bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P72: Pattern of Deactivation of Implantable Cardioverter Defibrillator in Inpatient Hospice Units
Authors: Lakshmanadoss Umashankar , Reddy Lohith , Sherazi Saadia , Anabtawi Abeer , DiSalle Michael , Williams Cheryl , Daubert James P , Shah Abrar H
Published: July 2021

Background:
There have been an increasing number of patients receiving implantable cardioverter defibrillators (ICDs) over the last decade. Although ICDs prevent arrhythmic death, patients may still develop other terminal illnesses, or progression of underlying heart failure. ICD- delivered shocks are associated with significant pain, anxiety and reduced quality of life. Therefore for this population of patients, it may become undesirable to receive shock therapy nearing the end of life. We reviewed the practices for ICD deactivation on a series of patients admitted to a hospice center. We hypothesized that for patients with ICDs, the frequency for ICD deactivation at end of life would be low.

Methods:
In this retrospective study we reviewed records of patients with ICDs who were admitted to the Hildebrandt Hospice Care Center, an inpatient hospice facility, in Rochester NY from January 2005 to December 2009. Information regarding patient's demographics, indications for ICD implantation, deactivation of ICD (frequency, location) and history of shock in hospice care was recorded.

Results:
We identified 32 patients who were admitted to inpatient hospice with ICDs for primary prevention of sudden cardiac arrest. The mean age was 78 + 9 years and 23 out of 32 (72%) were male. Sixteen patients had metastatic cancer, 8 patients had sepsis, 4 patients had stroke, 3 patients had renal disease and one patient had liver disease. Twenty (62%) patients had their ICD deactivated in the hospital before transferring to inpatient hospice. Nine (28%) patients were transferred to the center without ICD deactivation. Among these patients, 3 (10%) received ICD shock while in hospice and subsequently died in the center (average 2 days after receiving the shock). Three (10%) patients refused to have their ICD deactivated. Out of these three patients, two died in the hospice center while one patient was discharged home and none of them had ICD shock during hospice admission.

Conclusion:
The discussion about ICD deactivation should be initiated in terminally ill patients who are opting for hospice care for end of life care. Deactivating the device allows patients to die without the discomfort of electric shocks.
Abstract 1: Relationship Between Implementation of Public Smoking Bans and Acute MI Rates in 74 US Cities
Authors: Mathews Robin , Thomas Laine , Peterson Eric D
Published: July 2021

Background:
Public smoking bans have become common. The Institute of Medicine recently concluded that the risk for AMI declined acutely after smoking bans implementation. However, this was based on a few published studies with an estimated effect size range from 6 to 47%. We evaluated the impact of smoking bans on AMI rates in 74 US cities to determine more stable national estimate.

Methods:
Using methods similar to prior work, we used CMS data to determine AMI rates in the year before and after implementation of city-wide anti-smoking legislation. Characteristics of the smoking legislation were identified from the Americans for Non-Smokers Rights (ANR) Foundation. Cities were prospectively selected based on implementing anti-smoking legislation between 2003 to 2006 and populations ( ≥50,000). Poisson regression was used to compare AMI hospitalization rates 1 year before and after ordinance implementation.

Results:
In our Medicare population, there was an overall 3% reduction in rates of AMI after implementation of anti-smoking legislation (rate ratio 0.97, 95 CI 0.95-0.99). The impact of this effect varied widely among cities (Figure) (range -36% to 54%).

Conclusion:
Implementation of public smoking bans was associated with a more modest reduction in AMI than had been previously estimated. This may reflect: the heterogeneous nature of smoking laws under study; a more limited impact of smoking bans in the elderly; or an example of publication bias. Further investigation is needed to better understand this variability in smoke free air legislation and impact on cardiovascular events.
Abstract P102: Characteristics of Practice of Primary Angioplasty in Quebec, Canada (2008-2009): A Systematic Field Evaluation
Authors: Lambert Laurie , Xiao Yongling , L'Allier Philippe , Rinfret Stéphane , Kouz Simon , Ross Dave , Segal Eli , Maire Sébastien , Vanasse Alain , Bogaty Peter
Published: July 2021

Background:
Primary angioplasty (PPCI) is the predominant reperfusion therapy for ST-elevation myocardial infarction (STEMI) in Quebec where there are 13 PPCI centers. Our systematic province-wide field evaluation examined contemporary practice of PPCI such as arterial access site and use of stents and thrombus aspiration devices.

Methods:
The 82 hospitals that treat over 95% of all acute myocardial infarctions occurring annually in Quebec participated in a systematic evaluation in 2008-9. Designated medical record librarians abstracted data from medical charts of patients with a final diagnosis of myocardial infarction who presented to an emergency room with characteristic symptoms. STEMI was confirmed by ECG interpretation.

Results:
Of 1876 treated STEMI patients, 1505 (80%) were sent for PPCI with 594 (39%) presenting directly to a PPCI center and 911 (61%) transferred from a non PPCI-capable center. Of these, 1334 patients (88 %) underwent PPCI. Almost all (1265/1334; 95%) had stent insertion (12% were drug-eluting stents). The radial approach was used in 844 (63%) patients with a median 12 min (6-21; all ranges 10-90 percentile) from first arterial puncture to first device. Patients with a femoral approach had a similar median delay [11 min (6-25)]. Door-to-balloon times were similar: 98 min (55-203) for the radial approach and 101 min (50-207) for the femoral approach. The first reperfusion device was a balloon in 687 patients (52%), a thrombus aspiration device in 485 patients (37%), and a direct stent in 145 patients (11%). Median delays from first puncture to first device were 13 min (7-26) for balloon, 10 min (6-18) for thrombus aspiration device, and 12 min (6-25) for direct stent deployment. There was substantial variation in radial versus femoral approach and type of first device by PPCI center.

