bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 27: Mining Big Data to Estimate the Frailty Index in Patients with Congestive Heart Failure: Clinical Expert vs Machine Learning
Authors: Razjouyan Javad , Naik Aanand D , Najafi Bijan , Shahin Jacquelene , Virani Salim S , Horstman Molly J
Published: April 2019

Introduction:
Early recognition of frailty in older adults with Congestive Heart Failure (CHF) is needed to target interventions to slow functional decline and improve patient-centered outcomes. Previous studies have used laboratory values and vital signs to measure a frailty index (FI) to predict mortality; however, variable selection was based on expert opinion alone.

Hypothesis:
We hypothesize that a FI for CHF patients developed by mining laboratory values and vital signs with a machine learning algorithm will better predict mortality compared to a FI developed with expert opinion.

Methods:
This is a retrospective cohort study of patients with hospital admissions for CHF in the Veterans Health Administration from 2012 to 2014. Outpatient laboratory tests and vital signs where more than 50% of the cohort had a reported value were collected for the year prior to admission. Two physicians reviewed the laboratory tests and vital signs and used expert opinion to determine which variables may be associated with physical frailty. The laboratory tests and vital signs were also fed to a machine learning algorithm to select variables. We used the accumulation of deficits method to calculate the FI. Cox survival models were developed with the machine variables, expert opinion variables, and a combination (machine and expert). The outcome of interest was mortality. The performance of the models was compared by time dependent area under the curve (AUC) with 10-fold cross validation.

Results:
The cohort consisted of 24,457 patients (age 72±11 years, male 98%) with 70% mortality rate in six years. Out of 53 variables (49 laboratory tests and 4 vital signs), the physicians selected 29 variables, the machine selected 23, and the physicians and machine agreed on 14. The average AUC (95%CI) was 0.561 (0.561,0.562) for the expert opinion FI, 0.605 (0.604,0.606) for machine FI, and 0.607 (0.606,0.608) for combination FI.

Conclusions:
The FI developed using machine learning was a better predictor of mortality than a FI developed with expert opinion and used fewer variables. This study shows the potential for operationalizing a FI using laboratory values and vital signs from Electronic Health Records. In future studies, we plan to feed additional clinical variables to the machine learning algorithm to improve the accuracy of the FI model.
Abstract 273: Acute and Long-term Efficacy of Interleukin-1 Inhibitor Anakinra in Idiopathic and Secondary Pericarditis in Patients Refractory or Intolerant to Conventional Therapy
Authors: Saad Shaukat Muhammad Hamza , Singh Sukhraj , Davis Kathryn , Torosoff Mikhail , Peredo-Wende Ruben
Published: April 2019

Background:
In contrast to its use in idiopathic recurrent pericarditis, efficacy and optimal treatment duration of Anakinra are unclear in patients with pericarditis secondary to known autoimmune or inflammatory conditions, who are refractory or intolerant to conventional therapy (colchicine and corticosteroid [CS]).

Methods:
Retrospective chart review of 12 adults hospitalised between January 2016 and October 2018 treated with Anakinra 100mg SQ daily for pericarditis refractory or intolerant to conventional therapy (CT+A group), and 22 consecutive hospitalised patients treated with conventional therapy only (CT group).

Results:
Diagnosed autoimmune/inflammatory condition was present in 83.3% (10/12) of CT+A and 40.9% (9/22) of CT group (p=0.07, Table 1). The most common etiologies in CT+A group were RA and Undifferentiated Connective Tissue Disease (Figure 1). All 12 CT+A patients had symptom relief at discharge, 100% vs. 72.7% (16/22) in CT group (p=0.04). There was a trend in CT+A compared to CT group towards shorter time to symptom improvement (1.75+/-1.29 vs. 3.55+/-3.06 days; p=0.06) and symptom relief (3.75+/-1.87 vs 5.63+/-3.28 days; p=0.08). CS were tapered successfully in 71.4% (5/7) in CT+A vs. 66.7% (6/9) of patients in the CT group (p=0.56). Mean length of stay was longer in CT+A (13.0+/-16.2 vs. 8.68+/-5.07 days; p=0.25). There were no recurrences during treatment in CT+A group, 0% vs. 40.9% (9/22) in CT group (p=0.009). Treatment was discontinued at discharge or followup in all CT+A and 12 of 24 CT patients. There was a trend towards reduced post-treatment relapse risk in CT+A 16.7% (2/12) vs. 41.7% (5/12) in CT group (p=0.18). Within CT+A group, extended treatment in 6 patients after symptom relief at discharge (mean: 5.58+/-6.5 months) did not reduce post-treatment relapse risk, 16.7% (1/6) vs 16.7% (1/6) (p>0.9). Adverse effects were infrequent; elevated transaminases (n=1) and local injection-site reaction (n=1). Neither required permanent Anakinra discontinuation.

Conclusion:
In hospitalised patients with new-onset or recurrent pericarditis (secondary or idiopathic) refractory or intolerant to CT, Anakinra is associated with improved symptom relief and reduced recurrence risk. Extended continuation of Anakinra after symptom relief does not reduce post-treatment relapse risk.
Abstract 274: Healthcare Resource Use and Expenditures in Younger Women and Men Newly Diagnosed with Paroxysmal Supraventricular Tachycardia (PSVT)
Authors: Sacks Naomi C , Everson Katie , Cyr Philip L , Wood David R , Pokorney Sean D
Published: April 2019

Objective:
Characterize variations in healthcare resource use (HRU), costs, and ablation prevalence in younger women and men newly diagnosed with paroxysmal supraventricular tachycardia (PSVT).

