bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 120: Assessing the Impact of a Rural STEMI System of Care Initiative: Mission: Lifeline Wyoming
Authors: Langabeer James R , Gerard Daniel , Smith Derek T , Leonard Benjamin , Segrest Wendy , Khan Muhammad , Seo Munseok , Krell Chris , Owan Theophilus , Eisenhauer Michael D
Published: July 2021

Introduction:
Regional systems of care for ST-elevation myocardial infarction (STEMI), such as in Minnesota and North Carolina, have demonstrated improvements in quality of care outcomes. The objective in this study was to collect baseline data on Wyoming statewide STEMI incidence and assess changes in ischemic times and mortality following deployment of a statewide, system of care initiative in the rural state of Wyoming.

Methods:
American Heart Association organized a STEMI initiative in 2012 in Wyoming to address the needs for enhanced rural cardiovascular care. Participating were all 10 STEMI-receiving centers in and around the state, 25 acute care/critical access hospitals, Wyoming Department of Health, 56 emergency medical service (EMS) agencies, and hundreds of volunteer multidisciplinary stakeholders. The initiative deployed approximately 30 training programs, placed 165 12-lead electrocardiogram (ECG) devices in ambulance service, and developed dozens of protocols concerning transfers, treatment, and transport for Wyoming and surrounding border-states. The study design was pre-posttest design, using observational methods of de-identified myocardial infarction data extracted from all 10 participating percutaneous coronary intervention (PCI) facilities’ National Cardiovascular Data Registry (NCDR) submissions. There were 2,301 total MI’s, and 889 STEMIs during calendar years 2013-2014 (24 months). We established the first two quarters as our baseline period, and compared differences in median values using Kruskal-Wallis (KW) and chi-square analyses of variances relative to the the subsequent 6 quarters across several outcome measures (total ischemic time, mortality, thrombolytic administration rates).

Results:
Wyoming has an extremely high transfer rates into PCI, over twice the national average (62%). These transfers produced a long total ischemic time of 291 minutes (nearly 5 hours) in the baseline period, with door-in-door-out times consuming nearly 120 minutes, median. There was a statistically significant 51 minute median reduction in total ischemic times following the program (291 in baseline quarters vs. 241 minutes in subsequent post-intervention periods; KW χ2=4.327, p<.05). There was simultaneously a significant increase in the percent of patients undergoing primary PCI (pPCI) from 54% to 57% (χ2=7.610, p<.01), coupled with a statistically significant reduction in the rate of thrombolytic administration s (46% in the baseline period vs. 37% in the subsequent periods; χ2=6.359, p<.05). Mortality rates were lower than national benchmarks, averaging 3.9% for all MI (5.3% for STEMI), but there were no statistical changes in mortality rates over time.

Conclusions Mission:
Lifeline Wyoming demonstrated statistically significant reductions in median total ischemic time and higher primary PCI reperfusion rates.
Abstract 126: Cardiac Stress Testing: Optimizing Outcomes Through Dual Physician-Patient Education
Authors: Spyropoulos Jelena , Capparelli Catherine C , Bhatt Deepak L
Published: July 2021

Background:
Even though cardiovascular (CV) tests, which are used to assess coronary arterial disease (CAD) are included in medical guidelines, cardiologists have limited ability to adequately perform appropriate testing modalities. In parallel, many patients have concerns or anxiety related to CV testing, and are not proactively educated on how to prepare for their procedure.

Goals:
To determine if an online parallel physician-patient education interventions could improve performance of cardiologists related to CV stress testing, and patient knowledge about the procedure.

Methods:
An online CME activity was developed as a 25-minute roundtable discussion with 3 leading experts on criteria for appropriate use of stress testing and preparing physicians to communicate the risks and benefits of testing modalities to their patients. The activity included a transcript of the discussion and a downloadable slide deck to reinforce key recommendations. Participant responses to questions were collected after the education (post-assessment) and compared with each user’s baseline data (pre-assessment) using a 2-tailed paired T-test to provide
P
values for assessing the impact of education. The CME activity also included a link to a patient/caregiver education module, developed in parallel to educate patients and their caregivers about cardiac stress testing. Patient/caregiver responses post-education compared to pre-education were also assessed to measure improvement in knowledge.

Results:
A total of 312 of cardiologists who participated in the CME activity and answered all pre- and post-assessment questions were included in the analysis. In addition, 3458 patients preparing for a stress test, 640 family members, 116 caregivers, and 3299 other participants interested in the topic of CV testing who completed the patient/caregiver education module and the pre- and post-education questions were included in the assessment. Post-education, significant improvements were observed (Table).

Conclusion:
This study demonstrated that both knowledge/competence of cardiologists on evidence-based practices as well as the understanding of patient/caregivers on CV testing can be improved using a dual approach to education.
Abstract 14: Statin Use Before and After the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guideline
Authors: Pokharel Yashashwi , Tang Fengming , Nambi Vijay , Bittner Vera , Hira Ravi , Nasir Khurram , Chan Paul , Maddox Thomas , Borden William , Spertus John , Petersen Laura , Ballantyne Christie , Virnai Salim
Published: July 2021

Background:
The 2013 ACC/AHA guideline, first published in 11/2013, recommends moderate to high intensity statin therapy in 4 specific patient groups (Table). Whether this guideline has impacted clinical practice is not known.

Methods:
We examined statin use and dose intensity before (9/2012-10/2013) and after (2/2014-3/2015) the guideline in the 4 specific groups from cardiology practices participating in the ACC NCDR®’s PINNACLE Registry after excluding practices with missing data from either period. To assess the guidelines’ effect on statin use, using a hierarchical logistic model, we examined interaction between guideline publication and time to allow different slopes and intercepts during the 2 periods.

