bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 357: Effect of an Early Nurse Practitioner Based Transitional Care Program on Atrial Fibrillation Readmissions
Authors: Mahmood Redah Z , Bumpus Sherry M , Montgomery Daniel G , Kline-Rogers Eva , Froehlich James B , Eagle Kim A , Rubenfire Melvyn
Published: July 2021

Background:
BRIDGE is a nurse practitioner (NP) based transitional care program for cardiac patients(pts) discharged from a large tertiary care health system. Attendance at the BRIDGE clinic has been shown to reduce early readmission and ED visits for acute coronary syndrome (ACS) pts. Little is known about causes of readmission for atrial fibrillation (AF) pts and whether an NP based program affects overall readmissions.

Methods:
Retrospective data on 1188 pts was abstracted from 2008 to 2010 for pts referred to BRIDGE. Early (30 day) readmission of pts with discharge diagnosis of AF underwent qualitative chart audit by a trained MD abstractor. When examining if BRIDGE affected readmissions, we excluded pts with ED visits/readmits prior to BRIDGE.

Results:
Median time to BRIDGE was 16 days. Of 1010 with complete data, 148 (15%) had a discharge diagnosis of AF; 110/148 (74%) AF pts attended BRIDGE. Thirty day readmission (30DR) for AF was 23% (34/148); 17/34 (57%) were sent to the ED by a MD or nurse. Attending BRIDGE had no effect on outcomes at all time points (table 1); 17 patients were readmitted before BRIDGE. Readmission at 6 months for AF was 41% for those who attended BRIDGE, 29% for those who did not (p=0.190). Table 2 details reasons for all 30DR in AF pts. Chart review demonstrated that all 30DR were appropriate, 83% (25/30) of non-elective readmissions were unavoidable, and of 5 potentially avoidable readmissions, 2 were due to patient non-compliance.

Conclusions:
30-day readmission rates are high for pts recently discharged with a diagnosis of AF and most are unavoidable. A NP based transitional care clinic successful in reducing 30 day readmissions for ACS pts did not prevent either early or late readmissions in AF pts.
Abstract 359: Lack Of Blood Pressure Augmentation During Stress Testing Is Associated With Increased Mortality.
Authors: D’Cruz Geoffrey , Rastogi Ashish , Yager Neil , Bindra Amarinder , Fein Steven A , Torosoff Mikhail
Published: July 2021

Objective:
We investigated long-term outcomes associated with hypertensive response to exercise in patients with chest pain referred for stress echocardiography.

Methods:
Records of 404 patients with normal baseline LV systolic function (45% females, mean age 60+/-11 years, baseline SBP 136+/-20 mmHg, 26% with CAD, 4% with CHF, 39% with hypertension, 13% with diabetes mellitus, 5% with peripheral vascular disease, 21% with history of smoking or active smoking, 43% on beta-blockers, 23% on ACE-inhibitors/ARBs) referred for chest pain evaluation with stress echocardiography at a single tertiary care center were reviewed. Demographics, clinical data, and outcomes were collected. Median length of followup was 35+/-0.3 months. Patients were divided into four groups depending on their maximum blood pressure during exercise (greater or less than 180mmHg) and whether they achieved their age-adjusted target heart rate.

Results:
Contrary to the expectations, hypertensive response to exercise was not associated with the increased mortality (Table). Instead, lack of blood pressure augmentation during exercise and low double product were predictive of increased mortality. History of CHF (p=0.0003) and/or PVD (p=0.001) were the strongest predictors of failure to augment blood pressure during stress testing.

Conclusions:
Failure to augment systolic blood pressure during exercise appears to be associated with increased mortality. Although ischemia on echocardiography and reduced exercise capacity are the stress test outcomes traditionally associated with poor prognosis, failure to augment blood pressure during exercise may be an important predictor of mortality as well. Additional studies of this subject are needed.
Abstract 360: A Simplified Post-Discharge Telephone Intervention To Reduce Hospital Readmission for Patients with Cardiovascular Disease.
Authors: Kwan Gene F , Kwong Lana , Hong Yun , Khemka Abhishek , Huang Gary , Whalen Deborah , Philippides George J
Published: July 2021

Background:
Readmission rates are high for patients with cardiovascular disease, particularly heart failure (HF) and acute coronary syndrome (ACS). Telephone calls by clinical staff have had mixed effects. We aim to evaluate the degree of implementation and the effect of a quality improvement initiative using a simplified post-discharge phone call by administrative assistants.

