bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 46: Putting Class IIB Recommendations to the Test - The Influence of Unwitnessed and Non-VT/VF Arrests on Resource Consumption and Outcomes in Therapeutic Hypothermia
Authors: Buntaine Adam , Katz Jason , Pulikkotil Thelsa , Miller Abigail , Reed Brent , Dangerfield Cristie
Published: March 2022

Background.
Therapeutic hypothermia (TH) improves survival for patients with out-of-hospital (OOH) cardiac arrest. Largely studied in witnessed VT/VF populations, recent data may support broader application for other forms of arrest. Many institutions are electing to expand their inclusion criteria in response. However, no studies have described changes in patient characteristics, resource use, or outcomes that may result with such expansion.

Methods.
We studied consecutive patients receiving TH at UNC Hospital from Sep 2009 - Jan 2012.
Protocol #1
provided TH for witnessed OOH arrest with VT/VF only. In Nov 2010, criteria were expanded to include all cardiac rhythms and un-witnessed events (
protocol #2
). Baseline demographics, resource use, and survival were compared between protocol groups. Multivariable logistic regression was used to identify key variables associated with in-hospital mortality.

Results.
The arrest population cooled at our institution had numerous comorbidities. The median age was 57 (IQR 49,70) years and median BMI was 28 (IQR 25,32) kg/m
2
. The majority were male (55%), white (70%), and had history of hypertension (57%). In addition, there was a high prevalence of baseline diabetes (28%), CAD (34%), chronic kidney disease (19%), and heart failure (28%). Despite nominally greater representation of male patients (63 v. 41%) in the expanded protocol population, there were no significant differences in baseline characteristics between protocol #1 and #2. Most arrest events were witnessed, but there were more unwitnessed episodes with the protocol #2 (30 v. 0%, p =0.01). The initial cardiac rhythm was most commonly VT/VF, but there were greater rates of PEA (6 v. 17%, p=0.01) with protocol #2. This was a resource intensive population, with all patients mechanically ventilated, 1/3 receiving cardiac catheterization and anti-arrhythmic drug therapy, and 2/3 treated with vasopressor medications; however, only the rate of aspirin use differed among protocol groups (35 v. 67% for protocol #2, p=0.04). Overall, 68% of all patients died in the hospital. While there was higher mortality with the expanded protocol, this did not reach statistical significance (59 v. 73%, p=0.31). Not a single unwitnessed arrest survived, and age was also independently associated with mortality (OR per 10y = 2.52, 95% CI 1.26-5.05, p=0.009).

Conclusions.
No matter the inclusion criteria, patients who receive TH for OOH cardiac arrest have multiple comorbidities and consume numerous resources. However, there were no significant differences when comparing our two protocol populations. Mortality does seem to be increasing with broader application of TH, and future attention should focus on the unwitnessed arrests in particular, none of whom survived their hospitalization.
Abstract 59: The Effects of Dapagliflozin on Cardiovascular Risk Factors in Patients with Type 2 Diabetes Mellitus
Authors: Basile Jan , Ptaszynska Agata , Ying Lisa , Sugg Jennifer , Parikh Shamik
Published: March 2022

Background:
Patients with type 2 diabetes mellitus (T2DM) often have multiple cardiovascular (CV) risk factors and, thus, an increased CV risk. Dapagliflozin (DAPA), a selective SGLT2 inhibitor currently under evaluation for the treatment of T2DM, reduces hyperglycemia by promoting renal glucose excretion, independently of insulin secretion or action.

Methods:
Using prospective exploratory analysis, the effects of DAPA on CV risk factors, including body weight, waist circumference, blood pressure (BP), plasma lipids, uric acid, estimated glomerular filtration rate (eGFR), and hypoglycemia were evaluated in four phase 3 studies. Patients were randomized to DAPA 2.5, 5, or 10 mg or placebo (PBO) once daily for 24 weeks as monotherapy in drug-naïve patients (Study 1,
NCT00528372
, N=485 [main cohort n=274]), as add-on to metformin (Study 2,
NCT00528879
, N=546), as add-on to glimepiride (Study 3,
NCT00680745
, N=596), or as add-on to insulin (Study 4, NCT0067323, N=808). Non-protocol antidiabetic and weight-reducing drugs were prohibited; other background medications were not controlled. Mean changes from baseline to week 24 adjusted for baseline values were analyzed.

Results:
DAPA significantly reduced glycated hemoglobin in all studies
(Table).
Weight loss with DAPA was greater than with PBO in all 4 studies, with statistically significant differences in Studies 2, 3, and 4 (
P
<0.0001). There were numerical decreases in waist circumference with DAPA in all 4 studies. DAPA reduced systolic BP and to a lesser extent, diastolic BP in all studies. Patients treated with DAPA showed inconsistent changes in triglycerides or LDL-cholesterol, whereas there were consistent increases in HDL-cholesterol. Decreases in serum uric acid were observed with DAPA in all studies. No clinically meaningful changes in eGFR were observed. Hypoglycemic events were infrequent and occurred in a similar proportion of patients in PBO and DAPA groups in Studies 1 and 2, but were more frequent with DAPA than with PBO in Studies 3 and 4, when added to sulfonylurea or insulin therapy.

Conclusions:
DAPA has favorable effects on important CV risk factors in patients with T2DM.
Abstract 6: A Validated Contemporary Risk Model of Acute Kidney Injury in Patients Undergoing Percutaneous Coronary Interventions: Insights From the NCDR Cath-PCI Registry
Authors: Tsai Thomas T , Patel Uptal D , Chang Tara I , Kennedy Kevin F , Masoudi Frederick A , Matheny Michael E , Kosiborod Mikhail , Weintraub William S , Curtis Jeptha P , Messenger John C , Rumsfeld John S , Spertus John A
Published: March 2022

Background:
Acute Kidney Injury (AKI) is a serious complication of percutaneous coronary intervention (PCI) and is associated with adverse outcomes. Accurately estimating this risk may help clinicians better inform patients considering PCI of their potential risk of this complication.