Conclusion:
This contemporary evaluation of a complete system of STEMI care shows that most PPCI is performed in patients transferred from another hospital. The radial approach now predominates. The most frequent first reperfusion device is still the balloon but a substantial proportion of patients undergo thrombus aspiration. Drug eluting stent use was infrequent. Treatment delays did not vary by either arterial access site or type of first device.
Abstract P11: Use of Hospital Claims Data to Estimate the Clinical and Economic Burden of Acute Coronary Syndrome Rehospitalizations in Real-World Clinical Practice
Authors: Hess Gregory , Bhandary Durgesh , Gandhi Sanjay , Kumar Deepa , Fonseca Eileen , Gold Alex
Published: July 2021

Background:
Re-hospitalization rates are emerging as quality of care measures with reimbursement implications for inpatient care.

Objective:
To examine the rates of inpatient re-hospitalization and economic burden of acute coronary syndrome (ACS) patient admissions in real-world clinical practice.

Methods:
Patients (age >18 years) with an inpatient hospitalization for ACS [ICD-9-CM codes for acute myocardial infarction or unstable angina (UA)] between 1/1/2007-4/30/2009 were identified using claims from 450 hospitals representing 4.8 million inpatient visits. All-cause and ACS-related re-hospitalizations within 30 days and 12 months after index event were evaluated. In addition, the mean inpatient admission charges resulting from inpatient re-admissions at 30 days were also estimated.

Results:
Of 17,904 ACS patients [52% male; mean age 70.6 (median-73.0) years)], 13.3% had diagnostic coding for ST elevation myocardial infarction (STEMI), 47.9% had coding for non-ST elevation myocardial infarction (NSTEMI), 32.2% had UA, and 6.5% had not otherwise specified (NOS) ACS. The 30-day all-cause inpatient re-hospitalization rate was 14.7% (STEMI: 12.7%, NSTEMI: 17.1%, UA: 12.5%, NOS: 10.8%) and 5.5% for an ACS-related re-hospitalization (STEMI: 7.6%, NSTEMI: 7.0%, UA: 2.8%, NOS: 3.9%). The 12-month all cause re-hospitalization rate was 37.7% (STEMI: 31.3%, NSTEMI: 39.9%, UA: 39.7%, NOS: 25.4%) and 12.5% for an ACS-related re-hospitalization (STEMI: 12.7%, NSTEMI: 14.3%, UA: 10.9%, NOS: 7.0%). For patients with ages > 65 years (N = 12,627), the 30-day all-cause and ACS-related re-hospitalization rates were 15.1% and 5.8%, respectively. The mean per patient additional charges resulting from 30-day all-cause and ACS-related re-hospitalizations in the study cohort with an index hospitalization (N=17,904) were estimated to be $13,160 and $7,216, respectively.

Conclusion:
High rates of re-hospitalization for ACS patients within 30 days and 12-months post-index hospitalization were observed using real-world clinical practice data. More effective therapies may provide an opportunity to improve important clinical and economic outcomes in ACS patients.
Abstract P12: Medication Therapy Management Services - A Requirement for Medicare Part D Plans: Are Your Patients Eligible?
Authors: Spinler Sarah A , Cziraky Mark J , Chan Paul S , Tang Feng-ming , Duenas Gladys G , Thomas Tyan , Reinhold Jennifer A , Willey Vincent J
Published: July 2021

Background:
Medication Therapy Management (MTM) is a mandated component of Medicare Part D whereby a pharmacist-patient encounter identifies, resolves and prevents medication-related problems. MTM programs have been shown to improve drug therapy goal attainment while reducing overall costs in cardiac patients; however, MTM has been greatly underutilized. The purpose of this study is to identify the proportion of patients eligible for MTM from those enrolled in the NCDR's outpatient PINNACLE Registry.

Methods:
MTM eligibility is based on the presence of multiple chronic diseases and medications plus the likelihood of exceeding an annual drug cost threshold ($4000 in 2009 and $3000 in 2010). Patients from PINNACLE (5/1/08 to 9/30/10) with 3 or more of the following diseases were identified: HTN, HF, dyslipidemia, DM, CAD. Patient demographics, cardiac diseases, and cardiac drug classes prescribed (individual drugs not available) were captured. To estimate individual patient drug costs to determine MTM eligibility, a weighted average cost was calculated using nationally representative drug utilization data and average wholesale prices (AWP). Sensitivity analyses for determining MTM eligibility were performed by varying drug costs using AWP for the highest cost and clinician-defined most frequently prescribed drugs in each class.

Results:
Of the 160,593 Medicare patients enrolled in PINNACLE, 93,089 (58%) were identified with ≥ 3 cardiac diseases. The cohort’s mean age was 74.4 ± 9.2 yrs, 54.4% were male and 86.5% were white. Patients were prescribed a mean of 3.5 cardiac drugs. The table displays drug costs and MTM eligibility results.

Conclusions:
A substantial number of patients met MTM eligibility requirements with this conservative approach using only cardiac drug costs, although variability existed based on cost method. These data serve to raise cardiologists' awareness of their patients' potential eligibility to receive the benefits of MTM services.

Cost Methodology
Median Annual Cost (IQR)
2009 MTM Eligibility [N (%)]
2010 MTM Eligibility [N (%)]

Weighed average cost
$1329 (915,2609)
6,202 (6.7% )
19,903 (21.4%)

Frequently prescribed cost
$366 (193,1361)
1084 (1.2% )
7326 (7.9%)

High cost
$3,958 (2406,5358)
46,477 (49.9% )
59,619 (64%)

2009 and 2010 MTM eligibility based on likelihood of exceeding drug cost threshold of $4000 and $3000, respectively.

