bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 260: Restructuring a Failed Cardiac Surgery Program in an Under Served Minority Population County
Authors: Brown Jamie , Dawood Murtaza , Gammie James S , Odonkor Patrick , Siddiqi Imran , Gillespie Malinda , Dominique Guerda , Bartlett Steven T
Published: July 2021

Objectives:
Fifty years ago, Donabedian described the conceptual framework for quality in healthcare as the triad of process, structure and outcome. These principals were applied to a failed urban cardiac surgery program (volume, efficiency, and quality) in an underserved county of 900,000 people in which cardiovascular death rates are up to double the neighboring county and public health studies demonstrate high rates of cardio metabolic syndrome as well as poor access to health care. Using Cardiac Surgery as a highly measured clinical service model our hypothesis was that strict attention to all details related to Donabedian’s triad would achieve acceptable quality of care in Cardiac Surgery.

Methods:
The 205 patients undergoing coronary artery bypass (CAB) formed the study group. We performed a preliminary 6 month planning process evaluating and improving equipment, human resources, facilities, and patient care protocols. Emphasis was placed staff education. This process was facilitated and modeled through training and oversight by a medical school/academic health center. All structure and processes and of care including preoperative, intraoperative, and postoperative protocols were recreated and rehearsed prior to program re-start. Data for all cardiac operations were recorded using the Society of Thoracic Surgeons National database (STS).

Results:
205 coronary consecutive artery bypasses (CAB) were performed. Medical comorbid conditions were higher than the STS national mean. However, the risk adjusted outcome data for the first 205 CAB population yielded a mortality of 0.5% (expected 2.5%; O/E= 0.20) as well as a complication rate (Table 1) lower than expected. The first STS rating was 3-star for CAB, 2017 (top 10% of >1000 cardiac programs, p<0.05) indicating strict adherence to a quality-first standard of care.

Conclusions:
Strict attention to the process and structure fundamentals and details of Cardiac Surgical care in an underserved at risk population can result in acceptable outcomes and quality measures at low program volume.
Abstract 262: Preferences for Primary versus Specialty Palliative Care Among Patients With Heart Failure
Authors: Ikejiani Dara Z , Hadler Rachel A , Arnold Robert M , Bekelman David , Moreines Laura T , Harinstein Matthew , Kavalieratos Dio
Published: July 2021

Background:
More than 5 million people in the USA suffer from heart failure (HF). Palliative care (PC) is both a clinical subspecialty and overall approach to care that focuses on promoting seriously ill patients and their family’s quality of life. PC takes several forms, including consultation by a PC specialist, or attention to palliative domains by a non-PC specialist (aka “primary” PC). Despite guidelines calling for the integration of PC in HF, specialty PC remains underutilized. Patient preferences regarding primary vs specialty PC are unknown.

Objective:
To identify patient knowledge and perceptions regarding how primary and specialty PC could complement usual HF management, as well as barriers preventing PC utilization.

Methods:
We recruited individuals with NYHA class II-IV HF from general medicine wards and an outpatient advanced HF clinic, both at an academic quaternary care hospital. We conducted semi-structured interviews addressing: (1) patient-perceived physical, emotional, social, and decision-making needs; (2) perception, knowledge, and preferences regarding PC; (3) barriers and facilitators to PC. To understand patient preferences regarding primary vs specialty PC, in the interview guide, we conceptualized PC into 5 domains: physical, emotional, spiritual and social aspects of care, and advance care planning. For each domain, participants discussed unmet needs, and preferences about whether the needs would be best met by their existing cardiology team or a PC specialist. Two investigators independently analyzed data using template analysis, an inductive/deductive qualitative technique.

Results:
We interviewed 28 patients; 82% were white, 61% were >60 years, and 64% were male. 43% of participants had ejection fractions <30%, and 64% were of NYHA classes III or IV. Symptom burden was high and a source of dissatisfaction; yet, few believed that their disease management was suboptimal, often citing a sense of resignation that symptoms are inevitable in HF. We heard mixed and often incorrect understandings of PC (and its distinction from hospice). Once misperceptions of PC were corrected, respondents expressed variable preferences for specialty vs. primary PC. Proponents of primary PC cited trust and rapport in their existing clinicians, HF-specific expertise, convenience, and cost. Alternatively, participants preferring specialty PC involvement cited expertise in symptom management, addressing caregiver concerns, reduced time constraints, and a comprehensive non-HF-exclusive approach to care.

Conclusion:
We frequently identified limited and often incorrect understanding of PC. Though once corrected, patients articulated variable preferences for primary vs. specialty PC integration into their existing HF care. Research is needed to identify means of increasing primary and specialty PC delivery in HF in a manner that reflects patient preferences.
Abstract 268: Is There a Weekend Effect on Telestroke Code Time Metrics?
Authors: Asaithambi Ganesh , Castle Amy L , Marino Emily H , Ho Bridget M , Hanson Sandra K
Published: July 2021

Background:
It has been suggested that there is a “weekend effect” resulting in higher mortality rates for stroke patients admitted on weekends. We examine this phenomenon for acute ischemic stroke (AIS) patients presenting to telestroke (TS) sites to determine its effect on stroke code process times and outcomes.

Methods:
From October 2015-June 2017, we reviewed consecutive AIS patients receiving IV alteplase within our TS network who then were transferred to our CSC. We compared patients presenting to TS sites on weekdays (Monday 0700 to Friday 1859) to patients presenting on weekends (Friday 1900 to Monday 0659). We analyzed door to code activation, code activation to TS evaluation, door to imaging, and door to needle times. Rates of favorable outcome (modified Rankin Scale score ≤2) and death at 90 days were compared.

