , Schwartz Brian , Hahn Harvey
Published: July 2021

INTRODUCTION:
Octogenarians comprise

an increasing proportion of patients undergoing coronary angiography and percutaneous coronary interventional (PCI). Most interventional studies have focused on patients aged 50-65 years and as such there is paucity of scientific evidence regarding interventions in octogenarians. While there have been some improvements in intervention techniques with more octogenarians undergoing PCI safely, many physicians are still reluctant to recommend invasive treatment for this group. We sought to compare the clinical outcomes in the treatment options (PCI vs medical therapy) among octogenarians requiring urgent cardiac catheterization (CC).

METHODS:
This was a single center retrospective study of 1184 consecutive patients requiring urgent CC. Urgent CC was defined as catheterization within 24 hours of the admission symptom onset. Patients were categorized according to either PCI group (PCIG) versus medical treatment group (MTG) after coronary angiography. Patients were then followed for cardiovascular and all cause mortality as well as cardiovascular and all cause readmissions at 30 days and 1 year from the index event.

RESULTS:
There were 1184 patients that met inclusion criteria. Thirty five percent (416) underwent PCI and 65% (768) had medical treatment. Mean age was 84+/-3 for PCIG versus 83 +/- 3 for the medical group. (p=NS), 53% (220) of PCIG were male versus 51% (391) MTG (p =NS), 86% (358) of PCIG had HTN versus 87% (668) MTG. Hyperlipidemia was present in 79% (328) of PCIG vs 77% (591) of MTG. Ninety seven percent(403) of the PCIG presented with chest pain versus 94%(722) in the MTG (p=NS) Length of stay for both groups was 3+/-2 days (p=NS). Thirty-day mortality for PCIG was 3% (12) vs. 2 % (23) in the MTG (p=NS). One year mortality in the PCIG was 5 % (21) vs. 3% (23) in the MTG (p=NS) Thirty day all cause readmission for the PCIG was 8% (33) vs. 9% (69) in the MTG (p=NS) .One year all cause readmission for the PCIG was 18% (75) vs. 16% (122) for the MTG (p=NS). Thirty day cardiovascular readmission for the PCIG was 8% (33) vs. 10%(77) (p=NS) in the MTG. One year cardiovascular readmission for PCIG was 18% (75) vs. 21% (161) in the MTG (p=NS). Readmissions at one year for revascularization for both (PCI and coronary artery bypass graft surgery) was 13% (54) in the PCIG vs. 12%(92) in the MTG (p=NS).

CONCLUSION:
Percutanous intervention in octogenarians presenting for urgent cardiac catherterization had similar short and intermediate term outcomes when compared to those undergoing medical management.
Abstract 49: The Effect of Gender, Obesity, and Chronic Kidney Disease on Cardiovascular Events
Authors: Kolm Paul , Zhang Zugui , Bowen James , Israni Rubeen , Weintraub William S , Jurkovitz Claudine
Published: July 2021

Background:
Obesity and chronic kidney disease (CKD) are well known risk factors for cardiovascular (CV) events. Studies have shown that in patients with end-stage renal disease, the rate of CV events decreases as body mass index (BMI) increases. These studies, however, used only one measurement of BMI to predict CV events. The objective of this study was to assess whether rates of CV events changed according to variations in BMI and glomerular filtration rate (GFR) over time.

Methods:
A retrospective cohort of patients followed in outpatient practices from 1995 to 2010 was evaluated. Adult patients with at least 2 records of serum creatinine were included. The practices’ electronic health records (EHRs) were linked to the hospital EHR to assess CV events. GFR (mL/min/1.73m
2
) was calculated using the Modification of Diet in Renal Disease equation and stratified according to the Kidney Disease Outcomes Quality Initiative guidelines as Normal (≥ 60), CKD stage 3 (30-59) and stage 4-5 (< 30) at each patient’s encounter. Outcomes were identified using ICD9 codes for myocardial infarction, congestive heart failure, coronary heart disease, dysrhythmia, stroke and peripheral vascular disease. The data spanned up to 10 years from a patient’s index to last visit. CV events were modeled as a function of age, gender, race, BMI and CKD status by negative binomial regression for count data. The model included interactions of age, gender, race, BMI and CKD.

Results:
Over the 10-year period, there were a total of 1,024,891 observations from 39,605 patients with 8,901 CV events. There was a significant age by gender by race by BMI interaction as well as a significant CKD main effect (p < 0.01). Increasing age, being male, black, overweight and having CKD, were associated with higher event rates. However, this association between BMI and event rates was not present for black females over 70, thus the 4-way sex by race by age by BMI interaction (Figure).

