bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 325: Acute Pericarditis Associated Hospitalizations in the United States: A Nationwide Analysis From 2003 through 2012
Authors: Kumar Nilay , Garg Neetika , Jain Priyank , Pandey Ambarish
Published: July 2021

Background and objectives:
There are scarce data on the incidence and outcomes of acute pericarditis hospitalizations in the US. We sought to ascertain the burden of acute pericarditis hospitalizations and associated outcomes in the US over a ten-year period.

Methods:
We used the 2003-2012 Nationwide Inpatient Sample (NIS), the largest database of in-patient hospital stays in the US, to identify hospitalizations with primary or secondary diagnosis of acute pericarditis among patients >=16 years using ICD-9-CM codes 420.0, 420.90, 420.91, 420.99, 420.99, 036.41, 074.21, 093.81, 098.83, 115.xx, 391.0 and 411.0. Outcomes of interest included in-hospital mortality, cardiac tamponade, pericardiocentesis, length of hospital stay (LOS) and inflation adjusted charges. Trends and predictors were computed with Poisson regression, linear regression, logistic regression or chi-squared test as appropriate. Survey analysis techniques with discharge weights were used for all analyses.

Results:
There were 309,983 hospitalizations (mean age 57 ±18; 41.4% women) for acute pericarditis among adults from 2003 - 2012. Overall rates of primary and secondary hospitalizations related to acute pericarditis declined linearly from 164 cases per million in 2003 to 110 cases per million in 2012 (p-value <0.001, Figure). We also observed a significant temporal decline in in-hospital mortality (6.3% to 4%, p<0.001 Figure) and LOS (7.8 ± 11.0 to 6.5±8.4 days; p<0.001) among these patients during the study period. In contrast, rates of cardiac tamponade increased significantly (10.2% in 2008 to 12.02% in 2012; p<0.001) while that of pericardiocentensis remained stable (9.8% in 2003 to 11.2% in 2012; p=0.30) in the study population. Mean inflation adjusted charges increased from 62,478 USD in 2003 to 73,218 USD in 2012 (p<0.001). Old age, female sex, presence of co-morbidities such as heart failure, renal failure, coagulopathy and metastatic cancer were identified as significant predictors of inpatient mortality.

Conclusions:
Over the past decade, there has been a significant decline in hospitalization rates, in-hospital mortality and length of hospital stay among patients with primary or secondary diagnosis of acute pericarditis.
Abstract 328: Cardiovascular Disease Associated with Ability to Achieve Renal Transplant and Post-Transplant Adverse Events
Authors: Ismail Sahar J , Patel Meet , Gindi Ryan , Salah Ahmad , Tang Ignatius , Benedetti Enrico , Ardati Amer
Published: July 2021

Introduction:
Patients with end stage renal disease suffer from a high burden of cardiovascular disease (CVD). Renal transplant offers mortality and morbidity benefits.

Hypothesis:
We predict that patients with CVD are less likely to obtain a renal transplant after being listed and that CVD may be associated with post-transplant adverse events.

Methods:
We conducted a retrospective analysis of all adult patients listed for first time renal transplantation at the University Of Illinois Chicago from 2002 till 2006. We defined Coronary Artery Disease (CAD) as a history of myocardial infarction or coronary revascularization. We defined reduced ejection fraction (rEF) as an EF less than or equal to 40%. CAD equivalents were defined as a history of diabetes, stroke or peripheral vascular disease. We assessed the outcome of achieving transplantation in a multivariate logistic regression model. We assessed post-transplant events of death or graft failure in a Cox proportional hazards regression model.

Results:
Of the 460 patients studied African-Americans accounted for 52% and men for 58%. CAD was present in 10.9% of patients and rEF was present in 9.6%. Pre-operative revascularization occurred in 8.9% of patients (74% percutaneous coronary intervention, 26% bypass surgery. Patients with CAD or a CAD equivalent were older (54.7 vs. 43.2 years old, p <0.01), had higher systolic blood pressure (147.2 vs. 140.6 mmHg, p<0.01) and lower diastolic blood pressure (79.3 vs. 83.6 mmHg, p<0.01). Beta-blocker (63% vs. 54%, p = 0.06) statin (45% vs. 11%, p<0.01) and aspirin (40% vs 12%, p<0.01) use was more common in those with CAD or equivalent. In a multivariate logistic regression model controlling for sex, medications, pre-operative revascularization, and comorbidities, age (OR 0.975, 95% CI 0.954 to 0.997, p = 0.03) and history of CAD (OR 0.385 95% CI 0.159 to 0.932, p= 0.03) were associated with lower odds of receiving transplant. In a Cox proportional hazards model controlling for age, sex, pre-operative revascularization, type of transplant, and comorbidities, CAD (HR 2.56 95% CI 1.08 - 6.10, p = 0.03) and rEF (HR 2.37 95% CI 1.06 - 5.35, p = 0.03) were associated with an increased hazard of graft failure or death. Of 337 patients that received transplant only 4 peri-operative myocardial infarcts and 1 stroke occurred.

