bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 119: Daily Cardiac Catheterization Procedural Volume and Complications
Authors: Slicker Kipp , Lane Wesley , Oyetayo Ola , Zimmermann Jeremy , Copeland Laurel A , Stock Eileen M , Erwin John
Published: July 2021

Background:
Cardiac catheterization (CC) is a frequently performed procedure in US with over 1,000,000 procedures performed annually. Prior studies have demonstrated an inverse relationship between annual volume and complications with centers performing greater than 400 procedures annually having fewer complications. However, there has not been any investigation into the optimal daily volume of procedures to ensure the lowest risk. The objective of this study is to determine the relationship between daily volume and complication rates and to identify an optimal volume of procedures per day.

Methods:
We used data captured retrospectively from the NCDR and Lumedx© database of adult patients undergoing non-emergent CC at a high-volume (>400 procedures/year) tertiary care hospital catheterization laboratory from January 2005 - June 2013. We excluded patients undergoing CC on weekends and after business hours. In the event of multiple CC, only the first event was utilized for this analysis. Complications examined included: death, post-procedure MI, cardiogenic shock, heart failure, stroke, tamponade, major bleeding, hematoma or acute kidney injury as defined by the NCDR database. We analyzed the relationship between the volume of CC conducted per day and rates of complications.

Results:
Overall, 13,819 patients were included who underwent 18,287 CCs on 2,150 days. The average age was 63 years (SD 12.5; range 18-95) and 61% (8,430/13,819) were men. A total of 396 complications occurred in 305 patients on 292 separate days with a 2.2% (396/18,287) CC complication rate. The average volume per day was 8.5 CCs. On the days with a complication, the median procedural volume was 10 CCs compared to 8 CCs on days without a complication (p<0.01). We found a low correlation between the rates of complication and CC volume (Spearman’s rho=0.12; p<0.01). There was a U-shaped relationship with a higher complication rates on days with 1-5 CC and days with > 12 CC. Overall, the lowest complication rates were observed on days with 10-12 events.

Conclusions:
There is a U-shaped association between CC volume and rates of CC related complications. Unlike prior studies which identified high annual volumes were associated with lower complication rate, our study results suggests that this relationship does not hold true for daily volume. There appears to be a daily limit at which complication rates begin to rise in proportion to volume. Higher complication rates were seen on days with very low CC volume (<5 procedures) and days with very high CC volume (>12 procedures). It is important that individual high volume CC labs consider a quality control analysis of their daily CC volume to determine the optimal volume associated with the fewest complications.
Abstract 121: Vitamin D Deficiency Study in Postural Orthostatic Tachycardia Syndrome
Authors: Ashangari Chandralekha , Suleman Amer
Published: July 2021

Objectives
The aim of this study is to assess vitamin D levels, including the prevalence of vitamin D deficiency/insufficiency in Postural Orthostatic Tachycardia Syndrome (POTS) patients.

Background
: The Postural Orthostatic Tachycardia Syndrome (POTS) affects primarily young women. POTS is a form of dysautonomia that is estimated to impact between 1,000,000 and 3,000,000 Americans, and millions more around the world. We frequently find vitamin D deficiency in patients who present with POTS

Methods:
180 patients were selected randomly from our clinic with POTS. Patients Vitamin D levels charts were reviewed from electronic medical records, 25-OH vitamin D (Vitamin D3 ) status was defined as Normal (>30 ng/mL), Insufficient (20.0-29.9 ng/mL), and deficient (<20 ng/mL).

Results:
Out of 180 patients, 170 patients are female (94%, n=170, age 31.88±10.36), 10 patients are male (6% ,age 25.83±6.19). 79 patients had vitamin D3 level >30 ng/ml, 10 patients had vitamin D3 level range >20.0 to 29.9 ng/mL, 91 patients had vitamin D3 level < 20ng/mL.

Conclusion:
Our research results demonstrated that Postural Orthostatic Tachycardia Syndrome (POTS) patients have a higher rate of vitamin D3 deficiency (51% have Vitamin D3 less than 20 ng/mL). Vitamin D3 levels are low in more than half of POTS patients (56% had less than 30 ng/mL )
Abstract 126: Inside Transitional Care: What Actually Happens During These Visits?
Authors: Bumpus Sherry M , Bluhm Minnie , Sylvester Rachel , Dean Joshua , Steinbacher Michaela , Kline-Rogers Eva , Mollo Lynette , Eagle Kim A , Rubenfire Melvyn
Published: July 2021

Background:
Bridging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner (NP) delivered transitional care program designed to provide cardiac patients a timely, guideline-based, first post-discharge visit. BRIDGE follow-up within 14 days of discharge has been shown to reduce early adverse events, including rehospitalization, for ACS patients, at a cost savings. Despite this success, there is little evidence documenting what occurs during these visits. The purpose of this study is to examine the content of first post-discharge visits.

Methods:
Mixed methods design was used to examine content of BRIDGE visits and assess patient perceptions of rapport with their NP. Visits with 17 ACS patients were audio-recorded and transcribed verbatim. Transcripts were coded and analyzed using conventional content analysis to identify themes within and across visits. Patients completed the Consultation and Relational Empathy (CARE) scale and a modified Patient-Doctor Relationship Questionnaire (PDRQ9). Demographic information and details of 30-day readmissions were abstracted from patient charts.