Conclusion:
These results support the hypothesis that overweight / obesity is not protective of CV events in CKD patients.
Abstract 75: Practice-level Variation in use of Recommended Medications among Outpatients with Heart Failure: Insights from the NCDR PINNACLE Program
Authors: Peterson Pamela N , Chan Paul S , Spertus John A , Tang Fengming , Jones Phil , Ezekowitz Justin A , Allen Larry A , Masoudi Frederick A , Maddox Thomas M
Published: July 2021

Background:
Beta-blockers (BB) and angiotensin converting enzyme inhibitors (ACE)/angiotensin receptor blockers (ARB) are guideline recommended therapies for ambulatory heart failure patients with reduced left ventricular ejection fraction (HFREF). Real-world use of these therapies is suboptimal. Whether variations in treatment are dominated by practice-level or patient-level factors is unknown.

Methods:
Practices participating in the NCDR PINNACLE program, a national office-based cardiac quality improvement registry, between July 2008 and December 2010 were evaluated. Rates of treatment with BB and ACE/ARB were evaluated in patients with HFREF (EF ≤40%) and no documented contraindication. Multivariable hierarchical relative risk regression models, including demographics, insurance status, comorbidities and a random effect for practice were used to determine 1) patient-level and 2) practice-level variation in treatment rates. To quantify practice-level variation, the median rate ratio (MRR) was calculated, which estimates the typical rate ratio between two randomly selected practices for patients with identical covariates. In general, MRRs ≥ 1.2 indicate significant variation by practice. The MRR is always >1.0 but can be compared in magnitude to patient-level risks.

Results:
We studied 12384 patients in 45 practices. The mean practice rate for BB treatment was 87% (IQR 83%-95%; range: 43%-100%), and the mean practice rate of ACE/ARB treatment was 90% (IQR 75%-88%; range: 18%-100%). The MRR was 1.09 for BB and 1.16 for ACE/ARB therapy. For both BB and ACE/ARB, the adjusted MRR for site level variation was larger than the rate ratio for other patient factors. (Table)

Conclusions:
Although rates of BB and ACE/ARB treatment among outpatients with HFREF are high, clinically meaningful variation by practice is present and explains a larger amount of the observed variance than any patient characteristic. This suggests that addressing practice-level factors represents an important opportunity to improve the use of evidence-based HF therapy.
Abstract 83: Self-Reported Characteristics and Caregiving Responsibilities Among Caregivers Supporting Patients with Atrial Fibrillation
Authors: Vanderpoel Julie , Ruiz Juan , Galitsky Alex , Nelson Winnie , Mody Samir
Published: July 2021

Background:
Atrial fibrillation (AF) is the most common form of cardiac dysrhythmia and a strong stroke risk factor. Due to the nature of the disease and its treatment, many patients may require caregiver assistance. The purpose of this study was to describe the self-reported characteristics and caregiving responsibilities of caregivers supporting patients with AF.

Methods:
A survey of caregivers providing care to AF patients in the United States was administered. Caregivers ≥ 18 years of age providing care for adults who were currently diagnosed with AF and aged ≥ 55 years qualified for survey participation.

Participants completed a 50-minute online survey during 12/10-12/28/2010. Survey questions addressed a variety of topics such as population characteristics and caregiving responsibilities/burden. The data were weighted on demographic characteristics to represent the real world population of AF patients and caregivers. Weighted results percentages are reported.

Results:
The survey was conducted among 200 caregivers. Approximately 64% of the caregivers were female, mean age was 55 years, and 83% were Caucasian. Forty-three percent of caregivers were currently employed and median household income was $42,900. The relationship to the patient was reported as spouse or partner by 43% of caregivers, and 34% of caregivers were a child or child-in-law of the patient. Additionally, 63% of caregivers reported currently living with the patient. Caregivers reported several caregiving responsibilities, including going to doctor visits (84% of caregivers), going to monitoring clinics and getting lab tests (53% of caregivers), and helping patients take medications (54% of caregivers). Furthermore, 45% of caregivers reported making treatment decisions as a caregiving responsibility.

Conclusions:
Caregivers of AF patients provide support in various ways, including treatment decision-making. Given the role of caregivers in the lives of AF patients, understanding the caregiver population and their burden may be important for optimal care of AF patients. Inclusion and education of caregivers with regard to patient care, including treatment decision making and modalities to decrease burden, may facilitate optimal care management of AF patients.
Abstract 91: Are At Risk Outpatient Cardiology Patients being Appropriately Evaluated for Lower Extremity PAD as Recommended by ACC/AHA Guidelines?
Authors: Kabadi Rajesh M , Patel Ankitkumar , Sharma Rajani , Schmidt Rita , Iliadis Elias
Published: July 2021

Background:
Lower extremity peripheral artery disease (PAD) is a common syndrome that afflicts many individuals and leads to significant morbidity. Once appropriate at risk patients are identified, ankle-brachial index (ABI) testing is a relatively quick and inexpensive test that is recommended for proper assessment of PAD, per the recommendations outlined in the American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for the Management of Peripheral Artery Disease (PAD) (JACC, 2006). Outpatient cardiology practices often take care of individuals at risk for PAD and have the opportunity to test and appropriately treat this condition.