Conclusions:
CVD is common in patients listed for renal transplant. CAD is independently associated with lower odds of receiving a transplant. CAD and rEF are independently associated with increased hazard of post-transplant death or graft failure. Future efforts should focus measures to optimize outcomes in patients with CVD awaiting transplant.
Abstract 336: Cost-effectiveness of Implantable Cardiac Monitor-guided Intermittent Anticoagulation for Paroxysmal Atrial Fibrillation
Authors: Steinhaus Daniel A , Zimetbaum Peter J , Passman Rod S , Leong-Sit Peter , Reynolds Matthew R
Published: July 2021

Background:
Patients with atrial fibrillation (AF) and stroke risk factors are recommended for treatment with long-term anticoagulation, even when rhythm control interventions result in a low AF burden. A strategy of guiding anticoagulation with novel oral anticoagulants (NOACs) based on daily transmissions from an implantable cardiac monitor (ICM) in CHADS
2
1 or 2 AF patients has recently been explored in a single-arm pilot study. The aim of our study was to evaluate the cost-effectiveness of this strategy versus projected outcomes with the current standard of continuous anticoagulation.

Methods:
We developed a Markov model using data from the Rhythm Evaluation for AntiCoagulaTion With COntinuous Monitoring (REACT.COM) pilot study (N=59) and previously completed anticoagulant trials to calculate the costs and quality-adjusted life years (QALYs) associated with ICM-guided intermittent anticoagulation for AF vs. standard care. The model time horizon was 3 years (the battery life of an ICM). Health state utilities were estimated from the pilot study population using the SF-12. Costs were based on current Medicare reimbursement.

Results:
In the pilot study, over 14±4 months of follow-up 18/59 patients were observed to have 35 AF episodes, 60% of which spontaneously terminated and 63% were asymptomatic. The protocol resulted in a >90% reduction in anticoagulant use relative to standard continuous treatment. There were no strokes, 2 (3.4%) TIAs, 2 major bleeding events (on aspirin) and 3 minor bleeding events with the ICM-guided strategy. The model projected total 3-year costs of $10,558 for the ICM-guided strategy vs. $12,898 for literature-based expected outcomes with continuous anticoagulation. Projected QALYs were 2.46 for both groups. Detailed sensitivity and scenario analyses are ongoing.

Conclusions:
Based on the REACT.COM pilot study, a strategy of intermittent, ICM-guided oral anticoagulation with NOACs was cost-saving relative to expected outcomes with continuous anticoagulation, with equivalent quality-adjusted survival. This strategy requires validation in a larger, randomized study.
Abstract 339: Hospitalization Rates and Healthcare Costs Among Non-valvular Atrial Fibrillation Patients Who Were Naïve Users of Novel Oral Anticoagulants
Authors: Deitelzweig Steve , Bruno Amanda , Tate Natalie , Ogbonnaya Augustina , Shah Manan , Farrelly Eileen , Lokhandwala Tasneem , Gupta Kiran , Eaddy Michael
Published: July 2021

Background:
Novel oral anticoagulants (NOACs) are recommended for stroke risk reduction in non-valvular atrial fibrillation (NVAF) patients withCHADS
2
≥2. Efficacy and safety of the different NOACs are well documented in the clinical trial setting, however, real-world evidence of the effectiveness and safety of these agents is limited. This study provides an early assessment of all-cause hospitalizations and economic outcomes among NVAF patients initiated on different NOAC treatments in the real-world.

Methods:
A retrospective cohort study of patients diagnosed with AF (ICD-9-CM 427.31 and 427.32) who were naïve to anticoagulant therapy and initiated on a NOAC (dabigatran, rivaroxaban and apixaban) was conducted using PharMetrics Plus data from 01/ 2012 through 03/2014. The first NOAC prescription date served as the index date. Patients were required to be ≥18 years old and have no evidence of valvular disease, CHADS
2
score ≥ 1, and ≥ 1 month of follow-up. Follow-up ended upon the earliest of the following: treatment discontinuation, switch to a different NOAC, end of continuous enrollment, 1 year after the index date, or end of study. A Cox proportional hazards model were used to model the likelihood and timing of all-cause hospitalizations while a generalized linear model (GLM) was used for costs.

Results:
There were 9,150 patients included in the study. The majority of patients were prescribed rivaroxaban (61.5%), followed by dabigatran 1,374 (23.5%), and apixaban (15.0%). Males were 71.4% of the sample and mean age was 63.4 years, with the apixaban patients being slightly older (P=0.0170). Mean CHADS
2
score was 1.8. Mean HAS-BLED score was 2.0, and was slightly higher for patients on apixaban and rivaroxaban (P=0.0025). After adjusting for baseline characteristics, treatment with dabigatran (HR 1.37, 95% CI 1.10-1.69) and rivaroxaban (HR 1.57, 95% CI 1.30-1.90) was associated with increased rate of all-cause hospitalization relative to apixaban. Mean monthly all-cause costs were lower for patients on apixaban compared to those on dabigatran ($3,581 vs $4,236; P<0.0001) and rivaroxaban ($3,581 vs $4,144; P<0.0001).

Conclusions:
This early assessment shows that among anticoagulant naïve NVAF patients, treatment with apixaban was associated with a lower rate of all-cause hospitalization, as well as lower overall costs compared to other NOACs. Further evaluation is needed to provide additional detail on potential drivers of utilization differences.
Abstract 351: Comparisons of a Pre- and Post-Behaviorally Modified Lifestyle Intervention for Reducing Cardiometabolic Risk in an Employee Population: My Unlimited Potential
Authors: Aneni Ehimen , Das Sankalp , Osondu Chukwuemeka U , Guzman Henry , Mora Joseph , Rouseff Maribeth , Feldman Theodore , Agatston Arthur S , Veledar Emir , Nasir Khurram
Published: July 2021

Background:
A major shortcoming of lifestyle improvement programs has been the difficulty in understanding the recruitment and follow-up strategies that yield the best results in terms of targeted health outcomes and retention rates. In this study, we compare the retention rates, short and long-term outcomes of a tailored workplace lifestyle intervention program targeted at high CVD risk working populations before and after implementation of changes made to the program based on a behavioral assessment (BA) analysis.