Results:
Nineteen patients consented; 17 (89%) completed the study. Most were male (14, 73.7%) and white (15, 78.9%). Average age was 61.6 years. One (5%) had an unplanned readmission. NP priorities during visits included clinical history, medication reconciliation, patient education, and referrals. Patients were screened for guideline-driven secondary prevention queues such as physical symptoms, diet, physical activity, and smoking. Patient priorities included questions about daily life (can I play catch with my grandson); clinical questions (can a stress test cause a heart attack); feelings (he feels like dying; I feel helpless), and fear of death (I’m afraid if I go to sleep I might not wake up). On average, NPs contributed 59% of the verbal content of the visits. Patients felt highly connected with NPs (mean PDRQ9 43.05 + 3.1; possible range 5, 45, α=.95) and viewed them as deeply empathic (mean CARE 43.5 + 2.8); possible range 0, 50, α=.94).

Discussion:
A qualitative approach resulted in nuanced understandings of the content of first post-discharge visits. Patients and NPs have overlapping priorities for these visits. Both concern themselves with managing the medical condition. In addition, patients reveal other priorities, such as how to carry on with daily life and manage feelings and fears. Notably, assessment of psychosocial issues and mental health were absent, suggesting an opportunity to enhance patient care. NPs may be ideally suited to begin filling this gap given their excellent rapport with patients and expertise in motivational interviewing. It is plausible that these factors also contribute to the success of the BRIDGE program in reducing 30-day readmissions. Further research is needed with larger sample sizes and other types of providers to fully assess their impact.
Abstract 140: Women of Color: Where Race/Ethnicity, Sex/Gender, Culture and History Affect Cardiovascular Health and Disparities
Authors: Brooks Claudette E , Mistretta Amy , Brewinski-Isaacs Maggie , Miller Leah , Cornelison Terri L , Clayton Janine A
Published: July 2021

The United States is in the midst of a historic demographic shift in its population that will have multiple societal impacts including healthcare issues. In 2043 it is predicted that the majority of the US population will be persons of color (“racial and ethnic minorities”). This new majority will be 53.4% of the nation by 2050. Of the 49 million uninsured in the US in 2011, 55% were persons of color who were only 33% of the population. Women of color are projected to increase in number from 57 million in 2010 to 107 million in 2050, from 36 percent to 53 percent of the total US female population. The Women of Color Health Data Book, 4th edition, consists of US Government sourced, population-based health and disease data disaggregated by sex/gender and race/ethnicity with relevant discussions of the roles of historical, cultural and socio-geo-demographic factors in the health status of women of color. The impending hurdles facing the US and the globe in access, outcomes, and health disparities are underscored including those in cardiovascular diseases. Cardiovascular disease remains the leading cause of death for women in the US, even though sub-populations of women may have different prevalence rates for major risk factors for heart disease and stroke_i.e., diabetes, hypertension, high cholesterol, obesity, lack of exercise, and smoking. Cerebrovascular diseases (strokes), with a similar risk factor profile to heart disease, continue to be the third leading cause of death of black, Hispanic, and Asian or Pacific Islander females, the fourth for Non-Hispanic white females and the fifth for males overall. Age -adjusted death rates for stroke were still highest among black women. Despite the decline in both heart disease and stroke mortality overall and that Non-Hispanic white women are at significant risk, the majority of women of color continue to be disparately burdened with these two preventable causes of death and debilitating morbidity. This year, 2015, the US Census Bureau projects that black females will have the shortest life expectancy at birth in the nation. Understanding the underlying varied cultural dynamics and other factors that affect health status and influence differences seen across and among populations of women is critical to address prevailing cardiovascular health disparities and inform the design and implementation of interventions to improve outcomes within an increasingly diverse population.
Abstract 156: Everyday Discrimination and Risk of Myocardial Infarction Among Women
Authors: Jacobs Aryana S , Ngwa Julius S , Slopen Natalie , Zaslavsky Alan M , Dushkes Rimma , Buring Julie E , Williams David R , Albert Michelle A
Published: July 2021

Background:
Discrimination, a form of chronic psychological stress, is related to certain chronic health conditions such as poor physical health and hypertension. However, little is known about the associations of everyday discrimination with risk of myocardial infarction.

Methods and Results:
We assessed the association between everyday discrimination (discrimination) and myocardial infarction (MI) using a prospective, nested case control study of 548 women (267 cases, 281 controls), selected from 26,763 women without a history of cardiovascular disease at baseline who participated in the Women’s Heath Study (WHS). Among 267 MI cases, there was a mean follow-up of 8.8
+
4.1 years from date of WHS randomization to date of MI event. At baseline, the mean age of participants was 53.6
+
6.1 years. Cases and controls were matched for age and smoking history. Discrimination was assessed by 5 questions where women reported whether they were: 1) treated with less courtesy/respect than others; 2) treated as not being smart; 3) treated as if others were afraid of them; 4) received poorer service at restaurants/stores; or 5) felt threatened/harassed. Responses were based on a Likert scale of 1=never to 5=at least once/weekly with higher scores indicating more experiences with discrimination. In unadjusted logistic regression models of increasing tertiles of discrimination, we found no significant association between discrimination and odds of MI [Odds Ratios (OR) and 95% confidence intervals (95%CI): 1.00, 1.28 (0.85-1.94), 1.06 (0.69-1.64); p
trend
=0.5]. Adjustment for cardiovascular disease risk factors (lipid parameters, hsCRP, family history of MI, hypertension, body mass index, diabetes, and alcohol consumption) revealed an inverse-U-shaped relationship [OR, 95%CI: 1.00, 2.14 (1.21-3.77), 1.55 (0.87-2.78); p
trend
= 0.03], suggesting that these factors obscured the association in unadjusted models. Notably, addition of education and income to the crude model alone [1.00, 1.38 (0.89, 2.15), 0.97 (0.61, 1.54) p
trend
= 0.2] or to the model with the cardiovascular risk factors [1.00, 2.27 (1.25-4.10), 1.36 (0.73, 2.53); p
trend
= 0.02] had minimal impact on odds of MI in these women.