Methods:
Commercially insured patients age 18-40 from the Truven Health MarketScan database with newly diagnosed PSVT (ICD-9: 427.0; ICD-10: I47.1) from October 2012 to September 2016, were included when observable one year before and after index diagnosis. The outcomes were mean annual per patient HRU and costs paid by insurers 1 year pre- and post-diagnosis.

Results:
Among 5,466 study patients, a majority were women (N=3,655; 66.9%). Newly diagnosed women were older (mean age: 30.4y vs. 29.4y; P<0.0001), although there were no significant differences in the Charlson Comorbidity Index (CCI). Rates of hypertension (9.8% vs 15.3%), atrial fibrillation (0.8% vs 2.9%), and heart failure (1.3% vs 2.6%) were low, but significantly lower (p<0.01) in women; chronic pulmonary disease (10.9% vs 8.3%) and anxiety (13.9% vs 10.9%) were significantly higher (p<0.01) in women. Mean annual per patient costs increased for all patients in the post-index year relative to the pre-index year ($17,188 for women versus $25,279 for men, p<0.05). Post-diagnosis costs were significantly lower for women ($26,922 vs $33,112, p<0.05), reflecting lower spending for services with a PSVT diagnosis (women: $8,471 vs men: $11,405, p<0.05). Fewer women were treated with cardiac ablation (12.6% vs. 15.3%; P<0.01). Post-diagnosis rates of beta blocker and calcium channel blocker use were higher for women (46.1% vs. 44.2%; P<0.05), with larger increases in the proportions of women newly prescribed these medications. Patients having at least 1 emergency department visit post-diagnosis (47.9%) and at least 1 hospital admission post-diagnosis (7.6%) were frequent, and these were both more prevalent in women (p<0.01) [
Figure
].

Conclusion:
Healthcare spending increases significantly in younger patients newly diagnosed with PSVT. Despite the fact that emergency department visits and hospital admissions are more common in women than men after a PSVT diagnosis, spending after a PSVT diagnosis is significantly lower for women, reflecting lower ablation rates and spending for services with a PSVT diagnosis.
Abstract 278: Using mHealth to Assess Physical Activity Guideline Adherence in Smokers: A Secondary Analysis of mActive-Smoke
Authors: Shan Rongzi , Yanek Lisa R , Silverman-Lloyd Luke G , Kianoush Sina , Blaha Michael J , Martin Seth S
Published: April 2019

Background:
Rates of cigarette smoking are decreasing due to public health initiatives, pharmacological aids, and clinician focus on smoking cessation. However, a sedentary lifestyle increases cardiovascular risk and therefore inactive smokers have a particularly enhanced risk of cardiovascular disease. We previously linked acute bouts of physical activity, but not total daily steps, to a decreased urge to smoke. In this secondary analysis, we investigate adherence to guideline-recommended moderate-vigorous physical activity (MVPA) in smokers and its association with urge to smoke.

Methods:
We enrolled 60 active smokers (≥3 cigarettes/day) and recorded free-living continuous step counts with the Fitbit Charge HR. MVPA was defined as cadence ≥100 steps/min. Participants were prompted to report instantaneous smoking urges via text message 3 times a day, on a Likert scale from 1 to 9. The Wilcoxon rank-sum test was used to test between-group differences in MVPA. A mixed-effects linear model for repeated measures, controlling for demographics and baseline activity level, was used to investigate the association between MVPA and urge.

Results:
Fifty-three participants (aged 40 ± 12 years, 57% [30/53] women, 49% [26/53] nonwhite, 38% [20/53] obese) recorded at least 6 weeks of data and were thus included; 3,633 days were analyzed, with a mean of 69 days per participant. Among all participants, median daily MPVA was 6 minutes (IQR 2-13), and this differed by sex (12 min [IQR 3-20] for men versus 3.5 min [IQR 1-9] for women, p=0.004) and BMI (2.5 min [IQR 1-8.25] for obese versus 10 min [IQR 3-15] for non-obese, p=0.035). The median daily MVPA minutes was poorly correlated with self-report via the International Physical Activity Questionnaire (Spearman’s coefficient -0.162, p=0.25). Thirty-one out of 53 (58%) participants ever obtained 30 min/day of MVPA over the study duration, and these 31 participants obtained 30 min/day MVPA on a mean of 19% of days. Only 15/53 (28%) participants met the national guidelines of 150 min/week of MVPA at least once throughout the study, and the median total MVPA per week was 80 minutes (IQR 31-162). Adjusted models showed no association between the number of MVPA minutes per day and mean daily smoking urge (p=0.72).

Conclusion:
In this 12-week study of adult smokers, the prevalence of MVPA was low and participants rarely met national guidelines for physical activity. Given poor attainment of guideline-recommended physical activity goals and the dual cardiovascular risk of inactivity and smoking, more work is required to address risk factors in smokers through promotion of physical activity.
Abstract 279: Using the Familial Hypercholesterolemia ICD-10 Code to Track Clinical Management of Patients at a Tertiary Academic Center
Authors: Sheth Samip , Ajufo Ezim , Rader Daniel , Soffer Daniel , Jacoby Douglas , Hossain Eirk
Published: April 2019

Background:
Many guidelines suggest a target LDL-C of <100 mg/dL in individuals with familial hypercholesterolemia (FH) to avoid the lifelong burden of high LDL-C and onset of cardiovascular disease. However, the clinical characteristics and management of patients with FH in the United States remain poorly described. In 2016, a distinct ICD-10 for FH was introduced into clinical care settings to track FH patients.