Methods:
The My Unlimited Potential (MyUP) is a year long lifestyle intervention program conducted among high-CVD risk employees of Baptist Health South Florida. The program was initially designed to have a 9-week intensive phase, with a year long follow-up period. During the intensive phase, participants had supervised structured physical fitness training as well as nutritional counseling. Due to concerns about sub-optimal retention rates and outcomes, the program was modified based on the results of a behavioral assessment of the initial participants (see figure). An additional level of participant screening was introduced with the aim of recruiting those who were least likely to drop-out and most likely to succeed in the program. The program was also modified to have a 12-week intensive phase.

Results:
At all follow-up periods, the retention rate was higher among those in the post BA group (see table). Although persons in the post-BA group achieved significantly greater reduction in weight, BMI and body fat the absolute differences between groups was minimal. The measured reduction in systolic (SBP) and diastolic blood pressures (DBP) were greater in the pre-BA group at the end of the intensive phase but this was reversed by 1 year in which only those who received the revised intervention had sustained reduction in DBP. There was no significant between-group difference in the laboratory parameter changes, including HbA1c and hsCRP.

Conclusion:
Using a behavioral assessment modification module improves retention rates with minimal improvement in outcomes. BA modification should be used in programs with low retention rates but may be of minimal impact on long term outcomes.
Abstract 9: Consistency of Laboratory Monitoring during Initiation of Mineralocorticoid Receptor Antagonists in Heart Failure
Authors: Cooper Lauren B , Hammill Bradley G , Peterson Eric D , Pitt Bertram , Maciejewski Matthew L , Curtis Lesley H , Hernandez Adrian F
Published: July 2021

Introduction:
The ACC/AHA heart failure guidelines recommend routine monitoring of serum potassium and renal function of patients treated with mineralocorticoid receptor antagonists (MRAs). However, compliance with these safety recommendations in routine clinical practice is unknown.

Methods:
We analyzed a cohort of Medicare beneficiaries in 10 states with prevalent heart failure as of July 1, 2011 and incident MRA use between May 1, 2011 and September 30, 2011. Medicare claims data were linked to laboratory results data from a large vendor. Outcomes included guideline recommended testing of serum creatinine and potassium prior to MRA initiation as well as follow-up testing in the early (day 1-10) and extended (day 11-90) post-initiation periods. Additional outcomes included abnormal laboratory results and adverse events proximate to MRA initiation.

Results:
We identified 10,443 Medicare beneficiaries with heart failure started on an MRA with 19.7% (2,056 of 10,443) initiated during a hospitalization. The table displays the frequency of laboratory testing before and after inpatient or outpatient MRA initiation. While overall 91.6% (9,564 of 10,443) of patients received appropriate pre-initiation testing, only 13.3% (1,384 of 10,443) received appropriate early post-initiation testing and 29.9% (3,122 of 10,443) received appropriate extended post-initiation testing. Among those patients initiated on an MRA during a hospitalization, 25.2% (518 of 2,056) had appropriate testing across all time periods. Chronic kidney disease was associated with increased likelihood of appropriate laboratory testing (RR 1.83, 95% CI: 1.58, 2.13), as was concomitant diuretic use (RR 1.78, 95% CI: 1.44, 2.21). In the early follow-up period, 1.8% (184 of 10,443) of overall patients started on a MRA had hyperkalemia or acute renal insufficiency requiring hospitalization or emergency department visit, and 8.7% (910 of 10,443) experienced these adverse events within the 90-day follow-up period.

Conclusions:
Rates of guideline recommended laboratory monitoring of creatinine and potassium after MRA initiation were low, which represents an area for quality improvement to ensure MRAs can safely and effectively be used in care of heart failure patients.
Abstract 151: End-of-Life Care for Left Ventricular Assist Devices: Differing Perspectives of Cardiology and Palliative Care and Hospice Providers
Authors: McIlvennan Colleen K , Wordingham Sara E , Allen Larry A , Matlock Daniel D , Jones Jacqueline , Dunlay Shannon M , Koepp Katlyn E , Swetz Keith M
Published: July 2021

Background:
Destination therapy left ventricular assist devices (DT-LVADs) have become a treatment option for carefully selected patients with end-stage heart failure. Death is inevitable despite DT-LVAD, with 1-year mortality approximately 20% and median survival 5 years. However, end-of-life processes for LVAD patients vary significantly by institution, provider, and patient preference. Palliative care has played an increasing role in the care of this patient population, yet there remains little data on the most effective way to integrate palliative care and hospice in the DT-LVAD population. Therefore, we aimed to understand the end-of-life perspectives regarding LVADs among both cardiology and palliative care/hospice providers.

Methods:
Using internet-based, secure methods, we administered a 41-item survey via electronic mail to members of the American Academy of Hospice and Palliative Medicine, European Society of Cardiology-Heart Failure Association, the International Society for Heart and Lung Transplantation, and the Heart Failure Society of America to assess their perspectives on end-of-life care in patients with LVADs. Descriptive statistics were used to analyze data. Fisher’s exact test was used to compare categorical data.