Conclusion:
Among women participating in the WHS follow-up cohort, higher levels of everyday discrimination were related to increased odds of myocardial infarction in an inverse-U-shaped manner, a finding that is obscured by traditional cardiovascular disease risk factors. Access to measures associated with a healthy heart might be important to myocardial infarction risk attenuation among women reporting everyday discrimination. Further research is warranted to elucidate the relationship between everyday discrimination and increased risk of MI.
Abstract 165: In-hospital Serum HbA1c and Glucose Levels and 30-Day Hospital Readmissions Among Adults Hospitalized with an Acute Coronary Syndrome: TRACE-CORE
Authors: Erskine Nathaniel A , Waring Molly E , Gore Joel M , Gurwitz Jerry H , Lessard Darleen M , Kiefe Catarina I , Goldberg Robert J
Published: July 2021

Objective:
Abnormalities in glucose metabolism may worsen the prognosis of patients hospitalized with an acute coronary syndrome (ACS). We examined the association of in-hospital serum glucose and glycated hemoglobin (HbA1c) levels with the occurrence of 30-day hospital readmissions among adults discharged from the hospital after an ACS.

Methods:
Using data from the Transitions, Risks, and Action in Coronary Events - Center for Outcomes Research and Education (TRACE-CORE) study, we reviewed the medical records of 2,187 patients discharged from 6 hospitals in MA and GA after an ACS between 2011 and 2013. We stratified patients according to diabetes mellitus (DM) status at baseline, as defined by medical history of DM, admission medications, or a serum HbA1c > 6.5%. Using logistic regression models, we calculated crude and adjusted odds ratios to estimate the association between serum HbA1c and glucose levels during hospitalization with 30-day all-cause readmissions. We controlled for prior and inpatient insulin use, age, body mass index, ACS classification, length of stay, and hospital site.

Results:
Data on serum HbA1c and glucose levels were available for 1,102 (50%) participants. This study sample had a mean age of 60 (SD: 11) years, 68% were male, 77% were non-Hispanic white, and 52% had DM. The mean in-hospital serum HbA1c and maximum and minimum serum glucose levels were 8.2%, 277 mg/dL, and 101 mg/dL, respectively, for those with known DM (n = 526) and 5.7%, 155 mg/dL, and 92 mg/dL for those without known DM (n = 576). A higher, but non-significant, proportion of patients with DM (14%) were readmitted to an area medical center within 30 days of discharge compared to those without DM (11%, p = 0.27). Neither serum HbA1c levels, nor minimum or maximum glucose values during hospitalization were associated with all-cause 30-day readmissions among those with and without DM (Table).

Conclusions:
In this prospective study of adults with an ACS, we found no significant association between serum HbA1c or glucose levels with the occurrence of 30-day hospital readmissions. The low proportion of subjects with serum HbA1c testing may have biased the study results. Further investigation should examine the in-hospital management of ACS patients with varying serum glucose and HBA1C levels and their post-discharge outcomes.
Abstract 171: Incidence and Predictors of Recurrent 30-Day Readmissions after Hospitalization for Heart Failure, Myocardial Infarction and Pneumonia
Authors: Moradiya Yogesh , Murthy Santosh , Parikh Valay , Modi Sneha , Naval Neeraj
Published: July 2021

Background and Purpose:
Thirty-day readmission rate is an indicator of quality and efficiency of care. Patients admitted within 30 days after index hospitalization are at high risk for recurrent 30-day readmissions. Therefore, we aimed to study the incidence and predictors of recurrent 30-day readmission after hospitalization for heart failure (HF), myocardial infarction (MI) and pneumonia.

Methods:
California State Inpatient Database (SID), a discharge database of all acute care admissions in the state of California was analyzed for adults discharged alive during 2003 to 2011 with primary diagnosis of HF, MI, or pneumonia using ICD-9 codes as defined by CMS for public reporting. Index cases were followed up for all-cause recurrent 30-day readmission using revisit variables included in SID. Inter-hospital transfers were counted as one common admission. Each patient could provide more than one index admissions if admitted multiple times with diagnosis of HF, MI or pneumonia during the study period. Multiple logistic regression models were constructed to identify independent factors associated with recurrent 30-day readmissions.