Methods:
Clinical data were retrospectively reviewed at a single urban public hospital. From January through October 2012 all patient discharged home from inpatient cardiology services (intervention group, n=1034 discharges) were identified. Within 7 days, administrative assistants contacted patients via telephone and queried regarding (1) medication compliance, (2) awareness of follow-up appointments and (3) if clinician contact is requested. Outcome events were defined as readmissions (for any cause) within 30 days to the same hospital and are reported as patients experiencing readmission, and total readmissions. A comparison group of all patients discharged home from inpatient cardiology services from January through October 2010 (n=746) were selected as controls (no phone calls). Categorical data were compared in a univariate fashion using the Chi Square test. Statistical significance is defined as p<.05.

Results:
Of the 1034 discharge events in the intervention group, 620 (60.0%) had phone calls attempted. Of those, 419 (67.6%) were directly contacted. Patients were statistically different with respect to language, ethnicity and insurance status. Of the patients called, 48 (7.7%) reported medication abnormalities, 13 (2.1%) did not understand their follow-up and 38 (6.1%) had a question for a clinician. The rates of patients experiencing events was not statistically different (132 [17.7%] vs. 156 [15.1%], OR 0.85, p=.14). Total readmissions were significantly reduced (157[21.0%] vs. 179 [17.3%], OR 0.82, p=.047). Pre-specified subgroups of ACS and HF patients showed a trend towards decreased re-admissions but were not statistically significant.

Conclusion:
A simplified post-discharge telephone call strategy is associated with a trend towards reduced hospital readmissions for cardiology patients. Further refinements are needed to improve program implementation.
Abstract 37: Short-Term Clinical and Economic Consequences of Coronary Stent Thrombosis
Authors: Kohn Christine G , Kluger Jeffrey , Azeem Meena , Coleman Craig I
Published: July 2021

Objective:
To conduct a systematic review and meta-analysis to better quantify the real-world incidence of in-hospital or 30-day death or myocardial infarction (MI) following coronary stent thrombosis (ST), as well as ST-related treatment costs.

Methods:
We searched Medline, Embase and Scopus from January 2000-July 2012 to identify observational or registry studies that evaluated a cohort of ≥25 patients experiencing angiographically-confirmed thrombosis of a drug-eluting or bare-metal stent, required the use of dual-antiplatelet therapy for guideline recommended durations, and reported on the incidence of in-hospital or 30-day death or MI and/or ST-related treatment costs. Incidences and treatment costs from each study were pooled using random-effects meta-analysis. Statistical heterogeneity was assessed using the I2 statistic (>50% deemed significant).

Results:
A total of 23 studies were included. Among the 12 studies (N=8,832 STs) reporting in-hospital mortality, the pooled incidence rate was estimated to be 7.9%, 95%CI=5.4%-11.3%, I2=86%. Ten studies (N=1,294 STs) reported 30-day death, with a pooled incidence of 11.6%, 95%CI=8.8%-15.1%, I2=55%. Subgroup analysis suggested patients experiencing early ST (within 30-days of implant) had higher in-hospital and 30-day mortality than those experiencing very-late ST (interaction p<0.04 for both). Stent type (bare-metal vs. drug-eluting) had no significant effect on in-hospital or 30-day mortality (interaction p>0.22 for both). In the 5 studies (N=542 STs) and 3 studies (N=180 STs) reporting in-hospital and 30-day MI, respectively, the pooled incidence rates were 6.1%, 95%CI=2.1%-16.2%, I2=88% and 9.5%, 95%CI=3.8%-22.0%, I2=65%. Only one study reported costs associated with ST, estimating the median/patient cost of hospitalization to treat early ST at $11,134 (in 2000US$). Because of the small number of studies identified, no additional analyses were performed on the MI or the ST-treatment cost endpoints.