Results:
We identified 89 (54 weekday, 35 weekend) patients (mean age 71.8±13.3 years, 47.2% women) during the study period. Median door to code activation (15 [5, 27] vs 8 [1, 17] mins, p=0.01) and door to needle (61 [49, 73] vs 47 [35, 59] mins, p=0.003) times were significantly longer for patients presenting on weekends compared to weekdays. There were no significant differences in median door to imaging (weekend 17 [7, 30] vs weekday 11 [6, 21], p=0.1) and code activation to TS evaluation (weekend 7 [6, 10] vs weekday 5 [4, 9], p=0.14) times. The rates of favorable outcome (weekend 50% vs weekday 66.7%, p=0.18) and death (weekend 8.3% vs weekday 4.8%, p=0.56) at 90 days were not significantly different.

Conclusion:
While there were no significant differences in outcomes, the “weekend effect” results in slower door to code activation and door to needle times. Efforts to improve methods in increasing efficiency of care on weekends should be considered.
Abstract 3: Association of Video- vs. Text-Based Informed Consent With Multicenter Registry Enrollment
Authors: Fanaroff Alexander C , Li Shuang , Miller Vincent , Webb Laura , Navar Ann Marie , Peterson Eric D , Wang Tracy Y
Published: July 2021

Background:
Low patient participation in clinical research undermines the generalizability of findings. Conducting informed consent by video rather than a traditional text format may enhance the appeal of research and break down barriers to participation.

Methods:
The Patient and Provider Assessment of Lipid Management (PALM) Registry enrolled patients at U.S. cardiology, endocrinology, and primary care clinics to evaluate cholesterol management practices. PALM investigators developed an iPad-based video informed consent tool that included video segments totaling 8 minutes which patients navigated though a “game-ified” interface. At sites whose IRB did not approve the video tool, participants read a 6-page text consent form on the iPad. Characteristics of sites and site activation times were compared between sites that did and did not use the video consent tool using Pearson’s chi-square test for categorical variables and Wilcoxon’s signed rank test for continuous variables.

Results:
Of 140 sites that enrolled 7904 patients in PALM, 60 (42.9%) used the video informed consent tool. Compared with sites using text consent, sites using the video consent tool were more often rural (16.7 vs. 3.8%, p = 0.01) and used a central IRB (91.7 vs. 80.0%, p = 0.06). Sites using video consent enrolled a greater proportion of patients who were ≥ 75 years old (27.5 vs. 23.6%, p < 0.001) or non-white (17.7 vs. 14.2%, p < 0.001). Sites using video consent had shorter times from site approach to first patient enrollment (
Figure
). Median (IQR) enrollment was 33 (12, 98) patients at sites using video consent versus 24 (12, 86) at sites using text consent only (p = 0.54); there was also no significant difference in median weekly enrollment rate (2.9 [1.1, 7.5] vs. 2.8 [1.3, 6.6], p = 0.73).

Conclusions:
In this early experience with video consent in a multicenter registry, availability of video informed consent was associated with greater enrollment of older and non-white patients, faster speed to first patient enrolled, and numerically but not significantly more rapid enrollment compared with text informed consent.
Abstract P119: Comparison of Treatment of Acute Coronary Syndrome in a Cohort of Medicare Patients With and Without Diabetes Mellitus
Authors: Zhao Zhenxiang , Peng Xiaomei , Faries Douglas , Bae Jay , McCollam Patrick , LeNarz LeRoy
Published: July 2021

Objective:
This study compared real-world treatment patterns for ACS patients with and without DM in a cohort of Medicare population.

Methods:
A retrospective cohort study was conducted using the MarketScan Medicare claims database. Patients aged ≥65 years, hospitalized with a primary diagnosis of ACS between 01/01/2007 and 12/31/2007 were categorized into 2 groups: with and without DM. Patient characteristics, treatment patterns during the index hospitalization, and cardiovascular medications use 12 months pre- and post-index hospitalization were analyzed. (All p<.01 unless otherwise stated.)

Results:
Of 8,666 ACS patients identified, 2,407 (28%) were diabetic and 6,259 (72%) were non-diabetic. Patients with DM were more likely to be younger (77.6 vs. 79.6), male (58.8% vs. 54.6%), and have higher rates of previous MI (17.2% vs. 12.0%), congestive heart failure (28% vs. 16.1%), PVD (19.2% vs. 12.8%), TIA/stroke (10.0% vs. 7.3%), hypertension (54.4% vs. 49.6%), and renal diseases (17.1% vs. 7.0%). Patients with DM were significantly more likely to present with non-ST-segment elevation myocardial infarction at the index hospitalization compared to those without DM (66.4% vs. 61.2%). During the index hospitalization, DM patients underwent less PCI (27.8% vs. 34.6%) but more CABG (9.7% vs. 7.6%), and were more likely to have medical management during the index hospitalization compared to non-DM patients. Compared to their non-DM counterparts, patients with DM utilized more statins (66.9% vs. 48.0%), beta blockers (53.0% vs .42.4%), thienopyridine (24.5% vs. 13.2%), and ACE inhibitors (42.3% vs. 28.6%) during the 12-month pre-hospitalization period, while during the 12-month post-hospitalization period, they utilized slightly more statins (85.8% vs. 82.1%) and had similar level of beta blockers (86.1% vs. 85.6%, p=0.57) and thienopyridine (62.5% vs. 64.7%, p=0.12) and ACE inhibitors use (54.8% vs. 56.1%, p=0.37).