Methods:
Data were analyzed from 985,737 consecutive PCI patients performed at 1253 sites participating in the NCDR-Cath-PCI registry. AKI was defined as an absolute increase of ≥ 0.3 mg/dL or a relative increase of 50% in serum creatinine or a new requirement for dialysis following PCI (AKIN Stage 1 or greater). A parsimonious multivariable model in a 70% training cohort identified factors associated with AKI and assigned weighted integer scores. This score was validated in the remaining 30% of the population.

Results:
Overall, 69,658 (7.1%) patients developed AKI with an associated in-hospital mortality of 9.7% versus 0.5% in those without AKI. The model identified 16 variables predictive of AKI (Figure 1). The parsimonious integer showed good discrimination in validation (c-statistic = 0.72). Patients with increasing risk score had increasing risk of predicted and observed rates of AKI across low, medium and high risk groups (Figure 2)

Conclusion:
The NCDR AKI prediction model is a simple, contemporary and robust tool for predicting AKI in patients undergoing PCI. In certain clinical scenarios, the use of this tool may aid clinicians in counseling patient regarding the risk of PCI and identify patients for targeted interventions.
Abstract 71: Improving the Heart Failure Readmission Rate at an Urban Medical Center
Authors: Dickens Carolyn A , Vuckovic Karen , Nehmer Maria , DiDomenico Rob , Kerbow David , Stamos Tom , Kondos George , Piano Mariann
Published: March 2022

Background:
Heart failure (HF) is a chronic health condition that affects over 5 million people annually. It is the most common cause of 30-day readmissions with nearly 90% of these readmissions being unplanned. CMS requires hospitals to publicly report 30 day readmission rates for HF with the goal of improving accountability. In 2006, this hospital's 30-day readmission rate was 27% as compared to the national average of 24%.

Purpose:
To analyze the impact of several quality improvement interventions on 30-day readmission rates for HF at this urban medical center.

Intervention:
The following interdisciplinary interventions were implemented in the third quarter of 2009: (1) improved nursing discharge education regarding heart failure (ie. sodium restricted diet, medication adherence, daily weight); (2) a detailed medication list was given to patients; (3) patients received an appointment within 2 weeks with an advanced practice nurse (APN) specializing in heart failure; (4) HF patients received their medications prior to discharge; (5) all patients received a follow-up phone call by an APN within 7-10 days of discharge; (6) the hospital billing personnel analyzed patients charts to ensure that HF admissions were being coded appropriately.

Methods:
Patients were included if their initial admission was coded DRG 428 as their primary diagnosis and were readmitted within 30 days with any diagnosis. Data was summarized into 7, 14, and 30 day readmission rates. Rates were compared prior to the intervention and after. Pearson chi square was used to compare the two groups.

Conclusion:
At one year, the 30-day readmission rate decreased from 27.1% to 18.2% (p = 0.000) the 14 day readmission rate decreased from 15.1% to 9.1% (p=.003) and the 7 day readmission rate decreased from 8.8% to 5.5% (p=.038). Overall, patients were 1.6 times less likely to be readmitted for HF after the intervention.

Recommendations:
Hospitals can implement tailored interdisciplinary interventions to decrease their readmission rates. Sustainability of these process improvements will be critical to maintaining a high level of care for HF patients.
Abstract 8: Outcomes following Catheter Ablation of Atrial Fibrillation in Medicare Beneficiaries
Authors: Greiner Melissa A , Piccini Jonathan P , Sinner Moritz F , Heckbert Susan R , Benjamin Emelia J , Curtis Lesley H
Published: March 2022

Background:
Atrial fibrillation (AF) is the most common heart dysrhythmia and risk increases with advancing age. Guidelines advocate catheter ablation as a treatment for AF in patients who have failed antiarrhythmic drug therapy. However, little is known about outcomes associated with AF ablation in elderly patients.

Methods:
We obtained administrative claims for all Medicare fee-for-service beneficiaries ≥65 years who underwent intracardiac catheter ablation from 7/1/2007 to 12/31/2009. Outcomes included mortality, stroke/TIA, pericardial effusion, new MI, and vascular complications requiring surgery within 30 days, and mortality, stroke/TIA, heart failure, new hospitalization, and repeat AF ablation within 1 year. We used Kaplan-Meier methods to calculate unadjusted outcome rates overall and by age, and multivariable Cox models to examine predictors of 1-year outcomes.

Results:
Overall, 15,423 Medicare beneficiaries underwent AF ablation (mean age 72 years, 41% female and 96% white). Common comorbidities included hypertension (78%) and ischemic heart disease (51%). Dementia (0.6%) and stroke/TIA (6%) were relatively rare. Adverse outcomes at 30 days were fairly infrequent, including death (0.8%), stroke/TIA (0.8%), pericardial effusion (2%), MI (0.3%) and vascular complications (0.5%). Within 1 year, 4% of patients died, 43% required new hospitalization, and 11% had repeat ablation. AF or atrial flutter was the primary discharge diagnosis in a minority of new hospitalizations (38%). The death rate among patients aged ≥80 years (10%) was 5 times higher than among patients aged 65-69 years (2%). Whereas stroke/TIA, heart failure and hospitalization (Figure) also increased with age, repeat ablation was more common in younger patients. After multivariable adjustment, renal impairment (HR 2.07 [1.66, 2.58]), advanced age (HR for age ≥ 80 years, =3.09 [2.32, 4.11]), and heart failure (HR 2.54 [2.07, 3.13]) were notable risk factors for 1-year mortality following AF ablation.

