bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P248: Glycemic Markers and Risk of Peripheral Artery Disease: The Atherosclerosis Risk in Communities (ARIC) Study
Authors: Ding Ning , Kwak Lucia , Ballew Shoshana , Jaar Bernard , Hoogeveen Ron C , Ballantyne Christie M , Sharrett Richey , Folsom Aaron , Heiss Gerardo , Coresh Josef , Hirsch Alan T , Selvin Elizabeth , Matsushita Kunihiro
Published: July 2021

Introduction:
Hemoglobin A1c (HbA1c) is a risk marker for incident peripheral artery disease (PAD). However, its relationship to critical limb ischemia (CLI), the most severe form of PAD, has not been fully characterized. Also, the prognostic value of non-traditional glycemic markers, glycated albumin, fructosamine, and 1,5-anhydroglucitol (1,5-AG) for PAD/CLI risk is unknown.

Hypotheses:
These glycemic markers will be particularly strongly associated with incident CLI, and non-traditional markers may provide additional information on PAD risk beyond HbA1c.

Methods:
We quantified the associations of four glycemic markers with PAD (hospitalizations with PAD diagnosis [ICD-9: 440.2-440.4] or leg revascularization [eg, 38.18]) in 11,797 ARIC participants free of a history of PAD at baseline (1990-92) using Cox models. Within these PAD cases, CLI was defined with an ICD code of ulcer, gangrene, or leg amputation. All markers were categorized into five groups according to diagnosed diabetes status and percentiles for clinical cut-points of HbA1c as in Table.

Results:
Over a median follow-up of 20.7 years, there were 397 cases of PAD (137 were CLI). Compared with the non-diabetic reference group, elevated glycemic marker levels (or reduced levels for 1-5AG) significantly contributed to increased risk of PAD (Table). The glycemic contribution was particularly strong for CLI events, with hazard ratios ranging 14-18 (vs. 6-8 for PAD, p for difference <0.001 in all glycemic markers) in diagnosed diabetes with their elevated levels (reduced for 1-5AG). The associations of non-traditional glycemic markers with PAD/CLI risk were strongly attenuated with further adjustment for HbA1c.

Conclusions:
Glycemic markers were significantly associated with PAD, particularly with its severe form, CLI, supporting the importance of glucose metabolism in the progression of PAD. Non-traditional glycemic markers provide similar (but not much additional) predictive value as HbA1c for classifying PAD risk.
Abstract P252: Duration and Life-stage of Antibiotic Use and Risk of Cardiovascular Disease in Women
Authors: Heianza Yoriko , Zheng Yan , Ma Wenjie , Wang Tiange , Sun Dianjianyi , Rimm Eric B , Albert Christine M , Hu Frank B , Rexrode Kathryn M , Manson JoAnn E , Qi Lu
Published: July 2021

Background and Aims:
Growing data suggest that antibiotic use, which may alter the gut microbiome, is related to risk of cardiovascular disease (CVD) and mortality. However, evidence from prospective cohort studies is still scarce; and no large prospective study has investigated associations between cumulative antibiotic use during adulthood and risk of CVD. We aimed to examine duration of antibiotic use and risk of CVD among apparently healthy women from the Nurses’ Health Study (NHS).

Methods:
This study included 36,922 women without history of myocardial infarction (MI), angina pectoris, stroke, or cancer in the NHS and with available data on total days of antibiotics use per year (0 to <15 days, 15 days to <2 months, or 2 months or more) during ages 20-39, 40-59 and after age 60, as reported on the 2004 questionnaire. Incidence of CVD (MI or stroke) over 8 years was assessed. Hazard ratios (HRs) were estimated as categories of duration of use compared with the none to <15 days per year group, using multivariate-adjusted Cox proportional hazards model including traditional risk factors (such as demographic variables, hypertension, diabetes, hypercholesterolemia, smoking, physical activity, Alternative Healthy Eating Index score, body mass index, aspirin, and anti-inflammatory medication), and reasons for antibiotics use (respiratory infection, urinary tract infections, acne or rosacea, chronic bronchitis, or dental), as well as other medications (such as H2 blockers, proton pump inhibitors), and other diseases (such as lung or kidney disease).

Results:
As compared to women with “none to <15 days per year of use” during age 40-59 y, those with a history of antibiotics use “15 days to < 2 months” or “2 months or more” had a significantly increased risk of CVD with an adjusted hazard ratio (HR [95%CI])_ of 1.19 (1.03, 1.38) and 1.34 (1.08, 1.66), respectively. Reported use of antibiotics for 2 months or more per year after age 60 was also associated with a HR of 1.24 (1.02, 1.51) for CVD. A longer exposure of antibiotics use was more strongly associated with increased risk of stroke than MI Antibiotic use during young adulthood (age 20-39) was not significantly associated with elevated risk of CVD.

Conclusions:
Our results suggest greater duration of exposure to antibiotics in middle- and older adulthood may be related to an increased risk of future CVD, independent of traditional risk factors.
Abstract P254: Willingness to Restart Statins: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study
Authors: Tajeu Gabriel S , Colantonio Lisandro D , Tanner Rikki M , Monda Keri L , Dent Ricardo , Farkouh Michael E , Taylor Benjamin , Rosenson Robert S , Safford Monika M , Muntner Paul
Published: July 2021

Introduction:
Many patients who discontinue statins due to side effects can restart treatment without the return of side effects. However, statin rechallenge is often met with resistance. Statins are associated with a larger absolute cardiovascular disease (CVD) risk reduction among high risk individuals, but it is unclear whether individuals with higher CVD risk are more willing to be rechallenged.