Results:
There was a small increase in statin and a similar decrease in non-statin lipid lowering therapy use after the guideline in all 4 groups (overall change <6%, Table), mostly accounted for by a modest increase in high intensity statin use. Although there was significant interaction between guideline publication and time (p=0.034) with steeper slope in the post guideline period, the difference was only modest. For example, in 9/2014 the projected overall statin use was 68.6% without and 71.3% with the interaction the term, respectively.

Conclusion:
There is suboptimal implementation of the 2013 ACC/AHA cholesterol guidelines in cardiology practices. Most high-risk patients are not receiving high intensity statin therapy. More efforts are needed for effective guideline implementation.
Abstract 165: Hospital Variation in Time to Administration of Epinephrine After Cardiac Arrest With Initial Non-shockable Rhythm
Authors: Khera Rohan , Chan Paul S , Donnino Michael W , Girotra Saket ,   American Heart Association Get With the Guidelines–Resuscitation Investigators
Published: July 2021

Background:
For patients with in-hospital cardiac arrests due to non-shockable rhythms, delays in epinephrine administration beyond 5 minutes is associated with worse survival. However, the extent of hospital variation in delayed epinephrine administration and its impact on hospital-level outcomes is unknown.

Methods:
Within Get with the Guidelines-Resuscitation, we identified 103,932 adult patients (>18 years) at 548 hospitals with an in-hospital cardiac arrest due to a non-shockable rhythm who received at least 1 dose of epinephrine between 2000 to 2014. We constructed two-level hierarchical regression models to quantify hospital variation in rates of delayed epinephrine administration (>5 minutes) and its association with hospital rates of survival to discharge.

Results:
Among the 548 hospitals, there was substantial variation in rates of delayed epinephrine administration (median 13.5%, range: 0%- 53.8%). The odds of delay in epinephrine administration were 61% higher at one randomly selected hospital compared to a similar patient at another randomly selected hospitals (median odds ratio [OR] 1.61; 95% C.I. 1.54 - 1.67). After adjusting for patient characteristics, the median risk-standardized survival rate for non-shockable in-hospital cardiac arrests was 12.1% and varied significantly across hospitals (range: 5.2% to 30.9%). There was an inverse correlation between a hospital’s rate of delayed epinephrine administration and its risk-standardized survival rate for cardiac arrests due to non-shockable rhythm (ρ= -0.23, P<0.0001). Compared to hospitals in the best quartile, risk-standardized survival was 17.4% lower at hospitals in the worst quartile of delayed epinephrine administration (13.8% vs. 11.4%, P<0.0001, Figure).

Conclusions:
Although delays in epinephrine administration following in-hospital cardiac arrest are common, there is substantial hospital variation in rates of delayed epinephrine administration. Hospitals with high rates of delayed epinephrine administration were found to have lower rates of risk-adjusted survival. Further studies are needed to determine if improving hospital performance on time to epinephrine administration, especially at hospitals with poor performance on this metric will lead to improvement in outcomes.
Abstract 18: Impact of Malpractice Damage Caps on Cardiac Stress Testing and Medicare Spending
Authors: Farmer Steven A , Moghtaderi Ali , Hovey Nicole E , Black Bernard S
Published: July 2021

Objective:
Physicians report that they often order tests to reduce medical malpractice liability risk. We test the hypothesis that caps on non-economic damages (the most stringent commonly adopted reform) will decrease cardiac testing rates, or healthcare spending more generally, using patient-level data for the Medicare population.

Methods:
We fit a difference-in-differences model on a 5% random sample of Medicare claims between 1999 and 2012. Treatment states (n=9) were those that introduced damage caps during the “third wave” of medical malpractice reform between 2002 and 2005. The remaining states were controls. We compared rates of cardiovascular stress testing and overall spending per enrollee before and after damage caps were adopted. Our model incorporates extensive covariates: individual and zip-code fixed effects; calendar quarter dummies; patient age; the 17 elements of the Charlson comorbidity index, and county-level demographic, socioeconomic, and health care characteristics.

Results:
Damage caps did not significantly affect total Medicare spending per enrollee (coefficient +0.31%, 95% confidence interval [CI] [-0.44%, 1.06%]); part A (Inpatient) spending (coefficient +0.79%, 95% CI [-0.05%, 1.64%]) or part B (Outpatient) spending (coefficient +0.02%, 95% CI [-0.64%, 0.67%]). Damage caps predict a statistically significant but clinically modest rise in stress testing rates (annual increase = 0.31%, 95% CI [0.04%, 0.58 %]). This is a 2.5% increase in the likelihood that an individual will receive a cardiac test in a given year.

Conclusions:
We find no evidence that introduction of damage caps in 9 states in the 2000s decreased either cardiac testing or overall healthcare spending when compared with states without these reforms. Indeed, we find a modest increase in cardiac testing rates, and point estimates for overall spending are also positive. We thus provide evidence against the hypothesis that damage caps reduce overtesting or overall spending.
Abstract 209: Improving Appropriate Use of Pulmonary Artery Pressure as a Diagnostic in HF: Effect of Online CME
Authors: Spyropoulos Jelena , Januzzi James L , Nevins Holder , Kearns Charles
Published: July 2021

Introduction:
Detecting congestion and determining risk for hospitalization represents a clinical challenge in heart failure (HF). New technology allows clinicians to monitor pulmonary artery pressure (PAP) chronically and to tailor therapy in HF patients based on PAP changes. This study’s objective was to assess the relationship between cardiologists’ knowledge and attitudes with case-based decision making in HF.