Objective:
To determine the cardiovascular disease burden and treatment patterns among patients with the ICD-10 code for FH at a tertiary academic center.

Methods:
A retrospective query was conducted in The University of Pennsylvania Health System (UPHS) using the ICD-10 code, E78.01.

Results:
The query returned 1417 FH patients (703 seen in the lipid clinic, 714 seen elsewhere in UPHS) identified by E78.01. Among all patients, median age at initiation of lipid-lowering therapy was 52 years, and median age at FH diagnosis was 55 years. Prevalent coronary heart disease was reported in 30% (425 of 1417) of all patients, and 27% (382 of 1417) exhibited a family history of cardiovascular disease. Median untreated low-density lipoprotein cholesterol (LDL-C) was 197 mg/dL and median treated LDL-C was 112 mg/dL. Among all patients, 35% (495 of 1417) were taking high-intensity statin therapy, 24% (340 of 1417) were taking PCSK9 inhibitor (PCSK9i) therapy, and 29% (410 of 1417) were taking ezetimibe. Providers in the Penn Lipid Clinic prescribed approximately 71% (557 of 785) of all high-intensity statin and PCSK9i therapy to FH patients of whom 50% (392 of 785) achieved an LDL-C of <100 mg/dL and 24% (188 of 785) achieved an LDL-C <70 mg/dL. Factors associated with LDL-C <100 mg/dL included use of a PCSK9 inhibitor (odds ratio 1.96; confidence interval 1.55-2.48) and consultation with a lipid clinic provider (1.81; 1.45-2.25). Factors associated with prevalent coronary heart disease included hypertension (2.92; 2.31-3.70) and smoking (1.64; 1.30-2.09).

Conclusions:
The ICD-10 code for FH identifies a cohort of patients with a phenotype consistent with FH. A large minority of FH patients are not taking high-intensity statin or PCSK9i therapy, especially those who have not seen a provider in a dedicated lipid clinic. These findings highlight a way to monitor the clinical management of FH patients while explaining need for education about FH in an academic center.
Abstract 280: Adherence to Antihypertensive Prescription Medication Stratified by Gender and Age: An Employer-Sponsored Health Care Perspective
Authors: Goldberg Zachary , Louie Judy Z , Shiffman Dov
Published: April 2019

Background:
Patient adherence to antihypertensive medication is crucial for reducing adverse disease outcomes. However, about 40% of patients are non-adherent to antihypertensive medications.

Objective:
Investigate the effect of gender and age on adherence to antihypertensive medication in employees and spouses participating in an employer-sponsored health insurance program.

Methods:
We conducted a 3-year retrospective analysis of adherence to antihypertensive medication among 6763 patients who were prescribed antihypertensive medications in 2015 and participated in employer-sponsored health insurance for the duration of the study. Adherence was assessed by calculating medicine possession ratio (MPR) during a 6-month window each year. Patients were considered adherent if their MPR was >80%.

Results:
In the first year of the study, 81% of the patients were adherent (95%CI 80% to 82%). Adherence dropped steadily over 3 years to 63% in the third year (95%CI 62% to 64%; P<0.0001 for difference between first and last year). Men were more adherent than women in the first year of the study: 83% (95%CI 82% to 85%) vs. 79% (95%CI 77% to 80%; P<0.0001), but the decline in adherence was greater among men than women (P<0.0001) leading to similar adherence rates in years 2 and 3 (P>0.2). First year adherence, as well as decline in adherence over time differed by age group (Figure). In young patients (<45 years), the adherence in the first year: 69% (95%CI 66% to 72%) was lower than in those of intermediate age (45 to <60 years): 81% (95%CI 80% to 83%) and of older patients (≥60 years): 86% (95%CI 84% to 87%; P<0.0001). The decline in adherence over 3 years in the young group: 19% (95%CI 15% to 23%) was similar to the intermediate group: 15% (95%CI 13% to 17%; P = 0.8 for difference in decline). However, the older group had greater decline in adherence: 22% (95%CI 20% to 25%; P<0.0001).

Conclusions:
Initial adherence to antihypertensive medication prescriptions was >80% overall, but slightly less than 80% for women. However, rapid decline in adherence over 3 years results in low sustained adherence. Of particular concern are individuals <45 years who have low adherence even in the first year, and patients ≥60 years who have a rapid decline in adherence.
Abstract 286: The Heart Failure Clinic: Empowering the Armor Against 30-day All-cause Readmissions
Authors: Taklalsingh Nicholas , Wengrofsky Perry , Levitt Howard
Published: April 2019

Introduction:
Heart failure related recurrent hospitalizations are widely recognized as a source of burden to both patients and the health system. Hospital discharges represent a transition of care from a controlled environment to one of lesser physician oversight and can often become a catalyst for readmission. One strategy in reducing this burden is the implementation of dedicated heart failure clinics by providing ease of transition whilst ensuring disease specific care.

Methods:
A retrospective review of all patients discharged from the Kings County Hospital Center from October 1
st
2017 to June 30
th
2018 with a discharge diagnosis of heart failure was conducted. Patients following in the Heart Clinic (HC) were compared to those who opted for their standard follow up (SF). The option of following in the HC (intervention group) was made at the time of discharge. All included cases were followed for 30 days after discharge to determine whether an all-cause readmission occurred at any New York City Health and Hospitals affiliated hospital. Demographic data was extracted via chart review and analyzed by descriptive statistics. A Kaplan-Meier survival analysis was done to compare the time-to-event between both study cohorts.