Methods:
Between 2014 and 2016, 12,604 participants in theREasons for Geographic and Racial Differences in Stroke study completed a study examination and a questionnaire about their experiences with statins. Of 6,947 participants who reported ever having taken a statin, this analysis included the 688 (9.9%) who reported having discontinued treatment due to side effects and who were not currently taking a statin. We asked participants whether they would be willing to restart a statin, and among those who answered no, we asked whether they were willing to restart at a lower dose or less frequently. Data from the study examination were used to define CVD risk factors and 10-year predicted CVD risk was calculated using the Pooled Cohort risk equations.

Results:
Participant mean age was 62.4 years, 29.6% were African American, and 66.4% were women. Overall, 26.0% (n=179) of participants were willing to be rechallenged with a statin
(Table)
. After adjustment for sociodemographic characteristics, older age, cigarette smoking, hypertension, diabetes, or history of CVD were not associated with an increased willingness to be rechallenged with a statin
(Table)
. Higher 10-year predicted CVD risk was also not associated with willingness to be rechallenged.

Conclusions:
Over a quarter of participants who discontinued statin treatment due to side effects were willing to be rechallenged. The presence of CVD risk factors and higher predicted CVD risk were not associated with increased willingness to be rechallenged with a statin.
Abstract P301: The Association of Physical Activity and Inflammation is Independent of Central Obesity in the Multi-Ethnic Study of Atherosclerosis
Authors: Vella Chantal A , Allison Matthew A , Cushman Mary , Jenny Nancy S , Miles Mary P , Larsen Britta , Lakoski Susan G , Michos Erin D , Blaha Michael J
Published: July 2021

Purpose:
Physical activity is associated with decreased adiposity-related inflammation in adults. Whether this association is independent of central obesity is unknown but important for understanding the mechanisms associated with reducing cardiometabolic disease risk through physical activity. This study examined whether associations of physical activity and obesity-related inflammatory markers were independent of central adiposity.

Methods:
Between 2002 and 2005, 1970 participants from the Multi-Ethnic Study of Atherosclerosis completed detailed health history and physical activity questionnaires, underwent physical measurements including computed tomography to quantify abdominal visceral and subcutaneous fat, and measurements of adiponectin, leptin, interleukin-6, tumor necrosis factor-alpha, and resistin. Statistical analyses included analysis of covariance and multivariable-adjusted regression.

Results:
The mean (range) age of participants was 64.7 (55-84) years and 50% were female. After adjustment for age and sex, and compared to the lowest quartile, inflammatory markers in the highest quartile of moderate-to-vigorous physical activity were 16% higher for adiponectin and 30%, 26% and 9% lower for leptin, interleukin-6, and resistin, respectively (p<0.05 for all). In linear regression adjusted for demographics, dyslipidemia, hypertension, diabetes, smoking, glomerular filtration rate, renin and aldosterone, each standard deviation increment of moderate-to-vigorous physical activity was associated with significantly higher levels of adiponectin (β=0.04) and lower levels of leptin (β=-0.06), interleukin-6 (β=-0.08), and resistin (β=-0.05, p<0.05 for all). The associations with leptin, interleukin-6, and resistin were independent of total and central adiposity (p<0.05), whereas the association between moderate-to-vigorous physical activity and adiponectin was attenuated by central adiposity (p>0.05). There were no significant interactions by race/ethnicity or sex.

Conclusions:
Moderate-to-vigorous physical activity was associated with a more favorable profile of inflammatory markers, independent of relevant cardiometabolic disease risk factors including central obesity.
Abstract P307: Associations Between Physical Activity and Cardiac Functional Measures Assessed by Echocardiography: Echocardiographic Study of Latinos (ECHO-SOL)
Authors: Ponce Sonia , Upadhya Bharathi , Kapplan Robert , Swett Katrina , Allison Mathew , Stacy Richard , Qi Qibin , DeMaria Anthony , Schneiderman Neil , Hurwitz Barry , Daviglus Martha , Kansal Mayank , Evenson Kelly , Rodriguez Carlos
Published: July 2021

Introduction:
Physical activity (PA) is associated with cardiovascular health benefits including prevention of age related cardiac remodeling, systolic and diastolic dysfunction, and adaptive pro-hypertrophic effect. In this study we aim to measure the associations between PA and LV structure and function in a diverse Hispanic/Latino population.

Methods:
Participants included 1,818 self-identified Hispanic/Latino men and women, age 45-74 from the Echocardiographic Study of Latinos (ECHO-SOL). Standard echo measures included M-mode, two-dimensional (2-D), spectral, tissue Doppler and color flow. Participants wore an Actical hip accelerometer for 1 week. Multivariable regression models were completed to relate PA to echocardiographic parameters.

Results:
The mean ± SE age for the cohort was 56 ±0.4, 57% were female, the prevalence of diabetes was 28%, hypertension 50%, hypercholesterolemia 49%, and coronary heart disease 7%. Average moderate to vigorous PA (MVPA) was 20.9 ± 1.1 min/day and sedentary time ±SE was 736.5 ± 8.1 min/day. In multivariable models adjusted for age, gender, diabetes, hypertension, hypercholesterolemia, coronary heart disease, alcohol and cigarette use we found the following: left atrium volume index (LAVI) decrease by quartiles of MVPA (p-value<0.001). Global circumferential strain (GCS) decreased across these quartiles of MVPA. Moreover, LAVI decreased by 0.3 per 100 min/day of sedentary time (p-value<0.01) and GCS also decreased across quartiles of sedentary time.