Results:
Of the 741,318 cases of HF, 374,860 cases of MI, and 676,412 cases of pneumonia included in the analysis, 70,629 (9.5%), 18,314 (4.9%) and 36,254 (5.4%) resulted in recurrent 30-day readmissions respectively. Rates of recurrent 30-day readmission after initial 30-day readmissions were 36.4%, 25.5%, and 29.4% for HF, MI and pneumonia respectively. Among 30-day readmissions, 66.6%, 69.0% and 66.5% were readmitted again within first 15 days of discharge from the initial 30-day readmission respectively. The most common etiology for recurrent 30-day readmission after HF and MI was HF (37.5% and 17.6% respectively), and after pneumonia was pneumonia (14.1%). In multivariate analysis, recurrent 30-day readmission rate was higher among younger, non-white race, Medicaid and Medicare (vs. private insurance), higher comorbidity index, hospitals with lowest case volume, and discharge against medical advice, discharge to facility or home health care (vs. home/self-care).

Conclusion:
Patients admitted within 30 days from discharge remains at high risk for recurrent 30-day readmission. Two-thirds of readmissions occurred within 15 days of discharge from the previous admission thus, interventions implemented before the discharge and during early post-discharge follow up are keys to successfully reducing recurrent 30-day readmissions.
Abstract 207: The Stroke Prevention Clinic, Extending Care Past The Stroke Center
Authors: Johnson Brenda , Bojang Binta , Butler Jaime , Urrutia Victor C
Published: July 2021

Background:
While the incidence and mortality from stroke in the United States has declined in the past 20 years, there are still more than 795,000 strokes per year, of which 185,000 are recurrent events. There remains great disparity between racial groups -the incidence and mortality among African Americans, is two to four times higher than Non-Hispanic Whites.

Despite great advances in drug therapies, the impact on stroke prevention has not been fully realized. There is a need for improved delivery of effective treatments.

Several randomized clinical trials have demonstrated the effectiveness of a comprehensive; clinic based, navigator-assisted approach to disease management, although in the context of specific clinical situations. Examples are, SAMMPRIS, and Look AHEAD.

We propose that learning from the development of the “stroke center” for acute stroke care, we may apply a similar model to stroke prevention.

We have created a Stroke Prevention Clinic (SPC), organized like an outpatient “stroke center”, offering evaluation, treatment, and long-term follow up of patients for risk factor control and lifestyle interventions for secondary prevention. Our Stroke Prevention Nurse is an integral part of this model. In this abstract we report the impact of this program on follow up rates.

Methods:
In 2011 we launched our SPC. The specific elements of this program included:

A Stroke Prevention Nurse:

a. Meets the patient in the hospital.

b. Facilitates scheduling of appointments, including in the SPC, which is given to the patient upon discharge.

c. Calls the patient within 7 days to do medication reconciliation and answer questions. Also, at 90 days for a modified Rankin score and whenever it is necessary to follow up on blood pressure readings.

d. Administers screening tools upon follow up, consents for research studies.

e. Educates the patient on stroke prevention.

Dedicated day for clinic. All providers in the same area.

Use of Advance Practice Nurse and stroke fellows, as well as vascular neurology attending.

Database.

We assessed the proportion of completed appointments within 90 days after discharge from the hospital and compared it with the year prior to implementation.

Results:
A sample from July 2010 to February 2011 revealed completed follow up by 90 days of 28.3% (70/247), for the period July 2011 to February 2012 the proportion was 35.6% (89/250).

During calendar year 2014, 54.3% (233/429) completed their appointments within 90 days.

Conclusion:
Implementation of the Stroke Prevention Clinic increased follow up completion within 90 days of discharge.
Abstract 222: Angina Severity, Depression, and Response to PCI in Patients With Chronic Total Occlusion of Coronary Arteries
Authors: Bruckel Jeffrey , Jaffer Farouc A , O’Brien Cashel , Pomerantsev Eugene , Yeh Robert W
Published: July 2021

Background:
Chronic total occlusions of coronary arteries (CTOs) are common in patients with chronic angina. Patients with chronic angina exhibit rates of depression that are higher than the general population, and depressed patients with coronary disease have a poorer prognosis. The study aims were to quantify rates of depression in patients referred for CTO PCI, determine whether depression is related to symptom severity, and determine whether depression modifies the effect of PCI on symptoms.

Methods and Results:
The study enrolled 56 consecutive patients referred for CTO PCI at a single center between 10/2013 and 10/2014. PCI was successful in 48/54 (88.9%) patients. 45 patients had complete data and were included. Responses to Seattle Angina Questionnaire (SAQ7), Rose Dyspnea Scale (RDS), and Patient Health Questionnaire (PHQ-2) were recorded in the medical record routinely on the day of the procedure and after 30 days. Data were abstracted from the medical record along with demographic, clinical, and procedural data. Depression was defined as PHQ-2 score ≥3 with 18/45 (40%) depressed at baseline. There were few differences in demographics, comorbidities, or medical therapy between depressed and non-depressed groups. PHQ-2 was linearly correlated with symptoms, most highly with SAQ7-SS (R2=0.264, p=0.0002) and RDS (R2=0.289, p=0.0001). Baseline SAQ7-SS and SAQ7-AF scores for depressed patients were 35.4 [28.4-42.4] and 54.4 [43.0-65.8], compared with 67.3 [57.5-77.1] and 77.8 [68.5-87.1] for non-depressed patients (p<0.0001 and p=0.003). All scores improved significantly between the pre- and post-procedure measurements (p<0.0001). Depressed patients had significantly larger improvements in their symptoms. Mean improvement in SAQ7-SS and SAQ7-AF scores for depressed patients were 48.5 [35.4-61.5] and 32.8 [21.0-44.5], compared with 16.5 [5.87-27.2] and 12.6 [3.0-22.2] for patients without depression (p=0.0004 and p=0.01). Fewer patients reported depression after PCI, with 5/45 (11.1%) patients reporting depression post-PCI (p=0.003 compared with 40% pre-PCI rate).