Results:
From October to November 2011, there were a total of 440 respondents (palliative care/hospice=137; cardiology=303). Most were physicians (80%; n=320) and male (59%; n=232). The majority of providers in both groups viewed an LVAD as a life-sustaining treatment. The groups differed in their attitudes, beliefs, and comfort with end-of-life care in patients with an LVAD. Few palliative care/hospice providers believed a patient needed to be imminently dying to turn off an LVAD; whereas most cardiology providers noted patients should be imminently dying in order to consider LVAD deactivation (2% vs 60%; p=<0.001). Most palliative care/hospice providers believed requests for turning off an LVAD in a patient who is not nearing death should be honored. In contrast, just over half of cardiology providers contended the request should be honored (88% vs 57%; p=<0.001). The provider groups also disagreed on requiring ethics consultation, with most cardiology providers stating it was necessary prior to turning off an LVAD near the end of life (67% vs 24%; p=<0.001).

Conclusion:
Cardiology providers and palliative care/hospice providers collectively have different perceptions on management of end of life in patients with an LVAD. Bridging the gaps between these two disciplines is a critical first step in creating a more cohesive approach to end-of-life care for these patients—one that honors autonomy but respects individual provider comfort levels.
Abstract 223: Non-Cardiac Comorbidities in Predictive Models for Valvular Heart Disease Interventions
Authors: Wessler Benjamin , Lundquist Christine , Raman Gowri , Lutz Jennifer , Paulus Jessica , Kent David
Published: July 2021

Background:
Interventions for patients with valvular heart disease (VHD) now include both surgical and percutaneous procedures. As a result, treatments are being offered to increasingly complex patients with a significant burden of non-cardiac comorbid conditions. There is a major gap in our understanding of how various comorbidities relate to prognosis following interventions for VHD. Here we describe how comorbidities are handled in clinical predictive models for patients undergoing interventions for VHD.

Methods:
We queried the Tufts Predictive Analytics and Comparative Effectiveness (PACE) Clinical Prediction Model (CPM) Registry to identify de novo CPMs for patients undergoing VHD interventions. We systematically extracted information on the non-cardiac comorbidities contained in the CPMs and also measures of model performance.

Results:
From January 1990- May 2012 there were 12 CPMs predicting measures of morbidity or mortality for patients undergoing interventions for VHD. There were 2 CPMs predicting outcomes for isolated aortic valve replacement, 3 CPMs predicting outcomes for isolated mitral valve surgery, and 7 models predicting outcomes for a combination of valve surgery subtypes. Ten out of twelve (83%) of the CPMs for patients undergoing interventions for VHD predicted mortality. The median number of non-cardiac comorbidities included in the CPMs was 4 (range 0-7). All of the CPMs predicting mortality included at least 1 comorbid condition. The top 3 most common comorbidities included in these CPMs were, renal dysfunction (10/12, 83%), prior CVA (7/12, 58%) and measures of BMI/BSA (7/12, 58%). Diabetes was present in only 25% (3/12) of the models and chronic lung disease in only 17% (2/12).

Conclusions:
Non-cardiac comorbidities are frequently found in CPMs predicting morbidity and mortality following interventions for VHD. There is significant variation in the number and type of specific comorbid conditions included in these CPMs. More work is needed to understand the directionality, magnitude, and consistency of effect of these non-cardiac comorbid conditions for patients undergoing interventions for VHD.
Abstract 228: Patients’ Views of Consent for STEMI Trials: Are All Trials the Same?
Authors: Hendershot Kristopher A , Fehr Alexandra E , Speight Candace D , Dickert Neal W
Published: July 2021

Background:
Informed consent for clinical trials in acute MI- especially STEMI- is controversial. Prior data suggest patients want to be asked for permission before enrollment. It is unknown whether trial features affect this desire. This is particularly important in the context of debate about the role of consent in standard of care comparative effectiveness trials.

Methods:
This interview study included patients admitted with acute MI. Structured, in-depth interviews were conducted in hospital or after discharge. Participants considered 3 scenarios modeled on existing STEMI trials: 1) comparative effectiveness trial of approved antiplatelet drugs; 2) placebo-controlled trial of a novel drug to reduce myocardial injury; and 3) comparative effectiveness trial of intraaortic balloon pump versus medical therapy. Participants were asked their desired involvement in enrollment decisions and willingness to participate in each trial.

Results:
Thirty patients were interviewed. Most (73-80%) wanted to be asked for permission to be enrolled in all scenarios (Table 1). Willingness to enroll, however, was affected by trial type. For example, 50% vs 20% were unlikely to enroll in scenario 3 vs. scenario 1 (p=0.018). Attitudes regarding enrollment focused on distinctive trial features. Many participants specifically stated they were comfortable with scenario 1 because it involved only approved drugs. Participants split regarding scenario 2 based on whether they viewed the novel agent as a potential benefit or risk, and some had concerns about placebo. The invasive nature of the balloon pump in scenario 3 was the most common basis for not wanting to enroll. For some, this was driven by a desire to receive the intervention; for others, it was driven by a desire to avoid it.

