bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 121: Association between Diabetes Mellitus and Angina Assessed Using a Mobile Technology Platform in Patients Undergoing Percutaneous Coronary Intervention
Authors: Butala Neel M , Bruckel Jeffrey T , Wagle Neil , Pomerantsev Eugene , Kennedy Kevin F , Yeh Robert W
Published: July 2021

Background:
Empiric data on whether patients with diabetes suffer a differing burden of angina are conflicting. Population studies have found similar or less angina in patients with diabetes, whereas studies in patients with ACS or MI have found more angina. Few studies have incorporated coronary angiographic findings.

Methods:
We examined all 203 patients undergoing non-emergent PCI at our institution who completed a baseline patient-reported outcomes survey using a novel mobile technology platform integrated with the EMR between January-September, 2014. The primary exposure was diabetes status. The primary outcome was angina burden as measured by the Seattle Angina Questionnaire (SAQ) Short Form summary score (lower scores indicate worse angina). We additionally examined SAQ sub-scores for angina severity, physical limitation, and quality of life. Additional covariates selected a priori included age, race, gender, smoking, hypertension, dyslipidemia, history of MI, PCI, or heart failure, CAD presentation (asymptomatic, stable angina, UA, or NSTEMI), and number of major epicardial vessels with ≥50% stenosis on angiography. Analyses were performed using multivariable linear regression.

Results:
In our study, 79 patients (39%) had diabetes. Mean SAQ summary score for patients with diabetes was 55.2 (SD 28.3) versus 64.3 (SD 25.4) among patients without diabetes. In the unadjusted model, diabetes was associated with a significantly lower SAQ summary score (B: -9.1; 95% CI: -16.83, -1.38), which persisted in the fully adjusted model (B: -7.36; 95% CI: -14.19, -0.52). This effect was driven by sub-scores for angina severity (B: -7.45; 95% CI: -14.67, -0.24) and physical limitation (B: -10.88, 95% CI: -19.03, -2.72), with no association between diabetes and quality of life.

Conclusion:
Patients undergoing PCI with diabetes had worse burden of angina relative to those without diabetes, despite controlling for historical and angiography findings. This effect was driven by angina severity and physical limitation. Our results can guide future clinical decision-making regarding angina symptoms in this high-risk diabetic cohort. Furthermore, our study demonstrates that using a mobile technology platform is feasible for routine assessment of angina in patients with and without diabetes undergoing PCI.
Abstract 122: Attainment of Optimal Blood Pressure in Hypertensive Ambulatory Heart Failure Patients
Authors: Piatetsky Yana , Scheidler Matthew , Garcia Rachel , Torosoff Mikhail
Published: July 2021

Objective:
We investigated the prevalence of blood pressure <130/80 mmHg and studied factors associated with elevated blood pressure in hypertensive ambulatory heart failure patients.

Methods:
Records of 194 unselected consecutive heart failure patients were reviewed. Demographic and clinical data were collected. ANOVA, chi-square, and logistic regression analyses were used.

Results:
Systolic blood pressure less than 130 mmHg and diastolic blood pressure less than 80 mmHg was achieved in 52.9% of patients, in 58.4% of men and in 41.6% of women (p=0.076). Patients with diabetes (62%) were more likely to achieve optimal blood pressure (46.4% of patients without diabetes, p=0.033). Age, depressed ejection fraction, body mass index, hemoglobin, creatinine clearance, and histories of dyslipidemia, coronary artery disease, or peripheral vascular disease were not predictive of suboptimal blood pressure control.

There was no association between treatment with ACE inhibitors (52.5% of patients with optimal blood pressure vs. 47.8% of patients with suboptimal blood pressure, p=0.517), ARBs (16.8 vs. 15.6%, p=0.811), or beta-blockers (90 vs. 85.6%, p=0.336) and achieving optimal blood pressure. Patients with optimal blood pressure were more likely to have been treated with diuretics (65.3 vs. 50%, p=0.032) or aldosterone receptor antagonists (36.6 vs. 16.7%, p=0.017). Increased use of calcium-channel blockers (CCBs) (12.9 vs. 30%, p=0.003) was noted in patients with suboptimal blood pressure control.

Conclusions:
Only half of the hypertensive patients with heart failure achieved blood pressure less than 130/80 mmHg, and women were less likely than men to attain optimal blood pressure control. Optimal blood pressure control was more prevalent if the therapeutic regimen included diuretics or aldosterone receptor antagonists. Whether CCBs are used more commonly in patients with elevated blood pressure or whether CCBs are less useful for blood pressure control cannot be established.
Abstract 131: Cognitive Impairment Predicts Mortality in Patients with Heart Failure
Authors: Lan Howard , Hawkins Lee Ann , Silvet Helme
Published: July 2021

Introduction:
In our previously published study, we evaluated a Veteran cohort of 250 outpatients with heart failure (HF) and found 58% (144 of 250) incidence of previously undiagnosed cognitive impairment (CI). Previous studies have suggested that HF patients with CI have worse clinical outcomes including higher mortality but this has not been studied in the Veteran population.

Methods:
Current study was designed to prospectively follow this cohort of 250 patients. Cognitive function was previously evaluated in all patients at baseline using the St. Luis University Mental Status (SLUMS) exam. The primary outcome for this follow-up study was all-cause mortality. Data analysis including Cox regression analysis and Kaplan-Meier curves were generated using SPSS.