Hypothesis:
A positive relationship will exist between knowledge and case-based application of PAP in HF management.

Methods:
A 31-question, online, continuing medical education (CME) survey was developed, including knowledge (pathophysiology of HF/PAP, clinical trials) and case-based questions. Chi-square analysis was used to compare the effects between attitudes of respondents among knowledge and case-based questions. Logistic regression was employed to determine impact of knowledge and attitudes on treatment practices in HF.

Results:
485 cardiologists completed the survey with average cumulative correct scores of 54% for case-based questions. Cardiologists had poor knowledge of the pathophysiology of HF, PAP, and the clinical trials related to this topic, with only 6% answering 80% or more questions correctly. There was strong association between higher knowledge and case competency. Cardiologists who understood the importance of fluid retention were more knowledgeable (
P
<0.0001;
d
=0.69) and performed better on case questions (
P
<0.0001;
d
=0.46) than those that did not. Cardiologists comfortable managing and titrating HF medications were more knowledgeable (
P
<0.0001;
d
=0.82) and performed better on case questions
(P=
0.003;
d
=0.51) than those that were not. Linear regression analysis suggested increase in HF/PAP pathophysiology knowledge by 1 question would result in an 18% improvement in performance
(P<
0.0008), indicating that knowledge of HF/PAP pathophysiology is a strong predictor of physician performance.

Conclusions:
A significant positive relationship between cardiologists’ knowledge/attitudes and their case-based application of PAP in management of HF supports the need to develop CME activities that align physicians’ knowledge and performance to improve outcomes and reduce hospitalizations.
Abstract 210: Improving Evidence-Based Decisions in SIHD Management: Simulation in Continuing Education
Authors: Spyropoulos Jelena , Capparelli Catherine C
Published: July 2021

Background:
Guideline-directed medical therapy (GDMT) to manage angina is widely underused in patients with stable ischemic heart disease (SIHD), and patients are often misdiagnosed and not managed appropriately.

Goals:
This study was conducted to determine if an online, simulation-based continuing medical education (CME) intervention could improve performance of cardiologists in medical management of patients with SIHD.

Methods:
The CME intervention consisted of two cases presented in a platform that allowed learners to choose from numerous lab tests, diagnoses and treatments matching the scope and depth of actual practice. The clinical decisions made by the learners were analyzed using an artificial intelligence engine, and clinical guidance (CG) was then provided based on current evidence and expert recommendation. Learner decisions were collected after CG and compared with each user’s baseline (pre-CG) data using a 2-tailed paired T-test to determine
P
values for assessing the impact of education on clinical decisions.

Results:
As a result of CG, significant improvements were observed among cardiologists post- CG compared to pre-CG, related to patient assessment, diagnosis and appropriate treatment of SIHD (Table).

Conclusion:
This study demonstrated that simulation-based CME can improve evidence-based practices of cardiologists related to management of SIHD. In addition, ongoing educational gaps were uncovered related to appropriate patient assessment, ability to diagnose SIHD, as well as ability to appropriately order step-up antianginal therapy.
Abstract 22: Impact of CHA2DS2-VASc Risk Factors on Anticoagulant Prescription in Patients with Atrial Fibrillation: Insights From the NCDR® PINNACLE Registry
Authors: Thompson Lauren E , Maddox Thomas M , Lei Lanyu , Grunwald Gary K , Bradley Steven M , Peterson Pamela N , Daugherty Stacie L , Masoudi Frederick A
Published: July 2021

Background:
The CHA2DS2-VASc score is a tool to assess thromboembolic risk in patients with non-valvular atrial fibrillation (AF). Whether individual components of the CHA2DS2-VASc score are considered equivalent in decisions to use oral anticoagulant (OAC) in current clinical practice is unknown.

Method:
Using data collected in the outpatient National Cardiovascular Data Registry (NCDR) PINNACLE registry from 2010-2014, OAC use (warfarin or novel anti-coagulants versus none) was compared in patients with non-valvular AF and an indication for OAC (CHA2DS2-VASc ≥ 2). We assessed the association between individual CHA2DS2VASc components (female gender, congestive heart failure (CHF), hypertension (HTN), age 64-75, age ≥ 75, diabetes mellitus (DM), vascular disease, and stroke/transient ischemic attack (TIA)) and OAC use, adjusting for demographics, clinical factors, modified HASBLED (mHASBLED) scores, and accounting for clustering by hospital and provider with multivariable logistic regression models.

Result:
Of 706,308 patients with non-valvular AF and an indication for OAC use (CHA2DS2-VASc ≥2), 65% were white and mean age was 74.4±10.7. The mean CHA2DS2-VASc score was 3.93±1.42; 48% were female, 26% had CHF, 80% had HTN, 84% were age ≥ 65, 24% had DM, and 4% had stroke/TIA. Among this cohort with an indication for OAC use, in unadjusted models, female gender (OR 0.83, 95% CI 0.82-0.84) and vascular disease (OR 0.75, 95% CI 0.71-0.79) were associated with significantly less OAC use. In adjusted models, gender and vascular disease remained significantly associated lower OAC use whereas age and HTN were associated with higher OAC use. (FIGURE)

Conclusions:
Among this cohort of AF patients with an indication for OAC use, older age and HTN were strongly associated with greater OAC use whereas female gender and vascular disease were associated with less OAC use. Further investigation is needed to understand reasons for these differences in how risk factors influence decisions to provide OAC, such as patient or provider preference or gender bias.
Abstract 237: Prognostic Significance of Left Ventricular Hypertrophy (lvh) by Electrocardiography in a Minority-predominant Heart Failure (hf) Cohort
Authors: Majeed Muhammad U , Oseni Abdullahi , Akanbi Olabisi , Agboto Vincent , Okafor Henry E
Published: July 2021

Background:
Left ventricular Hypertrophy (LVH) has been associated with higher cardiovascular morbidity and mortality but most of these studies were conducted in majority (white) populations. LVH is known to be more common in African Americans (AA) who also have a higher prevalence of cardiovascular morbidity and mortality. The prognostic significance of LVH in AA with Heart Failure (HF) has not been well studied.

