bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 15853: Long-Term Outcomes of Young Patients With Chest Pain and Normal Epicardial Coronary Arteries: A 10-Year Prospective Study
Authors: Naderian Mohammadreza , Saadatagah Seyedmohammad , Ramandi Alireza , Alipasandi Kian , Pourhosseini Hamidreza , sadeghian saeed
Published: December 2023

Introduction:
Long-term outcomes of young patients with chest pain and normal epicardial coronary arteries (NECA) in angiography remain understudied.

Methods:
We conducted a prospective study in a tertiary heart hospital between 2004-2020, enrolling men<45 and women<55 years presenting with symptoms or objective findings of coronary artery disease (CAD) and confirmed NECA in angiography. Patients with cardiomyopathy, coronary anomaly, and significant valvular, renal, pulmonary, or liver diseases were excluded. The primary outcome was MACCE, defined as the composite of death, CCU admission (for MI or unstable angina), stroke, and revascularization. Follow-ups were done every 5 years using a standardized questionnaire and a committee of experts reviewed all the events. Expected age and sex-adjusted mortality rates were estimated using national data. The association between exposures and MACCE was studied using multivariable Cox-proportional hazard models.

Results:
1257 patients, 340 (27.05%) men (38.34±5.46 years), and 917 (72.95%) women (48.41±4.94 years) were included. 698 (55.53%) had acute and 559 (44.47%) had chronic symptoms. Over the median 9.4 (8.5-11.0) years of follow-up, 134 (10.66%) events happened. CCU admission (6.33%) was the most common event (Figure). The 10-year mortality rate (per 100,000-person-years) was 265 for men and 174 for women, which were 1.6 and 2.5 times higher than the age-sex-matched rate of the normal population, respectively. Diabetes, hypertension, and presenting with acute symptoms were associated with higher MACCE with the hazard ratios (95% CI) of 1.87 (1.05-3.31, P:0.03), 1.72 (1.13-2.61, P:0.01), and 1.56 (1.03-2.36, P:0.04), respectively. During follow-up, 192 (15.27%) repeated angiographies were done and 19.8% developed obstructive CAD.

Conclusions:
In young patients with chest pain and NECA, approximately 10% experienced MACCE during a 10-year follow-up, and the mortality is higher than expected.
Abstract 15862: Risk Prediction Model for Early Detection of Left Bundle Branch Associated Nonischemic Cardiomyopathy: Insights From the UK Biobank
Authors: Kingsley Jeffrey , Bhave Prashant , Mitra Raman
Published: December 2023

Introduction:
Ventricular dyssynchrony resulting from left bundle branch block (LBBB) can lead to development of nonischemic cardiomyopathy (NICM) in some individuals. Increasing evidence suggests early treatment with cardiac resynchronization therapy yields a greater treatment effect while a delayed diagnosis of LBBB NICM may fail to capture the critical period to reverse the progressive myocardial damage. Early identification of LBBB patients most likely to develop NICM would be valuable to clinical management.

Methods:
International classification of diseases (ICD) codes from the linked health data in the UK Biobank were used to identify individuals with LBBB NICM along with baseline demographics and comorbidities. Logistic regression models adjusted for covariates in baseline characteristics were used to identify early predictive indicators based on electrocardiogram (ECG) parameters and physical activity data obtained at time of enrollment into the UK Biobank

Results:
Among 3,766 individuals with LBBB, 481 developed LBBB NICM. The adjusted logistic regression analyses demonstrated a one standard deviation increase in p-axis was associated with a 128% higher incidence of LBBB NICM (OR 2.28, CI 1.10-4.73, p=0.01) and an increase of one day per week of vigorous physical activity was associated with an 8% lower incidence of LBBB NICM (OR 0.92, CI 0.87-0.98, p=0.006). A risk prediction model using the predictive indicators of p-axis and vigorous activity per week yielded an area under the receiver operating characteristic curve of 0.87.

Conclusions:
A risk prediction model using ECG parameters and physical activity was developed which provides personalized estimation of the likelihood of development of NICM in individuals with LBBB using readily accessible clinical parameters. Further investigations are necessary to refine risk stratification strategies, validate this in a larger population, and optimize patient management based on these findings.
Abstract 15864: Genetic Findings of Cardiac Sarcoidosis in a Case of Apical Variant Hypertrophic Cardiomyopathy With Recurrent Ventricular Tachyarrhythmias
Authors: Ding Jeffrey , AZCARATE PATRICK , Duran Jason M , Soto-Hermida Angel , Bushway Paul , Ainsworth Richard , Wang Wei , Hu Jingjing , Adler Eric
Published: December 2023

Background:
Genetic sequencing is changing the way physicians practice medicine. Hypertrophic cardiomyopathy (HCM) is one of the most common inheritable cardiac diseases. Sarcoidosis is a multisystem disease involving granulomatous infiltration of the lungs, heart, and other organs thought to be caused by a dysregulated immune system, influenced by genetic factors. Here, we present a case where an individual initially diagnosed with HCM was experiencing frequent episodes of ventricular tachycardia (VT). Further workup, including advanced imaging along with whole genome screening (WGS), revealed an unlikely diagnosis of concurrent cardiac sarcoidosis (CS).

Clinical History:
A 62-year-old man had ventricular fibrillation with workup notable for an ECG with deeply inverted T-waves, normal coronary angiography, and an echocardiogram and MRI showing apical HCM. An ICD was placed. Six years later, he had VT requiring a shock and was started on sotalol. He has now developed recurrent exercise-induced VT. While VT is seen HCM, the increasing frequency prompted further evaluation. A CT coronary angiogram showed normal coronaries and mediastinal lymphadenopathy. Lymph node biopsy revealed noncaseating granulomas and a PET/CT revealed hypermetabolic basal myocardium meeting HRS criteria for CS. Given minimal apical FDG uptake and a low likelihood that he had CS for 9 years without significant fibrosis, he likely has both HCM and CS. Using WGS, four genetic variants previously described in CS and HCM were identified confirming this diagnosis, HLA-DRB1, HLA-DQA1, ALPK3, and TTN.