Methods:
A randomly selected group of 367 outpatients seen in a large academic cardiology practice from September 2011 underwent retrospective chart review. Risk factors for PAD that were assessed include history of smoking, hypertension, diabetes, hyperlipidemia, homocysteine levels, and CRP. Those that had three or more risk factors were classified as high risk and those with less than that were classified as low risk and frequency of ABI testing was evaluated. Fishers exact test was utilized for statistical analysis.

Results:
Fifty-one percent (N=187) of our population were classified as high risk for PAD, forty-three percent (N=158) were low risk, and six percent (N=22) were known to already have PAD. Amongst the high risk individuals, only six percent (N=12) had ABI testing performed while there were three percent (N=6) of low risk individuals that had this test (p=-0.34).

Conclusions:
There was no difference in ABI testing between high and low risk populations. Limitations of this study include lack of information regarding other diagnostic modalities that may have been used in place of ABI testing. Quality improvement may be achieved by increased use of such testing as this would allow for quicker identification of the disease, prompter treatment, and better outcomes, at a minimal cost.
Abstract 107: Quality Of Care In Heart Failure Patients Hospitalized For Any Cause
Authors: Blecker Saul , Agarwal Sunil K , Chang Patricia P , Rosamond Wayne D , Casey Donald E , Kucharska-Newton Anna , Radford Martha J , Coresh Josef , Katz Stuart
Published: July 2021

Background:
Hospital quality performance measures for heart failure (HF) target patients with a principal discharge diagnosis of HF. However, patients with chronic HF are commonly admitted for other causes and are recommended treatments such as angiotensin converting enzyme (ACE) inhibitors for left ventricular (LV) systolic dysfunction. The purpose of this study was to assess the quality of care for HF patients who are hospitalized for all causes.

Methods:
We conducted a community-wide surveillance of hospitalized patients with acute or chronic HF as part of the Atherosclerosis Risk in Communities (ARIC) Study from 2005-2009. HF diagnosis was validated by chart abstraction and adjudication by physician committee. We assessed rates of compliance for two available Centers for Medicare & Medicaid Services (CMS) inpatient quality measures: LV function assessment and discharge prescription for an ACE inhibitor or angiotensin receptor blocker (ARB) for patient with LV systolic dysfunction; rates were compared for HF patients with a principal ICD-9 discharge diagnosis of HF and those with another principal discharge diagnosis. Cox proportional hazard models were used to assess the association of quality measures with post-discharge mortality.

Results:
Of 4,345 hospitalizations of HF patients, 39.6% carried a principal discharge diagnosis of HF. Individuals with a principal discharge diagnosis of HF had higher rates of LV function assessment (89.1% versus 82.5%, p<0.0001; adjusted prevalence ratio (aPR) 1.07, 95% CI 1.04-1.10) and ACE inhibitor/ARB use in LV dysfunction (64.1% versus 56.3%, p<0.01; aPR 1.11, 95% CI 1.03-1.20) as compared to individuals hospitalized for another cause. LV assessment and ACE inhibitor/ARB use were associated with significant or near significant reductions in post-discharge mortality (adjusted hazard ratios 0.69, 95% CI 0.50-0.90 and 0.73, 95% CI 0.52-1.03, respectively). The associations between quality measures and post-discharge mortality did not differ for patients with versus without a primary discharge diagnosis of HF (p-interaction=0.8 for LV assessment; p-interaction=0.6 for ACE inhibitor/ARB use).

Conclusions:
Compared to individuals hospitalized with a principal diagnosis of heart failure, heart failure patients hospitalized for other causes are less likely to receive aspects of guideline recommended care. Quality initiatives may improve care and outcomes by targeting hospitalizations with both a principal and secondary HF diagnosis.
Abstract 11: Use of Novel Anticoagulants Among Atrial Fibrillation Patients Hospitalized with Ischemic Stroke or Transient Ischemic Attack: A Get With The Guidelines-Stroke Registry Analysis
Authors: Patel Priyesh A , Zhao Xin , Fonarow Gregg C , Lytle Barbara L , Smith Eric E , Xian Ying , Bhatt Deepak L , Peterson Eric D , Schwamm Lee H , Hernandez Adrian F
Published: July 2021

Background:
The FDA recently approved the direct thrombin inhibitor dabigatran (DTI) and factor Xa inhibitor rivaroxaban for atrial fibrillation (AF) stroke prophylaxis based on large randomized trials showing non-inferiority to warfarin for stroke prevention. However, real-world utilization patterns and predictors of use for these novel anticoagulants (NAC) remain poorly characterized.