Conclusions:
Depression is common among patients with CTO, and is associated with increased angina severity. Depressed patients undergoing CTO PCI have a more dramatic improvement in their angina symptoms and depression.
Abstract 225: Frequency and Assessment of Poor Global Outcome in Patients with Left Ventricular Assist Devices
Authors: Fendler Timothy J , Nassif Michael E , Kennedy Kevin F , Spertus John A , LaRue Shane J , Vader Justin M , Silvestry Scott C , Joseph Susan M , Arnold Suzanne V
Published: July 2021

Background:
Left ventricular assist device (LVAD) therapy can improve survival and quality of life in advanced heart failure (HF), but some patients may still do poorly after LVAD. Understanding the likelihood of experiencing poorer outcomes after LVAD can better inform patients and calibrate their expectations.

Methods:
We analyzed patients receiving LVAD therapy from January 2012 to October 2013 at a single, high-volume, high-acuity center. We defined a poor global outcome at 1 year after LVAD as the occurrence of death, disabling stroke (precluding transplant), poor patient-reported health status (most recent KCCQ at 3, 6, or 12 months < 45, corresponding to NYHA class IV), or recurrent HF (≥2 HF readmissions post-implant). We compared characteristics of those with and without poor global outcome.

Results:
Among 164 LVAD recipients who had 1-year outcomes data, mean age was 56, 76.7% were white, 20.9% were female, and 85.9% were INTERMACS Profile 1 or 2 (cardiogenic shock or declining despite inotropes). Poor global outcome occurred in 58 (35.4%) patients at 1 year, of whom 37 (63.8%) died, 17 (29.3%) had a most recent KCCQ score < 45, 3 (5.2%) had ≥2 HF readmissions, and 1 (1.7%) had a disabling stroke (Figure). Eight of the patients who died also experienced one of the three other poor outcomes prior to death. Patients who experienced a poor global outcome were more likely to be designated for destination therapy (46.4% vs. 23.6%, p=0.01) than bridge to transplant, have longer index admissions (median [IQR]: 39 [24, 57] days vs. 25 [18, 35] days, p=0.003), and have major GI bleeding (44.2% vs. 27.7%, p=0.056), and were less likely to undergo LVAD exchange (0% vs. 12.3%, p=0.004).

Conclusion:
In this large, single-center study assessing global outcome after LVAD implantation, we found that about a third of all patients had experienced a poor global outcome at 1 year. While LVAD therapy remains life-saving and the standard of care for many patients with advanced heart failure, these findings could help guide discussions with eligible patients and families. Future work should compare patients’ pre-LVAD expectations with likely outcomes and create risk models to estimate the probability of poorer outcomes for individual patients using pre-procedural factors.
Abstract 257: Discharge Heart Rate and Beta-blocker Dose in Patients Hospitalized with Acute Heart Failure
Authors: DeVore Adam D , Mi Xiaojuan , Mentz Robert J , Fonarow Gregg C , Van Dyke Melissa K , Maya Juan F , Hardy N. Chantelle , Hammill Bradley G , Hernandez Adrian F
Published: July 2021

Background:
The SHIFT study (Systolic Heart failure treatment with the I
f
inhibitor ivabradine Trial) demonstrated the importance of elevated heart rate (defined as
>
70 beats per minute [bpm]) despite beta-blocker use as a treatment target in patients with heart failure with reduced ejection fraction (HFrEF). Limited data are available that describe the proportion of HFrEF patients that have an elevated heart rate despite beta-blocker therapy.

Methods:
We analyzed data from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) to describe discharge heart rate as a function of beta-blocker use and dose. We included adult patients with a left ventricular ejection fraction <40% and excluded those with a history of a pacemaker or cardiac resynchronization therapy. For beta-blockers, we considered the 3 evidence-based beta-blockers as well as atenolol and described the dose at discharge as a percentage of the target daily dose (categories included no beta-blocker, <25%, 25-49%,
>
50%).

Results:
Among 14,186 patients hospitalized with acute HFrEF between January 2003 and December 2004, the median discharge heart rate was 76 bpm (25
th
-75
th
percentile, 68-86). Of these, 10,264 (72%) were discharged on a beta-blocker. For patients not on a beta-blocker, the median discharge heart rate was 80 bpm (70-88), compared to 77 bpm (68-87) on <25% target dose, 75 bpm (66-84) on 25-49% target dose, and 74 bpm (66-83) on
>
50% target dose (P<0.001) (Figure). For patients on
>
50% target dose of a beta-blocker, 1397(65%) had a heart rate
>
70 bpm.