Discussion:
HLA-DRB1 and HLA-DQA1 are both major histocompatibility complexes associated with CS. ALPK3 encodes alpha kinase 3 while TTN encodes titin. Truncating variants of ALPK3 are associated with HCM while pathogenic TTN variants have been described to cause HCM, DCM, and ARVC. This case reflects the potential of WGS in aiding clinicians in confirming an unlikely diagnosis.
Abstract 15873: Association of Heart Failure With Lipoprotein (a) Level: A Systematic Review and Meta-Analysis of Observational and Mendelian Randomization Studies
Authors: Singh Sandeep , Desai Rupak , Singh Dyutima , Brereton Brian , Pinto-Sietsma Sara-Joan
Published: December 2023

Background and Aims:
The rising incidence of heart failure (HF) in the Western world, despite advancing clinical care, necessitates further exploration of preventive tools and strategies. Lipoprotein(a) [Lp(a)], a recognized cardiovascular risk factor, has been implicated in heart failure. However, existing evidence is inconclusive, which is the impetus for this meta-analysis.

Methods:
We systematically searched PubMed/Medline, EMBASE, and Scopus for studies on the association of Lp(a) with heart failure occurrence until February 2023. Pooled hazard ratios (HR) and odds ratios (OR) were estimated using random effects models, and heterogeneity was assessed using I2 statistics. Leave-one-out sensitivity analyses were performed by sequentially removing one study at a time.

Results:
After screening, 11 study populations were included, consisting of 7 mendelian randomization (MR) and 2 adjusted observational studies. MR analysis showed a significant association between increasing Lp(a) levels and heart failure risk (OR 1.064, 95% CI: 1.043-1.086, I2= 97.59%, p<0.001) (Fig 1a). However, in the observational studies, Lp(a) ≥30mg/dL was not associated with increased heart failure risk after adjusting for confounders (OR 0.97, 95% CI: 0.64-1.47, I2=62.01%, p=0.894) (Fig 1b). Leave-one-out sensitivity analysis confirmed the robustness of the MR findings (Fig 1b).

Conclusions:
Our meta-analysis of mendelian randomization data demonstrates an association between increasing Lp(a) levels and increased risk of heart failure. The underlying mechanisms, whether direct effects on heart muscle contraction or increased risk of ischemic cardiac disease, require further elucidation.
Abstract 15885: A Masquerading Early Beat Induces Ventricular Fibrillation
Authors: Kloo Juergen H , Laslett David B , Gunchenko Melissa , Cronin Edmond
Published: December 2023

Clinical Case:
A 51 year old male with a history of hypertension, G6PD deficiency, thrombotic thrombocytopenic purpura, prior stroke, and morbid obesity presented with resuscitated out of hospital VF arrest. Electrolytes and ECG were normal. During his admission, the patient had two VF events that were induced by what appeared to be a short coupled right bundle branch block (RBBB) morphology PVC. He was brought to the electrophysiology lab for PVC ablation and ICD implantation. Baseline rhythm was sinus with what appeared to be both RBBB morphology PVCs and junctional extrasystoles. With both extrasystoles, the His potential preceded the QRS by 50 ms, and atrial activation in the His catheter and coronary sinus catheter was also earlier than the QRS. Activation mapping of the right bundle showed later activation than the His potential. This was all consistent with junctional premature complexes (JPC) with frequent RBBB aberrancy rather than fascicular PVCs. Slow pathway modification was performed to attempt to ablate the JPCs. After multiple ablations along the tricuspid annulus and back to the coronary sinus os that triggered slow junctional beats, the patient’s JPC burden was significantly reduced. An ICD was also implanted. The patient was discharged on flecainide. At 4 month follow up he had not had recurrence.

Discussion:
Early coupled PVCs are a well-known cause of ventricular fibrillation, but JPCs inducing VF have not been described previously. Placement of a coronary sinus and His catheter helped identify early that this was not simply a fascicular PVC. This case demonstrates the importance of keeping a broad differential diagnosis when starting any EP study. Ablating the slow pathway area can be effective to treat JPCs while preserving native AV conduction as demonstrated in this case.
Abstract 159: Long-Term Survival and Neurological Follow-Up of Cardiac Arrest Survivors: Results From the French Multicentric Prospective Cohort the DESAC Study
Authors: Dumas Florence , Bougouin Wulfran , PERIER Marie-Cécile , Marin Nathalie , Goulenok Cyril , Vieillard-Baron Antoine , Diehl Jean-Luc , Legriel Stephane , Deye Nicolas , Cronier Pierrick , Ricome Sylvie , Chemouni Frank , Mekontso-Dessap Armand , BEGANTON Frankie , Marijon Eloi , Jouven Xavier , Empana Jean-Philippe , Cariou Alain
Published: December 2023

Background:
While short-term prognosis of cardiac arrest (CA) patients has been extensively studied, less is known regarding the mid- and long-term outcome of survivors.

Aims:
The aim of the DESAC study was to describe mid- and long-term survival and neurological status of CA survivors, and to assess the influence of pre- and intra-hospital therapeutic strategies on these outcomes.

Methods:
Between Jul 2015 and Oct 2018, patients over 18 years who were discharged alive from intensive care units in Paris and suburbs (France) after a non-traumatic CA were included and interviewed every 6 months during at least 24 months and up to 48 months in this multicentric study. Factors associated with Cerebral Performance Category (CPC) scale at 24 months were assessed with logistic regression, with CPC 1 or 2 level considered as a favorable neurological outcome. Trajectories of CPC were derived by mixed linear model in survivors with at least 3 evaluations.