Methods:
We performed a retrospective analysis of a predominantly minority HF cohort (69.3% AA); after obtaining approval from our institutional review board. Our primary goal was to compare the HF outcomes [All-cause hospitalizations (ACH), hospitalizations primarily due to HF and ER visits] in patients with EKG evidence of LVH versus those without LVH. We also examined the racial (Blacks vs Whites), gender (males vs females) and age-based (≥60 Vs <60 years) differential impact of LVH on HF outcomes and determined the prevalence of LVH in the cohort. Levene’s Test and t-test were used to analyze the data for equality of variances and means respectively.

Result:
Our HF cohort consisted of 599 patients (415 AA, 142 Caucasian, 22 others, 20 unknown). The prevalence of LVH in overall cohort was 26.7%. We noted that black had higher prevalence of LVH ( 31%) vs Whites (15.5%) while prevalence of LVH was not very different in males ( 27.9%) vs females( 25.7%) and ≥60 years of age( 27.5%) vs <60 (27.3%).

The analysis showed that there were statistically significant differences in the number of ACH (p-value = 0.014), HF hospitalizations (p-value = 0.019) and ER visits (p-value = 0.001) in the LVH group compared with the non-LVH group. .

There were no racial, gender or age-based statistically significant differences in the impact of LVH on HF outcomes.

Conclusion:
Electrocardiographically determined LVH in a minority - predominant HF cohort is associated with worse outcomes. This needs to be prospectively validated in a larger cohort of HF and could serve as a prognostic marker to guide the care of HF patients.
Abstract 240: Regional Variation in 30-Day Ischemic Stroke Mortality and Readmissions in Get With the Guidelines-Stroke Hospitals
Authors: Thompson Michael P , Zhao Xin , Bekelis Kimon , Gottlieb Daniel J , Fonarow Gregg C , Schulte Phillip J , Schwamm Lee H , Smith Eric E , Reeves Mathew J
Published: July 2021

Objective:
To explore regional variation and correlation between 30-day ischemic stroke mortality and readmissions in ischemic stroke patients treated at Get With The Guidelines (GWTG)-Stroke hospitals.

Methods:
Hospital-level 30-day ischemic stroke mortality and readmission rates were generated by linking GWTG-Stroke national registry data (2007-11) to Medicare fee-for-service data. We then aggregated GWTG-Stroke hospitals into hospital referral regions (HRR) as defined by the Dartmouth Atlas. Frequency-weighted 30-day event rates were estimated for each HRR, which were risk-adjusted using HRR-level patient and hospital characteristics. A Pearson correlation coefficient (r) was used to estimate the linear relationship between mortality and readmission rates at the HRR level.

Results:
There were 429,631 ischemic stroke patients at least 65 years of age treated at 1,344 GWTG-Stroke hospitals in 282 different HRRs. The average HRR-level risk adjusted 30-day mortality rate was 10.3% (SD=1.1%), with range 7.4% to 15.6%. The average HRR-level risk adjusted readmission rate was 13.2% (SD=1.4%), with range 9.7% to 23.3%. HRR-level maps suggest that some regions with higher than average mortality - such as the Mountain West and Upper Midwest regions - had lower than average readmission rates. (Figure 1) There was a modest, but statistically significant negative correlation between 30-day mortality and readmission rates (r = -0.23, p<0.0001). (Figure 2)

Conclusions:
HRR-level 30-day ischemic stroke mortality and readmission rates exhibit substantial regional variation and are inversely correlated. Further research is ongoing to determine the origin of the regional variation and correlation between 30-day event rates.
Abstract 244: Sex-based Differences in Economic and Health-related Burden of Depression on Adults With Cardiovascular Disease
Authors: Valero-Elizondo Javier , Salami Joseph A , Ogunmoroti Oluseye , Ali Shozab , Arrieta Alejandro , Spatz Erica S , Rana Jamal S , Virani Salim S , Blankstein Ron , Blaha Michael J , Veledar Emir , Nasir Khurram
Published: July 2021

Background:
Depression is commonly present in patients with cardiovascular disease (CVD). Among those with established CVD, depression is more common in women and associated with worse outcome. However, how depression affects overall health care expenditures, as well as whether depression among women has a greater impact on medical costs, has not been well studied, which is the aim of the present study.

Methods:
The 2012 Medical Expenditure Panel Survey was analyzed to explore this project. Variables of interest were defined as CVD (coronary artery disease, stroke, peripheral artery disease, dysrhythmias or heart failure) and depression diagnoses, ascertained by ICD-9-CM codes (410, 413, 433-437, 427-28, 440, 443, 447 and 296, 311, respectively). We restricted our study population to non-institutionalized adults ≥ 18 years of age. Two-part models were utilized to study cost data; a generalized linear model with gamma distribution and link log was used to assess the mean expenditure per capita for each sex/depression status.