IQR - interquartile range; MTM - medication therapy management.
Abstract P154: Factors Affecting the Decision to Treat Cardiovascular Risk in an Urban Underserved Population with Intermediate Framingham Risk
Authors: Afari-Armah Nana , Kashem Abul , Memon Nabeel , Alkhouli Mohamad , Reed Ashley , Rakita Val , Hewitt Valaine , Homko Carol , Santamore William P , Bove Alfred A
Published: July 2021

Management of cardiovascular disease risk in intermediate risk (Framingham score ≥10%, <20%) patients remains controversial. Recent studies have suggested that imaging of coronary atherosclerosis be performed in these patients to identify patients who require therapy. In this study, we stratified a population of urban, underserved subjects with no history or symptoms of coronary disease into high and intermediate risk to determine those patients who would need adjunctive imaging or biomarker data for a decision to treat CVD risk. Methods We screened 210 inner city underserved subjects for CVD risk as candidates for a study of risk reduction using nurse intervention and telemedicine, 68.6% (144) were at Intermediate risk (56.9% males, 80.6% African American, 11.8% white, 6.3% Hispanic, Age 56.2±9.9 years, BMI 31.7±7.2, hypertension 45.1%, hyperlipidemia 81.9%, diabetes 46.5%, smoker 36.8%, obese 54.2%). Results Based on presence of hypertension or hyperlipidemia, 133 of 144 intermediate risk subjects (93.3%) require therapy to reduce CVD risk. Of the remaining 11 patients, 10 had either diabetes, or were smokers or both. One patient reached intermediate risk based on age alone. Thus 143/144 patients (99.3%) screened for CVD using clinical measures would require risk reduction therapy based on current clinical standards, and addition risk stratification would be unnecessary. Conclusions In an urban underserved community known to be at high risk for CVD, clinical measures that identify hypertension, hyperlipidemia, diabetes and cigarette smoking in subjects at intermediate risk based on Framingham score, would direct CVD risk reduction therapy to 99.3% of subjects without need for further risk stratification with imaging or other biomarkers.
Abstract P193: Are There Gender Differences in Treatment and Survival of Patients with Heart Failure?
Authors: Giedrimiene Dalia , Rai Mridula , Zaeem Faisal , O'Bara Lynn , Statz Cara , Moorer Molly , Mueller Kelly , Mulamala Roja , Radojevic Joseph , Gluck Jason , Wencker Detlef
Published: July 2021

Background
An increasing interest has been shown in identification of gender differences treating patients with heart failure (HF) and managing their care. The purpose of the study was to evaluate whether there are any differences in the management and in treatment outcomes with respect to gender in patients treated at Outpatient Clinic.

Methods
The data analysis included the records of 350 visits during 2 years period (April 2008 to May 2010) related to 59 pts (21 females and 38 males) who had multiple daily treatment sessions at Infusion Center for outpatient treatment with IV diuretics. Primary disorders, co-morbidities and ICD implantation were evaluated, and patients were followed for 12 months in order to assess the frequency of re-hospitalizations and their survival.

Results

Primary Disorder
Total n=59
Females n=21
Males n=38
P-value

Hypertension
53 (89.8%)
19 (90.5%)
35 (92.1%)
NS

Renal Disease
36 (61.0%)
7 (33.3%)
29 (76.2%)
0.012*

CAD
38 (64.4%)
9 (42.9%)
29 (76.2%)
0.05*

Diabetes
31 (52.5%)
12 (57.1%)
19 (50.0%
NS

COPD
15 (25.4%)
3 (14.3%)
12 (31.6%)
0.045*

Thyroid Disease
3 (5.1%)
0
3 (7.9%)
NS

Atrial Fibrillation
23 (39.0%)
8 (38.1%)
15 (39.5%)
NS

ICD
17 (28.8%)
3 (14.3%)
14 (36.8%)
0.012*

Re-hospitalization and Survival

Total n=59
Females n=21
Males n=38
P-value

Re-hospitalization at 30 days months
8 (13.6%)
3 (14.3%)
5 (13.2%)
NS

Re-hospitalization 6 months
19 (32.2%
7 (33.3%)
12 (31.5%)
NS

Re-hospitalization 12 months
26 (44.0%)
8 (38.1%)
18 (47.7%)
NS

Death at 12 months
8 (13.6%)
4(19.1%)
4 (10.5%)
0.045*

P < 0.05 = SD

Conclusions:
The study demonstrated that hypertension was the most common primary diagnosis in men and women, and diabetes mellitus was found at the same frequency in both gender groups, however renal disease, CAD and COPD were more prevalent in males than females. Despite very similar frequency of cardiac arrhythmias, such as Atrial Fibrillation in both gender groups, significantly more males had the ICD implanted as compared to females. The rate of re-hospitalizations at 30 days, during 6 and 12 months period did not differ based on the gender, however the survival during 12 months follow-up was lower in females than males.
Abstract P213: Outcomes of a Postdischarge Coronary Artery Disease Management Program
Authors: Dele-Michael Abiola , Henckel Brandon , Krishnan Sangeetha M , Housholder-Hughes Susan , Kline-Rogers Eva , Eagle Kim , Rubenfire Melvyn
Published: July 2021

Background:
The coronary artery disease management (DM) program was designed to improve patient care with the same or lower costs in patients discharged from a university hospital. We tested whether the DM program reduced emergency department (ED) visits, re-hospitalizations, and adverse cardiovascular outcomes.

Methods:
In this prospective study, we analyzed 141 subjects from the Global Registry of Acute Coronary Events (GRACE). There were 47 subjects that participated in the DM program and 94 subjects participated in GRACE alone with conventional care (CC). DM program subjects received a comprehensive risk assessment, education regarding medication, recognition of significant symptoms, emergency response, review of basic nutrition and exercise and psychosocial support. The primary end point was ED visits at 6 months. Secondary end points were re-hospitalization and incidence of major adverse cardiovascular events (MACE). Disease management subjects were matched 1:2 to controls based on age, gender and GRACE 6 month mortality risk score.