Conclusion:
ACS patients with DM presented additional clinical risks than those without DM. Observed treatment patterns varied correspondingly between the 2 groups. Differences in cardiovascular medications usage between the 2 groups narrowed after the ACS hospitalization.
Abstract P153: Factors Influencing Admissions to America's Lowest Performing Hospitals for AMI Care
Authors: Girotra Saket , Vaughan-Sarrazin Mary S , Cram Peter , Popescu Ioana
Published: July 2021

Background
Research has identified a group of hospitals with consistently poor performance for acute myocardial infarction (AMI) care as compared to other US hospitals. Factors influencing patients' selection of these hospitals are unknown.

Methods
We used 2004-06 Hospital Compare data to identify hospitals reporting AMI process performance measures. We calculated composite AMI performance scores and classified hospitals as low performing (lowest score decile for all 3 years, n = 100), top performing (top score decile for all 3 years, n = 64) and intermediate (all others, n = 2595). We used 2004-05 Medicare data to identify AMI patients living within 5 miles of low performing hospitals and alternative hospitals within 30 miles of patient residence. We used conditional multinomial logit models to evaluate the likelihood of choosing a low performing hospital over alternative hospitals. Models accounted for distance from patient residence to available hospitals, provision of revascularization (based on Medicare CABG volumes), and patient characteristics including age, race and residential social disadvantage (derived from US Census data).

Results
AMI patients admitted to low performing hospitals were older (mean age 80 vs. 79, p <.01), more likely female (56% vs. 51%, p < .01). These patients were more likely to live in zip codes with high (top quartile) social disadvantage (46% vs. 34%, p<.01) and closer to a low performing hospital (1.6 vs. 2.9 miles, p < .01). In multivariate models adjusting for distance and the presence of hospital revascularization services, patients were overall
less
likely to be admitted to low performing hospitals over alternative hospitals (HR 0.28, 95%CI 0.25 - 0.31, p < .01). However, patients living in areas with high disadvantage were
relatively more
likely to be admitted to low performing hospitals as compared to patients from intermediate and low disadvantage areas (HR 2.72 95% CI 2.24 - 3.30, p < .01), even after adjusting for age, race, and sex.

Conclusion
AMI patients are less likely to seek care at low performing hospitals except patients who live in zip code areas with high social disadvantage. Disincentives for poor performance against low performing hospitals could adversely impact care for this vulnerable population.
Abstract P160: Do Clinics With Focus on Heart Failure Provide Better Care for Patients? CHF QUERI
Authors: Sahay Anju , Heidenreich Paul A
Published: July 2021

Objectives
Heart failure (HF) is increasing in prevalence in the VA. Best processes of care have been identified that can markedly affect the outcomes. This effort was to examine how facilities with formal HF programs varied in terms of providing care for HF patients at all the facilities at the Department of Veterans Affairs (VA).

Method
The Chronic Heart Failure (CHF) Quality Enhancement Research Initiative (QUERI) conducted a survey of all the VA facilities to examine the processes of care for HF patients. From a total of 144 facilities the Chiefs of Cardiology or the Chiefs of Medicine completed the survey with focus on the facility's current processes of care for HF. 100% response rate was obtained for these surveys.

Results
Data was analyzed for 144 facilities. Of them 64 facilities (45%) reported having a clinic with special focus on heart failure. Comparison of processes of care for the facilities with and without HF clinics consistently showed that facilities with HF clinics have more HF focused structure and processes of care. They have cardiologists with a special focus on HF (86% vs. 14% p<.001), protocol for diuretic titration by provider (64% vs. 36% p<.05), protocol for diuretic titration by patient (73% vs. 27% p<.001), provided HF related patient education program (64% vs. 36% p<.001), used pharmacists (60% vs. 40% p<.001) and inpatients at their facility were routinely seen by practitioner affiliated with HF program (80% vs. 20% p<.001). Regarding standardized HF orders no significant difference was observed between inpatients and outpatients.

Conclusions
Facilities which have clinics with special focus on HF programs with standardized programs and activities that have been associated with improved care for patients with heart failure

Impact
Formal heart failure clinics are associated with improved process of care for patients with heart failure
Abstract P168: Clinical Benefit of Reduction in LDL and Triglycerides: Meta-Analyses of Major Coronary Events
Authors: Mandema Jaap W , Pradhan Raj S , Thakker Kamlesh M , Sleep Darryl J , Padley Robert J , Awni Walid
Published: July 2021

Objective:
The primary objective of the analysis was to characterize the multivariate relationship between changes in LDL-C, HDL-C and triglycerides (TG) and risk for major coronary events after treatment with statins, fibrates or niacin.

Methods:
Randomized controlled trials that compared statin, fibrate or niacin treatment with placebo, usual care, or active control and that reported on major coronary events were identified by a literature search, prior meta-analyses and review articles. The dependency of the odds-ratio between active and control arm on the differences in on-treatment LDL-C, HDL-C and TG was determined using a meta-regression analysis. Differences in the risk reduction per unit change in lipid values between drug classes (fibrates, statins and niacin) and drugs within a class were evaluated. Differences in risk reduction per unit change in lipid values for certain patient groups such as diabetes, males, elderly, prior CHD were also evaluated.