Results:
There were 258 patient discharges after exclusion-criteria were applied. Overall, a sicker population was present in the HC cohort evidenced by greater NYHA Class 3 and 4 symptomatology (54.1% vs 30.4%, p=0.007) and more patients with an ejection fraction <30% (58.2% vs 36.8%, p=0.014). A Kaplan Meier analysis was conducted for the 9 months of follow up. Readmission within 30 days of discharge occurred in 5 (5.4%) of the 93 patients in the intervention group, compared with 27 (16.4%) of the 165 patients without intervention. The Heart clinic group had a better event free survival with a 67.1% reduction in readmission (log rank p=0.009). The mean time to readmission in the HC cohort was lower at 27.1 days compared to 29.5 days in the SF cohort (p=0.002).

Conclusion:
Our study revealed a 67.1% reduction in 30-day all-cause readmission following the initiation of the clinic. There is noticeable clinical interpretation of this outcome since the heart clinic patients were a sicker cardiac population at a safety net hospital that has a large volume of uninsured, low socioeconomic status patients. The compounded biological, social and environmental factors make the case load highly prone to CHF readmissions and underscores the need for a clinically useful strategy in fighting the high morbidity, mortality and economic burden of chronic heart failure. The presented study has wide implications in promoting high quality care, reducing readmission penalties, and minimizing the cost associated with inpatient admission, especially in centers where tight financial operating margins can be a barrier to allocation of resources.
Abstract 287: Does a Higher Level of Education Translate Into a Lower Prevalence of Cardiovascular Disease
Authors: Tayeb Taher M , Alzahrani Talal , Mercader Marco
Published: April 2019

Background:
Education is one of the determinants of health as described by the WHO, and it is one of the primary determinants of Socio-Economic Class (SEC), a higher level of education is associated with a higher level of SEC. Few researchers have addressed the link between the level of education and cardiovascular disease. However, there remains a need for a national study to determine the relationship between the level of education and cardiovascular disease. In this study, we investigated the effect of the level of education on the rate myocardial infarction (MI) and cardiovascular risk factors including diabetes mellitus, hypertension, hypercholesterolemia, and smoking status.

Methods:
The National Health Interview Surveys of 2016 (n=73,353) were utilized to measure the effect of level of education on MI and other risk factors. Subjects were assigned into four groups based on the level of education. The first group labeled as no education till the 12th grade, the second group identified as General Education Diploma (GED) or a high school diploma, the third group included subjects with some college, associate degree or bachelor, and the fourth group designated for subjects with master’s degrees, professional degrees, or doctorates. Logistic regression models were used to examine the association between level of education and cardiovascular risk factors. The final model examined the association between level of education and MI after adjusting for demographics and cardiovascular risk factors.

Results:
A higher level of education was associated with lower odds of having cardiovascular risk factors. The final logistic regression model revealed that subjects with GED and high school education (OR 0.80, 95% CI 0.65-0.97; p 0.027), subjects with some collage degree/ bachelor degree (OR 0.74, 95% CI 0.61-0.90; p <0.003), and subjects with master degrees or professional degrees (OR 0.58, 95% CI 0.43-0.78; p <0.001) have lower odds of having MI compared to the first group after adjusting for other risk factors including age, gender, diabetes mellitus, hypertension, hypercholesterolemia, and tobacco use.

Conclusion:
This study unveiled that a higher level of education is associated with a lower rate of myocardial infarction and cardiovascular risk factors.
Abstract 288: Payments, Mortality and Readmission Rates in US News and World Report “Best Hospitals” in Cardiology
Authors: Vadlamani Lina , Annapureddy Amarnath , Desai Nihar
Published: April 2019

Background:
Little is known regarding how well the
U.S. News & World Report
“Top-Ranked Hospitals for Cardiology and Heart Surgery” rankings reflect performance on key measures such as thirty-day risk-standardized mortality, readmissions, and payment.

Methods:
We used publicly available US News and World Report rankings of the top 50 best hospitals from 2014 to 2017 to stratify hospitals into ranked and unranked hospitals and utilized data from Medicare’s Hospital Compare database. Risk-standardized measures for payments, mortality rates, and readmission rates for Acute Myocardial Infarction (AMI) and Heart Failure (HF) in ranked and unranked hospitals were compared using two-tailed t-tests.

Results:
There were n=66 ranked hospitals and n=1846 unranked hospitals included in the analysis. As compared with unranked hospitals, top ranked hospitals had significantly lower thirty-day mortality rates for both AMI and HF (p<.001 for both; Table 1). There were no differences in thirty-day readmission rates. Thirty-day payments were significantly higher for top ranked hospitals for AMI (2014 and 2015) and HF (2015) over the study period.

Conclusion:
We found that
US News and World Report
“Best Hospitals” performed significantly better on mortality measures but not on readmission measures. While payment in ranked hospitals may have been significantly higher in 2014 and 2015, greater increases in payments of unranked hospitals closed the gap between payments in ranked and unranked hospitals. As cost-efficiency is an important component of hospital performance, future research should explore how “Best Hospitals” are keeping costs down, and future ranking algorithms should incentivize decreased payments.
Abstract 290: A Risk Prediction Model for Heart Failure in Patients with Chronic Coronary Artery Disease
Authors: Geba Daniela , Patel Aarti , Pesa Jacqueline A , Williams Brent
Published: April 2019

Background:
Coronary artery disease (CAD) is strongly associated with development of heart failure (HF). Most studies have focused on predictors of HF among patients with acute CAD presentations (e.g., myocardial infarction (MI)). Although there is a significant risk to develop HF among patients with chronic CAD, the risk factors have been less frequently studied in that group. Thus, the goal of this study is to develop a HF risk prediction model for patients with chronic CAD.