Results:
27,288 surveyed persons constituted our study population (mean age 67 ± 12.4, 46% female), translating to an approximate of 231 million people across the U.S. Overall, CVD was noted in 15.6 million, of which 18% were patients with depression (2.9 million). Of this nationally representative sample, those with CVD were 86% more likely to be diagnosed with depression (OR 1.86, 95% CI 1.51, 2.28, p<0.001) than Non-CVD. Additionally, among CVD individuals, females were 66% more likely be diagnosed with depression than males (OR 1.66, 95% CI 1.23, 2.23, p=0.001). CVD diagnosis was independently associated with higher healthcare costs among individuals with depression. Moreover, on adjusted analysis, females with depression were also associated with $4,380.14 higher medical costs than those without depression (Table 1). When comparing female vs. males with CVD and depression diagnoses, adjusted mean expenditure per capita was $14,162 (95% CI 10,211 - 18,112) and $11,325 (95% CI 7,769 - 14,881), respectively.

Conclusion:
CVD patients, especially women, were more likely to have depression, and had considerable higher medical expenditures. The results reinforce the paramount importance of assessing and managing depression among those with CVD to favorably impact healthcare costs.
Abstract 3: Patient Satisfaction and Healthcare Service Utilization Following Premature Acute Coronary Syndrome
Authors: Okano Marisa , Pelletier Roxanne , Behlouli Hassan , Pilote Louise ,   GENESIS-PRAXY Investigators
Published: July 2021

Objectives.
Patient centered care is recognized as central to a high-quality healthcare system. Satisfaction with healthcare services may be differentially experienced among young adults suffering from heart disease. The current study examined the association between patient satisfaction with healthcare services, utilization, and clinical outcomes in patients with premature acute coronary syndrome (ACS).

Methods and Results.
We used data from 1033 patients (≤ 55 years) hospitalized for ACS and enrolled into the prospective cohort study, GENESIS-PRAXY (GENdEr and Sex determInantS of cardiovascular disease: from bench to beyond PRemature Acute Coronary SYndrome). Participants were recruited between January 2009-April 2013, from 24 centers across Canada, 1 in the US, and 1 in Switzerland. Patient satisfaction with treatment and subsequent healthcare service utilization/clinical outcomes were assessed within 12 months post-index ACS through questionnaire and medical chart review. The median age of our cohort was 48 years and 30% were female. Ninety two percent of males and females reported high satisfaction with healthcare services; however, among patients with low satisfaction we observed lower social support (48% vs. 24%; p<.0001) and higher rates of depression (46% vs. 22%; p<.0001) at baseline. Multivariable Cox regressions adjusted for patient characteristics and clinical risk factors indicated lower risk of cardiac ER visits (HR=0.56; 95%CI, 0.34-0.93; P=0.01) and cardiac rehospitalization (HR=0.55; 95%CI, 0.28-1.07; P=0.08) among patients with higher satisfaction. There was no association between patient satisfaction level and risk of major adverse cardiac events (MACE) (HR=0.61; 95% CI, 0.32-1.19 P=0.15).

Conclusions.
Patients with lower satisfaction with healthcare services at index ACS were more likely to visit the ER and to be rehospitalized for cardiac reasons. Patient satisfaction level was not associated with risk of adverse clinical outcomes. Our results suggest that the younger ACS population may be a tangible target for reducing healthcare utilization through increased patient satisfaction.
Abstract 9: Post-Discharge Use of Statin and Lipid Testing After Myocardial Infarction
Authors: Wang William T , Hellkamp Anne , Doll Jacob , Thomas Laine , Navar Anne M , Fonarow Gregg C , Julien Howard , Peterson Eric D , Wang Tracy Y
Published: July 2021

Background:
The 2013 ACC/AHA cholesterol guidelines recommend high intensity statin use for all post-myocardial infarction (MI) patients, instead of treating to a low density lipoprotein cholesterol (LDL-C) goal on follow-up lipid testing. We examined whether high intensity statin use was common in U.S. practice prior to these guideline updates.

Methods:
We linked the ACTION Registry-GWTG to Medicare data and evaluated 11,046 post-MI patients aged ≥65 years discharged alive on a statin from 347 hospitals between 2007 and 2009. Rates and dosing of lipid therapy as well as follow-up lipid testing within 90 days after discharge were studied. Multivariable logistic regression was used to evaluate the association of lipid testing with 1-year statin use and intensity.

Results:
Only 21% of MI patients were discharged on a high intensity statin. By 90 days post-MI, 44% (n=4,884) of patients underwent lipid testing. Among patients discharged on low/moderate intensity statins, 43% underwent lipid testing within the next 90 days, and 49% of patients discharged on high intensity statins received lipid testing within 90 days. Rates of lipid testing did not differ substantially between patients with LDL-C ≥100 mg/dL vs. <100 mg/dL during the MI hospitalization (47% vs. 43%). Among MI patients alive at 1 year, 74% remained on a statin, yet only 14% were on a high intensity statin. Only 4% of those discharged on low/moderate dose statin had been titrated up to a high intensity statin. Patients undergoing lipid testing within 90 days of discharge were more likely to be on a statin at 1 year (Figure, adjusted OR 1.17, 95% CI 1.07-1.29), and more likely to have their statin therapy intensified (adjusted OR 1.92%, 95% CI 1.52-2.41).