Conclusion:
While major complications following AF ablation were fairly infrequent, new hospitalization was common. Given the association of complications and death with increasing age, randomized trials should inform the risk-benefit of AF ablation for elderly patients.
Abstract 82: Six-Minute Walk Test as a Prognostic Tool in Patients with Stable Coronary Heart Disease: Data from the Heart and Soul Study
Authors: Beatty Alexis L , Schiller Nelson B , Whooley Mary A
Published: March 2022

Background:
The prognostic value of the six-minute walk test (6MWT) in patients with stable coronary heart disease (CHD) is unknown. We sought to determine the ability of the 6MWT to predict cardiovascular events in patients with stable CHD.

Methods:
We measured 6MWT distance and treadmill exercise capacity in 555 outpatients with stable CHD between September 2000 and December 2002. Participants were followed for an average of 6.8 years for cardiovascular events (heart failure, myocardial infarction, and death).

Results:
Patients in the lowest quartile of 6MWT distance (87-419 meters) experienced cardiovascular events at 4 times the rate of patients in the highest quartile (544-837 meters) (62% vs. 22%, unadjusted HR 4.26, 95%CI 2.80-6.48, p<0.0001) (see Figure). Each standard deviation (SD) decrease in 6MWT distance (104 meters) was associated with an 86% higher rate of heart failure (age-adjusted HR 1.86, 95%CI 1.51-2.30), a 47% higher rate of myocardial infarction (age-adjusted HR 1.47, 95%CI 1.15-1.89), a 54% higher rate of death (age-adjusted HR 1.54, 95%CI 1.32-1.80), and a 55% higher rate of any event (age-adjusted HR 1.55, 95%CI 1.35-1.78). After adjustment for traditional risk factors and cardiac disease severity measures (ejection fraction, inducible ischemia, diastolic dysfunction, NT-proBNP, and CRP), each SD decrease in 6MWT remained associated with a 28% higher rate of cardiovascular events (HR 1.28, 95%CI 1.08-1.51). When added to the Framingham Risk Score, the 6MWT resulted in category-free net reclassification improvement of 48% (95%CI 32% - 66%). The discriminative ability of 6MWT was similar to treadmill exercise capacity for predicting cardiovascular events (c-statistics 0.70 vs. 0.70, p=0.97).

Conclusions:
Distance walked on 6MWT predicted cardiovascular events in patients with stable CHD. The addition of 6MWT to traditional risk factors improved risk prediction and was comparable to treadmill exercise capacity.
Abstract 87: Comparison of Pretest Probability Clinical Assessment and 2011 ACCF/ASE/AHA/ASNC/HFSA/HRS/ SCAI/SCCM/SCCT/SCMR Appropriate Use Criteria for Transthoracic Echocardiography and Association with Clinical Impact
Authors: deLuna Andres , Price Angela L , Rohatgi Anand , Das Sandeep R , Reimold Sharon C , Matulevicius Susan A
Published: March 2022

Background:
Although most transthoracic echocardiograms (TTEs) performed today meet Appropriate Use Criteria (AUC), the ability of AUC to predict whether these TTEs will impact clinical management remains unclear.

Methods:
The charts of 143 consecutive inpatient or outpatient TTEs at an academic medical center were retrospectively reviewed. Patients with a history of cardiac transplant or left ventricular assist device, or with inadequate pre-/ post- TTE clinical documentation were excluded; 123 studies were analyzed. Each TTE was assigned an AUC, pre-test, and clinical impact category. TTE indications were assigned by a cardiologist blinded to pre-study and post-study clinical data and categorized as: 1) inappropriate; 2) appropriate; or 3) uncertain based on 2011 AUC. Pre-test clinical course was analyzed by two independent cardiologists blinded to AUC and post-TTE clinical course and categorized as 1) TTE should not be performed, 2) TTE would likely alter clinical management, 3) TTE should be performed for reassurance/ continuity of care. Post-test clinical course was analyzed by two independent cardiologists blinded to AUC and pre-test assignment and categorized as 1) TTE did not alter clinical management, 2) TTE led to active change in management, 3) TTE led solely to reassurance/ continuity of current care.

Results:
By 2011 AUC, 85% of studies were appropriate, 11% were inappropriate, and 4% were uncertain. Active change resulted from 30% of studies, while 49% of studies provided reassurance/ continuity of care, and 21% had no clinical impact. These proportions were not statistically significant across AUC categories (p=0.54). Pretest clinical assessment suggested that 31% should not have been performed, 63% should have been performed for reassurance / continuity of care alone, and 7% were likely to alter clinical management. These pretest assessments were significantly associated with impact on clinical management (p=0.0067), with 75% (n=6/8) of those studies expected to alter clinical management actually doing so, 56% (n=43/77) of those predicted to primarily result in reassurance actually doing so, and 37% (n=14/38) of those predicted not to alter clinical management actually having no clinical impact.

Conclusions:
Classification by AUC is not associated with clinical impact. Although classification by pre-test probability is associated with clinical impact, a significant number of studies not predicted to have clinical impact actually had clinical impact. Further studies on methods to improve prediction of clinical utility for transthoracic echocardiography are warranted.
Abstract 88: The effect of statins on incidence of infections after Coronary Artery Bypass Grafting
Authors: Kayani Waleed T , Bandeali Salman , Elayda McArthur , Lee Vei- Vei , Nambi Vijay , Alam Mahboob , Jneid Hani , Birnbaum Yochai , Virani Salim
Published: March 2022

Statin therapy has been associated with improved outcomes in patients with infections. Our aim was to determine whether preoperative statin therapy is associated with a decrease in the incidence of infections after coronary artery bypass grafting (CABG) surgery.