Conclusions:
Regardless of stent type used, the short-term clinical and economic consequences of coronary stent thrombosis (ST) appear significant. While stent type does not seem to affect the incidence of post-ST outcomes, an earlier occurrence of ST may be associated with higher mortality.
Abstract 40: Temporal Trends of SPECT Myocardial Perfusion Imaging in Patients without Coronary Artery Disease: A 17-Year Experience from a Tertiary Academic Medical Center
Authors: Jouni Hayan , Askew J. W , Crusan Daniel J , Miller Todd D , Gibbons Raymond J
Published: July 2021

Background:
Between 1990-2006, there was a tremendous increase in utilization of single photon emission computed tomography myocardial perfusion imaging (SPECT). Characteristics of the observed increase of SPECT utilization have never been studied.

Methods:
Using the Mayo Clinic nuclear cardiology database, we examined all SPECT tests performed between 1/1/1991-12/31/2007 in patients without prior coronary artery disease (CAD). Patients with history of CAD, left bundle branch block, paced rhythm, bicycle/ rest-only tests, cardiomyopathy, valvular heart disease, and technically unsatisfactory studies were excluded. The study cohort was divided into 4 time periods: 1991-5, 1996-2000, 2001-5, and 2006-7.

Results:
There were 29255 eligible SPECT tests (mean age 62.4 ± 12y, 54% men). Annual utilization of SPECT studies increased from 682 in 1992 to a peak of 2738 in 2002, and then decreased to 2134 in 2007, Fig 1. There were very modest changes in CAD risk factors over time. Testing of asymptomatic patients nearly doubled (21.9% in 1991-5 to 42.7% in 2006-7). Tests on patients with typical angina decreased dramatically (18.3% in 1991-5 to 5.3% in 2006-7), Fig 2. Summed stress score, summed difference score, and high risk SPECT tests decreased over time, Fig 3. Normal SPECT studies and negative study ECG increased for both pharmacologic and exercise tests.

Conclusions:
In Mayo Clinic Rochester, annual SPECT utilization in patients without prior CAD increased between 1992 and 2002, but then decreased in advance of national trends. Normal tests increased, while summed stress score, summed difference score, and high risk tests all decreased. These data suggest that SPECT was increasingly utilized in patients with a lower prevalence of CAD.
Abstract 45: Hemodynamic and Clinical Determinants of Coronary Sinus Flow in Patients Referred for Cardiac Catheterization
Authors: Saunders Jessica , Lyubarova Radmila , El-Hajjar Mohammad , Torosoff Mikhail
Published: July 2021

Background:
Coronary sinus blood flow (CSBF) can be used as a measure of total coronary blood flow. Hemodynamic and clinical determinants of coronary sinus flow are not well investigated. Decreased CSBF is expected in obstructive coronary artery disease (CAD) and elevated left ventricular end-diastolic pressure (LVEDP).

Material and Methods:
A prospective cohort study of patients referred for cardiac catheterization was performed. CSBF (ml/min) was measured non-invasively as a product of heart rate, coronary sinus cross-sectional area (obtained in modified apical 4 chamber view), and coronary sinus time velocity integral (obtained in modified right ventricular inflow view). In patients with normal sinus rhythm and preserved atrial contraction, retrograde diastolic CSBF was subtracted from forward CSBF. Repeated measures ANOVA and chi-square analyses were used.

Results:
Study cohort consisted of 39 patients (19 females, 63+/-11 years old, 9 with diabetes, 30 with hypertension (HTN) and 6 with atrial fibrillation). CSBF was obtained in 24 (61%) patients.

CSBF was increased in patients with normal blood pressure (1353+/-862 vs. 647+/-397 in patients with HTN, p=0.011) and in patients with right atrial (RA) pressure exceeding 5 mmHg (1228+/-654 vs. 478+/-356 in RA pressure less than 5 mmHg, p=0.002). HTN appeared to be a less important determinant of CSBF than RA pressure (RAP) in multiple ANOVA comparison (HTN p=0.643, RAP p=0.005, Figure).