Conclusion:
Prior to the 2013 ACC/AHA cholesterol guideline updates, only 1 in 5 MI patients were discharged on high intensity statin therapy. Although follow-up lipid testing was associated with both higher rates of statin persistence to one year and increased likelihood of statin intensification, it was performed in only a minority of patients. The new cholesterol guidelines may promote more aggressive lipid management and cardiovascular risk reduction by eliminating treatment dependence on follow-up lipid testing.
Impact of Mitral Valve Regurgitation Evaluated by Intraoperative Transesophageal Echocardiography on Long-Term Outcomes After Coronary Artery Bypass Grafting
Authors: Schroder Jacob N. , Williams Matthew L. , Hata Jonathan A. , Muhlbaier Lawrence H. , Swaminathan Madhav , Mathew Joseph P. , Glower Donald D. , O’Connor Christopher M. , Smith Peter K. , Milano Carmelo A.
Published: July 2021

Background—

It is unclear if mild or moderate mitral valve regurgitation (MR) should be repaired at the time of coronary artery bypass grafting (CABG). We sought to determine the long-term effect of uncorrected MR, measured by intraoperative transesophageal echocardiography (TEE), in CABG patients.

Methods and Results—

Between May 1999 and September 2003, data were gathered for 3264 consecutive patients who underwent isolated CABG and had MR graded by intraoperative TEE. MR was graded on the following 5 levels: none, trace, mild, moderate, and severe. Patients who had severe MR or who underwent mitral valve surgery were eliminated from the analysis. The remaining patients were combined into the following 3 groups: none or trace, mild, and moderate MR. Preoperative and follow-up data were 99% complete. The median length of follow-up was 3.0 years. Multivariable analysis controlling for important preoperative risk factors was performed to determine predictors of death and death/hospitalization for heart failure. Increasing MR was a risk factor for death [hazard ratio (HR), 1.44;
P
<0.001] and death/heart failure hospitalization (HR, 1.34;
P
<0.01). When patients with moderate MR were eliminated from the analysis, mild MR was a risk factor for death (HR, 1.34;
P
=0.011) and death/hospitalization for heart failure (HR, 1.34;
P
<0.001).

Conclusions—

Even mild MR, identified by intraoperative TEE, predicts worse outcomes after CABG. Revascularization alone did not eliminate the negative long-term effects of mild MR. CABG patients with uncorrected mild or moderate MR are at increased risk for death and heart-failure hospitalization; consideration for surgical repair or more aggressive medical management and follow-up is warranted.
Bradykinin Preconditioning Improves the Profile of Cell Survival Proteins and Limits Apoptosis After Cardioplegic Arrest
Authors: Feng Jun , Bianchi Cesario , Sandmeyer Jennifer L. , Sellke Frank W.
Published: July 2021

Background—

We hypothesized that preconditioning the heart with bradykinin (BK) would improve the profile of antiapoptotic proteins and inhibit myocardial apoptosis.

Methods and Results—

Eighteen rabbit hearts were retrogradely perfused with Krebs-Henseleit buffer (KHB). Six control hearts were perfused with KHB for 90 minutes without cardioplegia ischemia. Six hearts were arrested for 30 minutes (37°C) with crystalloid cardioplegia (CCP). Six BK preconditioning (BKPC) hearts received a 10-minute coronary infusion of 10
−8
M BK-enriched KHB followed by a 5-minute recovery period and were then arrested for 30 minutes with CCP. The hearts were reperfused for 30 minutes with KHB. BKPC significantly improved the recovery of left ventricular pressure (73±5 versus 51±4 mm Hg;
P
<0.05) and reduced the percentage of myocardial apoptosis (3.4±0.3% versus 1.2±0.2%;
P
<0.05) as compared with CCP. There were no significant differences in total protein levels of caspase 3, Bcl-2, Bad, and Bax, among the groups. Both BKPC and CCP induced phosphorylation of Bad at Ser
112
, but the BKPC group had higher phosphorylated Bad than CCP (4.4±0.5 versus 2.0±0.3;
P
<0.05). Both BKPC and CCP alone increased caspase 3 cleavage and activity as compared with controls (
P
<0.05 and
P
<0.01, respectively), but BKPC caused less cleavage and activation of caspase 3 than CCP alone (
P
<0.05).

Conclusions—

BKPC increased Bad phosphorylation, inhibited caspase 3 activation, and limited myocardial apoptosis, which were associated with improvement of left-ventricular performance. These results identify novel molecular mechanisms underlying the protective effects of BKPC during cardiac surgery.
Impact of the Maze Operation Combined With Left-Sided Valve Surgery on the Change in Tricuspid Regurgitation Over Time
Authors: Kim Hyung-Kwan , Kim Yong-Jin , Kim Kwang-Il , Jo Sang-Ho , Kim Ki-Bong , Ahn Hyuk , Sohn Dae-Won , Oh Byung-Hee , Lee Myoung-Mook , Park Young-Bae , Choi Yun-Shik
Published: July 2021

Background—

Atrial fibrillation (AF) has been reported to be a predisposing factor for the progression of TR in patients with previous mitral or combined mitral/aortic valve surgery. We hypothesized that the maze operation (MAZE) can prevent the progression of tricuspid regurgitation (TR) in these patients.

Methods and Results—

We analyzed 170 patients (age, 45.5±10.9 years) who had undergone mitral or combined mitral/aortic valve surgery. On the basis of preoperative rhythm, patients were divided into 3 groups; GrI was composed of 44 patients with sinus rhythm, GrII of 48 who had undergone MAZE, and GrIII of 78 with AF who had not undergone MAZE. Echocardiographic examinations were performed before, immediately after, and 92.2±17.2 (range, 50 to 131) months after surgery. Preoperative and immediate postoperative clinical and echocardiographic parameters were similar among the groups. Insignificant TR at the immediate postoperative examination worsened with time in 7.3% of GrI (3 of 41), 12.8% of GrII (6 of 47), and 38.8% of GrIII (26 of 67) patients at the final examination (
P
=0.63 for GrI versus GrII,
P
=0.001 for GrI versus GrIII,
P
=0.005 for GrII versus GrIII). The incidence of significant TR at the final echocardiographic examination was higher in GrIII (39.7%) compared with GrI (9.1%) and GrII (14.6%) (
P
=0.001 for GrI versus GrIII,
P
=0.005 for GrII versus GrIII), whereas GrI and GrII did not show any difference (
P
=0.63). By multivariate analysis, the only factor identified to prevent TR progression was the group factor (GrI and GrII versus GrIII,
P
=0.002 and
P
=0.005, respectively). In a subgroup analysis of GrII according to the presence or absence of atrial mechanical activity, the absence of atrial mechanical activity was identified as an independent parameter for the progression of TR (
P
=0.001).