Results:
Out of 593 survivors, 525 had a 24 months follow-up (mean age 57.6 +/-15.3, 79% men). CA occurred in public location in 251/525, with an initial shockable rhythm in 392/525. Prognostic factors independently associated with a favorable neurological outcome at 24 months were initial shockable rhythm (OR= 3.53 (1.65; 7.58)) and previous practice of sport (OR= 3.12 (1.20 ; 8.11)), whereas older age (OR per 10 years= 0.52 (0.40; 0.68)) and previous ischemic cardiomyopathy (OR= 0.34 (0.15 ; 0.77)) were poor prognostic factors. Therapeutic hypothermia or coronary procedures were not related to prognosis. Five trajectories of CPC could be derived among the 514 patients. Overall, 64% remained in CPC1, 13% in CPC2, 11% improved from CPC2 to CPC 12% died either early or lately (Figure 1).

Conclusions:
In this multicentric and prospective study, practice of sport and shockable rhythm were strongly associated with a favorable neurological recovery at 24 months. Furthermore, two thirds of the survivors remained in CPC 1 over time.
Abstract 15908: A Meta-Analysis Revealing an Association Between High Sensitivity C-Reactive Protein Levels and Cognitive Impairment After 3-Months of Ischemic Stroke
Authors: Manne Suvidha , Lekkala Sai Prasanna , Mohammed Adil S , Gurram Priyatham , Damarlapally Nanush , Mahadevan Arankesh , Abrishami Shabnam , Tera Chenna reddy , Katukuri Nishanth , Raval Maharshi , Desai Rupak
Published: December 2023

Introduction:
Cognitive impairment has a significant impact on functional recovery and quality of life in stroke patients. Given the emerging role of high sensitivity C-reactive protein (hs-CRP) as a biomarker for predicting post-stroke cognitive decline, we conducted a meta-analysis to investigate this association.

Methods:
We systematically searched SCOPUS, PubMed, and Google Scholar databases until May 2023 using relevant keywords. Pooled effect sizes were estimated using a random-effects model, and I2 statistics and leave-one-out sensitivity analysis were performed to assess heterogeneity and robustness, respectively (p-value < 0.05 considered significant).

Results:
The final analysis included five studies spanning the years 2018-2023, with a total sample size of 9,625 patients, all from China, and predominantly male (57.85%). The median follow-up period was 3 months. Patients with higher hs-CRP levels had a higher burden of smoking, alcohol consumption, hypertension, diabetes, hyperlipidemia, and lower education levels. The meta-analysis revealed an increased risk of cognitive impairment after ischemic stroke associated with higher hs-CRP levels (adjusted odds ratio [aOR] 1.15; 95% CI: 1.01-1.30, p - 0.03). Substantial heterogeneity was observed among the studies (I2 = 79.23%; p < 0.01). However, a leave-one-out sensitivity analysis confirmed the robustness of the findings, indicating that no single study strongly influenced the overall results.

Conclusion:
This meta-analysis provides evidence of an association between elevated hs-CRP levels and cognitive impairment following ischemic stroke. However, the limited number of studies, mainly from a specific population, highlights the need for further research to enhance the generalizability of these findings.
Abstract 15928: D-dimer as a New Biomarker of Aortic Stenosis Progression and Outcomes: Results From the PROGRESSA Study
Authors: Abdoun Kathia , Tastet Lionel , Sebastien Hecht , Abdeldjebbar Yassine , Fleury Marie-Ange , Jacob Simon , Capoulade Romain , Shen Mylene , Arsenault Marie , Bédard Élisabeth , Cote Nancy , Clavel Marie-Annick A , Pibarot Philippe
Published: December 2023

Background:
Aortic stenosis (AS) induces left ventricular (LV) remodeling and hypertrophy, which are key markers of the transition to heart failure. The present study aimed to evaluate the association between D-dimer plasma levels, LV hypertrophy and mortality with AS.

Method:
One-hundred and forty-six asymptomatic patients (mean age 65±13, men 76%) with mild or moderate AS prospectively recruited in the PROGRESSA study (NCT01679431) were included in this sub-analysis. All patients underwent Doppler-echocardiography annually to measure AS severity, LV mass indexed to body surface area (LVMi) and myocardial contraction fraction (MCF). The annualized changes in LVMi and MCF were calculated between baseline and last follow up.

Results:
Higher plasma levels of D-dimers at baseline were significantly associated with faster progression rate of LVMi and MCF (r
2
=0.18 and -0.22, respectively; all p<0.01). On multivariable analysis adjusted for age, sex, comorbidities, creatinine level, peak aortic jet velocity at baseline, D-dimers remained significantly associated with faster change in LVMi and MCF (all, p<0.01). Moreover, in multivariate analysis adjusted for age, sex, AS severity at baseline, higher levels of D-dimer were significantly associated with the progression to a higher grade of AS severity (HR [95% CI] 1.67 [1.14-2.46], p=0.009). During a median follow-up of 8.1 (5.6-9.9) years, 38 (26%) patients died. On multivariable Cox regression analysis, higher levels of D-dimer were associated with an increased risk of all-cause mortality (HR [95% CI]: 1.97 [0.98-1.97], p=0.05).

Conclusion:
Higher levels of D-dimer are associated with faster progression of AS severity, LV hypertrophy and dysfunction, and increased risk of mortality in patients with AS. This new blood biomarker may improve risk stratification and management of asymptomatic patients with AS. Further studies are needed to determine the mechanisms underlying this association between D-dimer and outcomes in AS.
Abstract 15934: Trends and Disparities in Patients Admitted With Bradyarrhythmias: Insights From the National Inpatient Sample 2016-2020
Authors: Vardar Ufuk , Gajjar Rohan , Battikh Naim , Jamshed Aneeza , AZIZ IMRAN , Kumi Dennis , Yilmaz Mahir , Vij Aviral
Published: December 2023

Introduction:
Bradyarrhythmias are caused by a dysfunction in the cardiac conduction system at the level of the sinus node, the atrioventricular node, or the His/Purkinje system. We aimed to investigate national trends and outcomes in patients with bradyarrhythmias, grouped as sinus node dysfunction, atrioventricular block, and conduction disorder (with 1:1 AV conduction).