Methods:
We conducted a retrospective cohort study of 6,253 patients undergoing isolated CABG from January 1, 2000 to December 31, 2010 (3,869 receiving statins and 2,384 not receiving statins). Primary outcome was the development of any postoperative infection (composite of deep sternal wound infection, leg harvest-site infection, pneumonia and sepsis) after CABG. Secondary outcome was the effect of statins on incidence of each aforementioned infection individually. Logistic regression analyses were performed.

Results (Table):
Incidence of any postoperative infection in patients who received statins preoperatively was 6.5% (250 of 3,869) compared to 8.3% (198 of 2,384) in controls. In fully adjusted models, preoperative statin therapy was independently associated with a significant reduction in the development of any postoperative infection. Among individual infections, preoperative statin therapy was associated with a reduced incidence of sternal wound and leg harvest site infections. An association with a reduced incidence of pneumonia and sepsis was not found.

Conclusions:
Preoperative statin use is associated with a decreased incidence of sternal wound infections and leg harvest site infections after CABG
Abstract 90: Contemporary Use of Renin-Angiotensin System Blockers in Acute Coronary Syndromes: Findings from Get With The Guidelines-Coronary Artery Disease Program
Authors: Bainey Kevin , Fonarow Gregg , Cannon Christopher , Hernandez Adrian , Peterson Eric , Peacock Frank , Laskey Warren , Zhao Xin , Schwamm Lee , Bhatt Deepak
Published: March 2022

Background:
Angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) initiated after myocardial infarction (MI) reduce mortality and are American College of Cardiology / American Heart Association (ACC/AHA) guideline recommended. Yet, contemporary use of ACEI or ARB in acute coronary syndrome (ACS) patients at hospital discharge has not been well studied.

Objective:
To examine ACEI/ARB prescription based on current Class I guideline criteria, patient and hospital factors associated with use, and temporal trends in patients hospitalized with ACS.

Methods:
We performed an observational analysis of 80,241 patients admitted with an ACS and discharged home from 311 hospitals participating in the Get With The Guidelines - Coronary Artery Disease Program from January 01 2005 to December 30 2009. Patient and hospital characteristics, measures and other outcomes were summarized descriptively by ACEI/ARB vs. no ACEI/ARB for ACC/AHA Class I indication. Pearson Chi-square test was used for categorical variables and Wilcoxon test was used for continuous variables. A multivariable logistic regression model with GEE method was fitted to identify influencing factors on ACEI/ARB use at discharge.

Results:
Among the 60,847 patients with an ACC/AHA Class I indication (left ventricular dysfunction or medical history of heart failure, hypertension or diabetes mellitus), 49,682 (81.7%) received ACEI/ARB with modest increase in treatment over the study period (76.7% to 84.6%). Patient and hospital factors independently associated with ACEI/ARB therapy use in patients meeting ACC/AHA Class I indication are shown in Table 1.

Conclusion:
Results from this large national registry suggest that one in five eligible patients hospitalized for ACS failed to receive ACC/AHA Class I guideline recommended ACEI/ARB therapy and use varies by patient factors. In particular, the low likelihood of ACEI/ARB post coronary artery bypass grafting surgery (CABG) raises concern. Thus, additional quality improvement efforts are warranted.
Abstract 99: Beta-Blocker Monotherapy is Inferior to Treatment with Angiotensin-Converting-Enzyme Inhibitor/Angiotensin-Receptor Blocker or Combined Therapy after Hospital Discharge among Patients with Acute Decompensated Heart Failure with Reduced Ejection Fraction
Authors: Grebla Regina C , Wellenius Gregory A , Eaton Charles B , Gatsonis Constantine , Wu Wen-Chih
Published: March 2022

Introduction
AHA/ACC guidelines recommend combination therapy with an angiotensin-converting-enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) and a beta-blocker (BB) at discharge for patients hospitalized for heart failure (HF) with reduced ejection fraction. However, there is little information available to compare outcomes associated with these three treatment options at discharge, and the optimal monotherapy with either an ACEI/ARB or BB for patients who cannot tolerate combination therapy is unknown.

Hypothesis
We hypothesized that: 1) patients receiving ACEI/ARB or BB monotherapy would have higher rates of mortality and HF re-hospitalization than patients receiving combination therapy; and 2) patients receiving ACEI/ARB monotherapy would experience similar rates of mortality and lower rates of HF re-hospitalization when compared with patients receiving BB monotherapy.

Methods
We studied 21,849 patients with left ventricular ejection fraction < 40% hospitalized for HF at 144 VA hospitals nationwide and who were assessed for HF quality measures between 2003 and 2007. Patients who received any of the three therapies (n=19,303) were 1:1:1 propensity score matched. We evaluated the association between treatment at hospital discharge and outcomes using the Kaplan-Meier method, pair-wise log-rank tests to test for significant differences in event-free survival, and hazard ratios (HR) and 95% confidence intervals (CI) from Cox proportional hazards regression models.

Results
Among 4,995 patients in our matched sample, BB monotherapy at discharge was associated with increased 30-day mortality compared with ACEI/ARB monotherapy (HR: 1.62; 95% CI: 1.15, 2.29; log-rank P=0.009), which was not observed at six months (HR: 1.08; 95% CI: 0.91, 1.27; log-rank P=1.00). BB monotherapy at discharge was associated with increased mortality risk when compared with combination therapy at 30 days (HR: 1.67; 95% CI: 1.19, 2.36; log-rank P=0.009) and at six months (HR: 1.28; 95% CI: 1.08, 1.52; log-rank P=0.030). No significant differences in mortality between patients receiving ACEI/ARB monotherapy and combination therapy were observed. No significant association between HF therapy at discharge and risk of HF re-hospitalization was found.