Conclusions—

AF predisposes patients undergoing mitral valve surgery to the progression of TR, which can be prevented by MAZE. This additional benefit of MAZE is largely dependent on the restoration and maintenance of atrial mechanical function.
Hemodynamic and Vascular Effects of Ventricular Sourcing by Stent-Based Ventricle to Coronary Artery Bypass in Patients With Multivessel Disease Undergoing Coronary Artery Bypass Surgery
Authors: Boekstegers Peter , Raake Philip , Hinkel Rabea , Pohl Tilmann , Kupatt Christian , Knez Andreas , Christ Frank , Eifert Sandra , Steinbeck Gerhard , Reichart Bruno , Vicol Calin
Published: July 2021

Background—

The hemodynamic and vascular effects of ventricular sourcing by a stent-based (VSTENT, Percardia) left ventricle-to-coronary artery bypass were studied in a patient subgroup of the European multicenter ADVANTAGE study (ADjunctive treatment with the VCAB/VSTENT myocardial implANT system in coronary Artery bypass Graft patiEnts).

Methods and Results—

Twelve patients who underwent VSTENT implantation in addition to coronary artery bypass surgery were studied up to 12 months after the procedure. The VSTENT was implanted distal to a hemodynamically relevant coronary artery stenosis. Coronary flow velocity was assessed at rest and during dobutamine stress. Intraoperative VSTENT implantation was successful in 11 of 12 patients. Early postoperative angiograms showed patent VSTENT in 8 of 11 patients, with predominantly systolic flow distal to the VSTENT. Coronary flow velocity reserve induced by dobutamine stress was 1.7±0.1 (
P
=0.006). VSTENT patency at 2- to 6-month follow-up was present in 5 of 11 patients, with concomitant VSTENT stenosis in 4 of those 5. In all patients, coronary flow velocity increased 3- to 4-fold proximal to the VSTENT, which was associated with a moderate degree of arterial remodeling. Except for target vessel reintervention (n=5), no other major adverse events were observed in 11 of 12 patients. One patient died on the second postoperative day, though the cause was probably not related to the VSTENT implantation.

Conclusions—

VSTENT implantation seems to be safe in the mid-term follow-up and leads to a predominantly systolic coronary flow pattern in the vessel supplied by the VSTENT, with a flow reserve similar or close to that seen with conventional bypass. VSTENT patency rate, however, was unacceptably low at 3- to 6-month follow-up and needs to be improved.
Long-Term Results in Patients With Idiopathic Dilated Cardiomyopathy After Weaning From Left Ventricular Assist Devices
Authors: Dandel Michael , Weng Yuguo , Siniawski Henryk , Potapov Evgenij , Lehmkuhl Hans B. , Hetzer Roland
Published: July 2021

Background—

Since our first successful left ventricular assist device (LVAD) explantation in a patient with idiopathic dilated cardiomyopathy (IDCM) in 1995, an additional 31 IDCM patients have been weaned in our department. Echocardiographic evaluations during repeated “off-pump” trials were the cornerstone for weaning decisions. After 9 years of experience, we assessed the reliability of our weaning criteria in light of the long-term results.

Methods and Results—

We evaluated all of the IDCM patients who were weaned between March 1995 and March 2004 with regard to preservation of cardiac function without LVAD support and survival after weaning. Additionally, we reviewed our echocardiographic data to assess their predictive value for long-term stability of cardiac function after weaning. The 32 weaned IDCM patients showed a survival rate of 78.3%±8.1 at 5 years after LVAD explantation. Heart failure (HF) recurred during the first 3 years after weaning in 31.3%. Only 2 patients died because of HF after weaning; the other patients with HF recurrence were successfully transplanted. Off-pump LV end-diastolic diameter >55 mm and/or LVEF <45% before LVAD removal, as well as history of HF ≥5 years before LVAD implantation, appeared to be major risk factors for early recurrence of HF. Patients without any of these 3 risk factors showed no HF recurrence during the first 3 years after weaning, but at the same time, all of those with at least 2 of these 3 risk factors developed early recurrence of HF. In patients with HF recurrence during the first 3 postweaning years, a significant LVEF decrease already occurred during the first month after weaning, whereas in those with long-term stable cardiac function even at the end of the sixth postweaning month, the LVEF was not different from that before LVAD removal.

Conclusions—

For selected patients with IDCM, weaning from LVADs is a clinical option with good results over >9 years and should, therefore, be considered in those with cardiac recovery after LVAD implantation. Off-pump echocardiographic data are reliable for the detection of LV recovery and prediction of long-term cardiac stability after weaning.
Extracellular Matrix Scaffold for Cardiac Repair
Authors: Robinson Keith A. , Li Jinshen , Mathison Megumi , Redkar Alka , Cui Jianhua , Chronos Nicolas A.F. , Matheny Robert G. , Badylak Stephen F.
Published: July 2021

Background—

Heart failure remains a significant problem. Tissue-engineered cardiac patches offer potential to treat severe heart failure. We studied an extracellular matrix scaffold for repairing the infarcted left ventricle.