Results:
A total of 70 trials were identified and included in the meta-analysis. The meta-analysis found a significant contribution of lowering TG on top of reducing LDL-C to the risk reduction for a major coronary event after treatment with statins, fibrates or niacin (p<0.001). The risk reduction for major coronary events was estimated to be 18.5% [14.1 to 22.7%] for every 1 mmol/L (38.7 mg/dL) reduction in LDL-C and 27.5% [15.7 to 37.7%] for every 1 mmol/L (88.6 mg/dL) reduction in TG. The reduction in TG was found to explain most (84%) of the risk reduction for treatment with fibrates. For statins, the reduction in LDL-C was found to explain most (71%) of their benefit, but the reduction in TG was found to provide a statistically and clinically significant contribution to their overall risk reduction. The risk reduction per unit change in LDL-C and TG was not dependent on age, gender, diabetes and prior CHD and was not different between fibrates and statins.

Conclusions:
A significant additional risk reduction is expected by providing a reduction in TG on top of LDL-C changes. The independent effect of TG and LDL-C lowering supports the role for treatment combinations such as statins and fibrates that impact LDL-C and TG differentially.
Abstract P181: Gender Disparities in 12-Month Cardiac Related Hospitalization and Functional Status Among Outpatients With Heart Failure
Authors: Pelle Aline J , Smolderen Kim G , Szabó Balázs M , Denollet Johan
Published: July 2021

Objective:
Heart failure (HF) is a leading cause of hospitalizations and poses a significant burden on patients, caregivers, and health care systems. Little is known about potential gender differences in cardiac-related hospitalizations in patients with HF, and whether these gender differences are related to disparities in functional status. We examined the association between gender and 12-month cardiac-related hospitalization, taking into account the 12-month course of both objective and patient-reported functional status.

Methods:
In this 12-month follow-up study, 188 HF outpatients (78.78% male, mean age 66.76±8.41 years) from two hospitals in The Netherlands completed the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the 6-minute walk test (SMWT) at inclusion and follow-up. Data on cardiac-related hospitalizations (HF exacerbation, myocardial infarction, arrhythmia, or revascularizations) were collected from patient records. Multiple multivariable models were constructed with 12-month hospitalization, KCCQ summary change scores and changes in SMWT distances as dependent variables, and demographics and baseline disease severity (NYHA class and left ventricular ejection fraction) as independent variables.

Results:
At 12 months, 45/188 (23.94%) patients were admitted for cardiac reasons. Men had an increased odds of 12-month hospitalization (OR=4.78, 95%CI [1.49-15.38],
p
=.009), adjusting for demographic and clinical factors. There were no gender differences in 12-month health status (β=.02, 95%CI [-.02-.02],
p
=.77) nor in SMWT distance (β=.13, 95%CI [0.04-2.33],
p
=.08) change scores. Male patients with HF remained at increased odds of cardiac-related hospitalization after controlling for health status and SMWT change scores (OR=4.61, 95%CI [1.43-14.93],
p
=.01), and following additional adjustment for partner status, education, and depression.

Conclusions:
Male HF outpatients experience a higher disease burden, as manifested in higher odds of 12-month cardiac hospitalization. These gender differences were not paralleled by similar gender differences in changes in patients' functional status scores. Future studies need to confirm these findings and explore explanations for these gender disparities.
Abstract P204: Reasons for Unauthorized Discharges Among Patients With Cardiovascular Disease: A Qualitative Study
Authors: Onukwugha Eberechukwu , Saunders Elijah , Mullins C. Daniel , Pradel Francoise G , Zuckerman Marni , Weir Matthew R
Published: July 2021

Background:
Approximately one percent of inpatient discharges are against medical advice (AMA) and national data show that diseases of the circulatory system rank third in terms of discharges AMA. Cardiovascular disease (CVD) patients are at risk of the consequences of discharges AMA (e.g. hospital readmission) however the reasons for discharges AMA in a CVD population are not known. This qualitative study aimed to identify reasons for discharges AMA among patients with a CVD admission, and from patient and provider perspectives.

Methods:
Healthcare providers (nurses, social workers, and physicians) and CVD patients were recruited to participate in focus groups interviews (FGIs) to discuss why CVD patients admitted at three urban hospitals discharge AMA. All FGIs took place between April 2009 and July 2009 in Maryland. Patient and provider groups were held separately in order to minimize incentives to withhold information about the reasons for discharges AMA. Thematic analysis identified themes separately for the patient groups, the physician groups, and the combined nurses and social workers group, for a total of 3 groups.

Results:
Nine (78% male; 67% African American; mean age=56 yrs) patients, 10 physicians (80% male) and 23 nurses/social workers (9% male) were placed in scheduled FGIs. Seven FGIs were held: 2 patient-only groups, 2 physician-only groups, and 3 nurse/social worker groups. A theme identified across all 3 groups included the patients' desire to leave AMA to see their own physician/cardiologist. Another theme, identified only from the patient groups, related to patients' knowledge of their (improved) condition and a resulting confidence in their decision to leave AMA. Patients had formed expectations regarding their level of involvement in their management plan and expressed frustration when these expectations were not met. Other themes (i.e. poor communication between/among providers and patients, obligations outside the hospital, long wait time) reported across the 3 groups have been noted in previous studies and are not new.