Conclusion:
In this exploratory study, most patients would prefer to be asked for permission prior to enrollment in 3 different STEMI trial scenarios, including 2 trials evaluating standard of care alternatives. While desire to be involved in enrollment decisions was relatively insensitive to trial features, these features impacted willingness to enroll. This study supports the notion that the form and content of consent processes for STEMI trials should be trial and context specific. Refining these processes requires further study.
Abstract 232: Postgraduate Education in Quality Improvement Methods: Initial Results of the Fellows’ Applied Quality Training Curriculum
Authors: Winchester David E , Choi Calvin , McKillop Matthew S , Burkart Thomas A , Beyth Rebecca J , Dahm Philip
Published: July 2021

Background:
Formal training in quality improvement (QI) methods is sporadic in medical educational settings. QI is a growing expectation for individual professional certifications and facility accreditations; future physicians will need to understand and apply QI methods as part of their practice. We developed a curriculum with both didactic and applied components to teach QI methods to cardiology fellows.

Methods:
The Fellows Applied Quality Training (FAQT) curriculum started in July 2013 with an initial cohort of 23 postgraduate trainees in general and subspecialty cardiovascular medicine fellowships. The FAQT is a multifaceted QI curriculum consisting of online learning modules, didactic training, and the start-to-finish completion of a team-based, self-directed quality improvement project under supervision of a faculty mentor. Trainees completed selected modules from the Institute of Healthcare Improvement Open School including basic terminology and background of QI methods. Trainees were assigned to small groups and challenged to identify an area in need, design an intervention to improve quality or safety, select an appropriate metric to measure, determine how to acquire the necessary data, implement their plan, analyze data to measure their success, and formally present the results. Prior to, during, and at the completion of the FAQT, trainees completed the 13 question self-assessment from the Quality Assessment and Improvement Curriculum. This assessment asks participants to rate their confidence to perform QI activities independently. The primary outcome of our investigation was an increase in the median confidence score reported on a 4 point scale (1=not at all confident, 2=slightly confident, 3=moderately confident, 4=extremely confident) compared by Wilcoxon signed rank test.

Results:
Prior to the FAQT, 15 trainees reported no prior formal QI training. Of those with prior training, 4 were practical and 4 had only didactic training. At baseline, the median score given on the assessment was 3.0. After completion of online training modules, the median score did not increase (3.0, p=0.51). At the conclusion of the self-directed projects, average confidence was higher (3.27, p=0.004). The proportion of fellows reporting they were “extremely” confident about using quality assessment and improvement in your future career increased from15% to 50% while the proportion reporting “slight” confidence decreased from 30% to 5%.

Conclusion:
At our institution, the majority of post-graduate medical trainees had no formal exposure to QI training. After completing a curriculum with practical application of QI methods, trainees reported an increase in their self-confidence to independently conduct QI; no increase was observed with didactic training alone.
Abstract 251: The Association Between Receipt of Healthcare Services and Post-stroke Hypertension Control
Authors: Kohok Dhanashri , Sico Jason J , Baye Fitsum , Myers Laura , Masoor Kamalesh , Bravata Dawn M
Published: July 2021

Hypertension is a known risk factor for primary as well as recurrent stroke. Improving blood pressure (BP) control has been associated with decreased risk of recurrent stroke. Several factors have been associated with poor BP control among stroke patients such as non-compliance and clinical inertia. We examined the receipt of health care services by patients in the one-year period following discharge for ischemic stroke.

This was a retrospective cohort study of patients who were admitted for acute ischemic stroke at a Veterans Affairs hospital during year 2011 and who were discharged with a BP >140/90 mmHg. The following were reviewed: primary care visits; sub-specialty clinic visits; emergency department (ED) visits; hospitalizations; utilization of ancillary care (i.e., telehealth, pharmacy, nutrition services); medications upon discharge; adherence to medications and occurrence of recurrent stroke during the one-year post-discharge period.

The cohort included 124 patients with an average age of 66.4 years (± standard deviation of10.3); 123 were male; 62.9% were white; diabetes mellitus was present in 32.5%; and 13.0% had history of coronary artery disease. The average BP at the time of discharge from the index stroke hospitalization was 149.5/82.6 (±11.3/9.8) mmHg. Only 38.7% of patients had an average BP over the one year period of <140/90 mmHg. The average number of primary care visits during this period was 2.8 (±1.6). The overwhelming majority of patients had at least one primary care visit (N=119, 95.9%) however the median time from discharge to the first primary clinic visit was 32 days (IQR 59). Forty four percent of patients were seen as outpatient by neurology, 19.4% by cardiology, 9.7% by nephrology, 5.7% by nutrition, 23.4% by clinical pharmacy, and 9.7% by the telehealth service. BP monitors were issued to or being used by 39.5% patients. Non-adherence was documented in the medical record as an interfering issue in 25.8% of patients. More than two antihypertensive agents were prescribed at discharge in 50.8% patients. During the one-year post-discharge period 29.0% of patients were hospitalized at least once and 24.2% had at least one ED visit. Recurrent stroke occurred in 3.2% of patients. The stroke rate was 4.23% among patients with uncontrolled BP compared with 2.08% among patients with well-controlled BP (p=0.40).

This indicates that patients with elevated BP at the time of discharge from an ischemic stroke hospitalization remain with poorly controlled BP in the year post-discharge. Although patients appear to be receiving primary care services, these visits are not successfully achieving BP control. Relative underuse of certain resources for hypertension management such as ancillary services and home BP monitoring is observed.Future intervention studies seeking to improve the hypertension management of post-stroke patients should address these observed gaps in care.
Abstract 262: The Predictive Ability of a 30-Day Heart Failure Readmission Model Improves with Multi-level Analysis
Authors: Sterling Madeline , Goyal Parag , Beecy Ashley , Boutin-Foster Carla , Horn Evelyn M , Jones Erica C
Published: July 2021

Background:
Although readmission occurs following 25% of heart failure hospitalizations, identifying patients at greatest risk has been challenging. To date, prediction models have offered only modest discriminatory power (C-Statistic: 0.58-0.65). Their limitations underscore the need for novel approaches to risk prediction.