Methods:
We utilized the National Inpatient Sample (NIS) Database 2016-2020 to identify the cohort with principal diagnosis of sinus node dysfunction (SND), atrioventricular block (AVB), and conduction disorder with 1:1 AV conduction using ICD-10-CM codes. For inpatient mortality analysis, COVID-19 patients were excluded from NIS 2020. Outcome analysis included hospitalization rates per 10,000 admissions and adjusted inpatient mortality rate utilizing predictive margins, during each calendar year stratified by sex, age, race, and median household income (MHOI).

Results:
There were a total of 1,557,806 hospitalizations (713,321 with SND; 297,037 with AVB and 547,448 with conduction disorder with 1:1 AV conduction) with a principal diagnosis of bradyarrhythmia from 2016-2020. Adjusted rates for hospitalizations per 10,000 admissions significantly increased throughout the years 2016-2020 for all three types of bradyarrhythmias, as demonstrated in Figure 1. Between the years 2016 and 2020, adjusted inpatient mortality rates amongst admissions with SND, AVB and conduction disorder with 1:1 AV conduction were similar, p-trend 0.201, 0.823 and 0.965 respectively; demonstrated in Figure 2.

Conclusion:
Our findings indicate that, throughout the years of 2016-2020, there was a trend suggesting an increase in hospitalization rates for bradyarrhythmias including sinus node dysfunction, atrioventricular block, and conduction disorder with 1:1 AV conduction. These findings may help the healthcare system recognize and decrease the healthcare burden of bradyarrhythmias.
Abstract 15937: The Impact of Social Vulnerability on Aortic Arch Surgery
Authors: Carroll Adam M , Suarez-Pierre Alejandro , Shah Ananya , Rove Jessica Y , Velopulos Catherine , Aftab Muhammad , Reece T B
Published: December 2023

Introduction:
Socioeconomic status is a known factor influencing morbidity and mortality. The CDC’s social vulnerability index (SVI) quantifies neighborhood-level vulnerability. Although high SVI has been associated with adverse outcomes in trauma, CABG, and AAA repair, its impact on aortic arch surgery remains unknown.

Hypothesis:
In total aortic arch (TAR) and hemiarch (HAR) replacement, higher SVI will correlate with increased comorbidities, surgical acuity, and post-operative morbidity and mortality.

Methods:
This single-center retrospective study examined patients undergoing HAR and TAR performed for aortic aneurysm and/or dissection between 2010 and 2022. SVI was calculated by patient residential ZIP code. The cohort was stratified into three groups: SVI<0.33, SVI 0.33-0.66, and SVI≥0.66. The primary endpoint was postoperative mortality, with control for confounding bias through multivariable logistic regression.

Results:
For 753 patients, higher SVI correlated with more baseline comorbidities and minority status. SVI was associated with dissection pathology (p=0.04) and urgent/emergent procedure (p=0.02). Higher SVI was associated with TAR (p=0.01), reflected by lower nadir bladder temperatures (p=0.01), longer cardiopulmonary bypass (p=0.02) and circulatory arrest times(p=0.01), and more coagulation product usage. High SVI patients had longer length of stay, higher rates of infection (p=0.01) and a trend towards increased stroke risk. SVI did not correlate with in-hospital or late mortality, confirmed by multivariable regression.

Conclusion:
Socially vulnerable patients, often from minority backgrounds, tend to have more comorbidities and present urgently or emergently with dissection pathology, requiring more extensive arch repair. Post-procedure, they have a higher risk of infection and a trend towards more stoke risk, but not higher rates of other adverse outcomes or increased mortality during or after hospital stay.
Abstract 15960: Mortality Differences Among Myocardial Injury Subtypes in Acute COVID-19, the Omicron Wave Was Different
Authors: Satterfield Benjamin A , Dikilitas Ozan , Alhalabi Lubna , Gersh Bernard J , Kullo Iftikhar J
Published: December 2023

Introduction:
Hospitalization for COVID-19 is often associated with myocardial injury (elevated cardiac troponin [cTn]). In the initial pandemic waves, patients with myocardial injury had increased likelihood of cardiovascular complications and inpatient mortality; however, the differences in impact of distinct subtypes of myocardial injury on mortality is unclear. In addition, little is known about how these outcomes compare with the subsequent, milder, Omicron wave.

Methods:
Utilizing Mayo Clinic enterprise patients we developed algorithms based on diagnostic/procedural codes, cTn levels, and temporal relationships to positive COVID-19 PCR tests, to determine 5 common subtypes of myocardial injury: stress cardiomyopathy, myocarditis, pericarditis, pulmonary embolism, and myocardial infarction. We examined hospitalized adults with COVID-19; those with elevated cTn designated as cases and others as controls. We fitted Cox models using the following covariates: spline transformed age, sex, race, ethnicity, index date and clinical comorbidities. Patients were analyzed based on admission dates coinciding with either the Alpha-Delta or Omicron waves.

Results:
Across both wave cohorts, hospitalized patients with acute COVID-19 complicated by myocardial injury had an increased risk of mortality compared to those without (
Figure
). Patients with one of the 5 subtypes examined tended to have higher risk than those in the “other myocardial injury” category. Admission during the Omicron wave, compared to the Alpha-Delta waves, tended to have higher mortality risk in all subtypes except myocarditis.