Results:
The study population was predominantly Caucasian (72%, 179 of 250) and male (99%, 247 of 250) with mean age of 69 ± 10 years. Mean follow up was 31 ± 11 months. During follow up, 26% (64 of 250) of patients died. Univariate and multivariate Cox proportional hazards regression analyses were performed and shown in Table 1. Using the SLUMS score, subjects were stratified into three groups: no CI (42%, 106 of 250), mild CI (42%, 104 of 250), and severe CI (16%, 40 of 250). Kaplan-Meier survival curves were generated to compare the three CI groups in Figure 1.

Conclusion:
Current study demonstrates that CI is an independent risk factor for mortality in outpatient HF patients. This is an important finding because CI is commonly unrecognized in this vulnerable population. Routine CI screening could help to identify those who are at greater risk for worse outcomes. Future studies are needed to derive possible interventions to improve outcomes in these patients.
Abstract 139: Costs to Implement Components of Stroke Systems of Care Under the Paul Coverdell National Acute Stroke Program
Authors: Yarnoff Benjamin , Khavjou Olga , Lowe Kincaid , Joo Heesoo , Bradley Christina , Teixeira-Poit Stephanie , Chapel John , Coleman King Sallyann M
Published: July 2021

Objective:
During 2012-2015, the Centers for Disease Control and Prevention’s (CDC) Paul Coverdell National Acute Stroke Program (PCNASP) funded state health departments to improve the quality of stroke care in key clinical settings. The objective of this study was to assess costs for health departments and partners implementing PCNASP newly established programs.

Methods:
We developed Excel-based data collection instruments to collect costs associated with implementing stroke systems of care from volunteer PCNASP-funded health departments. Nine PCNASP-funded health departments were eligible based on program characteristics, six of which agreed to participate; five focused on pre- and in-hospital stroke care, and one also included transitions to post-hospital settings. These health departments partnered with a total of 467 organizations in their six states (37 to 125 partners per state). We used an activity-based costing approach to allocate costs across primary program activities: data collection, linkage, and management; clinical guidance and expertise; quality improvement (QI); building and maintaining partnerships; program evaluation; and administration. We collected costs to the health departments paid directly by PCNASP funds, in-kind contributions from the health department, and in-kind contributions from partners. Four of the six health departments received in-kind contributions from select partners. We analyzed costs by resource category (labor; materials, travel, services, equipment; contracts, consultants; overhead) and program activities across three settings: pre-hospital, in-hospital, and post-hospital.

Results:
Six health departments reported grant expenditures averaging $991,549 (ranging from $790,123 to $1,298,160) per health department over 36 months. Three of those health departments reported health department in-kind contributions averaging $374,439 (ranging from $5,805 to $1,394,097) for the same 36 months. Health departments reported greatest expenditures on labor (46%, ranging from 15% to 79%) and contracts and consultants (37%, ranging from 5% to 76%). Across program activities, health departments incurred costs for QI (37%, ranging from 17% to 60%); administration (19%, ranging from 7% to 39%); data (17%, ranging from 15% to 79%); partnerships (10%, ranging from 2% to 23%); clinical guidance (9%, ranging from 4% to 16%); and evaluation (8%, ranging from 4% to 15%). Four health departments collected in-kind contributions for 22 partners. Partners had average in-kind contributions of $373,211 (ranging from $1,040 to $1,421,729).

Conclusion:
Results from this study highlight key cost drivers of implementing components of stroke systems of care. This study was the first to comprehensively document actual costs of implementing QI for stroke systems of care across multiple programs and can inform future planning efforts.
Abstract 141: Depression and Cardiovascular Disease: Improving Patient Care
Authors: Gordon Linda , Ansani-Jankowski Nicole
Published: July 2021

Background:
Depression affects up to 20% of patients with coronary artery disease (CAD), diabetes mellitus (DM), and congestive heart failure (CHF); and is associated with poorer health outcomes. HEDIS Depression Care Measure Set includes the utilization of PHQ-9 survey to monitor depression and appropriate treatment and follow-up. The goal of this program is to design, implement, and measure the success of a quality improvement (QI) initiative addressing HEDIS depression measures in the cardiovascular (CV) population.

Methods:
First an analysis of current practice and HEDIS compliance was conducted; 2. A plan was developed to address gaps in care; 3. A QI program was executed in the cardiac catheter lab; and 4. Outcome measures and methods to determine program success were designed.

Results:
Current practice analysis of the catheter lab revealed that depression screening, monitoring, and follow-up were not routinely conducted. Further, it was identified that the PHQ-9 screener was available in the EMR system but not being utilized. Therefore, a QI program was designed with the following components: 1. Patients
>
18 years old receive the PHQ-9 upon discharge from the catheter lab; 2. If a patient scores
>
10 on the PHQ-9 they receive education and are scheduled for follow-up; 3. A clinical database collects information on Framingham risk scores, CV risks, PHQ-9 scores, medical history, and biometric data. These data are then used to provide customized CV care plans including depression education; 4. A shared medical appointment (SMA) format provides additional depression education and follow-up. This program was executed in January 2014. The outcomes plan evaluates the impact of this QI program on HEDIS goal attainment and CV care. A control group receives screening, initial education, and standard of care. The intervention group receives screening, initial education, entry into the disease management database, customized education, therapeutic lifestyle counselling, and participation in the SMA focusing on depression. Currently 39 patients are enrolled in each arm. Interim analysis reveals 100% depression screening in both groups and high rates of follow-up in the intervention group (2 initial components of the HEDIS goals).