Conclusion:
We find new reasons for discharges AMA among CVD patients as well as sources of potential patient disengagement from the treatment plan, not all of which were recognized by providers.
Abstract P210: People With Both Heart Disease and Arthritis are Twice as Likely to Have Multiple Heart Disease Risk Factors Than People With Heart Disease Alone
Authors: Murphy Louise , Bolen Julie , Greenlund Kurt , Keenan Nora
Published: July 2021

Purpose:
Arthritis and heart disease (HD) are common co-occurring conditions which may have implications for preventive efforts. Among people with heart disease (HD), we examined the association between HD risk factors and the presence of arthritis.

Methods:
The study sample comprised adults aged ≥18 years with HD (n=5,493) in the 2007 and 2008 National Health Interview Survey, a nationally representative survey of civilian, non-institionalized persons in the United States. We estimated the association between cardiovascular/heart disease risk factors among people with HD by arthritis status using multivariable adjusted odds ratios (OR) and 95% confidence intervals (CI); odds ratios were adjusted for age, sex, education and race/ethnicity. HD risk factors were analyzed individually and categorized: 1) biological risk factors (hypertension, high cholesterol and diabetes), 2) behavioral risk factors (current smoking, obesity, physical inactivity) and 3) multiple risk factors (≥2 of biological and behavioral combined).

Results:
People with HD and arthritis were more than twice as likely to have ≥ 1 biological risk factor (OR=2.5; 95% CI=2.1-2.8) than those with HD alone. Hypertension was the most common biological risk factor for both groups and respondents with both conditions were two times as likely to report hypertension (OR=2.2; 95% CI=2.0-2.6) than HD alone. The OR for the association between arthritis status and the presence of ≥1 behavioral risk factor was OR=1.3 (95%CI = 1.1- 1.5). The most common behavioral risk factor was physical inactivity, which was 40% higher among people with both HD and arthritis compared with those with HD alone (OR=1.4; 95% CI=1.2-1.6). Last, people with HD and arthritis were twice as likely to report ≥2 risk factors than those with HD only (OR=2.1; 95% CI=1.8 - 2.4).

Conclusion:
Multiple HD risk factors, especially biological, are common among people with HD and arthritis. Biological risk factors such as hypertension are modifiable and can be prevented and managed through interventions such as physical activity. We found that people with both HD and arthritis were more likely to be physically inactive suggesting that the pain and physical limitations associated with arthritis may be a barrier to physical activity.
Abstract P231: Patient-Centered Care of Stage I and II Hypertension in Underserved Communities
Authors: Alkhouli Mohamad , Kashem Abdul , Homko Carol J , Gonzalez Jorge , Gupta Ankur , Santimore William P , Bove Alfred A
Published: July 2021

Background:
Inadequate BP control leads to excess cardiovascular disease risk (CVD), especially in underserved communities. Patient-centered care tools including home monitoring of BP are key components in BP control and CVD risk reduction. We compared two communication methods to modify CVD risk in hypertensive patients. We also tested whether either strategy is more effective in stage I or II hypertension.

Methods:
388 asymptomatic subjects (59% white, 37% AA) with Framingham risk score >10% from one urban and one rural center completed our trial. 37% had StageI HTN (SBP 140-159 mmHg), and 24% StageII HTN (SBP≥160 mmHg). Subjects were randomized to nurse management (NM) with 4 visits/year, or nurse management plus Telemedicine (T). T group reported weight, BP, steps/day at least weekly via internet (average 6.3 reports/month). Periodic summaries were sent to patients and to their care providers

Results:
BP decreased substantially in both groups, with a significant difference in BP reduction between NM and T in patients with stageI HTN (P=0.037-see graph). T had a lower 8 month average BP compared to NM (T: 134.6 ± 15.0, NM: 140.4±16.9 mmHg, P<0.02). StageII HTN patients had significant reduction in BP with no difference between NM and T (P=.900). Risk score was reduced by 2.6±6.8% (P< 0.001), with no difference between NM and T (P=0.750)

Conclusion:
Telemedicine improved BP control in patients with StageI HTN more than with StageII HTN. It appears that SBP ≥160 is more likely to be immediately treated by care providers than SBP in the (140-159) range. StageI patients, therefore, had greater benefit from Telemedicine as it stimulated a more effective intervention by their care providers.
Abstract P246: Hospital Acquired Pneumonia and Dysphagia Screening in Patients With Acute Ischemic Stroke: Findings From Get With the Guidelines-Stroke
Authors: Masrur Shihab , Smith Eric E , Reeves Mathew , Zhao Xin , Olson DaiWai , Fonarow Gregg C , Schwamm Lee H
Published: July 2021

National guidelines recommend dysphagia screening (DS) before any oral intake in hospitalized stroke patients to reduce the risk of hospital-acquired pneumonia (HAP). We examined the relationship between DS and HAP in acute ischemic stroke patients in the Get With the Guidelines-Stroke (GWTG-S) program.