Conclusions:
Our algorithms successfully identified subgroups of myocardial injury in patients hospitalized with acute COVID-19 leading to stratification of mortality risk. Surprisingly, among hospitalized patients during the Omicron wave, myocardial injury of most subtypes was tended to have increased risk of mortality compared to the Alpha-Delta waves.
Abstract 15973: Ambient Air Pollution is Associated With Coronary Artery Disease and Adverse Outcomes in Patients With Stable Chest Pain Across the U.S.: Insights From the PROMISE Trial
Authors: Langenbach Marcel C , Mayrhofer Thomas , Langenbach Isabel L , Lu Michael T , Karady Julia , Pagidipati Neha J , Shah Svati H , Ferencik Maros , Motsinger-Reif Alison , Douglas Pamela S , Foldyna Borek
Published: December 2023

Introduction:
Air pollution is associated with coronary artery disease (CAD) and cardiovascular (CV) outcomes.

Hypothesis:
The relationships of air pollutants to CAD and outcomes are independent of traditional CV risk factors and socioeconomic determinants of health (SDoH) and vary by pollutant type.

Methods:
Clinical and CT data from stable chest pain patients without known CAD in the PROMISE trial, were linked by home zip code to U.S. EPA-derived PM
2.5
and PM
10
(Figure 1a)
. CT metrics included any plaque, obstructive CAD (≥50%), and high-risk plaque (HRP); major adverse CV events were defined as death (all cause or CV), myocardial infarction, or unstable angina. Logistic and Cox regressions were adjusted for age, sex, obesity, ASCVD risk, statins, and US Census-based SDoH by zip code. We conducted a mediation analysis for the effect of pollutants on events using obstructive CAD as mediator.

Results:
In 4,343 individuals (48% men; age: 61±8 years), 46.9% were exposed to PM
2.5
above the standard cut point of 9.5 μg/m
3
and 62.1% to PM
10
≥15 μg/m
3
. Participants exposed to PM
2.5
≥9.5 μg/m
3
had 27% higher odds of obstructive CAD (aOR=1.27, 95%CI: 1.03-1.56, p=0.026), not significant for PM
10
. No associations existed between pollutants and any plaque or HRP. PM
2.5
and PM
10
were independently associated with CV events in fully adjusted models
(Figure 1b)
. In mediation analysis, the effects of PM
2.5
on events were significant (direct effect: OR=1.66, 95%CI: 1.11-2.50, p=0.014; indirect effect: OR=1.06, 95%CI: 1.01-1,12, p=0.022) with comparable results for PM
10
.

Conclusions:
Air pollution relates independently to adverse events in stable chest pain patients, only partly driven by CAD phenotypes, specifically an association between small particular matter and obstructive CAD. Further studies investigating the pathogenesis of atherosclerotic disease in people exposed to pollution may help form strategies to reduce exposure.
Abstract 15982: Management and Follow-Up of Inpatients With Cardiac Implantable Electronic Devices and Bacteremia With and Without Electrophysiology Consultation
Authors: Horton Edward R , Saporito Richard , Fleece David , Enevoldsen John T , Cronin Edmond , Cooper Joshua M , Whitman Isaac R , Gangireddy Chethan
Published: December 2023

Introduction:
Transvenous cardiac implantable electronic device (CIED) infection is a significant cause of morbidity and mortality. Expert consensus recommends a multidisciplinary approach to bacteremia in the context of CIED incorporating both infectious disease (ID) and electrophysiology (EP) consultation to balance the risks of infection with those of CIED removal.

Hypothesis:
Not all patients with CIEDs and bacteremia are evaluated with EP consultation, and this difference is associated with variability in management.

Methods:
Using the EMR, we retrospectively identified inpatients with a CIED and a positive blood culture across three hospitals: one academic, one specialty and one community. True infection versus contaminant was determined by an EP or ID attending at the time of presentation or adjudicated retrospectively by an EP who performs extractions. We examined the rates of EP consultation based on hospital site, CIED removal and appropriate follow-up in those without CIED removal. Fisher’s exact test was used to compare the rates of follow up.

Results:
We identified 88 inpatients with a CIED and positive blood culture between January 2020 - February 2023. True bacteremia was adjudicated in 48 patients (55%). Of these patients, 24 were seen by EP (50%), 22 were seen by EP and ID (46%), and 14 were seen by neither (29%). Patients admitted to an academic hospital were more likely to be seen by EP (22/38, 57%) than those admitted to a specialty or community hospital (2/10, 20%). CIED removal was performed in 15 of 24 patients seen by EP (63%). Patients seen by EP were significantly more likely to have documented plans, repeat blood cultures after antibiotic completion, and appropriate follow up than those not seen by EP (24/24 100% vs. 3/24, 8%, p<0.001).

Conclusion:
Even at a high-volume extraction center, EP consultation for patients with true bacteremia in the context of CIED only occurred 50% of the time. Patients admitted to an academic hospital were more likely to be seen by EP than at a community or subspecialty hospital. EP consultation is important for all bacteremic patients with CIEDs, not only to recommend extraction if appropriate, but also to ensure timely follow-up and management of treatment failure, consistent with expert consensus.
Abstract 15984: Toxic Twist: A Case of Bupropion Induced Brugada Syndrome
Authors: Ketenci Melis , Way Hillary , Estep Zachary , Ehinmisan Ayara , Homayounrooz Forugh , Mitra Kathryn , Lader Joshua
Published: December 2023

Introduction:
Brugada syndrome is an inherited sodium channel pathology typically diagnosed by ECG findings. The condition can also be triggered by electrolye imbalances, fever and medications. It can result in ventricular tachycardia or fibrillation which can lead to sudden cardiac death. Therefore, it is vital to recognize the Brugada pattern on ECG and identify the potential triggers.