Conclusions:
Implementing a multi-faceted depression screening and follow-up QI program addresses HEDIS goals and has shown initial success in closing identified gaps in care. Future implications include a comparative analysis of the QI program to standard of care on composite HEDIS depression measures and CV goal attainment.
Abstract 145: Differences in Presenting Symptoms of Fibromuscular Dysplasia Patients With Family History of Fibromuscular Dysplasia, Arterial Aneurysm, Dissection, or Sudden Death: A Report from the United States Registry for Fibromuscular Dysplasia
Authors: Kim Joon B , Heidt Steven T , Gu Xiaokui , Gornik Heather L , Olin Jeffrey W , Mace Pamela D , Kline-Rogers Eva , Gray Bruce H , Sharma Aditya , Froehlich James B
Published: July 2021

Introduction:
Fibromuscular dysplasia (FMD) is a non-atherosclerotic, non-inflammatory vascular disorder which may lead to stenosis, tortuosity, dissection, or aneurysm in any arterial bed. Some affected patients have a family history of FMD, arterial aneurysm (AA), arterial dissection (AD) or sudden death (SD), supporting a genetic predisposition. The clinical characteristics of this patient population have not been described. We hypothesized that patients with a family history of FMD, AA, AD, or SD would present differently than those without.

Methods:
By July 2014, of 880 patients enrolled in the United States Registry for FMD, 295 had a family history of FMD, AA, AD, or SD. These patients were compared to those without family history, analyzing demographics, symptoms at time of diagnosis, and vascular bed involvement. Student’s t-tests and Fisher’s exact tests were used to analyze continuous and categorical variables, respectively.

Results:
Patients with a family history of FMD, AA, AD, or SD were younger at diagnosis and more likely to experience CNS symptoms (headache, tinnitus, neck pain), post-prandial abdominal pain, as well as stroke and TIA at time of diagnosis. They also exhibited a trend toward more frequent carotid dissection (Table 1).

Conclusions:
Patients with a family history of FMD, arterial aneurysm (AA), dissection (AD), or sudden death (SD) more commonly had extracranial arterial bed complications, and experienced symptoms related to this vascular territory at time of diagnosis. These results suggest that FMD may present differently in those with this family history.
Abstract 156: Facilitating End-of-Life Decision-Making and Preparedness Planning Among Heart Failure Patients Hospitalized for Advanced Disease
Authors: Fendler Timothy J , Swetz Keith M , Spertus John A , Austin Bethany A
Published: July 2021

Background:
To address the increasingly strident call for better, more informed shared decision-making about treatment decisions and goals of care in patients with end-stage heart failure (HF), we designed and implemented a supportive care intervention for hospitalized patients with a very poor prognosis.

Methods:
All patients admitted to the advanced HF service at a single hospital over a 6-mo. period were screened for inclusion criteria (deemed non-candidacy for LVAD/transplantation and high likelihood for death or persistently poor quality of life at 6 months, based on the Allen risk score). Enrollees were given a written exercise, The Conversation Starter Kit, to complete with their healthcare proxy before an outpatient visit with a HF nurse practitioner (NP) trained in supportive care techniques. The intervention provided at this visit consisted of 5 domains: disease understanding, symptom control, legal matters, goals of care, and the role of the healthcare proxy. The KCCQ, PEACE Illness Acceptance Scale, Decisional Conflict Scale, and Kaldjian’s Goals of Care were collected at enrollment and 1 month after the intervention, along with 6-month outcomes of readmission and death.

Results:
Of 77 patients admitted to the service who were not candidates for advanced therapies, 16 met eligibility criteria. Nine declined participation and 7 of a planned 10 were enrolled; the pilot was terminated early due to low enrollment. Only 2 patients completed the intervention; reasons for not completing varied for the 5 remaining patients. (Table) Despite a pre-existing relationship between patients and NPs, rigorous facilitator training, and a comprehensive, evidence-based, outpatient intervention, significant barriers to implementation included patient reluctance/fear, uncertainty surrounding disease progression, time constraints of completing the intervention within a scheduled clinic visit, and lack of efficacy due to patients having too-advanced disease.

Conclusions:
An intervention to engage very high-risk, advanced HF patients in shared decision-making about end-of-life care failed to be successfully and sustainably implemented. Future work should assess the feasibility and efficacy of designing an early and iterative intervention in a larger population of HF patients with less advanced disease.
Abstract 160: Health-related Quality of Life (HRQoL) Associated with Cardiovascular Disease (CVD) and Comorbidities in Patients with Diabetes
Authors: Sullivan Patrick , Ghushchyan Vahram
Published: July 2021

Objectives:
Diabetes (DM) and cardiovascular disease (CVD) are a significant threat to public health. We have previously estimated utility scores for CVD and diabetes-related comorbidities in a general population without diabetes. However, utility estimates may differ for those with pre-existing DM. The objective of this research was to estimate the utility associated with DM-related and CVD health states in patients with pre-existing DM.

Methods:
A comprehensive list of health states and corresponding ICD-9 codes related to DM was developed by clinicians. EQ-5D-3L responses were mapped from SF-12 questionnaire responses in the 2000-2011 Medical Expenditure Panel Survey. EQ-5D scores were estimated using tariffs from the US, UK, France and Spain. Regression analysis was used to estimate the disutility of each DM-related condition, controlling for comorbidity, geographic region, age, gender, race, ethnicity, education and family income. Censored Least Absolute Deviations (CLAD), Tobit and OLS regression methods were used.