Conclusion:
MVPA was significantly associated with lower LAVI. There was also a significant association with sedentary behavior. Our findings illustrate the complex relationship between PA, sedentary time and cardiac structure and function.
Abstract P312: High State and Trait Hopelessness Levels Predict Lower Home-based Exercise Participation in Patients With Coronary Heart Disease
Authors: Dunn Susan L , Dunn L M , Buursma Madison P , DeVon Holli A , Vander Berg Lucas , Tintle Nathan L
Published: July 2021

Introduction:
Hopelessness is associated with increased adverse events and decreased survival in patients with coronary heart disease (CHD). Hopelessness can persist in these patients and reduce their participation in hospital-based cardiac rehabilitation (CR) exercise following an acute event. Because the majority of CHD patients do not attend a hospital-based CR exercise program, examination of factors affecting home exercise is needed. The purpose of this study was to describe the impact of hopelessness levels on both home- and hospital based CR exercise participation in patients with CHD.

Hypothesis:
It was hypothesized that higher state and trait hopelessness levels would adversely affect both home- and hospital-based CR exercise participation.

Methods:
The Theory of Hopelessness Depression was used as a foundation for study aims. Using a descriptive, longitudinal design, 282 patients who had been hospitalized with a CHD event were asked to complete the State-Trait Hopelessness Scale (STHS) during their hospitalization and the STHS and the Cardiac Rehabilitation Exercise Participation Questionnaire at 3, 8, and 12 months after hospital discharge. Patients who provided data at any two concurrent time points over the year were included in the analyses. Regular exercise was defined as walking or biking ≥3 days/week in a home- or hospital-based Phase II CR exercise program. Logistic regression was used to evaluate the relationship between STHS scores on the likelihood that patients would participate in regular exercise in home- or hospital-based Phase II CR settings.

Results:
Patients were predominantly male (64.9%) with a mean age of 65.4±9.7 years. Patients had persistent, modest levels of state and trait hopelessness across all time points. High levels of state and trait hopelessness were predictive of lower home-based exercise participation (state: OR 0.4, 95% CI [0.1, 0.7], p=0.002; trait: OR 0.4, 95% CI [0.2, 0.8], p=0.01) but not hospital-based Phase II CR exercise, after adjusting for age and sex.

Conclusions:
These findings demonstrate the importance of assessing hopelessness in patients with CHD and provide critical evidence of the need for clinicians to encourage CHD patients who are feeling hopeless to participate in CR exercise, particularly in the home setting.
Abstract P317: Area Traffic Density Contributes to the Risk of Gestational Diabetes in a Sample of Central Ohio Pregnancies
Authors: Bollinger Claire E , Patel Sejal , Hood Darryl B , Bower Julie K
Published: July 2021

Background:
The prevalence of gestational diabetes mellitus (GDM) in the US and the state of Ohio is approximately 9.0%. GDM is associated with increased risks for mother and child, including macrosomia, preterm birth, preeclampsia, and development of type 2 diabetes. In addition to known risk factors, the role of exposure to environmental pollutants in development of GDM warrants further investigation. Because exposure to traffic-related pollutants has been shown to influence the development of type 2 diabetes, we assessed the contribution of exposure to high traffic to the development of GDM during pregnancy among women without prior diabetes history.

Methods:
A population of 275 pregnant women in Ohio reported perceived exposure to high traffic areas and health behaviors. Clinical information and addresses were obtained through their electronic health records. Using ArcMap
TM
10.2.2 (ESRI), addresses were geocoded to assess individual exposures, and linked with area exposures and demographic indicators at the level of the census block group from EJScreen (EPA). A woman was classified as “near” a major roadway if one fell within a 500m buffer of her home. Distance to nearest major roadway was also calculated. Logistic regression was used to examine the association between quintiles of traffic exposure at the census block group level, self-reported proximity, individual-level proximity, health behaviors, and demographic factors with development of GDM. Because assessment of individual-level exposures may be difficult to use in clinical and large scale population settings, a model was also fit using only data publically available from EJScreen and self-report.

Results:
The prevalence of GDM was 8.0% (22/275) and distribution of demographics factors were similar between those with and without GDM. After adjustment for potential confounders, quintile of traffic exposure was significantly associated with development of GDM (p=.036). Compared to those residing in block groups in the lowest quintile, the odds of GDM for those in the second quintile were 8.1 times greater [95% CI 1.2, 56.3] and for those in fourth quintile were 10.4 times greater [95% CI 1.6, 67.6]. Addition of individual-level proximity factors did not significantly improve the model (p=.08).

Conclusions:
This study suggests that living in an area with high traffic density contributes to the risk of developing GDM. For both the clinical practitioner and public health researcher it is difficult or impractical to obtain individual level environmental exposure data. From our analysis, the individually calculated exposure proxies did not significantly improve the fit of the model. We suggest examining ways to combine self-report measures with existing environmental data, such as EJScreen, to identify populations at elevated risk.
Abstract P333: Homelessness is an Independent Risk Factor for Cardiovascular Disease Hospital Readmission in the California Health Care Utilization Project
Authors: Shalen Evan F , Nah Gregory , Vittinghoff Eric , Tseng Zian H , Marcus Gregory M , Albert Michelle A , Parikh Nisha I
Published: July 2021

Introduction:
Persons who experience homelessness have been shown to have a high prevalence of cardiovascular risk factors, and high incidence of cardiovascular mortality, however little is known about the outcomes of patients experiencing comorbid homelessness and recurrent CVD admissions. We sought to study the effects of homelessness on CVD readmission in California.