Conclusions
In this cohort of veterans hospitalized with decompensated HF and reduced ejection fraction, receipt of BB monotherapy at hospital discharge was associated with an elevated risk of mortality when compared with ACEI/ARB monotherapy and combination therapy.
Abstract 10: Contraindications to Oral Anticoagulation in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF)
Authors: O’Brien Emily C , Holmes DaJuanicia , Koller Christopher R , Singer Daniel E , Ansell Jack , Allen Larry A , Hylek Elaine M , Kowey Peter , Gersh Bernard , Fonarow Gregg C , Mahaffey Kenneth W , Chang Paul , Ezekowitz Michael D , Peterson Eric D , Piccini Jonathan P
Published: March 2022

Background.
Oral anticoagulation therapy (OAC) reduces the risk of thromboembolic events associated with atrial fibrillation (AF), yet a substantial proportion of patients with AF are not prescribed OAC. The frequencies of and factors associated with contraindications to OAC therapy in clinical practice are not well-described.

Methods.
We used data from the ORBIT-AF study, a national, prospective, outpatient registry of incident and prevalent AF. OAC contraindications were uniformly collected at study enrollment by site personnel. Patient and provider characteristics were compared between participants with documented OAC contraindications at baseline and those without OAC contraindications.

Results.
From June 2010 to August 2011, 10124 patients ≥18 years old with electrocardiographically documented AF were enrolled at 176 practices. Of these, 1409 (13.9%) had OAC contraindications documented at the baseline visit: prior bleed (26.2%), patient refusal/preference (26.0%), high bleeding risk (22.6%), frequent falls/frailty (16.6%), other (11.9%), need for dual antiplatelet therapy (9.8%), unable to adhere/monitor warfarin (5.7%), comorbid illness (5.0%), prior intracranial hemorrhage (4.7%), allergy (2.3%), occupational risk (0.8%), and pregnancy (0.2%). Compared to patients without contraindications, those with contraindications had higher stroke risk (CHADS2>2) and were older, more likely to be female, more likely to be seen by a cardiologist and less likely to be seen by an electrophysiologist (Table 1). Among those patients with reported contraindications, 28.4% were taking warfarin.

Conclusions.
Contraindications to OAC therapy among AF patients are common and often due to high bleeding risk. Furthermore, many patients with reported contraindications are taking warfarin, suggesting that many contraindications to warfarin therapy are minor, relative, or temporary.
Abstract 108: Influence of Patient Gender and Physician Gender on Achieving Performance Measures in Cardiology Fellows’ Ambulatory Clinic
Authors: Chakilam Srujana , Szpunar Susan , Mesiha Nancy , Rosman Howard
Published: March 2022

Background:
The quality of care provided to ambulatory cardiac patients has been reported as being influenced by patient gender. It is unknown if the gender of the physician provider has an impact. For this study, we compared compliance with performance measures for patients enrolled into the American College of Cardiology (ACC) Practice Innovation And Clinical Excellence (PINNACLE) registry by patient gender and physician gender in our Fellow’s clinic.

Methods:
Data were collected from January 2009 to May 2012. We examined the proportion of patients whose care was compliant with 10 established ACC and American Heart Association performance measures for coronary artery disease (CAD), congestive heart failure (CHF), and atrial fibrillation (Afib). Analyses were performed using Student’s t-test, χ
2
analysis and logistic regression with

SPSS V21.0.

Results:
2001 patients were enrolled (age 66.4 ±14.9, 51% female and 75% Caucasian). Of these, 51% (1015 of 2001) had CAD, 17% (343 of 2001) had CHF, and 23.3% (471 of 2001) had non-valvular Afib. The overall compliance with performance measures was variable, highest being 96.6% for CAD patients on statin therapy and lowest at 32.7% for CAD patients with lipid profile. In univariate analysis, there was a trend towards female patients with Afib and CHADS2 score ≥ 2 being less likely to be on warfarin compared to males (p=0.09), but in multivariate analysis controlling for patient age, race and physician gender, there was no difference by patient gender. In univariate analysis, female physicians were more likely than males to provide self care education to CHF patients (p = 0.017), but in multivariate analysis controlling for patient age, race and physician gender there was no difference by patient gender in any of the select performance measures.

Conclusions:
Compliance with select performance measures was not influenced by the gender of the patient or the treating physician at our cardiology fellows’ ambulatory clinic. However, compliance with performance measures was variable, identifying an opportunity to improve quality of care of ambulatory patients.
Abstract 110: Racial Differences in Heart Failure Outcomes
Authors: Qian Feng , Parzynski Craig S , Chaudhry Sarwat I , Spertus John A , Krumholz Harlan M
Published: March 2022

Background:
Little is known about whether racial differences exist in patient-centered outcomes after a heart failure hospitalization. We sought to determine if there are racial differences in health status, readmission and mortality after hospitalization for heart failure.

Methods:
We analyzed 1427 patients with heart failure (636 non-Hispanic blacks, 45%; 791 non-Hispanic whites, 55%) in data from a randomized controlled trial (Telemonitoring to Improve Heart Failure Outcomes, NIH Clinical Trials #
NCT00303212
). We examined racial differences in quality of life by using the overall summary score of Kansas City Cardiomyopathy Questionnaire (KCCQ at baseline, 3 and 6 months), rehospitalization and mortality rates (30-day and 180-day). Generalized linear mixed models and propensity score methods were used to adjust for clustering within sites and differences between races.