Conclusion:
Despite treatment with beta-blockers, a substantial proportion of HFrEF patients have an elevated heart rate at hospital discharge.
Abstract 273: Myocardial Infarction with Non Obstructive Coronary Artery Disease: Prevalence, Clinical Features and Outcomes
Authors: Pasupathy Sivabaskari , Tavella Rosanna , Arstall Margaret , Chew Derek , Worthley Matthew , Zeitz Christopher , Beltrame John
Published: July 2021

Background:
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is an enigma that is being increasingly recognized with the frequent use of angiography following Acute Myocardial Infarction (AMI). The current study is a prospective, contemporary analysis of MINOCA vs. Myocardial Infarction with obstructive coronary artery disease (MI-CAD) in regards to prevalence, clinical features, and in-hospital outcomes.

Methods:
All consecutive patients undergoing coronary angiography for AMI (as per the Third Universal AMI Definition) in South Australian public hospitals from January 2012 - December 2013 were included. Data was captured by Coronary Angiogram Database of South Australia (CADOSA), a comprehensive registry compatible with the NCDR® CathPCI® Registry. The AMI patients were classified as MI-CAD or MINOCA on the basis of the presence or absence of a significant stenosis (≥50%) on angiography.

Results:
From 4,189 angiography procedures undertaken for AMI, 468 (11%) were classified as MINOCA. Patients with MINOCA were younger (59±15 vs. 64±13 years, p <0.01) and more likely to be female (53% vs. 26%, p <0.01), compared to those with MI-CAD. Age-adjusted analysis comparing patients with MINOCA to MI-CAD revealed differences in: (1) cardiovascular risk factors including hypertension (52% vs. 66%, p<0.01), diabetes (19% vs. 32%, p<0.01), dyslipidemia (46% vs. 62%, p<0.01), and current smoker status (27% vs. 37% p<0.01); (2) AMI type and size with fewer ST elevation myocardial infarcts (27% vs. 41%, p<0.01) and lower peak troponin values (180 ng/L, IQR 353 vs. 264 ng/L, IQR 680, p<0.01) amongst MINOCA patients. Furthermore, the GRACE Score for acute coronary syndrome risk stratification was lower for the MINOCA patients compared to MICAD (150±34 versus 160±35, p <0.01). Despite fewer cardiovascular risk factors, the absence of obstructive coronary artery disease, smaller infarcts, and a lower GRACE score, the in-hospital mortality was similar for MINOCA and MI-CAD patients (2.2% vs. 3.0%, p=0.22). Moreover, MINOCA patients were less likely to receive secondary prevention therapies at discharge including antiplatelet therapy (60% vs. 92%, p<0.01) beta-blockers (41% vs. 65%, p<0.01), statin (55% vs. 88%, p<0.01), ACE-inhibitor/angiotensin receptor blocker (59% versus 81%, p<0.01), or referral to cardiac rehabilitation (15% versus 52%, p<0.01).

Conclusions:
In contemporary cardiology practice, MINOCA may be more frequent than previously appreciated and has a guarded prognosis despite its apparent lower risk profile. Improving the use of secondary prevention therapies in these patients may improve their prognosis.
Abstract 286: Prognostic Value of Blood Urea Nitrogen / Creatinine Ratio in Patients Post Myocardial Infarction: Experience From the Survival and Ventricular Enlargement Trial
Authors: Onuegbu Afiachukwu G , Skali Hicham
Published: July 2021

Introduction:
Renal function assessed by serum creatinine-based estimated glomerular filtration rate (eGFR), is an established prognostic marker in the general population and following an acute myocardial infarction. Elevation of the blood urea nitrogen / creatinine ratio (BUN/CR) indicates appropriate renal response to systemic hypoperfusion and suggests acute cardio-renal alteration. We aimed to determine the prognostic value of the BUN/CR for adverse cardiovascular (CV) events and mortality in patients with acute myocardial infarction and left ventricular dysfunction.

Methods:
We used data from the Survival and Ventricular Enlargement (SAVE) trial that randomized 2231 patients 3 to 16 days following an acute myocardial infarction with left ventricular ejection fraction of ≤ 40% to captopril or placebo. Patients with a creatinine level >2.5 mg/dl were not included in the trial. Patients were categorized according to quartiles of BUN/CR, or as high BUN/CR (if ≥ 20) versus low. Cox proportional hazard regression models were used to evaluate the association of BUN/CR with mortality and adverse CV events.

Results:
There were 461 patients with high BUN/CR (≥ 20). They were older, more likely to be women, have a lower body mass index, higher eGFR, a prior myocardial infarction and a lower left ventricular ejection fraction at baseline. In univariable analysis, an elevated BUN/CR was associated with an increased risk of heart failure but not with other clinical endpoints (death, CV death, or a composite of death, MI or heart failure). In multivariable models that included age, gender, eGFR, diabetes, Killip class, hypertension, assignment to captopril arm, and left ventricular ejection fraction, a high BUN/CR was not predictive of any endpoint (p>0.5).

Conclusion:
Although an elevated BUN/CR may represent systemic hypoperfusion, it does not appear to be an independent prognostic marker for adverse CV events and mortality in patients with acute myocardial infarction and left ventricular dysfunction.
Abstract 324: The Non-Linear Relationship of Advancing Age to Death after Cardiac Valve Replacement in Patients with End-Stage Renal Disease
Authors: Krishnaswami Ashok , McCulloch Charles E , Leong Thomas K. , Go Alan S , Lee Hon
Published: July 2021

Background:
Age is a known risk factor for mortality after cardiac valve replacement. Little is known of the interaction between age and end stage renal disease (ESRD). To better comprehend the relationship between age as a continuum and cardiovascular outcomes, assessment of nonlinear relationships needs to be undertaken.