Methods:
We identified all patients admitted with a primary diagnosis of CVD (including ischemic heart disease, stroke and heart failure) in the HCUP California database between 2005 and 2009. Homelessness was defined using an HCUP indicator variable. We used multivariable Cox proportional hazards model to determine risk of readmission for potential sociodemographic and clinical confounder variables
(see Table).

Results:
There were 2,889 hospital admissions for CVD in patients who were identified as homeless during the baseline period (by means of a homelessness indicator). Of those, there were 928 hospital readmissions (median time to readmission=39 days). When adjusted for clinical and lifestyle factors (see Table), homelessness independently predicted recurrent CVD [HR of 1.44 (95% CI, 1.36-1.52)].

Conclusions:
In HCUP CA, homelessness independently predicted CVD readmission. Our findings suggest a potential need for development and study of interventions to improve post-hospital management of CVD in patients experiencing homelessness.
Abstract P341: Community Environment Associated with Cardiovascular Disease Hospitalization Rates in Denver, Colorado
Authors: Rooks Ronica N , DeYoung Kathryn , Shekiro Emery , Havranek Edward , Davidson Arthur
Published: July 2021

Introduction:
Hospitalization rates for acute myocardial infarction (AMI), coronary heart disease (CHD), and stroke have decreased over time, although trends are debatable for heart failure (HF). These trends are unequally distributed. There is a growing literature documenting the relationship between social and economic characteristics of people’s communities and cardiovascular disease (CVD). Based on a social ecological model of health through the life course, we descriptively examined associations between CVD hospitalization rates and patient characteristics and census tract (CT)-level community environment.

Hypothesis:
CVD hospitalization rates will be higher in community environments with higher percentages of individuals living below the federal poverty level, racial/ethnic minority groups, and non-residential (i.e., commercial/office, industrial, open space, public/civic, vacant, and miscellaneous space) vs. residential land use.

Methods:
Colorado Hospital Association (2009-2013) data were used to measure ICD-9 coded hospitalization rates (per 1,000) for Denver, Colorado residents ≥20 years. Data were merged with American Community Survey (2009-2013) and Denver County land use (2010) data. Using chi-square analysis, we examined associations between age-adjusted CVD hospitalization rates (N=15,521) and CT-level community environment (in quartiles) (N=144).

Results:
Denver’s annual CVD hospitalization rate was 6.6. Patient-level AMI (1.7), CHD (2.8), and HF (2.2) rates were higher among men. Women had higher stroke-related rates (2.4). Across CVD types, rates for those ≥65 years (6.5-13.5) were higher than middle-aged groups (2.1-3.4). Average annual age-adjusted AMI hospitalization rates were higher in CTs with the highest quartile of Hispanic Americans (2.0), Native Americans (1.9), and individuals below poverty (1.9). CHD rates were higher in CTs with higher percentages of Hispanic Americans (3.1), individuals below poverty (3.1), and Native Americans (3.1). HF rates were higher in CTs with higher percentages of industrial/office land use (3.5), individuals below poverty (3.3), and Hispanic Americans (3.2). Stroke rates were higher in CTs with higher percentages of Native Americans (3.0), industrial/office land use (3.0), and African Americans (3.0). The largest disparities for rate ratios comparing the highest to the lowest quartiles for each exposure by CVD outcome were the percentage of individuals below poverty (AMI 2.2; CHD 2.1; HF 2.4; Stroke 1.7), non-Hispanic Whites (AMI 0.7; CHD 0.7; HF 0.7; Stroke 0.7), Hispanic Americans (AMI 1.5; CHD 1.5; HF 1.5), and Native Americans (Stroke 1.30).

Conclusions:
In conclusion, associations exist between community environment and CVD hospitalization rates, suggesting opportunities for health policy development in Denver’s city government, council districts, and neighborhoods
.
Abstract P345: A Cross Sectional Analysis of High Depressive Symptoms and Antidepressants on Heart Rate Parameters in the Community. The Paris Prospective Study III
Authors: Laï Marie-Caroline , Boutouyrie Pierre , Tafflet Muriel , Tomas Frédérique , Guibout Catherine , Périer Marie-Cécile , Pannier Bruno , Jouven Xavier , Empana Jean-Philippe
Published: July 2021

Background:
Dysautonomy has been suggested to be a mechanism contributing to the well-established association between high depressive symptoms (HDS) and cardiovascular disease (CVD). So far however, at the population level, this question has been addressed using parameters of complex interpretation that are rarely used in the clinical setting. The aim of this study was to quantify the respective association of HDS and antidepressants (ATD) on different heart rate parameters of simple investigation.

Methods:
The Paris Prospective Study III included subjects recruited in a large health preventive centre in Paris (France) between 2008 and 2012. Four heart rate parameters were measured including resting heart rate (RHR), heart rate immediately after moderate effort (EHR), differences between EHR and RHR, and RR interval. A total score ≥ 7 on a 13-item standardized questionnaire defined the presence of HDS. Information on classes of ATD was obtained on a face-to-face interview with a medical doctor. The association between HDS or ATD and each of the 4 heart rate parameters were quantified in separate linear regression analysis adjusted for age, sex, body mass index, physical activity, personal history of CVD, smoking, diabetes, high blood pressure and beta blockers. To minimize indication bias, the analysis on ATD was adjusted for the propensity score of receiving ATD.