Results:
Seventeen health states related to DM were identified. There were 20,705 individuals with diabetes and valid EQ-5D scores (mean: EQ-5D 0.72; age 60; 4.5 chronic conditions). The mean unadjusted EQ-5D (UK) for those without MI was 0.74, but 0.62 for those with MI. Regression results showed a significant deleterious marginal impact of DM-related comorbid conditions on utility. Select results include (EQ-5D UK scores): MI -0.047; Stroke -0.060; CHF -0.050; Stable angina -0.042; Peripheral Vascular Disease -0.045.

Conclusions:
The results provided may be useful to estimate the impact of diabetes-related and CVD comorbid conditions on utility for public health and cost-effectiveness analyses. Limitations: Estimates reflect annual or chronic impacts because survey timing limited the ability to estimate acute effects. This research was unable to differentiate between type 1 and type 2 DM.
Abstract 215: Leveraging Electronic Health Record Documentation for Failure Mode and Effects Analysis Team Identification on an Inpatient Cardiology Unit
Authors: Kricke Gayle S , Carson Matthew , Lee Young Ji , Benacka Corrine , Ahmad Faraz , Mutharasan R Kannan , Kansal Preeti , Yancy Clyde , Anderson Allen , Soulakis Nicholas
Published: July 2021

Objectives:
Failure Mode and Effects Analysis (FMEA) is a frequently-used approach for prospective risk assessment and quality improvement in healthcare, particularly for high-risk care processes such as hospital discharge planning. Our goal was to evaluate whether secondary use of metadata collected by the electronic health record (EHR) during daily practice can inform assembly of a comprehensive FMEA team by showing: 1) discrepancies between expected and observed process activities and individuals involved, and 2) the presence of individuals who may be appropriate to include in an FMEA based on their variable familiarity with a process.

Methods:
We extracted discharge planning data for an inpatient cardiology unit from the Enterprise Data Warehouse (EDW) and compared it to a hand-drawn map (HDM) indicating clinicians’ understanding of discharge activities and providers expected to complete each activity. We assessed the presence of providers highly experienced in the process, the diversity of involved disciplines, and the accuracy of the HDM compared to observation from EDW data.

Findings:
Over 500 providers completed nearly 35,000 discharge-related activities across 18 activity types over 2,000 encounters. Experience was skewed such that 90% (510 of 569) of providers completed between 0 and 99 activities while the remaining 10% (59 of 569) performed up to 1,200 activities. Frequent performers completed similar activities to their peers, but did so as many as 12 times more frequently than average for their discipline. Expectation of who performed an activity closely matched observation for 11 discipline-specific activities, such as case management assessment. However, providers from up to 10 different disciplines performed the remaining 7 activities, such as scheduling a follow-up visit or ordering a therapy consult. Overall, 35% (12,183 of 34,939) of activities were performed by an unexpected provider.

Conclusions:
Analyzing metadata from EHRs is a novel method to inform FMEA of high-risk processes. This study provides a framework for assessing process activities and the providers involved. In the discharge planning process, there appears to be significant discrepancy between clinicians’ understanding and the actual discharge process and team, which suggests the presence of providers who could be overlooked during typical FMEA team construction. This methodology can empirically enrich the FMEA team and highlight quality improvement target areas.
Abstract 242: Resuscitation Practices Associated with Survival After In-Hospital Cardiac Arrest: A Nationwide Survey
Authors: Chan Paul S , Krein Sarah L , Tang Fengming , Harrod Molly , Kennedy Mary , Lehrich Jessica , Nallamotu Brahmajee K
Published: July 2021

Background:
Substantial facility-level variation in survival exists following in-hospital cardiac arrest. Yet, specific resuscitation practices that distinguish hospitals with higher cardiac arrest survival remain unknown.

Methods:
We surveyed hospitals that submitted >20 adult in-hospital cardiac arrest cases to Get With The Guidelines (GWTG)-Resuscitation between 2012 and 2013 about resuscitation practices at their facility. We then used data from GWTG-Resuscitation to calculate risk-standardized rates for survival to discharge for each hospital, and categorized facilities into the top quintile, middle 2 to 4 quintiles, and bottom quintile based on their performance. The association between resuscitation practices and quintiles of survival was evaluated using hierarchical proportional odds logistic regression models.

Results:
Overall, 150 of 192 active adult hospitals (78.1%) facilities completed the study survey and 131 facilities with >20 cases comprised the final study cohort. Risk-standardized survival rates after in-hospital cardiac arrest varied substantially (median: 23.7%; range: 9.2%-37.5%). Several resuscitation practices were associated with survival on bivariate analysis, although only three were significant after multivariable adjustment: tracking interruptions in chest compressions (adjusted OR for being in a higher survival quintile category, 2.7 [95% CI: 1.2-5.9]; P=0.01); reviewing cardiac arrest cases monthly or quarterly (adjusted OR for being in a higher survival quintile category, 8.6 [1.8-40.0] for monthly and 6.9 [1.5-31.3] for quarterly; P=0.03); and inadequate resuscitation training (adjusted OR for at least a moderate barrier, 0.31 [0.12, 0.83]; P=0.02).