Methods:
We enrolled 3,792 patients (3.1% ESRD) who underwent a cardiac valve surgery between January 1, 2000 and December 31, 2012 in Kaiser Permanente Northern California. Age was modeled as a linear variable (every 5 years) and as a cubic spline. The primary outcome was all-cause mortality at 5-years. We subsequently fit unadjusted logistic models and graphed the model-predicted probability of mortality versus age by the 2 aforementioned methods.

Results:
ESRD patients were slightly younger, had higher baseline comorbidities, prior cardiovascular interventions, and urgent surgeries. The odds of death with advancing age was greatly attenuated in the ESRD cohort (1.05, 95% CI: 0.90-1.23) compared to the non-ESRD cohort (1.32, 95% CI: 1.26-1.38). We noted that age had an effect modification on ESRD (p interaction=0.03). Furthermore, only in the ESRD cohort, age was noted to have a non-linear relationship with mortality with a peak risk around 60 years of age and a subsequent decrease (Figure 1).

Conclusions:
ESRD continues to be a high-risk cohort for mortality after cardiac valve replacement with advancing age having a lesser role in ESRD patients. Assessment of the continuum of age by non-linear methods is crucial to improving our care for the elderly.
Abstract 361: Utility of Transthoracic Echocardiogram to Assess Volume Status in the Intensive Care Unit
Authors: Rajeswaran Yasotha , Hill Brooke , Gemignani Anthony , Friedman Scott , Palac Robert , O’Rourke Daniel
Published: July 2021

Background:
There is increasing concern regarding the value and cost of using transthoracic echocardiograms (TTEs) to assess volume status in critically ill patients. Using clinical and echocardiographic parameters, we assessed whether TTE changed clinical management of patients in the intensive care unit (ICU).

Methods:
Using the Dartmouth-Hitchcock echocardiography database, we identified 218 ICU patients whose TTE was performed to assess volume status from 4/1/11 to 3/31/14. The following TTE parameters were assessed: left ventricular ejection fraction (LVEF), diastolic function parameters, left atrial size, significant valvular disease, pericardial effusion, inferior vena cava (IVC) size and collapsibility, right ventricular (RV) function and pulmonary artery systolic pressure. In addition, clinical data were collected from review of the medical record including: age, vitals, intubation status, labs, and management change after TTE results became available.

Results:
Of the 218 patients, cardiac tamponade was present in 6 patients and right heart strain suggestive of pulmonary embolus was present in 2 patients. Of the remaining 210 patients, TTE did not affect clinical management in 186 (88.6%), led to administration of diuretics in 8 (3.8%), and intravenous fluids in 16 (7.6%). Of the 218 total patients, 123 (56.4%) were intubated. Compared to non-intubated patients, intubated patients were more likely to have elevated right atrial pressure, RV dysfunction, IVC size and collapsibility index (p<0.05). There was no difference in the severity of pulmonary hypertension, LVEF, or indices of elevated left ventricular filling pressure (p=NS). Although the echo parameters were different, the decision by physicians to administer intravenous fluids or diuretics was similar for both groups (p=NS).

Conclusions:
Transthoracic echocardiogram is commonly ordered to assess volume status in the ICU. The use of echocardiographic parameters to assess volume status did not change clinical management in majority of patients and should be used with caution in this cohort. Continued investigation to identify the best modality to assess volume status in critically ill patients is warranted.
Abstract 372: Health Outcomes Associated With Triple Antiplatelet Therapy for the Secondary Prevention of Atherothrombotic Events
Authors: Ozer-Stillman Ipek , Whalen John D , Bash Lori D , Oguz Mustafa , Du Mark , Singhal Puneet K , Davies Glenn M
Published: July 2021

Vorapaxar is a protease-activated receptor-1 (PAR-1) antagonist indicated for the reduction of atherothrombotic cardiovascular (CV) events in patients with a history of myocardial infarction (MI) or with peripheral arterial disease (PAD), based on the findings of the TRA 2°P-TIMI 50 trial for patients without a history of stroke or transient ischemic attack. This analysis evaluated the health outcomes of triple antiplatelet therapy with vorapaxar when added to a standard care regimen of clopidogrel plus aspirin (ASA) in comparison with standard care alone, for patients without a history of transient ischemic attack or stroke who survived hospitalization for a qualifying MI.

A cohort-level state-transition model was developed in Microsoft Excel to estimate membership in health states over a lifetime time horizon: event-free, post-MI, post-stroke, dead due to bleeding, dead due to CV causes, and dead due to other causes. Predictive equations were developed from patient-level data from TRA 2°P, in order to estimate CV event-related transition probabilities, based on patient characteristics. These improve upon Framingham risk equations as they consider the time since the most recent myocardial infarction, and they are based on a greater number of CV events from a larger and more diverse population. Meta-analyses, national statistics, and other publications were used to estimate case fatality and bleeding rates, the risk of non-CV mortality, as well as utilities for estimation of quality-adjusted life years (QALYs). For validation, the risk equation and model results were compared with the observed event rates in TRA 2°P, risk estimates from Framingham Heart Study publications, as well as QALY and life-year outcomes from other published models.