Results:
The mean age of the 8430 participants was 59.6 years and 39% were women. HDS were noted in 473 subjects and 383 participants were on ATD: 58 on Tricyclics, 232 on Serotonin Specific Reuptake Inhibitor (SSRI) and 80 on Serotonin Norepinephrine Reuptake Inhibitors (NSRI) respectively. Beta-blockers were used by 4.2% of the participants and only 2.1% had a personal history of cardiovascular disease. HDS were associated with slightly higher RHR (+0.9 beats per minute (bpm), p<0.05) and lower RR interval (-21.1 ms, p<0.05). ATD of any class were related to lower RR interval (-22.3 ms, p=0.007), higher EHR (+1.7 bpm, p=0.02) and higher difference between EHR and RHR (+1.5 bpm, p=0.009). While tricyclics and NSRI were both associated with significantly higher RHR (+7.0 and +2.64 bpm respectively, p<0.05), higher EHR (+6.79 and +6.94 bpm respectively, p<0.001), higher difference between EHR and RHR (+2.74, p=0.06 and +5.70, p<0.001 respectively) and lower RR interval (-98.50 ms and -50.63 ms respectively, p<0.001), SSRI was related to lower RHR (-1.81 bpm, p<0.05) and almost significantly higher RR interval (+18.61 ms, p=0.08). Neither sex nor beta-blockers modified these associations. Consistent findings were observed when other propensity score methods were used.

Conclusions:
Our study suggests that ATD more than HDS are associated with dysautonomy as evaluated by simple and routinely used heart rate parameters.
Abstract P359: Difficulty Falling Asleep is Predictive of Metabolic Syndrome
Authors: Petrov Megan E , Zautra Alex J , Hoffmann Nicole , Davis Mary C
Published: July 2021

Introduction:
Insomnia symptoms are associated with cardiovascular disease and multiple metabolic syndrome components, yet few studies have investigated their association with metabolic syndrome.

Hypothesis:
Insomnia symptoms will be significantly associated with prevalent metabolic syndrome.

Methods:
Middle-aged, community-dwelling adults, ages 40-65 yrs, were recruited to participate in a study on healthy aging. All participants completed questionnaires on demographics, medical history, and sleep patterns in the past month including estimated sleep-onset latency, frequency of difficulty falling asleep, and severity of difficulty falling asleep, difficulty maintaining sleep, and early morning awakenings. Measurements for metabolic syndrome were collected at a home health visit. All metabolic syndrome criteria consisting of waist circumference, triglyceride level, HDL cholesterol level, blood pressure, and fasting glucose were identified using the American Heart Association definitions. Participants with three or more positive criteria were considered to have metabolic syndrome. Of a total sample of 770 individuals, 557 participants who did not have a history of cardiovascular events (n = 62), and had complete sleep and metabolic syndrome data were included in the analysis. We conducted logistic regression models predicting presence of metabolic syndrome from the sleep measures adjusting for age, sex, race, education level, smoking status, alcohol consumption, moderate physical activity minutes per week, and current major depression diagnosis.

Results:
Metabolic syndrome was prevalent in 24.2% of the sample (n = 135). Sleep onset latency of greater than 30 minutes and difficulty falling asleep three or more nights per week were significantly related to metabolic syndrome, but no other insomnia symptoms were related (see Table).

Conclusions:
Difficulty falling asleep, a marker of physiological and emotional hyperarousal, may be a modifiable risk factor for metabolic syndrome.
Abstract 1: The Impact of State Medicaid Expansions on Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure
Authors: Wadhera Rishi K , Joynt Maddox Karen E , Fonarow Gregg C , Zhao Xin , Heidenreich Paul A , DeVore Adam D , Matsouaka Roland , Hernandez Adrian F , Yancy Clyde W , Bhatt Deepak L
Published: July 2021

Background:
Heart failure (HF) is the leading cause of morbidity and mortality in the United States. Despite considerable advancement in the management of HF, outcomes remain suboptimal, particularly among the uninsured. In 2014, the ACA expanded Medicaid eligibility, and millions of low-income, non-elderly adults gained insurance coverage in 32 states. Little is known about Medicaid expansion’s effect on quality and outcomes of inpatient care for HF.

Methods:
We used the American Heart Association’s Get With The Guidelines-HF registry to assess changes in inpatient care quality and outcomes among low income, non-elderly patients hospitalized for HF prior to and following Medicaid expansion, in expansion and non-expansion states. Patients were classified as low income if covered by Medicaid, uninsured, or missing insurance. We considered expansion states to be those that implemented expansions in 2014. We constructed piecewise logistic multivariable regression models to track quarterly trends over time of quality and outcome measures in the pre-expansion (1/1/2010-12/31/2013) and post-expansion (1/1/14 - 6/30/17) periods, by state expansion status.

Results:
The cohort included 58,804 patients hospitalized across 391 sites - 53% were covered by Medicaid, 21.3% uninsured, and 25.6% missing insurance. Among expansion states, defect-free HF care increased significantly during the pre-expansion period (aOR 1.06, 95% CI 1.03-1.08) but did not change after expansion (aOR 0.99, 95% CI 0.97-1.02). Similarly, other quality measures, such as use of aldosterone antagonists, evidence-based beta blockers, and ICD implantation significantly increased prior to expansion, but did not change following expansion (Table). In-hospital mortality rates remained similar during the pre-expansion (aOR 0.99, 95% CI 0.96-1.02) and post-expansion periods (aOR 1.00, 95% CI 0.97-1.03). Trends in quality and outcome measures for non-expansion states are also shown in the table.

Conclusion:
The ACA Medicaid state expansions were not associated with improvements in quality of care or in-hospital mortality in expansion states among sites participating in a national quality improvement initiative. Future investigation should evaluate the long-term impact of expansion on HF care during the post-discharge period.
Abstract 111: Depression as a Risk Factor for Incident Ischemic Stroke Among HIV-infected Veterans
Authors: Sico Jason J , Kundu Suman , So-Armah Kaku , Gupta Samir , Chang Joyce , Freiberg Matthew , Stewart Jesse
Published: July 2021

Background:
HIV infection (HIV+) and major depressive disorder (MDD) are each associated with an increased risk of ischemic stroke. While depressive disorders are common among HIV+ people, it is not known if MDD is a risk factor for ischemic stroke in the HIV population.