Results:
Compared with whites, black patients were more likely to be younger, less well insured, a current smoker, have hypertension, cognitive impairment, and reduced left ventricular ejection fraction (<40%), but less likely to have hypercholesterolemia, coronary disease and peripheral vascular disease. While black patients reported better quality of life at baseline (black vs. white difference in KCCQ summary score: 6.22, 95% confidence interval [CI]: 2.98-9.46, P<0.001), after adjusting for patient demographics, comorbidities, and clinical laboratory values, we detected no significant racial differences at 3 (black vs. white difference in KCCQ score: 2.28, 95% CI: -0.84-5.41, P=0.15) or 6 months (black vs. white difference in KCCQ score: 1.91, 95% CI: -1.31-5.13, P=0.24). We observed no significant racial differences in 30-day (white: 18.3%, black: 16.4%, P=0.33) or 180-day unadjusted all-cause rehospitalization rate (white: 50.4%, black: 47.8%, P=0.32) and no differences in 30-day unadjusted mortality rate (white: 2.3%, black: 1.3%, P=0.15). Significant racial differences did occur in180-day unadjusted mortality rate (white: 13.4%, black: 9.0%, P=0.01), which were no longer apparent after adjusting for site and using propensity score methods to adjust for patient demographics, payer, socioeconomic status, comorbidities, and clinical laboratory values (adjusted odds ratio: 0.85, 95% CI: 0.52-1.37, P=0.49). Likewise, fully adjusted 180-day all-cause rehospitalization rates were similar (AOR: 0.92, 95% CI: 0.70-1.21, P=0.53).

Conclusion:
Compared with whites, black heart failure patients enrolled in this trial had higher self-reported quality of life at baseline. However, there were no racial differences in quality of life at 3 and 6 months and both blacks and whites experienced notable improvement in quality of life in the follow-up period. After adjustment for clustering and patient factors, no significant racial differences in mortality or rehospitalization rates were observed.
Abstract 114: Patterns of LDL-C Goal Attainment in Familial Hypercholesterolemia Patients after Coronary Artery Disease from a US Database
Authors: Wang Hongwei , Salimi Tehseen , Zhang Quanwu
Published: March 2022

Background:
Familial Hypercholesterolemia (FH) is a genetic disorder characterized by very high levels of LDL-C and an increased cardiovascular risk. However, effective therapeutic options remain limited. Study was to illustrate the present patterns of LDL-C goal attainment in pts with FH from a US database.

Methods:
Statin users between Jan 2004 and Jun 2010 were identified from the US IMPACT insurance claims database. Two FH cohorts were identified based on Simon Broome Criteria: High-LDL FH (HFH) LDL-C≥200 mg/dL; Moderate-LDL FH (MFH) 190≤LDL-C<200 mg/dL. A non-FH cohort was identified as HC, with 100<LDL-C<190 mg/dL. LDL-C goal attainment was ascertained in the subsequent 3-yr period, after 6-month stabilization of LDL-C post index (PI) CAD.

Results:
Mean age was 60 yrs; 52% female FH vs. 62 yrs with 38% in Non-FH. Mean LDL-C at 0-6 months PI CAD was 184, 153 and 129 mg/dL for HFH (n=284), MFH (n=135) and non-FH (n=1,466), respectively. Following 6-18 months PI CAD, 29.6% HFH and 31.1% MFH relative to 15.3% Non-FH pts progressed from mono- to combination lipid lowering therapy (LLT). Rate of LDL-C goal attainment (<70 mg/dL) was significantly lower in HFH (7.8%, Odds Ratio [OR]=0.17, p<0.01) and MFH (11.9%, OR=0.26, p<0.01), compared to non-FH (33.7%) pts. Goal attainment stayed lower in FH than non-FH [Fig], with a decreasing trend in HFH over 6-42 months PI CAD. Using relaxed criterion of LDL-C<100 mg/dL, the goal attainment of 6-18 months PI CAD remained significantly lower in HFH (35.2%, OR=0.17, p<0.01) and MFH (51.1%, OR=0.33, p<0.01), relative to non-FH (76.2%).

Conclusions:
Twice as many FH vs. non-FH pts progressed from mono- to combination therapy 6-18 months PI CAD. Despite more aggressive treatment, HFH pts showed no improvement in LDL-C goal attainment 6-42 months PI CAD. FH pts remained less likely to achieve target even with a more relaxed LDL-C cutoff. These findings support the need for more effective LLTs in FH pts with elevated cardiac risk.
Abstract 115: Experience with a Nurse Practitioner Post-Discharge Transitional Clinic Model in over 1000 Cardiac Patients
Authors: Mahmood Redah Z , Bumpus Sherry M , Smith Cydni A , Sylvester Rachel H , Spooner Kelly , Montgomery Daniel G , Kline-Rogers Eva , Vaishnava Prashant , Eagle Kim A , Rubenfire Melvyn
Published: March 2022

Background:
Current legislation imposes financial penalties for institutions with high 30 day readmissions for acute myocardial infarction (AMI). BRIDGE is a nurse practitioner (NP) based post discharge transitional care program aimed at ensuring prompt (target: within 2 weeks) follow up (f/u) and facilitation of care for cardiac patients. Herein we report the effect of BRIDGE on readmissions and ED visits in over 1000 cardiac patients.

Methods:
Retrospective data was abstracted from June ‘08 to Dec ’10 for all patients referred to BRIDGE including demographics, comorbidities, medications, days to f/u with health care provider and 6 month outcomes for each diagnoses.