Over a lifetime time horizon, the model predicted 8.3 fewer recurrent MIs, 3.8 fewer strokes, and 18.2 fewer CV deaths in the vorapaxar plus standard care arm in comparison with standard care alone, per 1,000 patients treated, with an increase of 26.4 transfusions, 3.6 intracranial hemorrhage, and 0.9 fatal bleeding events. Discounted life-years and QALYs increased by 0.4 and 0.3 respectively with vorapaxar treatment. In validation, modeled CV event counts were within 0.1% of the observed rates in TRA 2°P. The model’s prediction of 8.94 QALYs in the standard care arm is comparable to the prediction of 9.55 to 9.78 QALYs in a recent UK model of antiplatelet monotherapy after MI.

Based on model results, triple antiplatelet therapy with vorapaxar provides additional clinical benefit versus standard care after MI, for a patient population that is at high risk for recurrent and potentially fatal events. In validation, the model yielded projections of CV morbidity and mortality comparable to the observed outcomes from the TRA 2°P clinical trial, Framingham equations, and other models.
Abstract 375: Surgical Site Infection after Initial and Replacement Cardiac Implantable Electronic Devices: Leveraging the Electronic Medical Record to Develop a Surveillance Model
Authors: Anthony Faith , Phan Kim T , Kiley Mary-Lou
Published: July 2021

Objective:
While surgical site infection (SSI) rates tend to be low in patients with a Cardiac Implantable Electronic Device (CIED), the occurrence of infection can be devastating to the patient and costly to manage. Accurate surveillance and reporting of infections can assist in future risk stratification and mitigation in this population. Our purpose is (1) to describe the incidence of SSI after CIED implantation using a cardiac device registry in a large HMO and (2) to illustrate the process of infection validation utilizing a screening algorithm in the Electronic Medical Record (EMR) of registered patients.

Methods and Results:
A longitudinal cohort study was performed to identify patients with a CIED implanted between 1/1/2007 and 12/31/2013. A screening algorithm (Figure 1) for detection of SSI includes (1) triggers for review in the registry, (2) International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for screening in the EMR, and (3) validation of flagged cases in the EMR. There were 11,924 Implantable Cardioverter Debrillators (7929 initial and 3995 replacement); 33,519 Pacemakers(23,772 initial and 9747 replacement); and 4472 cardiac resynchronization therapy devices (2537 initial and 1935 replacement) registered during the study period in 47,312 patients. Deep infection rates are shown in Figure 2 below. Superficial and Organ Space Infection rates remained low for all device types for combined rates of ≤0.03 and ≤0.10 respectively.

Conclusion:
In a population where the incidence of infection is often less than 1%, a comprehensive, sensitive, and specific model for infection screening and validation is necessary to accurately identify and classify surgical site infections.
Abstract 8: Health Status and Outcomes Following Left Ventricular Assist Device Placement
Authors: Flint Kelsey M , Tang Fengming , Jones Philip , Fendler Timothy , Spertus John , Allen Larry
Published: July 2021

Background:
Health status predicts mortality and hospitalization in patients with heart failure, but its relation with such outcomes following left ventricular assist device (LVAD) placement is less clear. The current study describes the association of global and disease-specific health status before and 3 months after LVAD with subsequent mortality and hospitalization.

Methods:
We analyzed data from 3836 patients registered in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database. Global health status was measured using the visual analog scale (VAS) of the EQ-5D. Heart failure-specific health status was measured using the Kansas City Cardiomyopathy Questionnaire (KCCQ). Inverse propensity weighting was used to account for missing health status data. Weighted Kaplan-Meier curves were used to analyze the association of each health status measure with 2-year mortality and rehospitalization. The incremental prognostic value of health status beyond that of variables in a validated risk model (HeartMate II Risk Score (HMIIRS)) was measured using weighted Cox models.

Results:
Global and heart failure-specific health status were poor pre-operatively, (VAS median 43 (IQR 25-65); (KCCQ median 34.6 (IQR 21.4-50.5)), and improved 3 months after LVAD placement (VAS median 75 (IQR 60-85); KCCQ median 69.3 (IQR 54.2-82.3)). Prior to device implantation, patients missing pre-operative KCCQ data (42%) were significantly more likely to be in cardiogenic shock/worsening on inotropes or require extracorporeal membrane oxygenation, intra-aortic balloon pump, mechanical ventilation or dialysis. Neither pre-operative KCCQ nor VAS scores were associated with mortality or rehospitalization 2 years after LVAD. Only 3-month KCCQ was associated with 2-year mortality (p<0.001), whereas both 3-month KCCQ and VAS were associated with 2-year rehospitalization (p<0.001 and 0.01, respectively). Pre-operative health status and 3-month VAS did not add significantly to the HMIIRS in predicting 2-year mortality (HMIIRS c-stat 0.60) or rehospitalization (HMIIRS c-stat 0.51), however 3-month KCCQ did add incremental prognostic value to the HMIIRS in predicting 2-year mortality (c-stat increased to 0.66).

Conclusions:
Pre-operative health status among patients undergoing LVAD implantation is not associated with 2-year mortality or rehospitalization, suggesting that very poor health status alone should not be used to exclude patients from treatment. In contrast, health status measured 3 months after LVAD is associated with subsequent outcomes. Furthermore, the KCCQ significantly improves the discrimination of a previously validated risk model, suggesting that systematic health status assessment can improve prognostication and might be helpful in directing care following device implantation.