Methods:
Data from 1251 GWTG-S hospitals from 04/01/2003 to 03/01/2009 were analyzed. GWTG-S defines HAP as a clinical diagnosis of pneumonia requiring antibiotics. Use of a bedside, evidence-based swallow screen prior to any oral intake qualified as a DS. Univariate analyses (chi-square for categorical variables or Wilcoxon for continuous variables) and multivariate logistic regression analyses were performed to examine the relationship between DS and HAP, adjusting for patient and hospital characteristics

Results:
Among 365,726 ischemic stroke patients, 213097 (59.83%) underwent DS, and 25,166 (6.88%) developed HAP. When compared to patients without pneumonia (
Table 1
), patients with HAP were older and more frequently had CAD/MI, diabetes, prior stroke/TIA, dyslipidemia, atrial fibrillation. They, underwent DS less often, and had increased length of stay, morbidity and in-hospital mortality. Among the subgroup who had NIHSS recorded (n=160,837, 44%), HAP patients had higher median NIHSS (13 vs. 5). Among patients with NIHSS<2, 3.3% developed HAP. In multivariate analysis, factors independently associated with a lower risk of HAP were DS (OR 0.86 [0.83-0.90]), female (OR 0.83 [0.81-0.85]), dyslipidemia (OR 0.84 [0.82-0.86]), and hypertension (OR 0.96 [0.94-0.98]).

Discussion:
Our data suggests that dysphagia screening is associated with a lower likelihood of HAP, but screening rates remain low. Strategies that increase the rate of dysphagia screening among all stroke patients, even those with mild strokes, should be more broadly implemented. Prospective validation of these findings is warranted.

Table 1.

Unadjusted associations between patient and hospital characteristics and clinical outcomes

Overall(% or value)
HAP(% or value)
No HAP(% or value)

Study Population
365726 (100%)
25166(6.9%)
340560(93.1%)

Age (years) Median (IQR)
73(61, 82)
77(66, 85)
73(61,82)

Female
52.5
49.2
52.8

Dysphagia Screen Performed
59.8
54.8
60.2

In Hospital Death
5.7
18.1
4.8

P-values are <.0001 for all comparisons and are based on Chi-square test (for dichotomous and nominal factors) or Wilcoxon test (for ordinal and continuous factors)
Abstract P250: How Much Decrement in Renal Function During Heart Failure Hospitalization is Due to Loop Diuretic Exposure?
Authors: Krivospitskaya Olesya , Peterson Edward L , Singh Gurgit , Wells Karen , Williams L. Keoki , Lanfear David E
Published: July 2021

Background:
Worsening renal function (WRF) during heart failure (HF) hospitalization is an accepted correlate of poor prognosis. Loop diuretics are increasingly being considered as a potential cause of worsened HF outcomes, perhaps via WRF. However, the magnitude of worsening in renal function attributable to loop diuretics has not been quantified.

Methods:
This was a retrospective cohort study of patients who received care from a large health system and had a primary hospital discharge diagnosis of HF between Jan 1, 2000 and June 30, 2008. Patients with preexisting end-stage renal disease were excluded. Daily creatinine (Cr) measurements, furosemide dosing (only loop diuretic on hospital formulary), and radiocontrast dye studies were collected using administrative data. Day-to-day changes in Cr and MDRD estimated glomerular filtration (eGFR) calculated. The first Cr or eGFR value during hospitalization or in the emergency department was considered baseline. Generalized estimating equations were used to test the association furosemide exposure over previous 2 days to the daily change in Cr and eGFR. Covariates included undergoing radiocontrast study, age, race, gender, and baseline Cr or eGFR.

Results:
Among 6071 patients who met inclusion criteria there were a total of 20,645 observations. This cohort was 51% female, 68% African American, and baseline Cr was 1.36 mg/dl. Furosemide exposure was associated with an average daily increase in Cr of 0.021 mg/dL and decrease in eGFR of 0.72 ml/min/1.73m2 (per 100 mg furosemide daily, both p<0.001). Over a typical length of stay of 5 days this would amount to a Cr increase of 0.11 mg/dL or decrease in eGFR of 3.6 ml/min/1.73m
2
. Furosemide exposure accounted for only 0.4% and 0.1% of the variation in Cr and eGFR changes, respectively. Undergoing radiocontrast study, African American race, and higher age were associated with day-to-day creatinine increases (all p<0.01).

Conclusions:
While loop diuretic exposure is statistically associated with WRF among hospitalized HF patients, the associated magnitude of renal function change is very small, and loop diuretics explains little of the variability in renal function during hospitalization. More important predictive factors likely exist but remain unidentified.
Abstract P266: Off-Pump Procedure Reduced the Risk Adjusted Mortality and Morbidity of Coronary Bypass Surgery by Half in Comparison With Conventional Procedure, With and Without Propensity Score Matching: Through The Analysis of 11945 Procedures From 120 Hospitals in Japan, Using The Japanese National Database (JACVSD)
Authors: Motomura Noboru , Miyata Hiroaki , Tsukihara Hiroyuki , Takamoto Shinichi ,   JCVSDO
Published: July 2021

Background & Purpose
In Japan off-pump CABG (OPCAB) has much more widely spread than other countries. Recently a couple of papers reported that OPCAB could not show a significant positive effect on the early and mid-term outcome compared with on-pump CABG (OnCAB). The purpose of this study is to compare the effect of OPCAB to OnCAB on the early outcome using the National Database by propensity score matching analysis.

Methods
Using the Japan Adult Cardiovascular Surgery Database (JACVSD), procedural outcomes were compared for OnCAB and OPCAB between January 1, 2005 and December 31, 2007. The two groups were matched by propensity score.