Methods:
We conducted a retrospective study based on data from electronic medical records (EMR) of adults who received healthcare services for a minimum of 2 years during 2003-2018 at a single integrated healthcare system. Patients were eligible if they: i) had newly diagnosed CAD, defined based on diagnosis and/or procedures codes for CAD, MI, angina, coronary artery bypass graft surgery (CABG), and percutaneous coronary intervention (PCI), and ii) had a stable form of disease (either were not admitted to the hospital at diagnosis (i.e., non-acute presentation) or were admitted, but discharged alive and without a HF diagnosis; for the latter, the study follow-up started at the time of their first outpatient visit completed after discharge. Cox regression was used to examine the association of 79 candidate predictors, such as demographics, laboratory tests, and diagnoses at baseline, with HF. “High risk” level included patients at the 10% highest risk to develop HF based on the proposed prediction model.

Results:
Out of the 24,468 patients who met the definition of chronic CAD, 4,443 patients (18%) were diagnosed with HF over a mean follow-up of 5.4 years. The Kaplan Meier-based HF rates were 4%, 6%, and 16% at 6 months, 1 year, and 5 years, respectively. The strongest predictors of HF were older age, lower glomerular filtration rate, atrial fibrillation, edema, and higher blood glucose levels. The c-statistic for the final 12-predictor model (shown in figure) was 0.715. In the “high risk” level, the HF rates were 13%, 18%, and 43% at 6 months, 1 year, and 5 years, respectively.

Conclusions:
The proposed prediction model identifies patients with chronic CAD at high risk for HF, who would benefit from timely implementation of prevention measures.
Abstract 294: Changes in the U.S. Burden of Cardiovascular Mortality by Unique Weighting Methodologies
Authors: Ziaeian Boback , Fonarow Gregg C
Published: April 2019

Objective:
Currently, disease mortality and burden rates are standardized to the 2000 U.S. Standard Population. This standard population represents an age distribution that may not be reflective of other subpopulations and drifts with time. We sought to evaluate more objective standardization methods to communicate disease mortality burdens and disparities using detailed vital statistics from the National Center for Health Statistics.

Methods:
We identified 6 different standard populations to recalculate standardized mortality rates for leading causes of death in the U.S: the 2000 U.S. Standard Population, the 2016 U.S. Census Population, the WHO World Standard Population, life expectancy weights generated from the Global Health Estimate, a value of life function, and an age-blind population standard. Trends in national mortality were calculated using the 6 standards. Trends and ranks were described using U.S. mortality and Census files between 2005 and 2015.

Results:
Cardiovascular disease was the leading cause of death in the U.S. across all standard populations except when using the WHO population standard. The relative differences between cardiovascular disease mortality and cancer were 6% greater for cardiovascular disease using the 2000 U.S. Standard Population and the 2016 U.S. Census, 7% lower using the WHO standard, 39% greater using the life expectancy standard, 87% greater using the value of life method, and 138% greater using an ageless standardized mortality rate.

Conclusions:
The decision to use a standard population when calculating disease rates has marked influence on weighting the value of a diseases burden based on the age distribution of the population and age of death or incidence of particular diseases. Consideration should be given to measures that represent life expectancy or the value of life when reporting disease burdens.

Table 1: Leading causes of death in the United States for 2015 when estimated using different population standards per 100,000 people.

Table 2: Differences in the relative burden of heart disease and cancer based on standard population used for 2015.
Abstract 30: Association of Cardiovascular Risk Factor Profile with Financial Hardship from Medical Bills and Other Cost-Related Barriers to Care Among US Non-Elderly Adults: The National Health Information Survey 2013-2017
Authors: Grandhi Gowtham R , Valero-Elizondo Javier , Brandt Eric J , Annapureddy Amarnath , Saxena Anshul , Desai Nihar R , Spatz Erica S , Nasir Khurram
Published: April 2019

Background:
Atherosclerotic cardiovascular disease (ASCVD) remains a nation-wide crisis. Optimal cardiovascular risk factor (CRF) profile has been associated with lower mortality and morbidity, as well as lower healthcare expenditure and resource utilization. In this study, we examined the association of optimal CRF profile to financial hardship and other cost-related barriers to care, both with and without ASCVD.

Methods:
We used a nationally representative sample of non-elderly adults aged between 18-64 years from the National Health Interview Survey (2013-2017). We assessed atherosclerotic cardiovascular disease (ASCVD) status, CRF profile, financial hardship from medical bills, unable to pay bill at all, cost-related medication non-adherence, forgone/delayed care, and perceived financial distress from self-reported questionnaire.

Results:
A total of 119,388 individuals were included in the study. Individuals with ASCVD had financial hardship and inability to pay bills at 45% and 19%, respectively, significantly higher than those without ASCVD and optimal CRF profile at 24% and 6%, respectively. Similarly, the prevalence of other cost-related barriers to care was significantly higher among ASCVD (>2-fold) compared to non-ASCVD with optimal CRF profile. Individuals without ASCVD and optimal CRF profile among low/poor income and uninsured had higher prevalence of all the outcomes when compared to ASCVD among high income and insured. Individuals without ASCVD and optimal CRF profile had lowest odds of financial hardship (OR 0.44, 95% CI 0.41, 0.48), inability paying bills (OR 0.30, 95% CI 0.26, 0.34), cost-related medication non-adherence (OR 0.42, 95% CI 0.38, 0.48), foregone/delayed care (OR 0.41, 95% CI 0.37, 0.45), and high financial distress (OR 0.52, 95% CI 0.47, 0.58) (Table). There were no significant differences in these outcomes when comparing individuals without ASCVD and poor CRF profile to those with ASCVD.