Methods and Results:
We analyzed data on 106,363 (33,544 HIV+; 72,819 HIV-) participants who were free of baseline cardiovascular disease from the Veterans Aging Cohort Study, an observational cohort of HIV+ and matched uninfected veterans in care from April 1
st
, 2003 through September 30, 2012. International Classification of Diseases, Ninth Revision codes from medical records were used to determine baseline MDD and the primary outcome, incident ischemic stroke. The prevalence of MDD was similar for HIV+ and HIV- veterans (20.0% and 18.8%, respectively). After a median of 9.2 years of follow-up, stroke rates per 1000 person-years were highest among HIV+/MDD+ veterans (5.8; 95% CI:5.2-6.5), followed by HIV+/MDD- veterans (5.3; 95% CI:5.0-5.6), HIV-/MDD+ (5.1; 95% CI: 4.7-5.5), and HIV-/MDD- (4.8; 95% CI: 4.6-5.0). In Cox proportional hazard models, MDD was associated with an increased risk of ischemic stroke for both HIV+ and HIV- veterans, even after adjusting for sociodemographic adjusting for sociodemographic characteristics and cerebrovascular risk factors (Table). The risk persisted among HIV+ people after further adjusting for HIV factors (Table). These associations were modestly attenuated with the addition of cocaine and alcohol abuse/dependence.

Conclusions:
In the VACS, MDD was associated with an increased risk of ischemic stroke in HIV+ veterans after adjustment for sociodemographic characteristics, traditional cerebrovascular risk factors, and HIV factors; however, this association was modestly attenuated after adjustment for cocaine and alcohol abuse/dependence. Future research is necessary to: (a) fully elucidate the relationships among MDD, cocaine/alcohol use, and stroke risk and (b) determine whether intervening on MDD reduces stroke risk in HIV+ and HIV- people. Clinical providers should be aware of the increased stroke risk among HIV+ adults with MDD.
Abstract 135: Extended Thromboprophylaxis With Betrixaban is Cost-effective in Acutely Ill Medical Patients
Authors: Wei Huang , Anderson Frederick A , Bucior Iwona , Neuman W Richey , Cohen Alexander T
Published: July 2021

Objectives:
The APEX trial demonstrated that prophylaxis of venous thromboembolism (VTE) with betrixaban from hospital admission through post-discharge (35-42 days) in acutely ill medical patients reduced VTE events, including symptomatic VTEs, without significant increase in major bleeding versus standard-duration prophylaxis (6-14 days) with enoxaparin. Based on these data, betrixaban has been approved by the FDA for prophylaxis of VTE in adult patients hospitalized for an acute medical illness who are at risk for thromboembolic complications. Here, we analyzed the cost-effectiveness of this new thromboprophylaxis regimen with betrixaban versus standard-duration thromboprophylaxis with enoxaparin.

Methods:
We adopted our previously published decision-tree model to compare two thromboprophylaxis strategies from a US health care provider perspective among a hypothetical cohort of 10,000 acutely ill medical patients who are at risk of VTE: betrixaban (160 mg loading dose followed by 80 mg once daily for 35 days; $396) versus enoxaparin (40 mg daily for 9 days; $284). To estimate VTE-related deaths within 35 days that might have been averted by thromboprophylaxis, the model incorporated a clinical care path, including primary and secondary VTE prophylaxis as well as treatment of thromboprophylaxis-related adverse events. Parameter values and costs were estimated for each node in the decision tree based on publically available health data. All costs were converted to 2017 USD based on the US medical care consumer index.

Results:
For the base-case scenario, among a hypothetical cohort of 10,000 acutely ill medical patients at increased VTE risk, betrixaban was estimated to reduce risk of death by 0.16% and save nearly $1.8M (or $178.27 per patient treated). One-way sensitivity analyses indicated that betrixaban would dominate enoxaparin assuming: a) the cost of 35-day betrixaban was <$15.94 per dose (<$574 per 36 doses); b) the clinically relevant recognized bleeding rate was ≤3.8% or c) the VTE rate was ≤7.2%.

Conclusions:
Based on the rates of clinical events reported in the APEX study, extended-duration thromboprophylaxis with betrixaban from hospital admission through post-discharge in acutely ill medical patients is likely to prevent additional deaths and reduce costs compared with standard-duration thromboprophylaxis with enoxaparin.
Abstract 149: Care for Heart Failure Patients at the End of Life: Hospital Readmission and Mortality Amongst Heart Failure Patients Discharged to Hospice
Authors: Warraich Haider J , Devore Adam , Xu Haolin , Matsouaka Roland , Heidenreich Paul , Bhatt Deepak , Hernandez Adrian , Yancy Clyde , Fonarow Gregg , Allen Larry
Published: July 2021

Background:
While 1 in 10 patients hospitalized with heart failure (HF) die within 30 days, end-of-life care for this high-risk population is not well described.

Methods:
We analyzed patients discharged alive from the Get With The Guidelines-HF registry between 2005-2014, linked to Medicare claims. We compared patients discharged to hospice to non-hospice “advanced HF” patients (ejection fraction ≤25% and either on inotropes, sodium ≤130, blood urea nitrogen ≥45 mg/dL, systolic blood pressure ≤90 mmHg or comfort measures) and to other GWTG-HF patients.