Conclusion:
Tracking interruptions in chest compressions, frequent review of cardiac arrest cases, and adequate resuscitation training are potentially key resuscitation practices associated with higher in-hospital cardiac arrest survival.
Abstract 247: STEMI 365: Creating a Yearlong Program to Reduce Cardiac Recidivism After STEMI
Authors: Ryczek Daniel , Burt David
Published: July 2021

Survivors of myocardial infarctions are at increased risk of recurrent infarctions and have an annual death rate of 5%, six times that in people of the same age who do not have coronary heart disease. Despite the existence of published interventions and clinical recommendations aimed at secondary and tertiary prevention their application and adherence statistics in post-myocardial infarction patients are woeful.

The objective of this paper is to detail the creation of a template curriculum that gives best practice recommendations to post STEMI patients in an effort to reduce recidivism by combining current medical methodology with lessons learned from other fields currently addressing the problem of recidivism and relapse.

STEMI 365 is a yearlong program that aims to reduce cardiac recidivism in STEMI survivors. STEMI 365 is composed of three parts: best practice guidelines, evaluation toolkit, and template curriculum. The best practice guidelines document is broken into sections on cardiac rehabilitation, lifestyle modification, drug therapy, patient follow-up and screening, and patient education. All guidelines are informed by the latest recommendations and research in the fields of medicine and relapse prevention. The evaluation toolkit is composed of the cardiac recidivism risk tool, the self-evaluation tool, and the global evaluation tool. The goal of the toolkits is to guide resource allocation by understanding a patient’s unique cardiac recidivism risk, internal sources of potential relapse, and external sources of potential relapse. The Federal Post Conviction Risk Assessment developed by the Administrative Office of the United States Courts informs the toolkits’ construction. The template curriculum is a summation of the programs and interventions that can be utilized by a health system to decrease cardiac recidivism in STEMI survivors. The curriculum addresses one year of time divided into three phases: inpatient, outpatient, and maintenance. The interventions rage in scope from training a patient’s family members in bystander CPR to the creation of a centralized patient monitoring program and post-myocardial infarction clinic. Each phase combines the best modalities in treatment found in the fields of post-myocardial infarction care, hospital re-admission prevention, substance abuse relapse prevention, scholastic dropout prevention, and criminal justice. Personal interviews were conducted with leaders in each field to ensure the correct application of their methodologies.

STEMI 365 provides tools to identify patients at highest risk of cardiovascular relapse, to apply local and regional resources in an effective way based on patient risk, and to customize interventions to a health system’s available resources. STEMI 365 is beginning an application phase at this institution, and will be available to other health systems in the near future.
Abstract 252: The Association of Award Recognition From Get With the Guidelines-Resuscitation with Improved Survival Rates in In-Hospital Cardiac Arrest Events
Authors: Thomas Kathie , Miller Art , Poe Greg
Published: July 2021

Background and Objectives:
It is estimated that over 200,000 adults experience in-hospital cardiac arrest each year. Overall survival to discharge has remained relatively unchanged for decades and survival rates remain at about 20% (Elenbach et al., 2009). Get With The Guidelines-Resuscitation (GWTG-R) is an in-hospital quality improvement program designed to improve adherence to evidence-based care of patients who experience an in-hospital resuscitation event. GWTG-R focuses on four achievement measures. The measures for adult patients include time to first chest compression of less than or equal to one minute, device confirmation of correct endotracheal tube placement, patients with pulseless VF/VT as the initial documented rhythm with a time to first shock of less than or equal to two minutes, and events in which patients were monitored or witnessed at the time of cardiac arrest. The objective of this abstract is to examine the association between hospital adherence to GWTG-R and in-hospital cardiac arrest survival rates.

Methods:
A retrospective review of adult in-hospital cardiopulmonary arrest (CPA) patients (n=1849) from 21 Michigan, Illinois, and Indiana hospitals using the GWTG-R database was conducted from January 2014 through December 2014. This study included adult CPA patients that did and did not survive to discharge.

Results:
The review found that hospitals that had attained 84.6% or higher thresholds in all four achievement measures for at least one year, which is award recognition status, had a significantly improved in-hospital CPA survival to discharge rate of 29.6%. Hospitals that did not obtain award status had a CPA survival to discharge rate of 24.3%. The national survival rate for in-hospital adult CPA survival to discharge is 20%. Hospitals that did not achieve award recognition status still demonstrated improvement in survival rate when compared to the national survival rate, indicating the importance of a quality improvement program such as GWTG-R. No significant difference was found between in-hospital adult CPA survival rate and race between GWTG-R award winning and non-award winning hospitals. Hospitals that earned award recognition from GWTG-R had a survival to discharge rate of 30.2% for African Americans and 29.6% for whites. Hospitals that were did not earn award recognition from GWTG-R had a survival to discharge rate of 20.0% for African Americans and 20.1% for whites.

Conclusions:
Survival of in-hospital adult CPA patients improved significantly when GWTG-R measures are adhered to. Survival of in-hospital adult CPA patients also improves with implementation of GWTG-R. It is crucial that hospitals collect and analyze data regarding resuscitation processes and outcomes. Quality improvement measures can then be implemented in order to assist with improving in-hospital CPA survival rates.
Abstract 268: Using Lean Methodology to Reduce Variation in Care of Acute Coronary Syndrome Patients
Authors: Kmetic Andrew , Fradet Guy , Hamman Ronnalea , Laberge Carol , Galte Carol
Published: July 2021

Background:
Regional variation in the utilization of health services is a well-documented phenomenon in health care with numerous studies reporting substantial and unexplained variations in coronary revascularization. In the Canadian province of British Columbia (BC), five cardiac centers provide coronary revascularization services. In 2011 Cardiac Services BC (CSBC) undertook a study that identified substantial regional variation in coronary revascularization that could not be explained by patient characteristics or risk factors. Following this initial project, CSBC launched an initiative to help better understand the regional variations and possibly devise and implement strategies to reduce them.