Results
A total of 11945 procedures from 120 hospitals were analyzed. OPCAB represented 63% of all CABG procedures, and the raw and risk-adjusted operative mortality of OnCAB vs OPCAB was 2.0% vs 1.0%, and 3.9% vs 1.6%, respectively (Odds ratio 0.46, 95%CI 0.34-0.63). Following propensity score matching, 2283 OnCAB and 2301 OPCAB procedures were compared. The operative mortality was 3.9% and 2.1%, respectively (Odds ratio 0.52, 95%CI 0.37-0.74). In these matched groups, all the major morbidities were significantly reduced in OPCAB; stroke 2.0% vs 1.2% (Odds ratio: 0.42, 95%CI: 0.38-0.98), prolonged ventilation 10.8% vs 6.4% (0.55, 0.45-0.69), .any reason reoperation 5.8% vs 8.4% (0.67, 0.53-0.84), renal failure with new dialysis 4.6% vs 2.7% (0.57, 0.41-0.78), deep sternal infection 3.1% vs 2.0% (0.63, 0.43-0.92).

Conclusion
OPCAB was much more prevalent in Japan compared with other countries. From our National Database, raw and risk-adjusted mortality and morbidity were significantly lower in OPCAB group than OnCAB group, even after propensity score matching comparison. Further follow-up investigation is warranted to identify the long-term effect of OPCAB.
Abstract P296: Ultrasound Guided Peripheral IV Insertion by Nurses in a Cardiovascular Intensive Care Unit
Authors: Byrd Jeannie , Krokosky Kirk , Burns Kathleen , Parmley Lee , McPherson John , Wagner Chad
Published: July 2021

Background:
Prevention of hospital acquired infections in the critically ill patient is paramount to improving patient outcomes. A blood stream infection (BSI) prevention bundle (full body drape, chorhexidine prep, and daily line necessity review) was instituted in a medical/surgical cardiovascular intensive care unit (ICU) in mid 2007, but BSI rates remained above target goals.

Aim:
To identify patients at high risk for BSI and implement a strategy to decrease central line days, thereby decreasing the risk of BSI.

Method:
An intensive analysis was done on BSI cases that occurred during a 5 month period (July-November 2008, n=7 cases). We determined that medical cardiology patients who acquired BSI were all related to the presence of a peripherally inserted central catheter (PICC). Based on this analysis, we performed an education blitz with all staff regarding care and maintenance of central venous catheters, including PICC lines in early 2009. As a parallel course, we embarked on a process to find an alternative to inserting PICC lines in patients previously identified as non-peripheral intravenous (IV) access candidates. This designation was determined by presence of edema, obesity and unsuitable or poor quality veins. A review of literature revealed that ultrasound guided venous access technique has been used with success by physicians in the emergency setting. We then developed and implemented a competency based protocol for nursing insertion of ultrasound guided peripheral IV access.

Results:
The use of ultrasound guided technology has increased the success rate of obtaining peripheral IV access. (Table) As a result, we have been able to eliminate the need for or at least delay placement of central access.

Traditional Peripheral IV

Attempts
1
2
3
4
5

# of Patients
6
6
6
0
4

Success Rate
27%
27%
27%
0
18%

Ultrasound Guided Peripheral IV

Attempts

1

2

3

> 3

# of Patients

21

9

3

0

Success Rate

64%

27%

10%

Conclusion:
The use of ultrasound guided technique for placing peripheral IVs reduces the need for central IV access and is associated with a decrease in BSI rates.
Abstract P333: Heart Rate Control in Patients With Chronic Atrial Fibrillation and Heart Failure
Authors: Silvet Helme , Hawkins Lee Ann
Published: July 2021

Background.
Heart rate (HR) control is one of the main goals in management of patients with chronic atrial fibrillation (AF). However, rate control can be challenging in patients with heart failure (HF). The goal of our study was to determine if aggressive heart rate control in patients with both chronic AF and HF results in better exercise tolerance and/or quality of life (QOL) as compared to the “usual” care.

Methods.
This was a single center interventional study at VA Loma Linda Healthcare System using patients as their own controls. Patients with chronic AF and LVEF ≤ 40% were recruited. Intervention consisted of increasing doses of Metoprolol XL to achieve target resting heart rate less than 70 bpm. Clinical data was collected at baseline (“usual care”) and at follow-up (3 months) and included HR data, 6-minute walk test, QOL questionnaire (Minnesota Living with Heart Failure), and brain natriuretic peptide (BNP) levels. Paired t-test was performed to evaluate statistically significant change in these clinical measures. The study had 80% power to detect clinically significant improvement in 6-minute walk test (50 meters).

Results.
20 patients were recruited with an average follow-up of 98 days. Mean age was 66 years and all the patients were male with an average LVEF of 30 ± 8% and NYHA class of II-III. Average resting HR was 94 ± 14 bpm at baseline and 85 ± 12 bpm after the intervention. Average Metoprolol XL dose at the end of the study was 121mg with the average increase of the dose during the study of 59 mg. Further increases of Metoprolol doses to achieve target HR were not tolerated by the patients.

Conclusion.
In this small group of patients with chronic AF and HF aggressive HR control was difficult due to patient intolerance of increasing doses of beta-blockade and was not associated with better exercise tolerance, better QOL or improved HF based on BNP measurement. Further studies are needed to establish guidelines for target HR in patients with chronic AF who also have significant HF.

Clinical parameter
Baseline
Follow-up
p-value

6-min walk test (meters)
326 ± 83
330 ± 86
0.47

QOL score
42.5 ± 19
38 ± 21
>0.5

BNP
242 ± 306
279 ± 395
>0.5

NYHA class
2.4 ± 0.7
2.2 ± 0.7
0.009
Abstract P340: Prevalence and Correlates of Smoking Cessation Pharmacotherapy in Hospitalized Smokers With Acute Myocardial Infarction
Authors: Katz David , Tang Fengming , Faseru Babalola , Horwitz Phillip A , Jones Phillip , Spertus John
Published: July 2021

Background
ACC/AHA guidelines recommend pharmacotherapy for smoking cessation in smokers with AMI. The aim of this study was to determine the prevalence of smoking cessation pharmacotherapy in hospitalized patients with AMI and to identify patient factors associated with prescription of these medications.