Results:
Of 121,990 US patients, hospice patients (n=4588, 2164 facility-based, 2424 home hospice) compared with advanced HF (n=4357) and others (113,045) were older (median age 86 years vs 78 years vs 81 years), more likely white race (88% vs 80% vs 82%), have intravenous loop diuretics used (74% vs 57% vs 63%), have an advanced care plan/surrogate decision maker discussed or documented (76% vs 62% vs 66%), had more dyspnea at rest (55% vs 46% vs 48%) and worse/unchanged symptoms at discharge (35% vs 2% vs 1%) (all p<0.01). Discharge to hospice increased from 2% (n=109) in 2005 to 5% (n=968) in 2014. Median survival in hospice was 11 days (25
th
, 75
th
percentile: 3, 65 days) compared with advanced HF (318 days) and others (754 days); 34% of patients discharged to a hospice facility and 12% to home hospice died in <3 days. (Figure) Median survival in hospice did not change significantly from 2005 to 2014. Hospital readmission at 30 days was 4% among hospice, 27% for advanced HF, and 22% for others. Median hospice discharge rate was 3.0 (0.7, 5.5). Hospice discharges had lower adjusted hazards of all-cause readmission (hospice compared with others: advanced HF odd ratio (OR) 0.15 (95% confidence interval (CI) 0.13-0.18), others OR 0.15 (95% CI 0.13-0.18). Hospice patients also had lower 6-month and 1-year readmission rate. Non-white race (OR 1.59 [95% CI 1.18-2.17]) and younger age (OR per 5 years 1.18 [95% CI 1.10-1.27)] were the strongest predictors of readmission from hospice.

Conclusion:
Hospice use in patients hospitalized with HF is limited but increasing. Few hospice patients are rehospitalized and almost a quarter die within 3 days of discharge. These findings may inform interventions to improve hospice care for HF patients.
Abstract 150: Care for Heart Failure Patients at the End of Life: Hospital Readmission and Mortality Amongst Heart Failure Patients Discharged to Hospice
Authors: Warraich Haider J , DeVore Adam , Xu Haolin , Matsouaka Roland , Heidenreich Paul , Bhatt Deepak , Hernandez Adrian , Yancy Clyde , Fonarow Gregg , Allen Larry
Published: July 2021

Background:
While 1 in 10 patients hospitalized with heart failure (HF) die within 30 days, end-of-life care for this high-risk population is not well described.

Methods:
We analyzed patients discharged alive from the Get With The Guidelines-HF registry between 2005-2014, linked to Medicare claims. We compared patients discharged to hospice to non-hospice “advanced HF” patients (ejection fraction ≤25% and either on inotropes, sodium ≤130, blood urea nitrogen ≥45 mg/dL, systolic blood pressure ≤90 mmHg or comfort measures) and to other GWTG-HF patients.

Results:
Of 121,990 US patients, hospice patients (n=4588, 2164 facility-based, 2424 home hospice) compared with advanced HF (n=4357) and others (113,045) were older (median age 86 years vs 78 years vs 81 years), more likely white race (88% vs 80% vs 82%), have intravenous loop diuretics used (74% vs 57% vs 63%), have an advanced care plan/surrogate decision maker discussed or documented (76% vs 62% vs 66%), had more dyspnea at rest (55% vs 46% vs 48%) and worse/unchanged symptoms at discharge (35% vs 2% vs 1%) (all p<0.01). Discharge to hospice increased from 2% (n=109) in 2005 to 5% (n=968) in 2014. Median survival in hospice was 11 days (25
th
, 75
th
percentile: 3, 65 days) compared with advanced HF (318 days) and others (754 days); 34% of patients discharged to a hospice facility and 12% to home hospice died in <3 days. (Figure) Median survival in hospice did not change significantly from 2005 to 2014. Hospital readmission at 30 days was 4% among hospice, 27% for advanced HF, and 22% for others. Median per-hospital hospice discharge rate over the study perior was 3% (1%, 6%). Hospice discharges had lower adjusted hazards of all-cause readmission (hospice compared with others: advanced HF odd ratio (OR) 0.15 (95% confidence interval (CI) 0.13-0.18), others OR 0.15 (95% CI 0.13-0.18). Hospice patients also had lower 6-month and 1-year readmission rate. Non-white race (OR 1.59 [95% CI 1.18-2.17]) and younger age (OR per 5 years 1.18 [95% CI 1.10-1.27)] were the strongest predictors of readmission from hospice.

Conclusion:
Hospice use in patients hospitalized with HF is limited but increasing. Few hospice patients are rehospitalized and almost a quarter die within 3 days of discharge. These findings may inform interventions to improve hospice care for HF patients.
Abstract 180: Some Like it Hot; Radiation Safety in the Catheterization Lab
Authors: Lawson William E , Wilbert Lisa , Gulino Kathie , Liakos Matthew , Mani Anil , Kostic Pamela , Pyo Robert
Published: July 2021

Objective:
Ionizing radiation is an unseen and often unappreciated safety concern for patients and cath lab staff. Radiation exposure has both deterministic and stochastic effects, with patient risk estimated by peak Skin Dose and Air kerma Area product. In our lab exposure guidelines have been set for radiation safety (fluoro time < 60 min, 4,000 mGray and 20,000 cGray cm
2
). A prior audit of practice 2011-2013 found that 17.1% (758/4,439) of patients undergoing interventional procedures exceeded these limits. Safer radiation practices were implemented including: intra procedure operator feedback, decrease in cine frame rate and run length, promote mapping and less angled views. However changing patient characteristics (increased obesity, prior CABG) and an increase in structural procedures warrant reexamination of practice.