Hypothesis:
Multi-level analysis and the inclusion of population-level factors will improve the predictive ability of our 30-day HF readmission model.

Methods:
We studied patients with a principal diagnosis of HF who were discharged home from an academic hospital in 2013-2014. Index hospitalizations and 30-day readmissions were identified by query of the electronic medical record. Variables of analysis included demographics, HF characteristics, comorbidities, echocardiographic (echo) parameters and clinical indices. Heart failure with preserved ejection fraction (HFpEF) was defined as LVEF ≥ 50 on echo. Conventional logistic regression models were first used to examine the association between patient characteristics and 30-day readmissions. Next, multi-level modeling was used wherein hierarchical clustering techniques identified key drivers of readmission. The final predictive model incorporated these findings.

Results:
Of the 821 patients admitted with HF, 242 (29.5%) were readmitted within 30 days. HFpEF (p = .008), LVEF (p= .03) and NYHA classification (p=.002) were associated with early readmission, as were end stage renal disease (p=.04) and gastrointestinal bleeding (p =.02). In addition, serum sodium (p =.02), creatinine (p =.03) and hemoglobin (p =.002) were also associated with readmission. The initial multivariable logistic regression model based on patient characteristics was significant (p=.01) with 66% convergence. This model found ventricular tachycardia (VT) (OR = 3.47 CI 1.49-8.08) and HFpEF (OR =1.49 CI 1.01-2.22) to be associated with readmission. As expected, NYHA Class II (OR = 0.28 CI 0.09-0.834) and Hemoglobin (OR = 0.89 CI 0.80-0.98) were inversely associated with readmission. Multi-level analysis revealed that beyond the characteristics of the individuals alone, patients with HFpEF represented a significant sub-population that was driving readmissions. The final model incorporated this nested sub-group and was found to have an improved convergence of 73% (p =.02). In this model, the association of HFpEF and readmission increased in magnitude (OR = 3.43 CI 1.39-8.45), whereas factors including VT, NYHA Class II, and hemoglobin were no longer significant.

Conclusion:
Multi-level analysis increased the predictive ability of our 30-day HF readmission model (c stat 0.66 to 0.73) by accounting for both individual and population-level characteristics. HFpEF emerged as a key driver of readmission and its inclusion in the model led to a more accurate and clinically meaningful tool for our clinicians and medical center.
Subvalvular Repair
Authors: Langer Frank , Rodriguez Filiberto , Ortiz Saskia , Cheng Allen , Nguyen Tom C. , Zasio Mary K. , Liang David , Daughters George T. , Ingels Neil B. , Miller D. Craig
Published: July 2021

Background—

Residual or recurrent mitral regurgitation frequently occurs after mitral ring annuloplasty repair for ischemic mitral regurgitation (IMR), because annuloplasty primarily addresses annular dilatation. We describe a subvalvular repair technique addressing posterior papillary muscle (PPM) displacement.

Methods and Results—

Ten sheep had radiopaque markers placed on the left ventricle (LV) and mitral apparatus. A suture was anchored at the right fibrous trigone, passed through the PPM tip and LV wall, and exteriorized through a tourniquet (STRING-1). A second suture was anchored transmurally in the high septum (anterobasal LV wall) and passed through the PPM and LV wall (STRING-2). Reversible posterolateral ischemia was induced by temporarily occluding the proximal circumflex artery. Under open chest conditions, 3D marker coordinates were obtained with biplane videofluoroscopy at baseline and during acute ischemia before and after tightening of each STRING using transesophageal echocardiography to grade IMR. IMR decreased (mean±SEM, 2.0±0.1 to 1.2±0.1;
P
<0.05) when STRING-1 was tightened, did not change after tightening STRING-2 (2.3±0.1 to 2.3±0.1), and decreased after tightening both sutures (STRING-1+2, 2.3±0.2 to 1.3±0.2;
P
<0.05). STRING-1 and STRING-1+2 (STRING-1, 1.7±0.4 mm; STRING-2, 0.7±0.5 mm; STRING-1+2, 1.5±0.3 mm;
P
<0.05) resulted in significant PPM basal repositioning. Tightening of any STRING sutures did not affect anterior mitral leaflet excursion.

Conclusions—

Basal repositioning of the PPM with STRING-1 reduced acute IMR without concomitant annular reduction. This technique may be a useful adjunct if residual IMR is likely after undersized ring annuloplasty.
Hybrid Revascularization Strategy
Authors: Davidavicius Giedrius , Van Praet Frank , Mansour Samer , Casselman Filip , Bartunek Jozef , Degrieck Ivan , Wellens Francis , De Geest Raf , Vanermen Hugo , Wijns William , De Bruyne Bernard
Published: July 2021

Background—

Robotically enhanced minimally invasive direct coronary artery bypass (RE-MIDCAB) graft of the left internal mammary artery to the left anterior descending coronary artery (LAD) and/or the first diagonal branch might be the least traumatic surgical revascularization approach available so far. When combined with fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) in the non-LAD vessels, this “hybrid” strategy takes advantage of the survival benefit conferred by the internal mammary artery graft to the LAD while providing the patients with a truly minimally invasive, functionally complete revascularization.