Conclusion:
Optimal CRF profile is strongly associated with lower prevalence of financial hardship and other cost-related barriers to care. Upfront investment of preventive health programs, especially among vulnerable populations, may improve overall health and decrease financial hardship.
Abstract 38: Digital Strategies for Controlling High Blood Pressure
Authors: Casey Donald E , Kirley Kate
Published: April 2019

Background:
The 2017 ACC/AHA Hypertension Guideline recommends use of telehealth and other digital strategies to accurately diagnose and treat high blood pressure (HBP). While these recommendations are based on robust evidence demonstrating the effectiveness of digital health interventions for HBP management, physician practices and healthcare systems are uncertain as to how best to put these into practice. Furthermore, “telehealth” by itself is an enabling technology, not a stand-alone quality improvement strategy. Hence, it is important to implement those guideline-based interventions delivered via telehealth technologies with the highest quality of evidence to make a significant impact on the effective diagnosis and management of patients with HBP.

Session objectives:
From this presentation, attendees can 1) Recognize benefits and challenges of deploying digital technologies used to measure and control HBP, 2) Explain how the best evidence for proper use of digital technologies enables key patient interventions to diagnose and treat HBP 3) Describe how implementation of the
AHA/AMA
“
Target: BP
” initiative promotes guideline-based care enabled by digital technologies 4) Demonstrate how the use of the AMA Digital Health Implementation Playbook supports successful implementation of a HBP control strategy that addresses the needs of both physicians and patients.

Approach:
The presenters will 1) Summarize the 2017 ACC/AHA recommendations for telehealth in HBP management, which are based upon systematic evidence reviews 2) Discuss the
AHA/AMA Target: BP initiative
, a quality improvement program to improve HBP control tested in 16 physician practices ( with16,000 patients; this will include description of key components of the performance improvement program and summary of evidence for its effectiveness; 3) Provide an overview of the AMA Digital Health Implementation Playbook, developed with input from over 80 stakeholders with experience implementing digital health solutions; 4) Describe key steps to implementing a practice-based digital strategy for HBP management outlined by the Playbook; and 5) Summarize current related Medicare and Commercial payment policies for digital health services.

Conclusions:
To more effectively engage patients in managing HBP, healthcare teams must incorporate guideline-based clinical interventions enabled by digital solutions such as telehealth to optimize BP control in their patient populations. Utilizing practical guidance from the
AMA/AHA Target: BP
improvement program and the AMA Digital Health Implementation Playbook, healthcare providers are best positioned to deliver telehealth-enabled optimal BP care consistent with the ACC/AHA 2017 Hypertension Guidelines.
Abstract 4: Disparities in the Use of Direct Oral Anticoagulant Treatment of Venous Thromboembolism in the United States, 2010-2016
Authors: Nathan Ashwin S , Geng Zhi , Raman Swathi , Dayoub Elias , Adusumalli Srinath , Khatana Sameed A , Pugliese Steven , Kobayashi Taisei , Giri Jay , Groeneveld Peter
Published: April 2019

Background:
Venous thromboembolism (VTE) occurs in approximately 100 persons per 100,000 each year in the United States, and for decades warfarin had been the mainstay of therapy. However, beginning in 2012 direct oral anticoagulants (DOAC) were approved for treatment and prevention of VTE, and are now recommended as first-line therapy. We assessed the factors associated with direct oral anticoagulant use among commercially-insured VTE patients.

Methods:
We performed a retrospective cohort analysis of adult patients with an incident diagnosis of VTE between 01/01/2010 and 12/01/2016 using OptumInsight’s Clinformatics Data Mart, a large US health care claims database. We identified the first filled anticoagulant prescription within 30 days of discharge, as well as baseline demographic and socioeconomic characteristics for all VTE patients with available prescription data. We then performed a multivariate logistic regression, adjusting for age, sex, race/ethnicity, region of residence, household net worth, prescribing provider specialty, and clinical covariates to identify factors associated with the use of direct oral anticoagulants.

Results:
There were 12,390 patients included in the analysis. In adjusted multivariate analyses, there was no difference in the use of DOAC among men and women (OR 0.99, 95% CI 0.91 - 1.08, p=0.80). Black patients were less likely to receive a DOAC compared to white patients (OR 0.86, 95% CI 0.76 - 0.98, p=0.020). There were no differences in the utilization among Asian patients (OR 1.21, 95% CI 0.83 - 1.75, p=0.324) or Hispanic patients (OR 1.04, 95% CI 0.88 - 1.23, p=0.66) as compared to white patients.

Conclusion:
Although DOAC adoption has increased steadily, among a commercially-insured population, black race was independently associated with the use of warfarin as compared to DOAC for incident VTE despite controlling for other socioeconomic factors. This finding was not present among Asian or Hispanic patients. This suggests the possibility of a racial disparity in access to this new pharmacotherapy.
Connexin37‐Dependent Mechanisms Selectively Contribute to Modulate Angiotensin II‐Mediated Hypertension
Authors: Le Gal Loïc , Pellegrin Maxime , Santoro Tania , Mazzolai Lucia , Kurtz Armin , Meda Paolo , Wagner Charlotte , Haefliger Jacques‐Antoine
Published: April 2019

Background

Gap junction channels made of Connexin37 (Cx37) are expressed by aortic endothelial and smooth muscle cells of hypertensive mice, as well as by the renin‐secreting cells of kidneys.