Case Presentation:
36-year-old woman with past medical history of depression and prior suicidal attempt presented to emergency department with altered mental status secondary to intentional overdose of bupropion. Vitals were HR 118 beats per minute, BP 160/95 mmHg, RR 14 and SpO2 100% on room air. Physical examination was significant for tachycardia and lethargy. Laboratory values were significant for K
+
:3.3 mEq/L , HCO3
-
:20 mEq/L , anion gap: 15, lactic acid: 5.5 mmol/L, ABG pH: 7.3. ECG on admission showed sinus tachycardia with rate of 121 and prolonged QTc 488 ms. Patient was monitored with serial ECGs given concern for Qtc prolongation. Later in the hospital course, ECG showed coved ST segment elevation in V1-V2 followed by a negative T wave. Echocardiogram was without structural abnormalities with EF of 55-60%. ICD placement was not indicated given this condition was drug induced with type 1 Brugada pattern and there was no family or personal history of syncope, arrhythmia or sudden cardiac death. Patient’s medication regimen was optimized with discontinuation of bupropion which was contraindicated in Brugada syndrome and avoidance of medications with sodium channel blocking effects was emphasized.

Discussion:
Brugada syndrome is a rare but potentially fatal condition. It becomes more challenging diagnosis in the absence of personal or familial cardiac history. It is very important to consider medications as a possible trigger for the condition given the management differs from inherited type and it does not generally require ICD placement.
Abstract 15998: Impact of Atrial Fibrillation Detected by Cardiac Implantable Electronic Devices on Embolic Stroke Events in Cancer Patients
Authors: Nakano Miyo , Kondo Yusuke , Nakano Masahiro , Kajiyama Takatsugu , Ito Ryo , Chiba Toshinori , Sugawara Masafumi , Yoshino Yutaka , RYUZAKI SATOKO , Komai Yuya , Takanashi Yukiko , Kobayashi Yoshio
Published: December 2023

Background:
Cancer patients have a higher risk of atrial fibrillation (AF) than general population, however, the link between cancer and AF is not fully understood. The association between AF detected by implanted cardiac implantable electronic devices (CIEDs) and the incidence of embolic stroke events has been reported. However, little is known about the incidence of AF and embolic stroke events in Japanese cancer patients with CIEDs. Moreover, the cut-off value of new-onset AF duration detected by CIEDs for embolic stroke is still unknown, and a problem to be solved in the future. The aim of this study is to identify the incidence of embolic stroke in Japanese cancer patients with a CIED and to examine the risk factors of embolic stroke.

Methods:
We retrospectively analyzed the database of our CIEDs clinic. Every 6 months, AF events were checked by CIEDs. Patients who had a history of AF or had received anticoagulant therapies before a CIED implantation and who are prescribed anticoagulants after a CIED implantation were excluded. We examined the characteristics and incidence of embolic stroke events and investigated the relationship between new-onset AF detected by CIEDs and the incidence of embolic stroke.

Results:
We enrolled 138 consecutive cancer patients with CIEDs who had no prior AF and took no anticoagulant in this study (follow-up period, 76±48 months; age, 73±16 years). During the follow-up period, 13 patients (9.4%) had embolic stroke events. Receiver-operating characteristic curve analysis confirmed that 20 seconds was the best cut-off value of AF duration detected by CIEDs for embolic stroke events (AUC = 0.75). Multivariate analysis demonstrated that independent predictors for embolic stroke were left atrial diameter ≥ 40mm (P=0.018) and new-onset AF ≥ 20 seconds (P = 0.0082).

Conclusions:
AF episodes lasting for ≥ 20 seconds and enlarged left atrium were the risk factors of embolic stroke events. We consider examining AF burden carefully in this population.
Abstract 16011: Lymphatic Intervention Following Superior Cavo-Pulmonary Anastomosis Potentially Allows for Successful Fontan Completion
Authors: Vaiyani Danish , Ford Brooke , Gupta Mudit , Dietzman Thomas , Biko David , DeWitt Aaron G , Gillespie Matthew , Obyrne Michael L , Rome Jonathan , Smith Christopher , Dori Yoav
Published: December 2023

Introduction:
Superior cavopulmonary anastomosis (SCPC) inevitably exposes the thoracic duct to higher venous pressure, potentially triggering disordered lymphatic perfusion manifesting as chylothorax (CT) and/or plastic bronchitis (PB) . Though outcomes following lymphatic interventions after Fontan completion (FC) are well described, they are not well described in patients after SCPC.

Methods:
A single-center retrospective study of patients who underwent lymphatic intervention for PB or CT following SCPC 1/1/2011-12/31/2021 was performed, excluding those with planned two ventricle or 1.5 ventricle repair, patients who underwent thoracic duct ligation, and those in whom interventions were performed either prior to SCPC or following FC.

Results:
In total, 27 patients (56% male) were studied, of which 22% had PB and 78% with CT, 7% with Noonan’s syndrome and 19% with heterotaxy syndrome. Median age at intervention was 11.3 months (IQR 7.4 - 33.5). Median time following SCPC was 3.5 months (IQR 2.1 - 24.2). In terms of interventions, 41% (n=11) underwent selective lymphatic channel embolization. Of these 36% (4/11) underwent subsequent thoracic duct embolization (TDE). The remaining 59% (n=16) patients underwent TDE. The thoracic duct was able to be accessed in 23 patients (85.2%). Twenty-four patients (19/21 with CT, 5/6 with PB) had resolution of symptoms following transcatheter intervention at our center. Following intervention, seven patients (all of whom were of the type IV lymphatic subtype) were successfully referred for FC, ten are currently awaiting FC, five are not Fontan candidates and five passed away from non-procedural comorbidities. Median duration of post-operative chest tubes following FC was 7 days (IQR 6-8) and median follow up is 39.1 months (IQR 15.1 - 45.1).