Results:
At 6 months, a significantly lower number of ED visits were associated with patients in the DM group compared to CC (17 vs 59 visits, p=0.04). There were a total of 6 adverse cardiovascular events (myocardial infarction, n = 4 and death, n = 2), all of which occurred in the conventional care group. There were no significant differences in hospitalization rates resulting from ED visits among the CC and DM groups [76% (45/59) vs 71% (12/17), p=0.75].

Conclusion:
The DM program resulted in a significantly reduced number of ED visits, which would translate into lower cost of care. However, the program did not demonstrate a significant effect on the rate of re-hospitalization and MACE.
Abstract P246: A Naturalistic Assessment of Lipid Treatment Strategies: Further LDL-C Reduction Versus Comprehensive Lipid Management
Authors: Simko Robert , Cziraky Mark , Quimbo Ralph
Published: July 2021

Objective:
To compare cardiovascular (CV) outcomes between patients initiating adjunct therapy with either niacin extended-release (NER) for broader lipid panel management or ezetimibe (EZE) for continued LDL-C reduction.

Methods:
Statin-treated patients aged ≥30 augmenting with NER or EZE between 1/1/05-11/30/09 (Index Date) were identified. Patients with ≥12 months of health plan eligibility before the Index Date (baseline) were included, and patients with secondary risk and ≥1 full lipid panel were retained. A propensity score (PPS) model was developed controlling for the following baseline factors: age, gender, geographic region, type of health coverage, baseline lipids, mode of therapy augmentation, potency of adjunct statin therapy, baseline statin adherence, comorbidities, and alternative CV medications. NER and EZE patients were matched based on PPS. Clinical outcomes included incidence of a major adverse cardiovascular event (MACE). MACE was defined as a composite of acute ischemic heart (IHD), peripheral vascular (PVD), and cerebrovascular disease (CVD) events. The economic outcome was annual CV disease-related costs. These outcomes were compared using univariate Cox proportional hazards and generalized linear models respectively.

Results:
A total of 15,195 patients initiated adjunct therapy with NER (n=3,098) and EZE (n=12,097) meeting all study criteria. Post-PPS match, 2,261 patients were identified in each cohort with no statistically significant differences in baseline or concurrent treatment characteristics. Frequency of MACE was lower among NER patients (3.5%) vs. EZE (5.4%), with a hazard ratio (HR) of 0.89 (95% CI: 0.67-1.20). Specifically, NER patients demonstrated a lower risk of IHD (HR: 0.90; 95% CI: 0.65-1.25) and CVD (HR: 0.69; 95% CI: 0.34-1.41) events vs. EZE patients. These findings correspond to significantly lower adjusted annual cost among NER patients ($8,168; 95% CI: $7,720 - $8,641) vs. EZE ($9,030; 95% CI: $8,535 - $9,553) (
P=
0.0136).

Conclusions:
Positive clinical benefits observed in this broader naturalistic population are consistent with results from recent clinical trials and suggest that treating beyond LDL-C with statin + NER in secondary risk patients may reduce CV risk and associated costs.
Abstract P255: The Effects of COSEHC Physician Process Improvement Continuing Medical Education on Patient Cardiovascular Risk Factors Outcomes in Southeastern Primary Care Clinics
Authors: Joyner JaNae , Simmons Debra R , Moore Michael A
Published: July 2021

COSEHC has developed and implemented within 20 Southeast primary care clinics a continuous process improvement (CQI) continuing medical education (PI-CME) 18 month program tailored to physicians' scope of practice to reduce physician competency gaps in achieving recommended patient cardiovascular disease (CVD) risk factor goals. Physicians were taught CQI using patient outcomes for JNC7 systolic blood pressure (SBP) and ATP III LDL cholesterol (LDL-C) and HDL cholesterol (HDL-C) goals (SBP < 140 mmHg, < 130 mmHg diabetic; LDL-C < 100 mg/dL; HDL-C> 40 mg/dL). A project faculty of CVD experts was trained to utilize slide decks in live or web based formats to improve hypertension, hyperlipidemia, and glycemic control, patient expectations, physician-patient communication, lifestyle/behavior modifications and to utilize the CQI process. At baseline, 300-400 patient charts per clinic (ICD codes 250, 272, 401) were randomly selected (7,481 total patients [54% female, 29% African American, 30% elderly [> 65 years], and 31% with diabetes]). Changes in average CVD risk factors and the percentage of patients achieving JNC-7 and ATP-III goals were determined at baseline and at three months of 18 month follow-up after the initial CME. SBP statistically decreased and HDL-C statistically increased at follow-up compared to baseline in patients having both a baseline and follow-up value. 60% (12 of 20 clinics), 55% (11 of 20 clinics), and 70% (14 of 20 clinics) improved their percentage of total patients at therapeutic target goals for SBP, LDL-C, and HDL-C respectively. The greatest improvement was among the female subpopulation where 65% (13 of 20 clinics), 50% (10 of 20 clinics), and 75% (15 of 20 clinics) improved the percentage of females at therapeutic goal for SBP, LDL-C, and HDL-C, respectively, at 3 months. It is concluded that scope of practice designed PI-CME can improve therapeutic target goal rates for CVD risk factors through a CQI process.

Table 1. Changes in Cardiovascular Risk Factor Mean Values between Baseline and 3 Month Follow-up.