Methods and Results

To decipher whether Cx37 has any role in hypertension, angiotensin
II
(Ang
II
) was infused in normotensive wild‐type and Cx37‐deficient mice (Cx37−/−). After 2 to 4 weeks, the resulting increase in blood pressure was lower in Cx37−/− than in wild‐type mice, suggesting an alteration in the Ang
II
response. To investigate this possibility, mice were submitted to a 2‐kidney, 1‐clip procedure, a renin‐dependent model of hypertension. Two weeks after this clipping, Cx37−/− mice were less hypertensive than wild‐type mice and, 2 weeks later, their blood pressure had returned to control values, in spite of abnormally high plasma renin levels. In contrast, Cx37−/− and wild‐type mice that received
N
‐nitro‐
l
‐arginine‐methyl‐ester, a renin‐independent model of hypertension, featured a similar and sustained increase in blood pressure. The data indicate that loss of Cx37 selectively altered the Ang
II
‐dependent pathways. Consistent with this conclusion, aortas of Cx37−/− mice featured an increased basal expression of the Ang
II
type 2 receptors (
AT
2R), and increased transcripts levels of downstream signaling proteins, such as Cnksr1 and Ptpn6 (
SHP
‐1). Accordingly, the response of Cx37−/− mice aortas to an ex vivo Ang
II
exposure was altered, since phosphorylation levels of several proteins of the Ang
II
pathway (
MLC
2,
ERK
, and
AKT
) remained unchanged.

Conclusions

These findings provide evidence that Cx37 selectively influences Ang
II
signaling, mostly via a modulation of the expression of the Ang
II
type 2 receptor.
Prevention of Heart Failure in Hypertension—Disentangling the Role of Evolving Left Ventricular Hypertrophy and Blood Pressure Lowering: The ALLHAT Study
Authors: Johnson Kyle , Oparil Suzanne , Davis Barry R. , Tereshchenko Larisa G.
Published: April 2019

Background

Hypertension is a known risk factor for heart failure (
HF
), possibly via the mechanism of cardiac remodeling and left ventricular hypertrophy (
LVH
). We studied the extent to which blood pressure (
BP
) change and evolving
LVH
contribute to the effect that lisinopril, doxazosin, and amlodipine have on
HF
compared with chlorthalidone.

Methods and Results

We conducted causal mediation analysis of
ALLHAT
(Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial) data (1994‐2002; in‐trial follow‐up).
ALLHAT
participants with available serial
ECG
s and
BP
measurements were included (n=29 892; mean age 67±4 years; 32% black; 56% men): 11 008 were randomized to chlorthalidone, 5967 to doxazosin, 6593 to amlodipine, and 6324 to lisinopril. Evolving
ECG LVH
and
BP
lowering served as mediators. Incident symptomatic
HF
was the primary outcome. Linear regression (for mediator) and logistic regression (for outcome) models were adjusted for mediator‐outcome confounders (demographic and clinical characteristics known to be associated both with both
LVH
/hypertension and
HF
). A large majority of participants (96%) had
ECG LVH
status unchanged, but 4% developed evolving
ECG LVH
. On average,
BP
decreased by 11/7 mm Hg. In adjusted Cox regression analyses, progressing
ECG LVH
(hazard ratio [
HR
] 1.78 [95% CI 1.43‐2.22]), resolving
ECG LVH
(
HR
1.33 [95% CI 1.03‐1.70]), and baseline
ECG LVH
(1.17 [95% CI 1.04‐1.31]) carried risk of incident
HF
. After full adjustment, evolving
ECG LVH
mediated 4% of the effect of doxazosin on
HF
. Systolic
BP
lowering mediated 12% of the effect of doxazosin, and diastolic
BP
lowering mediated 10% of the effect of doxazosin, 7% of the effect of amlodipine, and borderline 9% of the effect of lisinopril on
HF
.

Conclusions

Evolving
ECG LVH
and
BP
change account for 4% to 13% of the mechanism by which antihypertensive medications prevent
HF
.

Clinical Trial Registration

URL
:
http://www.clinicaltrials.gov
. Unique identifier:
NCT
00000542.
Blood Flow Lateralization and Collateral Compensatory Mechanisms in Patients With Carotid Artery Stenosis
Authors: Zarrinkoob Laleh , Wåhlin Anders , Ambarki Khalid , Birgander Richard , Eklund Anders , Malm Jan
Published: April 2019

Background and Purpose—

Four-dimensional phase-contrast magnetic resonance imaging enables quantification of blood flow rate (BFR; mL/min) in multiple cerebral arteries simultaneously, making it a promising technique for hemodynamic investigation in patients with stroke. The aim of this study was to quantify the hemodynamic disturbance and the compensatory pattern of collateral flow in patients with symptomatic carotid stenosis.

Methods—

Thirty-eight patients (mean, 72 years; 27 men) with symptomatic carotid stenosis (≥50%) or occlusion were investigated using 4-dimensional phase-contrast magnetic resonance imaging. For each patient, BFR was measured in 19 arteries/locations. The ipsilateral side to the symptomatic carotid stenosis was compared with the contralateral side.