Methods:
Using Lean methodology, we are mapping the key processes of care for ACS patients across BC (initially excluding emergent STEMI and cardiogenic shock) at each cardiac centre. The ACS patient journey will be mapped from admission to discharge through several key decision points that determine whether they will continue through to diagnostic catheterization and revascularization or to be medically managed alone.

The key decision points are:

1. Decision to refer to diagnostic catheterization and subsequent transfer if necessary.

2. Decision to continue to a revascularization procedure (PCI or CABG) after diagnostic catheterization.

The map will summarized these key decision points using multiple sources of data:

1. Flow and patient volumes into and out of each of these decision

2. Times between decision points and key care processes

3. Clinical influencers (ex: standard orders, best practice, established patterns of referral, and consultations) and non-clinical influencers (ex: resource capacity, transportation) that are considered at each decision point (process mapping and interview data).

Discussion:
BC is attempting to reduce unexplained variation in coronary revascularization using the Lean methodology to take a systematic approach to the analysis of the process of ACS care across the province. Involving physicians and point of care staff in the detailed mapping process has proven to be a significant step in engaging key stakeholders in the project by allowing input into the process of describing the factors affecting variation of practice at each site. The next step is to convene provincially to determine where to improve standardized practice in order to improve patient outcomes at key points along the value stream.
Abstract 6: Treatment Effect of Clopidogrel Plus Aspirin Within 12 Hours of Acute Minor Stroke or TIA
Authors: Li Zixiao , Wang Yilong , Zhao Xingquan , Liu Liping , Xian Ying , Johnston S.Claiborne , Wang Yongjun ,   the CHANCE Investigators
Published: July 2021

Background and Purpose:
The aim of this study was to analyze the benefits and safety associated with the combination therapy of clopidogrel and aspirin within 12 hours.

Methods:
This was a subanalysis of the CHANCE (Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events) trial, mainly limited to the prespecified group of patients presenting within 12 hours to either the combination of clopidogrel plus aspirin or aspirin alone. The primary outcome was ischemic stroke during 90-day follow-up.

Results:
Among 2573 patients randomized within 12 hours, 282 (10.96%) patients had ischemic stroke events. Among them, 113 (40.07%) occurred within 24 hours of symptom onset. Randomization within 12 hours was an independent predictor of ischemic stroke events (P=0.02). One hundred and fifty-eight (12.34%) of 1280 patients on aspirin experienced ischemic stroke compared to 124 (9.59%) of 1293 patients on clopidogrel-aspirin (P=0.02). The dual antiplatelet was more effective than aspirin alone in reducing the risk of recurrent ischemic stroke (6.57% vs. 8.91%, P=0.03), but not progressive ischemic stroke (3.02% vs. 3.43%, P=0.28) (Table 1). There was no significant difference in hemorrhagic events (P=0.39).

Conclusions:
Among patients treated within 12 hours, the combination of clopidogrel and aspirin was more effective than aspirin alone in reducing the risk of recurrent ischemic stroke during the 90-day follow-up and did not increase the hemorrhagic risk. The higher ischemic stroke rate in the initial hours after stroke supports early more aggressive antiplatelet therapy.

Clinical Trial Registration-URL:
http//www.clinicaltrials.gov
. Unique identifier: NCT00979589.
Extra-Aortic Balloon Counterpulsation
Authors: Legget Malcolm E. , Peters William S. , Milsom F. Paget , Clark Judith S. , West Teena M. , French Renelle L. , Merry Alan F.
Published: July 2021

Background—

Current methods of counterpulsation or ventricular assistance have significant vascular and limb complications. The aim of this study was to determine the safety and performance of a new method of non-blood–contacting counterpulsation using an inflatable cuff around the ascending aorta (extra-aortic balloon [EAB]).

Methods and Results—

In 6 patients undergoing first time off-pump coronary bypass surgery via sternotomy, the EAB was secured around the ascending aorta and attached to a standard counterpulsation console. At baseline and with 1:2 and 1:1 augmentation, hemodynamic and echocardiographic parameters of ventricular function and coronary flow were measured. High-intensity transient signals were measured using transcutaneous Doppler over the right common carotid artery. No complications occurred. With EAB there was no significant change in heart rate or blood pressure and no increase in high-intensity transient signals. There was a 67% increase in diastolic coronary blood flow (mean left-main diastolic velocity time integral 15.3 cm unassisted versus 25.1 cm assisted,
P
<0.05). Measurements with transesophageal echocardiography at baseline and with 1:1 counterpulsation demonstrated a 6% reduction in end-diastolic area (
P
=NS), a 16% reduction in end-systolic area (
P
<0.01), a 31% reduction in left ventricular wall stress (
P
<0.05), and a 13% improvement in fractional area change (
P
<0.005).