Baseline
3 Month Follow-up
Patient Record Sample Size

Systolic Blood Pressure (mm Hg)
131.2 + 17.4

129.2 + 15.6
*

1958

LDL Cholesterol (mg/dL)
99.7 + 34.9
98.9 + 33.4
986

HDL Cholesterol (mg/dL)
46.7 + 15.7

48.2 + 22.4
*

1008

* p< 0.05. Values expressed as mean + standard deviation. Patients had to have both a baseline and follow-up value to be included in this paired t-test.
Abstract P266: Bypass of Local Acute Care Facilities for Primary Stroke Centers in North Carolina
Authors: Patel Mehul D , Brice Jane H , Rosamond Wayne D
Published: July 2021

In some regions of the US, emergency medical services (EMS) policies recommend transporting acute stroke patients directly to specialized stroke centers, bypassing local facilities unable to provide appropriate care. However, this prehospital care practice has not been thoroughly studied. We describe the pattern of bypass in a random sample of 301 suspected stroke patients transported by EMS from 53 of 100 North Carolina (NC) counties in 2010. We geocoded scene and destination addresses and calculated driving distances using GIS network analysis (ArcGIS 9.2, ESRI). EMS bypass was defined as the transport of a patient to a hospital other than the closest in driving distance. We characterized each destination as either a Joint Commission certified Primary Stroke Center (PSC) or not (non-PSC). The 301 stroke incidents were transported by EMS to 59 hospitals, including 16 designated as PSCs. EMS bypassed the closest facility for 91 patients (30%). On average, bypass resulted in an additional 10.0 miles of travel [median 4.7 miles (IQR 1.7, 10.6)]. Bypass did not vary widely by patient age, sex, or race. Bypass was more likely to occur in urban counties compared to rural counties (34% vs. 26%), with the mean additional travel distance shorter in urban counties (5.0 miles vs. 16.1 miles). Overall, 151 (of 301) patients were transported to a PSC while only 125 patients would have gone to a PSC if all had been transported to the closest hospital. Therefore, we found EMS bypass resulted in an additional 26 patients transported to a PSC. Further, EMS bypassed a closer non-PSC for a PSC in 36 cases while 10 patients were taken to a non-PSC instead of a closer PSC. Of these 10, the majority, 8, were transported based on patient or family choice. Our data suggest EMS bypass practices can increase access to specialized stroke care centers. Bypassing local hospitals appears to occur more frequently in urban areas where PSCs are more prevalent and in closer proximity. Yet, EMS bypass is not uncommon in rural areas of NC. EMS care, geographic location, and patient choice are all influential in determining a stroke patient's destination. Future studies should incorporate travel times in addressing access to timely stroke care.
Abstract P5: Outcomes of Acute Myocardial Infarction in Patients with Human Immunodeficiency Virus
Authors: Murugiah Karthik , Kumar Gagan
Published: July 2021

Background:
Acute Myocardial infarction (AMI) is common in patients with HIV. There is paucity of data on the outcomes AMI in patients with HIV.

Methods
Using the Nationwide Inpatient Sample (NIS) 2000-08, patients > 18 years, discharged with a primary diagnosis of AMI were identified through appropriate ICD-9-CM codes. Patients with HIV were similarly identified using the validated ICD-9 codes from the literature. Outcome variables were in-hospital mortality, length of stay (LOS) and likelihood of receiving coronary interventions.

Results
Of the 5,848,502 estimated adult discharges with AMI from 2000-2008, 14,045 had known HIV.

With HIV*
Without HIV
p value

Age (years)
50.31
67.67
0.0000

Male
83.4%
59.6%
0.0000

Smoking
40.4%
26.0%
0.0000

Diabetes
19.6%
29.7%
0.0000

Hypertension
51.4%
59.6%
0.0000

Hyperlipidemia
37.1%
40.7%
0.0004

LOS (in days)
4.94
5.36
0.000

In-hospital mortality
3.45%
6.24%
0.000

Thrombolysis
2.5%
2.8%
0.3769

PCI
42.2%
34.0%
0.0000

CABG
5.4%
8.3%
0.0000

Medical management
50.8%
55.9%
0.0000

Regression analyses:
Adjusting for age, sex, race, payer status, income quartile, hospital location (rural vs urban), hypertension, hyperlipidemia and modified charlson's co-morbidity index showed no difference in mortality (p=0.255) between the 2 groups but HIV was found to be an independent predictor of prolonged LOS (Coeff=0.198, p<0.000). Sub-group analyses found no difference in the adjusted mortality between patients with and without HIV who underwent thrombolysis (p=0.633), percutaneous coronary intervention (PCI) (p=0.617), coronary artery bypass grafting (CABG) (p=0.654) or were medically managed (p=0.358). In the adjusted analysis patients with HIV were more likely to be medically managed (OR 1.28, p<0.000) and less likely to receive PCI (OR 0.91, p=0.027) or CABG (OR 0.58, p<0.000).

Conclusion
Using nationally representative data this study shows that the in-hospital mortality of AMI in patients with HIV is similar to those without HIV, HIV is an independent predictor of increased LOS. Patients with HIV are less likely to receive coronary interventions.
Abstract P68: Effects of Health Services and Patient Characteristics on Length of Stay for Inpatients with Type 2 Diabetes and Myocardial Infarction
Authors: Okunji Priscilla O
Published: July 2021