Conclusions:
Selective lymphatic embolization and TDE are feasible in SCPC recipients with CT and PB, with most patients experiencing symptomatic improvement. Subsequent FC has been achieved in some patients with type IV lymphatic abnormalities, suggesting that these interventions may alter the unnatural history of lymphatic dysfunction in single ventricle patients. Future research is needed to define longer term outcomes of this high-risk cohort.
Abstract 16013: Non-Bacterial Thrombotic Endocarditis and Recurrent Cerebrovascular Accidents in Immune Checkpoint Inhibitor Myocarditis
Authors: Mitrani Lindsey , Jou Stephanie , Mendez Sean , song christopher , Yoon Joseph , Dangayach Neha S , SAHNI GAGAN
Published: December 2023

Background:
Nonbacterial thrombotic endocarditis (NBTE) is a rare condition associated with cancer, hypercoagulable state, and systemic emboli including stroke. This report presents a case of NBTE associated with metastatic lung adenocarcinoma and recurrent strokes despite anticoagulation for prior pulmonary embolism (PE) and highlights the challenges in management of NBTE.

Case:
66-year-old man with stage IV non-small cell lung adenocarcinoma treated with pembrolizumab complicated by immune checkpoint inhibitor (ICI) myocarditis treated with high dose steroids and PE treated with rivaroxaban, presented with diplopia and gait instability. MRI brain revealed a left corona radiata infarct and rivaroxaban was switched to apixaban. Three weeks later, the patient developed left internal carotid artery (ICA) occlusion, and underwent emergent thrombectomy. A transesophageal echocardiogram revealed a new 1.8 cm mass on the mitral valve with negative blood cultures. Anticoagulation was switched to therapeutic enoxaparin. Cardiothoracic surgery was consulted, though patient opted for palliative care.

Decision making:
Patient presented with recurrent multifocal strokes despite treatment with multiple direct oral anticoagulants (DOACs), just weeks after ICI myocarditis. The challenges here were approach to anticoagulation in a patient with recurrent strokes despite anticoagulation, the risk of hemorrhagic conversion of stroke, and the mechanism of stroke. The mitral valve mass was presumed to be NBTE, due to his metastatic malignancy and negative blood cultures. However, a recent history of ICI-myocarditis raised the possibility of an immune mediated mechanism of NBTE, given the growing association of auto-immune diseases and NBTE.

Conclusion:
NBTE is a rare complication of metastatic disease that can commonly lead to stroke and is treated with optimal anticoagulation and addressing the underlying malignancy. However, this case highlights the failure of multiple oral anticoagulants to treat NBTE and raises the question of additional mechanisms of NBTE beyond malignancy and hypercoagulable state. Further studies are required to elucidate a common immune mediated mechanism of NBTE and ICI myocarditis.
Abstract 16015: The Effect of the 2019 Reduction in Price of PCSK9 Inhibitors on Total Cost, Out-of-Pocket Cost, and Access Among Medicare Part D Beneficiaries
Authors: Liu Benjamin Y , Hernandez Inmaculada , TSENG CHIEN-WEN , Kazi Dhruv S
Published: December 2023

Introduction:
Uptake of Proprotein Convertase Subtilisin/Kexin type 9 inhibitors (PCSK9i) among Medicare beneficiaries was initially slow because of coverage restrictions and high out-of-pocket costs. In November 2018, manufacturers announced an unprecedented 60% reduction in the price of PCSK9is. The effect of this price reduction on access and cost has not been previously studied.

Hypothesis:
Did the large reductions in PCSK9i prices improve coverage and lower out-of-pocket (OOP) costs for Medicare Part D beneficiaries?

Methods:
Medicare Part D Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information files (2018-2022) were used to evaluate coverage, 30-day OOP and total costs, and formulary restrictions before (2018Q1-2019Q1) and after (2019Q2-2023Q1) the PCSK9i price reduction. Costs were calculated in the coverage phase, not the deductible or coverage gaps. Paired t-tests were used to determine statistical significance with a two-sided alpha of 0.05.

Results:
We examined Part D plans in the first quarter of each year from 2018 to 2023 (3,127 to 4,543 plans per year, 79% Medicare Advantage plans). Nearly all plans covered at least 1 PCSK9i before and after the price reduction (97% vs 100% of plans). The price reduction was associated with significant reductions in 30-day total costs (from $1,075 to $585; difference = $489; 95% CI $484 - $494; p <0.001) and 30-day out-of-pocket costs ($306 to $75; difference = $231; 95% CI $228 - $233; p<0.001) (Figure 1). The proportion of plans requiring coinsurance as a proportion as opposed to a fixed copayment amount declined from 97% to 15% (p<0.001).

Conclusions:
The reduction in prices of PCSK9i was associated with significant declines in total Medicare costs and projected OOP costs for Medicare Part D beneficiaries. Nearly all Part D plans cover at least 1 PCSK9i. Future studies should examine the impact of this price reduction on adherence and cost-effectiveness of these therapies.
Abstract 16019: Right Hemidiaphragm Paralysis Leading to Right Heart Failure
Authors: Naveed Shahmir , Mehta Samir P , Vanderland Mark , Qureshi Wasif
Published: December 2023

Background
Diaphragmatic paralysis occurs due to direct or indirect damage to the phrenic nerve and can cause unilateral elevation. Diaphragmatic paralysis is usually asymptomatic; however, we present a case of syncope caused by right hemidiaphragm paralysis leading to extrinsic compression of the right heart causing hemodynamic compromise.