Procedure:
The frequency of guideline excessive radiation exposure for cardiac cath lab patients was tracked over a 12 month period from 11/2016-11/2017. The frequency of radiation exposure exceeding our guidelines was tracked overall and by operator (16), and by specific intervention.

Results:
Over the one year period 10.2% of interventions [174/1,702] received excessive skin or total body radiation. Rates exceeding guidelines by operator ranged from 4% to 26% with operators performing structural or peripheral procedures having the highest patient radiation exposures. Structural procedures resulted in exposures as high as 123 min fluoro time, TAD of 226,385 cGray cm2, 11,129 mGray skin dose [patient had post procedure skin damage]. Factors associated with high radiation exposures included: increasing obesity, prior surgical revascularization, coronary anomalies, multivessel procedure or high complexity procedure, difficulties in imaging requiring highly angled or multiple views, procedural complications. Interventions associated with limiting exposure included: limiting fellow participation, decrease in frame rate, interim stills with limited cine runs. The default settings of X-Ray equipment have been modified to encourage safe and appropriate use of radiation in the cardiac catheterization lab (however, physician overide of settings is still possible).

Conclusions:
The changes made in imaging equipment and procedures 5 years ago have been largely sustained and have resulted in less frequent radiation outliers. Patient factors (e.g. obesity, prior CABG) complex and multivessel interventions, structural and vascular procedures are potentially frequently associated with excess radiation. Changing default settings and implementing radiation safety practices, including staging where appropriate, can significantly decrease radiation exposure to patients and staff. Cumulative and target organ specific patient doses of radiation should be tracked and more readily accessible in the patient’s medical record.
Abstract 194: Real-time Outcomes Analysis Dashboard: ROAD Map
Authors: Hancock Friesen Camille L , Unberhagen Keri , Boswell Patrick , Boswell Patrick , Jaquiss Robert D
Published: July 2021

Background:
Surveillance of risk-adjusted pediatric cardiac surgery outcomes has moved beyond mortality to complications. We report a novel dashboard that provides for real-time graphic presentation of risk-adjusted complications to ensure that program performance is maintained and to identify areas for improvement.

Methods and Materials:
This was a single center study, performed at a medium volume program after IRB approval. Data were collected on consecutive patients over a one-year period (Oct 4, 2016- Oct 3, 2017) coincident with the restart of a pediatric cardiac surgical program. Mortality data are plotted using Variable Life Adjusted Display (VLAD). Complications are collected for each patient prospectively using STS standard definitions and CUSUM and O-E plots generated. Complication burden (accounting for both frequency and severity of complications) was calculated for each STAT category and compared to historic data.

Results:
Mortality rate for the cohort was 3.6% (6/164, Fig 1, panel A). In 94 patients, there were no complications (57.3%). Thirty-five patients had 1 complication and 35 had
<
2 complications. Complications resulting in mortality (failure-to-rescue rate) is 8.7%. Most common complications were pulmonary (40, 23.4%) arrhythmia (27, 15.8%), and neurologic (28, 16.4%). High risk complications occurred infrequently including acute renal failure (n=14), bleeding requiring reoperation (n=4), unexpected cardiac arrest (n=3), low cardiac output (n=11), mechanical circulatory support (n=7), neurologic deficit (n=9), and sepsis (n=1) (Fig 1, panel B). Four outlier patients account for spikes in the O-E CUSUM plot (Fig 1, panel C). Complication severity and frequency escalate with increasing STAT category (Fig 1, panel D).

Conclusion:
A continuously updated dashboard permits real-time adverse outcome reporting, potentially allowing earliest identification of areas of concern or focus. Proof of the value of this approach will require replication in additional centers of various size.
Abstract 242: Can Belief Enhance Relief? A Multicenter Study
Authors: Alshami Abbas , Avila America , Romero Carlos , Villarreal Raphael , Einav Sharon , Surani Salim , Varon Joseph
Published: July 2021

Purpose:
While caring for patients, it is important to recognize more than just the apparent physical symptoms. Their emotional well-being, level of comfort, and spiritual concerns are relevant and should be taken into consideration. We aimed to identify if a greater commitment to spiritual belief systems by healthcare providers could have an effect on the patient care they provided.

Methods:
The Ethics in Intensive Care Study (ETHICS) was conducted in multiple centers all over the world utilizing a confidential survey. Questions were related to personal opinions on ethical issues, including personal beliefs, and patient care. We hypothesized that the personal beliefs of the healthcare providers should not affect the quality of care provided. Pearson’s correlation was used to ascertain statistical significance.

Results:
A total of 9,720 healthcare providers rated their level of spirituality from 1 (least) to 10 (greatest), and answered whether their beliefs affected their patient care. The majority of the people surveyed (65.6%; n=6,378) assessed themselves between 5 and 8 out of 10. In each individual level, most physicians felt patient care was not affected. However, on closer inspection and analysis, an interesting trend emerged. Only 11.4% (n=45) of those who rated themselves in level 1 of spirituality (n=394) stated their patient care was affected by their personal beliefs. Of people in level 5 (n=1,300), 13.3% (n=173) felt their beliefs affect the quality of care provided, and surprisingly, that number increased to 21.4% (n=193) among those healthcare provider rated in level 10 (n=899) [
p
<0.001,
Pearson’s R
correlation 0.94].

Conclusions:
A significant number of physicians identify themselves as religious, whether by belief in God, or based on a level of spirituality. We found a strong correlation between the level of spirituality a provider feels and the perception of how much his/her patient care is affected. We are not aware if this translates into real differences in patient care.