This study is a database analysis of health services outcomes for diabetic myocardial infarction inpatients admitted in non federal hospitals. Relatively little or nothing is known about the outcomes of hospital inpatients with both MI (Myocardial Infarction) and T2D (Type 2 Diabetes). To evaluate the effects of patient and hospital characteristics on patient length of stay (LOS) in this population, we analyzed database for 2006 Health care Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) using the International Classification of Diseases, Ninth Revision (ICD-9) codes (41000, 410001, 410011 for MI) and (25000 for diabetes). Included in this study were patients with age ranged from 20years to 84years.The study used descriptive analysis, bi-variate and linear regression to identify the association of patient and hospital characteristics with the inpatient diabetic MI LOS. The study had sufficient power > .80. The statistical analysis showed that the older patients stayed longer in the hospital than their younger counterparts, F (4, 2548) = 5.936, p < .001. Females stayed longer days in the hospital than their male counterparts, X2 (1, N = 2773) = 187.02, p < .001. The adjusted dummy coded regression results on the effects of variables on LOS was significant for Hispanics (B = .809, p = .021) when compared to Whites. Other predictors are Medicare (B = 2.227, p < .001), private including HMO (B = .899, p < .001), and self pay (B = 1.059, p = .009) when compared to Medicare; urban hospitals (B = -1.031, p = .014) when compared to rural teaching status; Midwest (B = -1.681, p < .001) and West (B = -1.662, p = .001) hospital regions when compared to the hospitals in the Northeast region of the country. Further adjusted regression with comorbidities on LOS was significant for coronary atherosclerosis (B = -1.386, p < .001) and hypertension (B = -2.079, p < .001) when compared to T2D uncomplicated. Atrial fibrillation (B = 1.500, p = .011) and cardiogenic shock (B = -2.195, p = .003) were significant when compared to cardiac arrest. Diabetics are to be screened for complications on admissions. In conclusion, equity in care warrants serious considerations in the formulation of National policies and programs to improve the quality of health care of inpatients with MI and T2D.
Postdischarge Proton Pump Inhibitor and Clopidogrel Use Among Medicare ACS Patients with Percutaneous Coronary Intervention
Authors: Burton Tanya , Bae Jay , Kulakodlu Mahesh , Zhao Zhenxiang
Published: July 2021

Objectives:
A retrospective study examined post-discharge proton pump inhibitor (PPI) use with clopidogrel for Medicare patients hospitalized for ACS and treated with percutaneous coronary intervention (PCI).

Methods:
Claims from a large national US health plan were analyzed. Subjects were enrolled in Medicare Advantage with Part D prescription drug coverage (MAPD), >65 years old, had at least one inpatient hospitalization with a primary ACS diagnosis code between 1/1/2007 and 12/31/2008, and were treated with percutaneous coronary intervention (PCI). Excluded were patients with baseline stroke or TIA. Patients were followed up until death or 365 days post-discharge, whichever came first.

Results:
Of 1350 patients that met the inclusion criteria, 53.5% (722 of 1350) were ≥75 years old, 36.6% (494 of 1350) had diabetes comorbidity, and 6.9% (93 of 1350) had a prior myocardial infarction (MI). Of patients ≥ 75 years old, 37.8% (273 of 722) had either diabetes comorbidity or a prior MI. In the post-discharge period, 88.3% (1192 of 1350) had at least one clopidogrel fill and 33.1% (447 of 1350) had at least one PPI fill. Mean number of PPI claims was 6.1 (±4.3); mean number of clopidogrel fills was 8.3 (±4.1). Of patients with any PPI use, 87.9 % (393 of 447) were also on clopidogrel for an overlapping period of time. Average overlapping period was 161.1 (±114.7) days. The most common PPI fill was 47.7% (213 of 447) for omeprazol, followed by 31.1% (139 of 447) for pantoprazole, 21.0% (94 of 447) for esomeprazole, and 10.7% (48 of 447) for all others.

Conclusion:
Concomitant use of clopidogrel and PPI following hospital discharge for ACS-PCI was frequently observed in this managed Medicare population.
Abstract P88: Novel Tool Improves Cardiovascular Risk Stratification and Guides Therapy
Authors: Kashani Mariam D , Eliasson Arn H , Bailey Karla , Vernalis Marina N
Published: July 2021

Background:
Accurate risk assessment is of critical importance to any cardiovascular (CV) disease prevention program. Risk stratification tools enable providers to implement appropriate therapies.

Objective:
We sought to compare the performance of the Framingham Risk Score (FRS) with a CV Score previously validated by the Integrative Cardiac Health Project (ICHP) in a cohort of subjects with known subclinical atherosclerotic disease by abnormal carotid intima-media thickness (CIMT) measurement.

Methods:
Consecutive subjects (n=93) identified with subclinical atherosclerosis by abnormal CIMT (>75
th
percentile by age/gender) were enrolled in a 6-month CV risk reduction program. Subjects were assessed for past medical history, family history of CV events, anthropometrics and a cardiac-relevant lab panel. FRS and ICHP CV Risk Score were calculated for each individual and were compared. The ICHP CV Risk Score incorporates additional factors such as family history of CV events as well as novel risk factors. All scores were categorized as low, medium and high for CV risk.

Results:
In 93 consecutive subjects, mean age was 53.1±11.13 yrs, 59% women, 47% African-American, 46% Caucasian, 3% Latina, 1% other. Diagnosis of diabetes was present in 13% of subjects. Means: BMI=31.2±5.3 kg/m
2
, WC=100.2±13.6 cm, fasting glc=99.1±35.9 mg/dL, insulin 15.6±14.4 ug/dL, Tchol=194.9±42.3 mg/dL, LDL 114.5±34.0 mg/dL, HDL 56.2±18.5 mg/dL, TG 117.3±66.3 mg/dL, Lp(a)=86.5±92.3 mg/dL, CRP 0.4±0.6 mg/dL. By FRS, 12 (14%) subjects scored high risk, 11 (12%) scored medium and 70 (75%) scored low risk. By ICHP CV Risk Score, 4 (36%) of the FRS medium upscored to high risk and 47 (67%) of the FRS low upscored to medium risk. In total, 63% upscored to an appropriately higher risk category by using the ICHP CV Risk Score.