Conclusions—

EAB counterpulsation augments coronary flow and reduces left ventricular afterload. Further testing is warranted to assess the use of the EAB for chronic non-blood–contacting support of the failing heart.
Intracoronary Injection of CD133-Positive Enriched Bone Marrow Progenitor Cells Promotes Cardiac Recovery After Recent Myocardial Infarction
Authors: Bartunek Jozef , Vanderheyden Marc , Vandekerckhove Bart , Mansour Samer , De Bruyne Bernard , De Bondt Pieter , Van Haute Inge , Lootens Nele , Heyndrickx Guy , Wijns William
Published: July 2021

Background—

Bone marrow CD133-postive (CD133
+
) cells possess high hematopoietic and angiogenic capacity. We tested the feasibility, safety, and functional effects of the use of enriched CD133
+
progenitor cells after intracoronary administration in patients with recent myocardial infarction.

Methods and Results—

Among 35 patients with acute myocardial infarction treated with stenting, 19 underwent intracoronary administration of CD133
+
progenitor cells (12.6±2.2×10
6
cells) 11.6±1.4 days later (group 1) and 16 did not (group 2). At 4 months, left ventricular ejection fraction increased significantly in group 1 (from 45.0±2.6% to 52.1±3.5%,
P
<0.05), but only tended to increase in case-matched group 2 patients (from 44.3±3.1% to 48.6±3.6%,
P
=NS). Likewise, left ventricular regional chordae shortening increased in group 1 (from 11.5±1.0% to 16.1±1.3%,
P
<0.05) but remained unchanged in group 2 patients (from 11.1±1.1% to 12.7±1.3%,
P
=NS). This was paralleled by reduction in the perfusion defect in group 1 (from 28.0±4.1% to 22.5±4.1%,
P
<0.05) and no change in group 2 (from 25.0±3.0% to 22.6±4.1%,
P
=NS). In group 1, two patients developed in-stent reocclusion, 7 developed in-stent restenosis, and 2 developed significant de novo lesion of the infarct-related artery. In group 2, four patients showed in-stent restenosis. In group 1 patients without reocclusion, glucose uptake shown by positron emission tomography with
18
fluorodeoxyglucose in the infarct-related territory increased from 51.2±2.6% to 57.5±3.5% (
P
<0.05). No stem cell-related arrhythmias were noted, either clinically or during programmed stimulation studies at 4 months.

Conclusion—

In patients with recent myocardial infarction, intracoronary administration of enriched CD133
+
cells is feasible but was associated with increased incidence of coronary events. Nevertheless, it seems to be associated with improved left ventricular performance paralleled with increased myocardial perfusion and viability.
Aprotinin Decreases Postoperative Bleeding and Number of Transfusions in Patients on Clopidogrel Undergoing Coronary Artery Bypass Graft Surgery
Authors: van der Linden Jan , Lindvall Gabriella , Sartipy Ulrik
Published: July 2021

Background—

Clopidogrel, an irreversible platelet inhibitor, is used to treat patients with unstable angina. These patients often present for coronary artery bypass graft surgery (CABG) and are at increased risk for perioperative bleeding. The current investigation evaluates the impact of aprotinin on bleeding and transfusion requirements in clopidogrel-treated patients undergoing CABG.

Methods and Results—

Seventy-five consecutive patients with unstable angina, administered clopidogrel <5 days before CABG, were randomized. Using a double-blind design, patients received full-dose aprotinin (n =37) or saline (n =38). Elapsed times between the last dose of clopidogrel and start of the operation were similar between the 2 groups [aprotinin, 58±28 hour (mean± SD); control, 54±27 hour;
P
=0.86], as were age (aprotinin, 66.4±10 years; control, 68.3±10 years;
P
=0.51), number of distal anastomoses (aprotinin, 3.6±1.0; control, 3.7±1.0;
P
=0.79), operative times (aprotinin, 192±48 minutes; control, 200±53 minutes;
P
=0.55), and lowest intraoperative hemoglobin level (aprotinin, 87±14 g/L; control, 88±14 g/L;
P
=0.60). Postoperative bleeding was 760±350 mL in aprotinin-treated patients versus 1200±570 mL (
P
<0.001) in control. During the hospital stay, patients in the aprotinin group received 1.2±1.5 and 0.1±0.4 U of erythrocytes and platelets, respectively, versus 2.8±3.2 (
P
=0.02) and 0.9±1.4 (
P
=0.002) units in the control. In the aprotinin group, 53% of patients received transfusions, whereas 79% of controls were exposed to blood products (
P
=0.02).

Conclusions—

Intraoperative aprotinin decreases postoperative bleeding and the number of transfusions in patients undergoing CABG and treated with clopidogrel <5 days before surgery.
Retroinfusion of Embryonic Endothelial Progenitor Cells Attenuates Ischemia-Reperfusion Injury in Pigs
Authors: Kupatt Christian , Hinkel Rabea , Lamparter Mathias , von Brühl Marie-Luise , Pohl Tilman , Horstkotte Jan , Beck Heike , Müller Susanne , Delker Sebastian , Gildehaus Franz-Josef , Büning Hildegard , Hatzopoulos Antonis K. , Boekstegers Peter
Published: July 2021

Background—

Adult endothelial progenitor cells (EPCs) reduce myocardial infarct size and improve postischemic myocardial function. We have recently shown that clonal embryonic EPCs (eEPCs), derived from 7.5-day-old mice, home specifically to hypoxic areas in tumor metastasis mouse models but spare normal organs and do not form carcinomas. Here, we assessed the potential of eEPCs to limit organ dysfunction after ischemia and reperfusion in a preclinical pig model.