Results—

Internal carotid artery BFR was lower on the ipsilateral side (134±87 versus 261±95 mL/min;
P
<0.001). BFR in anterior cerebral artery (A1 segment) was lower on ipsilateral side (35±58 versus 119±72 mL/min;
P
<0.001). Anterior cerebral artery territory bilaterally was primarily supplied by contralateral internal carotid artery. The ipsilateral internal carotid artery mainly supplied the ipsilateral middle cerebral artery (MCA) territory. MCA was also supplied by a reversed BFR found in the ophthalmic and the posterior communicating artery routes on the ipsilateral side (−5±28 versus 10±28 mL/min,
P
=0.001, and −2±12 versus 6±6 mL/min,
P
=0.03, respectively). Despite these compensations, BFR in MCA was lower on the ipsilateral side, and this laterality was more pronounced in patients with severe carotid stenosis (≥70%). Although comparing ipsilateral MCA BFR between stenosis groups (<70% and ≥70%), there was no difference (
P
=0.95).

Conclusions—

With a novel approach using 4-dimensional phase-contrast magnetic resonance imaging, we could simultaneously quantify and rank the importance of collateral routes in patients with carotid stenosis. An important observation was that contralateral internal carotid artery mainly secured the bilateral anterior cerebral artery territory. Because of the collateral recruitment, compromised BFR in MCA is not necessarily related to the degree of carotid stenosis. These findings highlight the importance of simultaneous investigation of the hemodynamics of the entire cerebral arterial tree.
A new black species of Kamimuria (Plecoptera: Perlidae) from Shaanxi Province, China
Authors: YAN YANHUA , LIU RUIJUN , LI WEIHAI
Published: April 2019

A new species of the perlid genus Kamimuria Klapálek, K. flavimacula sp. nov. from Shaanxi Province of northwestern China is described based on the male, female, eggs. The new species has an unusual dark habitus. The relationships of morphological characteristics of the new species and similar congener are discussed.
Five new species in the genus Leschenaultia Robineau-Desvoidy, 1830 (Diptera: Tachinidae) from Mato Grosso, Mato Grosso do Sul and Rondônia, Brazil
Authors: TOMA RONALDO
Published: April 2019

Five new species of Leschenaultia Robineau-Desvoidy, 1830 are described and illustrated based on SISBIOTA-Diptera project material collected in three Brazilian states: Leschenaultia andarae sp. n. and Leschenaultia belkysae sp. n. from Mato Grosso; Leschenaultia frangeri sp. n. and Leschenaultia marjorieae sp. n. from Mato Grosso do Sul; and Leschenaultia liriai sp. n., the first record of this genus from Rondônia. Leschenaultia bicolor (Macquart, 1846) is recorded for the first time from Mato Grosso do Sul. A key to all Brazilian species of Leschenaultia is provided.
Upper-Slope Jets and Gulf Stream Filaments Inshore of the Charleston Bump during Winter 2012
Authors: Seim Harvey , Edwards Catherine
Published: April 2019

A 3-month-long field program conducted in winter 2012 inshore of the seaward deflection of the Gulf Stream at the Charleston Bump observed several 7–21-day periods of strong (>0.5 m s−1) equatorward along-shelf flow over the upper continental slope. In sea surface temperature images, these phenomena resemble and appear linked to warm filaments, features known to be associated with meanders of the Gulf Stream as it traverses the southeast coast of North America. However, the character of these upper-slope features differs from previous descriptions of filaments, hence we describe them as “upper-slope jets.” We document the characteristics of the jets, which are approximately 30 km in width, centered on the 200-m isobath, with a maximum temperature variation at depth, and reasonably long-lived. Southwestward flow within the jet extends to 200 m and is in approximate thermal wind balance below a surface mixed layer. Maximum transport is estimated to be about 2.0 Sv (1 Sv ≡ 106m3s−1), driving a net equatorward along-shelf velocity over the deployment period. For this time period, at least, the jets form the equatorward flow of the shoreward flank of the Charleston Gyre. We suggest the features resemble the Pinocchio’s Nose Intrusion recently described by Zhang and Gawarkiewicz. Large-amplitude meander crests with sufficiently strong curvature vorticity are a plausible source of initiation of the upper-slope jets.
A Successive Threat Theory of Police Expenditures
Authors: Snipes Jeffrey B. , Maguire Edward R. , Wang Xia
Published: April 2019

Ethnic succession theory is concerned with the process and consequences of racial and ethnic migration into and out of cities. Minority threat theory is a branch of conflict theory that is concerned with the extent to which racial and ethnic minorities are perceived as threatening to the powerful. In this article, we propose a blend of these theories called successive threat theory which posits that racial and ethnic groups are perceived as threatening when they first move into a city, but as they assimilate, the perceived threat dissipates. The primary contribution of this theory is the previously undeveloped and untested notion that different minority groups may serve as threats in different time periods. Using time series analysis of annual data on Chicago from 1893 to 1965, we find support for the theory.
Commentary: Modern Political Economy and Public Policy
Authors: Skidmore Max J.
Published: April 2019

This article directly and bluntly challenges traditional thought by casting aside conventional wisdom regarding the national economy, replacing it with Modern Political Economy and Public Policy. American national policies, I argue, should always, whenever possible, be universal, not targeted toward specific groups. Moreover, policies need to be crafted to achieve their goals, not to fit within budgetary constraints. The least government is the worst, not the best, and a miserly approach to spending is not “wise use of the taxpayers’ dollars.” The national government controls the currency, paying its bills in dollars. It issues dollars as needed, in whatever amount it chooses, and is unrestrained by the need to “find the money” or “pay‐as‐you‐go.” Taxes are useful for purposes of regulation and control of income inequality, but are not relevant to expenditures. “Anything that is technically feasible,” I claim following Kelton and coauthors, “is financially affordable,” and there is no need to fear inflation so long as spending does not exceed the productive capacity of the economy. Despite conventional wisdom to the contrary, and regardless of the widely used jargon of politicians, when government spends, it is not using “The Taxpayers’ Money.”