Methods
In the 24-center TRIUMPH registry, 4340 AMI patients underwent detailed interviews and 1631 reported smoking within 30 days of admission. Prescription of first-line smoking cessation medications at discharge was assessed by medical record review. All factors associated with smoking cessation treatment based on literature review were included in hierarchical modified log Poisson models.

Results
Only 14% (222/1631) of AMI patients who smoked were prescribed smoking cessation medication at discharge. Younger age, high school graduation, heavy cigarette usage, and treatment variables (instruction on smoking cessation, in-hospital revascularization) were independently associated with prescription of smoking cessation pharmacotherapy (see Figure). There was significant variation in prescribing across sites: range: 0-28%, median rate ratio 1.42 (1.24, 2.70) after multivariable adjustment.

Conclusions
Smokers surviving an AMI are rarely prescribed recommended smoking cessation treatment and there is considerable variation in prescription rates among hospitals. Although inpatient cessation counseling alone has not been shown to increase cessation rates in AMI patients, it increases the likelihood that patients receive effective pharmacotherapy. More aggressive use of pharmacotherapy is justified in older, less educated, and lighter smokers.
Abstract P59: Aspirin Improves the Impact of Niacin-Associated Flushing on Quality of Life Measures
Authors: Jiang Ping , Parreno Rhea , Thakkar Roopal B , Krause Scott , Doan Thao T , Padley Robert J
Published: July 2021

Background:
Flushing related to niacin therapy is typically short-lived, occurring primarily during initiation of therapy. Aspirin significantly reduces flushing incidence and severity. We evaluated flushing-related troublesomeness, impact of flushing on usual daily activities, and sleep.

Methods:
Double-blinded treatments: 325 mg aspirin (ASA) or PBO 30 minutes prior to niacin extended release (NER) 500 mg/d (wk 1), 1000 mg/d (wk 2), and 2000 mg/d (wks 3-6), (NER+ASA or NER+PBO, respectively); or placebo for both NER and ASA (PBO+PBO) for 6 wks. Patients who flushed rated severity and troublesomeness, 0 (none) - 10 (very severe), daily and flushing's impact on usual daily activities and sleep, 0 (none) - 3 (severely), weekly. Mean scores were compared between treatment groups among patients who flushed using repeated measures mixed-effect model.

Results:
Of 269 patients randomized, 68 (76%) in the NER+ASA group, 78 (87%) in the NER+PBO group, and 56 (63%) in the PBO+PBO group reported at least 1 flushing episode. Ratings of flushing severity were significantly correlated with troublesomeness, impact on daily activities, and sleep (p < 0.001). Mean scores in the NER+ASA and PBO+PBO groups were similar for troublesomeness (figure). Results for impact on daily activities and sleep were similar to those for troublesomeness (data not shown).

Conclusion:
Aspirin reduces the burden of niacin-induced flushing by improving quality of life measures to a level similar to that of niacin placebo.
Abstract P70: Social Network Characteristics Are Associated With Long Term Outcomes After Myocardial Infarction
Authors: Havranek Edward P , Gosch Kensey L , Buchanan Donna M , Smolderen Kim G , Spertus John A
Published: July 2021

Background:
Lack of social support is associated with worse outcomes after myocardial infarction (MI). Social support is a complex concept that includes the quality of perceived support and the size and quality of one's social network. It is not known if having a geographically close social network affects outcomes post-MI. We hypothesized that patients with a greater number of close network contacts would have better post-MI outcomes.

Methods:
From contacts listed by subjects in TRIUMPH, a prospective registry of MI patients from 24 US centers, we characterized social network size (number of contacts listed) and closeness (number of nuclear family contacts and number of contacts residing in the same area code). We assessed univariate relationships between these indices and outcomes (mortality and health status by the EQ-5D Visual Analogue Scale [VAS], an overall assessment of patients' quality of life), and scores from the ENRICHD Social Support Instrument (ESSI). We created multivariable Cox proportional hazards and linear regression models with mortality and VAS as dependent variables and with demographic, clinical, treatment and social support measures as independent variables.

Results:
Of 4340 subjects enrolled, 472 died over a median of 28.6 months. Mean 12-month VAS score was 75.4 ± 21.1. Having no same area code contacts (19.3% vs. 15.9%) (p=0.025 for trend), no nuclear family contacts (40.9% vs. 33.8%) (p=0.010 for trend), and living alone (33.0% vs. 23.6%, p<0.001) were associated with higher mortality on univariate analysis; total number of contacts and ESSI tertile were not. Univariate relationships with VAS were similar. In a multivariable model, age, prior stroke, diabetes, kidney disease, ejection fraction <40%, and living alone were significantly associated with mortality. In the multivariable VAS model, fewer area code contacts was additionally significant (p=0.023 for trend across number of contacts). Subjects with no area code contacts had a VAS score 3.2 ± 2.0 points lower than those with 4 near contacts.

Conclusions:
Geographic closeness of patients' social networks is weakly associated with outcomes after MI. Further investigation is warranted before proposing interventions designed to compensate for low network-based support.