Conclusion:
In a population with documented subclinical atherosclerosis and unremarkable conventional risk factor profiles, the ICHP CV Risk Score appeared to be more sensitive in identifying subjects at risk. The ICHP CV Risk Score may be a more discerning tool to guide risk reduction therapy in a prevention program.
Abstract 107: Predictors and Frequency of ICD Implantation for Primary Prevention in ICD Eligible Patients: Results from a Prospective Multicenter Registry
Authors: Hachamovitch Rory , Nutter Benjamin , Cerqueira Manuel D ,   AdreView Myocardial Imaging for Risk Evaluation inHeart Failure investigators
Published: July 2021

Background
. The use of implantable cardiac defibrillators has been associated with improved survival in several well-defined patient (pt) subsets. Its utilization for primary prevention in eligible pts, however, is unclear. We sought to examine the frequency of ICD implantation (ICD-IMP) for primary prevention in a cohort prospectively enrolled in a prospective, multicenter registry of ICD candidates.

Methods
. We identified 961 pts enrolled in the AdreView Myocardial Imaging for Risk Evaluation in Heart Failure (ADMIRE-HF) study, a prospective, multicenter study evaluating the prognostic usefulness of 123I-mIBG scintigraphy in a heart failure population. Inclusion criteria limited patients to those meeting guideline criteria for ICD implantation; these criteria included left ventricular ejection fraction ≤35% and New York Heart Association functional class II-III. We excluded pts with an ICD at the time of enrollment, leaving a study cohort of 934 patients. Pts were followed up for 24 months after enrollment. Pts undergoing ICD-IMP after enrollment for secondary prevention were censored at the time of intervention. The association between ICD-IMP utilization and demographic, clinical, laboratory, and imaging data was examined using Cox proportional hazards analysis (CPH).

Results
. Of 934 pts, 196 (21%) were referred for ICD-IMP over a mean follow-up of 612±242 days. Implantations occurred 167±164 days after enrollment. Patients referred for ICD were younger (61±12 vs. 63±12), but did not differ with respect to proportion female (17% vs. 21%), African-American race (12% vs. 15%), diabetics (37% vs. 36%) (All p=NS). The frequency of ICD-IMP did not differ as a function of age, race, sex, LVEF, or imaging result (All p=NS). CPH revealed that a model including age, race, sex, diabetes, smoking, BMI, NYHA class, hypertension, heart failure etiology, and prior MI identified none of these as predictive of ICD-IMP.

Conclusion:
This analysis of prospective registry data reveals that in patients who are guideline-defined candidates for ICD-IMP, only about one in five receive an ICD over a two year follow-up interval. Multivariable modeling failed to identify any factor associated with ICD use.
Abstract 113: Technical Performance Scores as a quality assessment tool in Congenital Heart Surgery; preliminary analysis of validation data
Authors: Nathan Meena , Karamichalis John , Colan Steven , Liu Hua , Mayer John E , Pigula Frank A , Fynn-Thompson Francis , Emani Sitaram , Baird Christopher , del Nido Pedro J
Published: July 2021

BACKGROUND
: In previous work from our institution, individual practitioner technical performance of surgical procedures has been shown to be an important contributor to outcome and resource utilization in selected congenital cardiac operations. We have developed a Technical Scoring System for evaluation of majority of congenital cardiac procedures and wish to validate its efficacy as a self assessment tool for quality improvement.

METHODS
: All patients who were discharged between Jan 1 2011 and Dec 31, 2011 were included in this study. Based on discharge echocardiograms, a technical performance score was assigned using previously designed criteria. Case complexity was determined by RACHS-I category, postoperative adverse events and mortality were prospectively monitored. Outcomes were analyzed by non parametric methods.

RESULTS
: There were a total of 842 discharges encompassing all ages from neonates to adults. 560 (67%) were in RACHS-1 categories 1 to 3 (low risk) and 130 (15%) were in RACHS-1 categories 4 to 6 (high risk) and 152 (18%) could not be categorized. Technical performance scores were as follows: 436 (52%) class 1-optimal, 242(29%) class 2-adequate, 96 (115) class 3-inadequate, and 68(8%) could not classified. Occurrence of major adverse events, mortality and length of stay were all significantly higher in class 3.

CONCLUSION
: Preliminary data validates the usefulness of the technical scoring system as a quality assessment tool.
Abstract 122: Conflicts of Interest in Recent Cardiology Guidelines vs. Other Professional Society Statements
Authors: Vargas Alvaro , Mendelson Todd B , Caplan Arthur L , Meltzer Michele , Kirkpatrick James N
Published: July 2021

Background:
The Institute of Medicine (IOM) and the Council for Medical Subspecialty Societies (CMSS) recommended in 2010 that the majority of clinical practice guidelines (CPG) committee members be free of relevant conflicts of interest (COI). No such recommendation exists for other statements (expert consensus, practice management, appropriate use criteria, health policy and competence and training statements) produced by professional societies, and it is unclear whether there is a difference in the percentage of reported COI between these statements and CPG.

Methods:
We analyzed the recent AHA/ACCF guidelines and focused guideline updates, compared with other AHA/ACCF statements from 2010-2011. We catalogued the number and types of COI self-reported by participants, including chairpersons, authors/committee members and reviewers. Participation in production of one CPG or statement was considered a single episode. A COI was considered to be the report of an affiliation with one or more commercial entities by one individual in one episode. Affiliations with non-commercial entities (e.g. NIH) were excluded. COI were categorized according to type (research grant, honoraria/speaker’s bureau, consultant/advisory board, stock/other ownership, expert witness).