Methods and Results—

Pigs (n=42) underwent left ventricular (LV) infarction. At 6 to 8 weeks, either 4-layer multilaminate urinary bladder-derived extracellular matrix or expanded polytetrafluoroethlyene (ePTFE) was implanted as full-thickness LV wall patch replacement. At 1-week, 1-month, or 3-month intervals, pigs were terminated. After macroscopic examination, samples of tissue were prepared for histology, immunocytochemistry, and analysis of cell proportions by flow cytometry. One-week and 1-month patches were intact with thrombus and inflammation; at 1 month, there was also tissue with spindle-shaped cells in proteoglycan-rich and collagenous matrix. More α-smooth muscle actin-positive cells were present in urinary bladder matrix (UBM) than in ePTFE (22.2±3.3% versus 8.4±2.7%;
P
=0.04). At 3 months, UBM was bioresorbed, and a collagen-rich vascularized tissue with numerous myofibroblasts was present. Isolated regions of α-sarcomeric actin-positive, intensely α-smooth muscle actin-immunopositive, and striated cells were observed. ePTFE at 3 months had foreign-body response with necrosis and calcification. Flow cytometry showed similarities of cells from UBM to normal myocardium, whereas ePTFE had limited cardiomyocyte markers.

Conclusions—

Appearance of a fibrocellular tissue that included contractile cells accompanied biodegradation of UBM when implanted as an LV-free wall infarction patch. UBM appears superior to synthetic material for cardiac patching and trends toward myocardial replacement at 3 months.
Chromosome 2 Reciprocal Congenics to Evaluate the Effect of the Genetic Background on Blood Pressure
Authors: Negrin Cervantes D , Graham Delyth , Clark James S , McBride Martin W , Carr Fiona J , Anderson Niall H , Dominiczak Anna F
Published: July 2021

54

Background Localisation of QTL using a genome wide scan strategy is the first step towards gene identification. This is followed by the construction of congenics by which the existence of the QTL can be verified. Congenic strains for chromosome 2 using the Dahl S as the recipient and WKY and MNS as donors, showed variable blood pressure (BP) depending on the donor alleles
1
. Methods We used a speed congenic approach to produce several congenic strains of chromosome 2 using the SHRSP
Gla
and the WKY
Gla
as recipients to test the effect of the genetic background of a given congenic on BP. In some strains, the region introgressed was identical to avoid confounding effects of additional QTLs. Two reciprocal control congenic strains were also produced to determine the presence of any passenger loci. Baseline systolic BP was measured by radiotelemetry. Results Four congenic and 2 parental strains were phenotyped (n=3-6). Transfer of the region of rat chromosome 2 from the WKY into a SHRSP background significantly lowered both day and night-time systolic BP by approximately 16 and 20 mm Hg respectively in male congenic rats compared to the SHRSP parental strains (p<0.005, 95%CI: 8.6-21.0 mm Hg; and p<0.005, 95%CI: 16.7-24.7 mm Hg). In contrast, transfer of the same region from the SHRSP into a WKY background significantly increased both day and night-time systolic BP by approximately 25 and 28 mm Hg, respectively in male congenic rats compared to the WKY parental strains (p<0.05, 95%CI: -49.2-2.0 mmHg; and p<0.05%, 95%CI: -61.2-6.1 mm Hg, respectively). Reciprocal control congenic strain showed no deviation from the BP recorded in the parental strain (Strain WKY.SPGla2b vs. WKY parental strain, 128.8±5.2 mm Hg vs. 139.7±5.7 mm Hg, p= ns; and strain SP.WKYGla2b vs. SHRSP parental strain, 178.0±5.0 mm Hg vs. 179.9±2.1 mm Hg, p= ns). Conclusions The results show the effect of a permissive background on BP and confirm that the genetic background chosen for a congenic strain has a significant effect on the BP phenotype. Moreover, this work sheds new light on the different epistatic or pleiotropic effects according to the genetic background chosen. 1. Deng AY
et al
. Hypertension 1997;30:199-202
ACE Inhibitor Causes Kinin-Mediated Renal Vasodilatation in Goldblatt Rabbit
Authors: Zimmerman Ben G
Published: July 2021

P24

ACE inhibitors cause an increase in renal blood flow (RBF) by a kinin-mediated mechanism in the sodium-restricted dog with a high renin level. Previous findings of an inconsistent decrease in plasma angiotensin II after ACE inhibition in Goldblatt rabbits, lead to the hypothesis that a similar effect of ACE inhibition occurs in this high renin model. The systemic blood pressure (BP) and renal hemodynamic effects of enalaprilat (10 mg/kg IV) were compared in 2 groups of rabbits anesthetized with sodium pentobarbital. Blood pressure was measured from the carotid artery and right RBF determined by electroflowmetry. All rabbits underwent clipping of the left renal artery on the average 24 days prior to the acute experiment. Group 1 (n=7) was administered enalaprilat to elicit the normal response to ACE inhibition. Group 2 (n=5) was given the kinin B2 receptor antagonist icatibant as an IV infusion (5 μg/kg/min) during the administration of enalaprilat. This dose of icatibant blocked completely the depressor response to kallidin and itself had no effect on BP or RBF. Results of these experiments are summarized in the Table. Enalaprilat caused a marked rise in RBF and decrease in BP and renal vascular resistance in Group 1. No significant effect of enalaprilat was seen in Group 2. Thus, based on these results, it is concluded that the kallikrein-kinin system plays a major role in the BP and renal hemodynamic response of ACE inhibition in this high renin state.