Methods:
Using the AHA Get With The Guidelines Stroke Registry, we analyzed patients with AF who were hospitalized for ischemic stroke or transient ischemic attack (TIA) and discharged on warfarin or NAC. The first NAC approved by the FDA was dabigatran in 10/2010, so we chose a 2-year study period from 10/2010-9/2012. We excluded patients with contraindications for anticoagulation. Patient and hospital variables associated with discharge anticoagulant use were evaluated using Pearson chi-square and Wilcoxon tests.

Results:
Of 61,655 patients meeting inclusion criteria, 6,835 (11.1%) were discharged on NAC, of which 86.7% were prescribed DTI. Warfarin was prescribed in 54,820 (88.9%) patients. For patients discharged on NAC vs. warfarin, 51.8% vs. 53.3% (p=0.016) were female and median age was 77 [IQR 69-84] vs. 79 [IQR 70-85] (p<0.001). The majority of patients discharged on NAC or warfarin were white (82.7% vs. 80.8% respectively, p=0.005). Slightly higher proportions of patients discharged on NAC vs. warfarin had private/HMO insurance (41.7% vs. 37.6%, p<0.001) than Medicare (39.0% vs. 42.3%, p<0.001).

Patients discharged on NAC vs. warfarin had less severe ischemic stroke (NIH stroke scale=3 [IQR 1-8] vs. 5 [IQR 2-11], p<0.001), shorter length of stay (3 [IQR 2-5] vs. 4 [IQR 2-6] days, p<0.001), and higher proportions of patients who could ambulate at admission (32.5% vs. 26.1%, p<0.001) and discharge (47.5% vs. 39.2%, p<0.001). CHADS2 scores were lower among those discharged on NAC (Figure). More patients discharged on NAC were discharged to home (65.0%) than a healthcare facility, compared to 52.4% of patients prescribed warfarin being discharged to home (p<0.001).

Conclusion:
Among patients with AF and acute ischemic stroke or TIA discharged on oral anticoagulants, NAC use remains low and is prescribed to younger, more functional, and lower risk patients.
Abstract 112: Improved Resource Utilization and Patient Flow in an Outpatient Cardiomyopathy Clinic
Authors: Jefferies John , Brown James , Mays Wayne , Stahl Christopher , McDonald Mark
Published: July 2021

Background:
Given the increasing necessity to increase efficiency and decrease cost in outpatient cardiology, quality improvement efforts are necessary to enhance delivery of care. Our multidisciplinary clinic tailors care based on individual and family needs to include cardiac and genetic testing along with evaluation by multiple providers involved in the care of every patient. These individualized schedules can greatly impact clinic flow, wait times, and clinic resource utilization if they are not managed and executed appropriately. We see patients of all ages which necessitates dynamic resource utilization. There is a paucity of data evaluating quality improvement (QI) efforts in outpatient cardiology. We hypothesized that we could improve clinic flow via measured, planned interventions.

Methods:
All outpatients (children and adults) in the Cardiomyopathy/Heart Failure clinic at a single institution were assessed for anticipated and actual duration of clinic visits. Baseline assessments were made prior to QI efforts. A series of measured interventions were made as follows: designation of a flow coordinator for the clinic, implementation of a visual management system (VMS) showing patient status, and use of a clinic wide phone texting system to alert appropriate staff of status and next procedure/appointment. A time for Visit Length Expectation (VLE) was calculated based on the type of visit, complexity of patient, scheduled provider evaluations, and testing.

Results:
Baseline data revealed 20.6% of patients were meeting VLE. Over a third of patients (38.8%) had wait times > 20 minutes. Following our interventions, 75.6% were meeting their VLE with only 10% having wait times > 20 minutes. We are at 90% reliability in meeting expected VLE. Scheduling capacity has increased allowing for increased timely accessibility to clinic for patients and families. We have sustained these improvements for 6 months.

Conclusions:
Patient wait times and clinic resource utilization can be greatly improved with simple interventions such as identifying a clinic flow coordinator, utilization of a VMS, and enhanced communication internal and external to the clinic via a texting system. These interventions have increased available appointments and increased scheduling flexibility. Furthermore, we can now reliably predict VLE at the time of registration which better informs families of their anticipated total time in the clinic.