Results:
Of 1188 patients referred, 718 of 1020 (70.4%) patients attended BRIDGE, 178 patients were excluded from analysis due to invalid data or adverse events prior to the BRIDGE appointment. Diagnoses included: acute coronary syndrome (ACS) 268 (27%); angina 143 (14%), coronary disease 132 (13%); atrial fibrillation 148 (15%); heart failure 162 (16%); or other 157 (16%). There were no differences in baseline characteristics (table 1) of attendees vs. non-attendees, nor in Charlson Comorbidity Score for attend (4.42±2.48) vs. not attend (4.44±2.25; p=0.906). ACS patients attending BRIDGE had significantly lower rates of readmission at 30, 60, and 90 days, and a trend towards lower rates of ED visits at 30 and 60 days (table 2). This was not observed for other groups.

Conclusions:
A NP based transitional care clinic visit early post-discharge reduce early readmission and ED visits for patients with an ACS, but in this study did not impact other cardiac conditions.
Abstract 12: Evaluation of Medical Costs Associated with Use of Novel Oral Anticoagulants Compared with Warfarin Among Nonvalvular Atrial Fibrillation Patients with Moderate and High Stroke Risk
Authors: Deitelzweig Steve , Amin Alpesh , Jing Yonghua , Makenbaeva Dinara , Wiederkehr Daniel , Lin Jay , Graham John
Published: March 2022

Background:
Nonvalvular atrial fibrillation (NVAF) is a sustained cardiac rhythm disturbance, which increases stroke risk up to 5-fold and affects more than 5 million Americans. Warfarin is efficacious for reducing stroke risk among NVAF patients, but its use is complicated by it having a narrow therapeutic range, significant drug-drug interactions, and an increased risk of major bleeding. The ARISTOTLE, RE-LY, and ROCKET-AF clinical trials demonstrated the novel oral anticoagulants (NOACs), apixaban, dabigatran, and rivaroxaban, respectively are efficacious for stroke prevention among NVAF patients. This study evaluated medical costs of clinical events associated with the use of individual NOACs relative to that of warfarin among NVAF patients with moderate and high stroke risk.

Methods:
Rates for primary and secondary efficacy and safety outcomes (i.e. clinical events) per year among NVAF patients with CHADS
2
=2 and ≥ 3 were obtained or estimated from the 3 NOAC clinical trials. One year incremental costs among patients with clinical events from a US payer perspective were obtained from the literature and inflation adjusted to 2010 costs. Differences in medical costs for clinical events associated with use of individual NOACs instead of warfarin were then estimated.

Results:
For NVAF patients with moderate stroke risk (CHADS
2
=2), the overall differences in medical costs for clinical events relative to warfarin were $298, $143, and +$117 per patient year for apixaban, dabigatran (150 mg), and rivaroxaban, respectively (negative numbers=cost reduction). For NVAF patients with high stroke risk (CHADS
2
≥ 3) the overall differences in medical costs for clinical events relative to warfarin were $697, $2, and $100 for apixaban, dabigatran (150 mg), and rivaroxaban, respectively.

Conclusions:
Of the three NOACs, apixaban demonstrated greater medical cost reductions relative to warfarin among NVAF patients at moderate and high stroke risk. The medical cost reduction associated with apixaban use instead of warfarin was greater for NVAF patients at higher stroke risk vs. those at moderate stroke risk and was driven primarily by higher absolute reductions in clinical event rates for major bleeding, stroke and systemic embolism.
Abstract 122: Adult Congenital Heart Surgery Safely Performed at Pediatric Hospitals: 115 Consecutive Open Heart Surgeries Without a Mortality or Significant Morbidity
Authors: Phillips Alistair , Olshove Vincent
Published: March 2022

Objectives:
With increasing numbers of adult patients with congenital heart disease requiring surgical intervention, determining the best treatment location and treatment team is very important. We evaluated the results of treating all adults at a Children’s Hospital.

Methods:
We reviewed the surgical outcomes of all adult patients who underwent surgical repair of congenital heart disease on cardiopulmonary bypass, at the pediatric hospital, from July 2006 through June 2011.

Results:
The same surgeon operated on 115 patients with a median age of 27.31.8, average weight 74.82.3, 72.2% were redo, 1.7% requiring femoral cannulation and 53.9% were male. There were no mortalities. 67.8% were extubated in the OR, 2.6% required re-intubation, 87% were done bloodlessly. There were 4 major events (1) Re-exploration for bleeding, (2) Ventricular fibrillation that required shock and converted, (3) Minor stroke with no permanent neurological deficit, and (4) Vascular injury to axillary artery requiring return to the OR. Of the patients, 70 procedures were done on the left side with 32 aortic procedures, and 135 procedures on the right side including 9 patients with Hybrid PA stenting. 24 patients had cyro-ablation of RVOT for ventricular arrhythmias and 14 had atrial ablations.

Conclusions:
There is a growing need to develop care strategies for adults with congenital heart disease. By developing a focus of care at pediatric hospital, adults received outstanding surgical results with very little morbidity or mortality.
Abstract 123: Patterns of Statin Use, Adherence, and Persistence among Patients in Working Age Patients With High-Risk Vascular Diseases: Findings from a Multi-Employer Claims Database
Authors: Zhao Zhenxiang , Zhu Yajun , Fang Yun , McCollam Patrick L
Published: March 2022

BACKGROUND:
Despite progress in treatment, high-risk vascular diseases (HRVD), including cerebrovascular disease (CVD), coronary artery disease with diabetes (CADD), acute coronary syndrome (ACS), and peripheral artery disease (PAD), account for approximately half of the rates of morbidity and mortality in the US. Limited research has been done to systematically study statin use patterns, adherence, and persistence for HRVD patients using real-world large claims databases. The objective was to examine statin use patterns, adherence, and persistence in patients with HRVD.