Methods and Results—

Twenty patients with multivessel disease were selected to undergo combined PCI and RE-MIDCAB because they had a lesion amenable to PCI in the right and/or the left circumflex coronary artery and a lesion in the LAD and/or the first diagonal branch that was considered less than ideal for PCI. PCI was actually performed only when FFR was <0.80 (“provisional PCI”). In 7 stenoses, FFR was >0.80 and the planned PCI was not performed. Surgery was performed before provisional PCI in 6 cases. An angiogram was obtained in all patients before discharge, and a complete clinical follow-up including a stress test was obtained in all patients after a mean of 12 months. There were no significant intraoperative complications, conversions to cardiopulmonary bypass, or reinterventions for bleeding. At early control angiogram, 2 moderate stenoses just proximal to anastomosis were observed, both with normal run-off. After 12 months there were no objective signs of ischemia at stress testing. After an average follow-up of 19±10 months there were no deaths, myocardial infarctions, or repeat revascularizations.

Conclusion—

A hybrid strategy combining FFR-guided PCI and RE-MIDCAB seems safe and provides selected patients with a functionally complete revascularization with minimal surgical trauma and excellent clinical outcomes.
Surgical Treatment of Atrial Fibrillation Using Argon-Based Cryoablation During Concomitant Cardiac Procedures
Authors: Mack Charles A. , Milla Federico , Ko Wilson , Girardi Leonard N. , Lee Leonard Y. , Tortolani Anthony J. , Mascitelli Justin , Krieger Karl H. , Isom O. Wayne
Published: July 2021

Background—

The development of ablative energy sources has simplified the surgical treatment of atrial fibrillation (AF) during concomitant cardiac procedures. We report our results using argon-based endocardial cryoablation for the treatment of AF in patients undergoing concomitant cardiac procedures.

Methods and Results—

Sixty-three patients with AF who were undergoing concomitant cardiac procedures had the same left atrial endocardial lesion set using a flexible argon-based cryoablative device. Mean age was 65.1±1.3 years. Sixty-two percent had permanent AF, whereas 38% had paroxysmal AF. Mean duration of AF was 30.5±4.8 months. Mean left atrial diameter was 5.5±0.1 cm. Mean ejection fraction was 45±1.4%. All endocardial lesions were performed for 1 minute once tissue temperature reached −40°C. Follow-up echocardiograms were obtained to determine freedom from AF. Kaplan-Meier analysis demonstrated an 88.5% freedom from AF rate at 12 months. Ablation time was 16.8±0.6 minutes. There were no in-hospital deaths and no strokes. Twelve patients (19%) required postoperative permanent pacemaker placement.

Conclusions—

Cryoablation using this flexible argon-based device for the treatment of AF during concomitant cardiac procedures was safe and effective, with 88.5% of patients free from AF at 12 months.
Progression of Tricuspid Regurgitation After Repaired Functional Ischemic Mitral Regurgitation
Authors: Matsunaga Akira , Duran Carlos M. G.
Published: July 2021

Background—

Despite correction of left-sided cardiac lesions, associated functional tricuspid regurgitation (TR) that was surgically ignored can persist. It can also appear de novo. The aim of this study was to analyze TR in a group of patients who underwent successful revascularization and mitral valve repair (MVRep) for functional ischemic mitral regurgitation (MR).

Methods and Results—

Among 124 consecutive patients with MVRep, 70 left the operating room with MR ≤1+ and had a preoperative and follow-up transthoracic echocardiogra. Moderate or greater MR or TR was considered significant. Twenty-one patients (30%) had TR before surgery, and only 9 had TR repaired. The postoperative incidence of residual TR was not significantly different whether the tricuspid valve had been repaired (4 of 9 [44%]) or surgically ignored (8 of 12 [67%]). At last follow-up, 34 patients (49%) had significant TR. The incidence of TR increased from 25% at <1 year to 53% between 1 and 3 years and 74% at >3 years. Absence or presence of recurrent MR did not significantly affect TR (14 of 22 [64%] with MR versus 20 of 48 [42%] with no MR). Preoperative and postoperative tricuspid annulus size in patients with late TR was significantly larger than in patients without TR.

Conclusions—

Functional TR is frequently associated with functional ischemic MR. After MVRep, close to 50% of patients have TR. The incidence of postoperative TR increases with time. Preoperative tricuspid annulus dilation might be a predictor of late TR.
Prevention of Left Ventricular Remodeling With Granulocyte Colony-Stimulating Factor After Acute Myocardial Infarction
Authors: Ince Hüseyin , Petzsch Michael , Kleine Hans Dieter , Eckard Heike , Rehders Tim , Burska Detlev , Kische Stephan , Freund Mathias , Nienaber Christoph A.
Published: July 2021

Background—

Experimental and clinical evidence has recently shown that pluripotent stem cells can be mobilized by granulocyte colony-stimulating factor (G-CSF) and may enhance myocardial regeneration early after primary percutaneous coronary intervention (PCI) management of acute myocardial infarction. Sustained or long-term effects of mobilized CD34-positive mononuclear stem cells, however, are unknown.