There was also a trend towards decreased CSBF in patients with diabetes (647 +/-507 vs. 937 +/-685 ml/min in patients without diabetes, p=0.327) and /or obstructive CAD (663+/-381 vs. 832+/-748 ml/min in non-obstructive CAD or normal coronaries, p=0.613) and females (680+/-419 vs. 1095+/-828 ml/min in males, p=0.119). There was no significant correlation between CSBF and LVEDP.

Discussion and Conclusions:
Coronary sinus blood flow is determined by patient morbidities and central hemodynamic parameters. CSBF tends to be lower in patients with obstructive CAD, diabetes and/or HTN. Increased RA pressure and systemic HTN are associated with augmented CSBF. We speculate that effects of RA pressure on CSBF are reflective of preload and intrathoracic pressure parameters. Increased intrathoracic pressure may augment coronary blood flow by compression of the aorta and improved coronary perfusion gradient.
Abstract 48: Neurological Outcomes of Inpatient Cardiopulmonary Resuscitation in a University Hospital
Authors: Thomas Lia M , Benavides Miguel , Kory Pierre , Acquah Samuel , Bergmann Steven
Published: July 2021

Background:
Despite advances in out- of- hospital resuscitation practices, the prognosis of most patients after a cardiac arrest remains poor. The long term outcomes of patients successfully resuscitated from cardiac arrest are often complicated by neurological dysfunction. Therapeutic hypothermia has significantly improved neurological outcomes in patients successfully resuscitated from out- of- hospital cardiac arrests. The objective of this study was to look into the neurological outcomes in inpatients after successful cardiopulmonary resuscitation (CPR) in a university hospital setting.

Methods:
This was a retrospective observational study of 68 adult patients who experienced cardiac or respiratory arrest over an 18 month period at a metropolitan teaching hospital with dedicated, trained code teams. Arrests that occurred in the Emergency Department, Critical Care Units or Operating Rooms were excluded.

Results:
Of the 68 consecutive patients included in this study, 53% were resuscitated successfully. However, only 12 (18%) survived to discharge from the hospital and only 6 (10%) were discharged with intact neurological status. The initial survival was better in patients who received prompt CPR and in those with less co - morbidities. Pulseless electrical activity (PEA) or asystole were the most common rhythms (47% of the arrests). Most patients who survived and were neurologically intact had PEA (67%). We believe that most PEA arrests were more likely severe hypotension with the inability to palpate a pulse rather than true PEA. The mean time to defibrillation for all patients with an initial shockable rhythm (n=5) was 8.2 minutes. Patients who had an initial shockable rhythm and survived to discharge were shocked within 1 minute (n=2).

Conclusion:
Despite advances in critical care, survival from inpatient cardiopulmonary arrest to neurologically intact discharge remains poor. Therapeutic hypothermia should be expanded to those resuscitated from in - hospital cardiopulmonary arrest to determine if neurological outcomes would improve.
Abstract 57: NT-proBNP Decreases Exponentially Following Left Ventricular Assist Device Implantation and Can Predict Future Hospitalization
Authors: Wehbe Ramsey M , Jensen Brian C , Chang Patricia P , Bowen Amanda , Sheridan Brett C , Katz Jason N
Published: July 2021

Background:
Unlike in classic heart failure populations where natriuretic peptides (NPs) are well-validated biomarkers for diagnosis and prognosis, the utility of NPs in patients with mechanical circulatory support is unknown. No prior study has systematically evaluated the predictive value of changes in NP levels on outcomes among contemporary patients after LVAD implantation.

Methods:
We reviewed records for all consecutive patients implanted with a continuous-flow LVAD at our institution from 2008-2012. Trends in NT-proBNP during LVAD support were measured, and the association of pre-implant NT-proBNP, as well as relative change in NT-proBNP, with mortality and hospitalization were analyzed.

Results:
Ninety-eight patients were included - 79 as bridge to transplantation (BTT), 19 as destination therapy (DT). Median follow-up was 256d, during which 24 patients died, 31 received a heart transplant, and 43 remained on LVAD support. Median NT-proBNP (pre-implant = 5540 pg/mL) decreased exponentially following device implant and stabilized at 60d (1950 pg/mL; Fig 1). In a Cox-proportional hazards model, neither pre-implant nor 60d NT-proBNP levels were associated with survival or readmission. However, a greater relative decrease in NT-proBNP from pre-implant to 60d was significantly associated with freedom from hospitalization (HR 1.77, p=0.04; Fig 2).