Results:
Disclosure information was available for 11 CPG and 17 other statements and comprised episodes by 834 individuals. The number of episodes per individual participant averaged 1.2 (range, 1- 7) for both CPG and for other statements. In a majority (51%, 579/1129) of the episodes, a COI was reported (54% of CPG and 51% of other statements). The most common form of COI was consultancy (32%, 370/1129), followed by research grant (30%, 339/1129), honoraria/speakers’ bureau (17%, 191/1129), institutional, organizational or other financial benefit (6%, 72/1129), stock/other ownership (5%, 55/1129), and expert witness (5%, 55/1129). Consultancy was reported in 37% (214/571) of episodes in CPG and 30% (156/558) in other documents. COI was reported by >50% of individuals for 7/11 of the CPG and 9/17 of other statements. The chairperson/first author reported COI in 4/11 of the CPG and 11/17 of other statements.

Conclusion:
There was no difference in commercial COI’s reported by participants in CPGs or other professional society statements. Consultancy and research grants were much more common than other forms of COI. More than half of cardiology CPG writers and reviewers and some of the chairpersons in 2010 and 2011 CPG report COI, despite the IOM and CMSS recommendations.
Abstract 132: Cost-Effectiveness of Stress Echocardiography and Long-Term Outcomes in Framingham Risk Score Stratified Patients with Non-anginal Chest Pain, Normal ECG and Normal Cardiac Biomarkers
Authors: Padala Arun , Ojha Chandra , Shea Micheal , Torosoff Mikhail
Published: July 2021

Background:
We investigated cost-effectiveness of stress echocardiography (SE) and long-term outcomes in Framingham risk score (FRS) stratified patients referred for stress testing after having presented with non-anginal chest pain, normal ECG, normal cardiac biomarkers.

Material and Methods:
Of 619 consecutive patients, 238 patients with complete dataset were divided into groups based on the interquartile range of the FRS (Table). Cost per CAD diagnosis was inferred based on post-test likelihood of CAD assuming accepted clinical practice of cardiac catheterization in patients with a SE demonstrating inducible ischemia. Long-term outcomes were ascertained using the Social Security Death Index and hospital records. Cause of death was identified in all but 3 patients. Chi-square test and analysis of variance were used to analyse categorical and continuous variables.

Results:
Study population consisted of 48% females, 52+/- 12 years old, 23% diabetics, and 40% current smokers. Intermediate and high FRS patients were more likely to develop ischemia by SE (4% vs. 9% in higher FRS, p<0.05, Table). When post-test likelihood of CAD was considered, four-fold higher relative value units (RVUs) per single case CAD diagnosis was needed in patients with low FRS (Table). No cardiovascular deaths were recorded during the mean follow-up of 60+/-12 months. While FRS≥0.216 was associated with 4-fold higher mortality, it was not affected by stress tests results. Most common causes of death were renal, pulmonary, and hepatic failure.

Conclusion:
In patients presenting with non-anginal chest pain, normal EKG and normal biomarkers, long-term follow-up suggests very low cardiovascular mortality. In this patient population further stratification by stress testing does not aid in predicting cardiovascular outcomes nor is it cost-efficient. For differences vs. CAD patients: p<0.05; †) p<0.01; ‡) p<0.005; §) p<0.001; blank - NS.
Abstract 135: Impact of Massachusetts Health Care Reform on the Risk of Hospitalization for Cardiovascular Ambulatory Care Sensitive Conditions.
Authors: McCormick Danny , Hanchate Amresh D , Kressin Nancy R , Lin Mengyun , D'Amore Meredith , Lasser Karen E
Published: July 2021

Research Objective:
Massachusetts (MA) health reform increased the number of insured residents, particularly among racial/ethnic minorities. Yet, it is not known if this insurance expansion translated into improvements or decreased racial/ethnic disparities in access to medical care. Ambulatory care sensitive conditions (ACSCs) such as congestive heart failure (CHF), hypertension and angina are a set of medical conditions for which good outpatient care can potentially prevent the need for hospitalization. Thus, we used changes in rates of hospitalization for these 3 ACSCs to assess potential changes in access to care following MA health care reform.

Methods:
Using complete data on acute care hospital admissions in MA and in two states that did not implement comprehensive health care reform, New York (NY) and Pennsylvania (PA), we identified all hospital admissions for cardiovascular ACSCs (CHF, angina and hypertension) during the 21 months preceding and following health reform implementation (7/1/2006-12/31/2007). Using US census population data we calculated pre- and post-reform age- and sex-standardized admission rates for the 3 ACSCs combined among patients 18-64 (those affected by reform). Treating MA as the intervention cohort, and NY and PA together as the control cohort we used multivariate Poisson regression models to conduct “difference-in-difference” analyses to estimate post-reform changes in admission rates in MA adjusted for contemporaneous changes occurring in control states. The models were also adjusted for age, gender and race. Using this approach, we also assessed whether health reform was associated with decreases in admission rates for racial and ethnic minorities compared with whites.

Principal Findings:
There were 84,286 hospital admissions for CHF, angina and hypertension combined in the pre- and post-reform periods in MA and 535,726 during the same time periods in control states. The hospital admission rate (number/100k population) for ACSCs declined in MA (128.7 to 121.7 [5.4%]) and in control states (232.2 to 208.4 [10.2%] from the pre- to post-reform period. When adjusted for secular trends in control states, age, gender and race, however, there was a 6.2% (95% CI, 2.9-9.6) increase in admissions in MA. After adjustment, there was no significant change in the admission rate for blacks compared with whites in MA (+3.7% [95% CI, -11.1 - 4.5]) or for Hispanics compared with whites in MA (+9.3% [95% CI, -18.2 - 0.6]).

Conclusions:
Hospital admissions for cardiovascular ACSCs did not decline in MA as a whole, or for minorities relative to whites, in comparison with 2 large control states that did not implement health reform. Additional insurance or health care system reforms in MA may be needed to decrease potentially avoidable hospitalizations and improve access to care.