Case
A 78-year-old female with a history of advanced dementia, and hypertension presented following a syncopal episode and was found altered and hypotensive. A chest X ray showed an elevated right hemidiaphragm. A Transthoracic echocardiogram demonstrated hyperdynamic systolic function of the left ventricle with an ejection fraction of 70 to 75% and a left ventricular outflow tract (LVOT) gradient of 64 mmHg. It was suspected that extrinsic compression of the right atrium and ventricle lead to underfilling of the left ventricle causing LVOT obstruction resulting in hypotension and syncope.

Discussion
. Due to the patient’s underlying severe dementia her family wished for a conservative approach and additional cardiac investigation was deferred. She was treated conservatively with beta blockers to increase her diastolic filling time and intravenous fluids to promote LV filling in order to reduce her LVOT obstruction. Treatment of diaphragm paralysis depends on the severity of symptoms such as dyspnea on exertion, fatigue and syncope. An option that was discussed was diaphragmatic plication to decrease the intrathoracic pressure and the extrinsic compression on the right heart. More commonly, unilateral diaphragmatic paralysis is asymptomatic and is managed conservatively with observation.

Conclusion:
Cardiac complications of hemidiaphragm paralysis are rare but this case illustrates how extrinsic compression of the right heart can lead to dynamic LVOT obstruction and highlights the importance of integrating imaging findings when evaluating patients for syncope.
Abstract 16025: Impact of COVID-19 on Major Adverse Cardiovascular and Cerebrovascular Events in Metabolically Healthy Obese (MHO) Individuals: A National Inpatient Sample Analysis, 2020
Authors: Kanagala Sai Gautham , Vuddandam Dinesh Kumar , Muvva Durga Mounika , James Alpha , Mallapu Prathistitha , Nallapothula Shantha , Katukuri Nishanth , Chiluka Swetha , Adelli Raja Anvesh Reddy , Kotharu Devi Meghana , Polavarapu Vaibhavi , Mandadi Leela Krishna prasad , Desai Rupak
Published: December 2023

Background:
The obesity paradox is a phenomenon observed in certain chronic diseases, particularly cardiovascular diseases, where individuals with obesity have better outcomes compared to those of normal weight. We aimed to study how COVID-19 affects MACCE results in metabolically healthy obese (MHO) individuals who have a BMI >30.

Methods:
Using the National Inpatient Sample (2020) and appropriate ICD-10-CM codes, we identified adult hospitalizations with COVID-19 and grouped them into two cohorts with and without obesity (MHO+ and MHO-, omitting hypertension, diabetes, and hyperlipidemia). MACCE (all-cause inpatient mortality, cardiac arrest, including ventricular fibrillation, and stroke) in COVID-19-related hospitalizations was the primary outcome.

Results:
84,145 (21.9%) of 397,040 COVID-19 hospitalizations were MHO+. The MHO+ group was younger (median 43 vs 52 years), female (56.9% vs. 49.4%), black (19.4% vs 15.1%), Hispanic (35.2% vs 30.5%), and Native American (1.5% vs 1.2%) (p<0.001). Tobacco use disorder, past PCI, prior VTE, depression, chronic pulmonary disease, hypothyroidism, and other thyroid problems were more common in MHO+ patients (p<0.05). MHO+ patients were discharged routinely (76% vs. 66.7%) but stayed longer (5 days vs 4 days). After correcting for baseline variables, the MHO+ cohort had a lower rate of MACCE than the MHO- cohort (8% vs. 11.3%, OR 0.81, 95CI 0.74-0.89, p<0.001), and lower all-cause mortality (6.6 % vs 9.4%) compared to the MHO- cohort. On subgroup analysis, females had lower odds (aOR 0.79) than males (aOR 0.82), older individuals ≥65 years old had lower odds (aOR 0.71) vs 45-64 (aOR 0.79), and race- wise comparison, whites had lower odds of MACCE events (aOR 0.76).

Conclusions:
MHO+ patients had lower odds of MACCE events. The MHO group was younger, suggesting higher cardiorespiratory fitness, which could explain the obesity paradox and reduced odds of MACCE outcomes.
Abstract 16044: Coronary Artery Calcium Score, a Superior Predictor of Cardiac Revascularization Risk Than Framingham
Authors: coy kevin , Singh Aditya , Petrasko Mark , Petrasko Phillip , Rynders Beatrice , Sjovold Alexander , Weaver Max , stys patryk T , Stys Veronica , Singh Komaldeep , Saad Shaukat Muhammad Hamza , Varga Zoltan , Hajek Catherine , Sincan Murat , Petrasko Marian S , Stys Adam , Stys Tom
Published: December 2023

Introduction:
The coronary artery calcium (CAC) score is a powerful independent screening tool for coronary artery disease (CAD). Elevated CAC score has been significantly associated with increased rates of revascularization, however the Framingham Risk Score remains the most used method of predicting patients’ risk for future revascularization.

Hypothesis:
The CAC score is a superior predictor of adverse cardiac events than the traditionally accepted Framingham Risk Score.

Methods:
Data was analyzed retrospectively of patients who underwent calcium score scans between August 2011 and April 2021 as part of the Sanford Cardiovascular Prevention Program and were categorized into low (<100), moderate (100-399), or high (≥400) CAC groups. The accuracy of revascularization prediction between subjects with CAC score and those without CAC score were evaluated by a ROC curve.

Results:
A total of 28,187 patients were screened for CAC score. 46% were females and the mean age was 61.4 ± 9.9 years. ROC predictive accuracy of patients with CAC scores (0.76) compared against those with no CAC score (0.71) was found to be statistically significant (Z = -6.27, P<0.01). Furthermore, total CAC was found to a significant predictor (b=.001, p<0.01) of revascularization above and beyond the additional risk factors with the pseudo R2 increasing from .08 for starting risk factors to .15 when total CAC was added for a pseudo R2 change of .07

Conclusions:
In our study, CAC scoring was not only able to better predict the need for future revascularization compared to Framingham components but also able to improve the specificity of revascularization prediction when added to the Framingham components.