Methods and Results—

Thirty consecutive patients with ST-elevation myocardial infarction undergoing primary PCI with stenting and abciximab were selected for the study 85±30 minutes after PCI; 15 patients were randomly assigned to receive subcutaneous G-CSF at 10 μg/kg body weight for 6 days in addition to standard care including aspirin, clopidogrel, an angiotensin-converting enzyme inhibitor, β-blocking agents, and statins. In patients with comparable demographics and clinical and infarct-related characteristics, G-CSF stimulation led to sustained mobilization of CD34 positive mononuclear cells (MNC
CD34+
), with a 20-fold increase (from 3±2 at baseline to 66±54 MNC
CD34+
/μL on day 6;
P
<0.001); there was no evidence of leukocytoclastic effects, accelerated restenosis rate, or any late adverse events. Within 4 months, G-CSF–induced MNC
CD34+
mobilization led to enhanced resting wall thickening in the infarct zone of 1.16±0.29 mm (
P
<0.05 versus control), which was sustained at 1.20±0.28 after 12 months (
P
<0.001 versus control). Similarly, left ventricular ejection fraction improved from 48±4% at baseline to 54±8% at 4 months (
P
<0.005 versus control) and 56±9% at 12 months (
P
<0.003 versus control and paralleled by sustained improvement of wall-motion score index from 1.70±0.22 to 1.42±0.26 and 1.33±0.21 at 4 and 12 months, respectively), after G-CSF (
P
<0.05 versus baseline and
P
<0.03 versus controls). Accordingly, left ventricular end-diastolic diameter showed no remodeling and stable left ventricular dimensions after G-CSF stimulation, whereas left ventricular end-diastolic diameter in controls revealed enlargement from 55±4 mm at baseline to 58±4 mm (
P
<0.05 versus baseline) at 12 months after infarction and no improvement in diastolic function.

Conclusion—

Mobilization of MNC
CD34+
by G-CSF after primary PCI may offer a pragmatic strategy for improvement in ventricular function and prevention of left ventricular remodeling 1 year after acute myocardial infarction.
Biventricular Assist Device Utilization for Patients with Morbid Congestive Heart Failure
Authors: Tsukui Hiroyuki , Teuteberg Jeffrey J. , Murali Srinivas , McNamara Dennis M. , Buchanan Julianne R. , Winowich Stephen , Stanford Eileen , Mathier Michael A. , Cadaret Linda M. , Kormos Robert L.
Published: July 2021

Background—

The rationale for the use of a biventricular assist device (BiVAD) for morbid congestive heart failure (MCHF) has been questioned because of historically unacceptable rates of postimplant and post-transplant mortality as well as perceived barriers to their outpatient management.

Methods and Results—

All patients who received a Thoratec BiVAD from January 1990 to December 2003 at the University of Pittsburgh were studied retrospectively. There were a total of 73 patients (32% ischemic, 21% idiopathic, and 47% other) who had a BiVAD implanted. Before implantation, 100% were on ≥1 inotropic agent, and 77% had an intra-aortic balloon pump. Overall survival was 69%; 42 patients (84%) received cardiac transplantation, 5 patients (10%) were weaned, and 3 (6%) remained supported on BiVAD. If the 14 patients with postcardiotomy failure and acute myocardial infarction with shock are excluded, the overall survival improves to 75%. Five-year actuarial survival after heart transplantation was 58%. Of the 29 patients implanted before 2000, the 4-month actuarial freedom from driveline infections, bloodstream infections, and neurological events was 10%, 54%, and 48%, respectively, whereas the rates of these events for the 44 patients implanted after 2000 improved to 70%, 79%, and 80%, respectively. Since 2000, 21 (48%) patients were discharged from the hospital, of whom 38% went to an outpatient residence, 33% to a skilled nursing facility, and 29% to home. Once discharged, ≥1 readmission occurred in 45% and ≥2 readmissions in 48%.

Conclusions—

BiVAD support for MCHF has an acceptable overall mortality and survival to transplantation. Morbidity has been significantly reduced in the past 4 years, and management as an outpatient is achievable.
Improved Survival in Asymptomatic Diabetic Patients With High-Risk Spect Imaging Treated With Coronary Artery Bypass Grafting
Authors: Sorajja Paul , Chareonthaitawee Panithaya , Rajagopalan Navin , Miller Todd D. , Frye Robert L. , Hodge David O. , Gibbons Raymond J.
Published: July 2021

Background—

The Bypass Angioplasty Revascularization Investigation trial demonstrated that symptomatic diabetics with multivessel coronary artery disease had a survival advantage with initial coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI). No published study has examined different treatments and outcome in asymptomatic diabetics.

Methods and Results—

This study group consisted of 826 asymptomatic diabetics (age 62±12 years; 76% men) without known coronary artery disease who had abnormal myocardial perfusion during stress single photon emission computed tomography (SPECT). SPECT images were classified as low-, intermediate-, and high-risk. Early revascularization (CABG or PCI ≤4 months after SPECT) was performed in 76 patients. Survival (follow-up, 5.3±3.3 years) was compared in patients treated with CABG, PCI, or medical therapy. Revascularization (CABG or PCI) was performed in 54 of 261 patients with high-risk scans and was independently associated with improved survival (χ
2
=4.55;
P
=0.03 after multivariate adjustment). Subset analysis demonstrated that the survival advantage was confined to patients treated with CABG (n =39), with a 5-year survival CABG at 85%, PCI at 72%, and medical therapy at 67% (
P
=0.02 for 3 groups). Although CABG was associated with better survival, mortality remained high (3% per year). There was no survival advantage by treatment for patients with less-severe SPECT abnormalities.

Conclusions—

These nonrandomized data suggest that CABG improves survival in asymptomatic diabetic patients with high-risk SPECT, although revascularization was performed infrequently in these patients. These results parallel those of the Bypass Angioplasty Revascularization Investigation trial in symptomatic diabetic patients.