Methods and Results—

Pigs were subjected to ischemia (60-minute left anterior descending [LAD] artery occlusion) and reperfusion (7 days). At the end of ischemia, we applied medium with or without 5×10
6
eEPCs by either pressure-regulated retroinfusion or intravenous transfusion. One hour after reperfusion,
99
Tc-labeled eEPCs engrafted to a 6-fold higher extent in the ischemic myocardium after retroinfusion than after intravenous application. Regional myocardial function (subendocardial segment shortening [SES] at 150/min, given in percent of nonischemic circumflex region) and infarct size (TTC viability and Methylene-blue exclusion) were determined 24 hours and 7 days later. Compared with medium-treated animals, retroinfusion of eEPCs decreased infarct size (35±4% versus 51±6%) and improved regional myocardial reserve of the apical LAD region (SES 31±4% versus 6±8%), whereas intravenous application displayed a less pronounced effect (infarct size 44±4%; SES 12±3%). Retroinfusion of an equal amount of neonatal coronary endothelial cells (rat) did not affect infarct size (49±5%) nor regional myocardial reserve (16±7%). The eEPC-dependent effect was detected at 24 hours of reperfusion (infarct size 34±7% versus 58±6%) and was sensitive to Wortmannin coapplication (50±5%).

Conclusion—

Our findings show that eEPCs reduce ischemia-reperfusion injury in a preclinical pig model. The rapid effect (as early as 24 hours) indicates a role for enzyme-mediated cardioprotection, which involves, at least in part, the phosphatidylinositol 3-kinase/AKT pathway.
Annular Height-to-Commissural Width Ratio of Annulolasty Rings In Vivo
Authors: Timek Tomasz A. , Glasson Julie R. , Lai David T. , Liang David , Daughters George T. , Ingels Neil B. , Miller D. Craig
Published: July 2021

Background—

A “saddle-shaped” mitral annulus with an optimal ratio between annular height and commissural diameter may reduce leaflet and chordal stress and is purported to be conserved across mammalian species. Whether annuloplasty rings maintain this relationship is unknown.

Methods and Results—

Twenty-three adult sheep underwent implantation of radiopaque markers on the left ventricle and mitral annulus. Eight animals underwent implantation of a Carpentier-Edwards Physio ring, 7 underwent a Medtronic Duran flexible ring, and 8 served as controls. Animals were studied with biplane videofluoroscopy 7 to 10 days postoperatively. Annular height and commissural width (CW) were determined from 3D marker coordinates, and annular height:CW ratio (AHWCR) was calculated. Annular height was similar in Control and Duran animals but significantly lower in the Physio group at end diastole (8.4±3.8, 6.7±2.3, and 3.4±0.6 mm, respectively, for Control, Duran, and Physio; ANOVA=0.005) and at end systole (14.5±6.2, 10.5±5.5, and 5.8±2.5 mm, respectively, for Control, Duran, and Physio; ANOVA=0.004). Both ring groups reduced CW significantly relative to Control. AHCWR did not differ between Control and Duran but was lower in Physio (23±11%, 24±7%, and 12±2% at end diastole and 42±17%, 37±17%, and 21±10% at end systole, respectively, for Control, Duran, and Physio, respectively; ANOVA <0.05 for both).

Conclusions—

Mitral annular height and AHWCR of the native valve were unchanged by a Duran ring, whereas the Physio ring led to a lower AHWCR. Theoretically, such a flexible annuloplasty ring may provide better leaflet stress distribution by maintaining normal AHWCR.
Clinical Predictors of Major Infections After Cardiac Surgery
Authors: Fowler Vance G. , O’Brien Sean M. , Muhlbaier Lawrence H. , Corey G. Ralph , Ferguson T. Bruce , Peterson Eric D.
Published: July 2021

Background—

Major infections are infrequent but important complications of cardiac surgery. Predicting their occurrence is essential for future prevention. The objective of the current investigation was to create and validate a bedside scoring system to estimate patient risk for major infection (mediastinitis, thoracotomy or vein harvest site infection, or septicemia) after coronary artery bypass grafting.

Methods and Results—

Using the Society of Thoracic Surgeons National Cardiac Database, we analyzed 331 429 coronary artery bypass grafting cases from January 1, 2002, to December 31, 2003, to identify risk factors for major infection. Using logistic regression, 2 models were generated and validated using split-sample validation: (1) One limited to preoperative characteristics (preop model) and (2) one model including both preoperative and intraoperative characteristics (combined model). Major infection occurred in 11 636 patients (3.51%) (25.1% mediastinitis, 32.6% saphenous harvest site, 35.0% septicemia, 0.5% thoracotomy, 6.8% multiple sites). Patients with major infection had significantly higher mortality (17.3% versus 3.0%,
P
<0.0001) and postoperative length of stay >14 days (47.0% versus 5.9%,
P
<0.0001) than patients without major infection. Both the preop model (c-index 0.697) and combined model (c-index: 0.708) successfully discriminated between high- and low-risk patients. A simplified risk scoring system of 12 variables accurately predicted risk for major infection.

Conclusions–

We identified and validated a model that can identify patients undergoing cardiac surgery who are at high risk for major infection. These high-risk patients may be targeted for perioperative intervention strategies to reduce rates of major infection.