METHODS:
A retrospective cohort study was conducted using a large US administrative claims database for over 10 million beneficiaries annually from more than 100 self-insured Fortune 500 companies. HRVD patients (defined as patients with CVD, PAD, CADD, or a history of ACS [≥30 days through 365 days after discharge for ACS between 10/01/2008 and 09/30/2009]) aged 18 to 64 years, with minimum 12-month pre-index and 24-month post-index health plan eligibility, were identified for this study. Statin use, statin median/mean dose, percent of patients using maximal statin dose (defined as atorvastatin ≥80 mg and rosuvastatin ≥40 mg), and statin adherence (calculated using the medication possession ratio [MPR]) were measured at 6-month, 12-month, and 24-month follow-up periods. Persistence was assessed with survival analysis techniques using a ≥30-day gap to define a discontinuation.

RESULTS:
Among 516,863 identified HRVD patients, 38.7% used statins during the baseline period (PAD: 31.5%; CVD: 29.2%; CADD: 54.6%; ACS: 65.5%). The number increased to 40.6%, 43.3%, and 45.6% during the 6-month, 12-month, and 24-month follow-up periods, respectively, with greater increase of statin use in PAD and CVD patients (38.3%, 37.9%, respectively, during the 24-month follow-up period). Simvastatin (39.0%, 39.0%, 39.2%), atorvastatin (31.0%, 29.1%, 27.5%), and rosuvastatin (18.0%, 18.6%, 19.2%) were the most commonly used statins with 8.1%, 7.4%, and 7.3% of patients using maximum statin doses at 6-month, 12-month, and 24-month follow-up periods, respectively. There appeared to be little changes in statin doses during the 24-month follow-up period (mean/median dose: simvastatin 44.1/40 mg, 44.3/40 mg, 44.7/40 mg; atorvastatin 36.7/30 mg, 37.2/30 mg, 37.6/40 mg; rosuvastatin 17.2/10 mg, 17.4/10 mg, 17.9/10 mg). The mean/median MPR was 0.64/0.66, 0.60/0.66, and 0.49/0.49 among HRVD patients who used a statin with only 13.8%, 14.0%, and 10.9% of patients adherent (MPR≥80%) to their statin therapy during the 6-month, 12-month, and 24-month follow-up periods, respectively. The mean time to statin discontinuation was 357 days during the 24-month follow-up period.

CONCLUSIONS:
Nonadherence to statins is common for patients with HRVD, and the patterns of statin adherence persist over time with little titration in doses.
Abstract 126: Trends in Cardiac Rehabilitation Referral after Myocardial Infarction: Data from the National Cardiovascular Data Registry (NCDR®)
Authors: Beatty Alexis L , Li Shuang , Thomas Laine , Amsterdam Ezra A , Alexander Karen P , Whooley Mary A
Published: March 2022

Background:
Cardiac rehabilitation reduces mortality in patients with recent myocardial infarction (MI), but rates of referral to cardiac rehabilitation in the United States have been low, with referral of only 53% of post-MI patients in a quality improvement registry from 2000-2007. In 2007, the American Heart Association and American College of Cardiology introduced new performance measures for post-MI patients that included referral to cardiac rehabilitation prior to discharge.

Objective:
We sought to investigate whether cardiac rehabilitation referral rates after MI have changed since publication of this performance measure.

Methods:
We examined referral to cardiac rehabilitation among 301,247 eligible patients with non-ST segment elevation MI or ST-segment elevation MI from 624 hospitals contributing to the NCDR® ACTION Registry® - Get with the Guidelines (GWTG)™ from January 1, 2007 to June 30, 2012. We evaluated the trend in referral to cardiac rehabilitation using the Cochran-Armitage trend test.

Results:
Following the inclusion of cardiac rehabilitation referral in performance measures, the percentage of eligible post-MI patients referred to cardiac rehabilitation increased from 73% in 2007 to 81% in 2012 (p<0.0001 for trend) (Table). Patients referred to cardiac rehabilitation were more likely to have undergone catheterization (95.1% vs. 82.8%, p<0.0001) or revascularization (73.6% vs. 44.4%, p<.0001) during the hospitalization than patients who were not referred. Hospitals with a higher rank in performance metrics (not including cardiac rehabilitation referral) had a higher percentage of patients referred to cardiac rehabilitation (86.5% in the highest quartile vs. 61.2% in the lowest quartile, p<0.0001).

Conclusions:
A significant increase in the proportion of post-MI patients referred to cardiac rehabilitation was observed after referral to cardiac rehabilitation was included in published performance measures.
Abstract 128: Pre-operative Team Huddle Improves Communication and Reduces Variability in Surgical Repair of Congenital Heart Disease
Authors: Phillips Alistair , Olshove Vincent
Published: March 2022

Background:
A team communicating openly, that defines patient goals and utilizes a consistent management approach can reduce care variability, reduce errors and improve outcomes.

Methods:
Team huddle outlining the surgical, anesthesia, perfusion and nursing goals was evaluated. A team huddle occurred prior to the patient getting into the OR, with the goal to reduce the utilization of blood products in the OR from 67% of procedures receiving blood to 25% of procedures.

Results:
The huddle reduced the variablity of care by limiting IV fluids while improvement in countermeasures;a reduction of patients’ lactate levels in the ICU, as well as a reduction in overall patient events.

Conclusions:
A team approach to care had a tremendous effect on patient outcomes, by improving communication of the plan and helps guide critical decisions.