Conclusions:
NT-proBNP decreased exponentially and reliably, before reaching a steady state at 60d following device implantation. Our study is the first to show that serial changes in NPs may be useful in predicting LVAD outcomes. Future study should focus on whether NT-proBNP changes are influenced by baseline variables, and if NPs can be used to guide clinical management.
Abstract 6: What Proportion of High-Cost Patients’ Inpatient Spending is Preventable?
Authors: Joynt Karen E , Gawande Atul , Orav E. John , Jha Ashish K
Published: July 2021

Objective:
A small proportion of patients accounts for a substantial proportion of healthcare spending in the U.S., and the majority of costs in this group are due to inpatient hospitalizations. Many interventions targeting high-cost patients have aimed to prevent hospitalizations for common medical conditions. However, there is surprisingly little data on the proportion of inpatient hospitalizations among high-cost patients that are potentially preventable. We sought to determine the proportion and dollar value of preventable hospitalizations among the high-cost Medicare population, and if these patterns differ for non-high-cost beneficiaries.

Methods:
We assigned standardized costs to each inpatient and outpatient service contained in standard 5% Medicare files from 2009. Patients under the age of 65, those with any Medicare Advantage enrollment, and those who died during in 2009 were excluded. Costs were summed across the year and across settings for each patient in our sample. We defined those in the top decile of cost as “high-cost” patients. We then used the Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQIs) to identify potentially preventable hospitalizations. These include conditions such as heart failure, diabetes, hypertension, and asthma, for which good outpatient care can potentially prevent the need for hospitalization. We calculated the proportion of short-stay acute-care hospital costs that were accounted for by these preventable hospitalizations for the high-cost and non-high-cost patient groups. All costs are projected to the total Medicare sample.

Results:
There were 1,710,989 patients in our sample. High-cost patients were older (median age 75 versus 73), more often male (43.2% versus 39.3%), and more often black (12% versus 9%) than non-high-cost patients, and had a higher burden of comorbid illnesses. Inpatient spending, projected to the total Medicare population, was $90.3 billion. The 10% of Medicare patients that made up the “high-cost” cohort accounted for 72% ($65 billion) of all inpatient spending. However, within the high-cost group, only 9.7% of the spending ($6.3 billion) was due to preventable hospitalizations, while the remaining 90.3% ($58.9 billion) was spent on other causes of hospitalization. Within the non-high-cost group, though their overall spending was lower, a slightly higher proportion of hospitalizations were potentially preventable (14.7%, or $3.7 billion).

Conclusions:
Though high-cost patients account for the majority of inpatient spending, fewer than one in ten of their hospitalizations are potentially preventable through better outpatient care. Thus, focusing on outpatient interventions such as case management may not be optimally targeted. We also need strategies that make hospital care more efficient so that each episode of inpatient care is less expensive regardless of its cause.
Abstract 65: Identifying and Adapting a Prognostic Risk Equation for Relevant Subpopulations in a Pharmacoeconomic Model of Major Adverse Cardiovascular Event Prevention
Authors: Ariely Rinat , Klein Robert , Tham Weng-Kian , Bell Chris , Smolen Lee , Tynan Aodan
Published: July 2021

Background:
Pharmacoeconomic models in cardiovascular disease (CVD) are typically developed on the basis of an assumed relative risk reduction (RRR) for new treatments which is in turn applied to estimates of baseline risk in patients subject to standard of care medications for coronary heart disease. However, baseline risk of CVD varies by relevant patient characteristics (e.g., age, gender, event history) and additional risk factors (e.g., smoking, diabetes, chronic kidney disease, lipids, blood pressure, obesity) which can be applied across diverse populations and settings. This study aimed to find and adapt a prognostic equation to adjust baseline risk of major adverse cardiovascular events (MACE=CV death, non fatal MI, Stroke), in a general pharmacoeconomic model, based on population risk factor prevalence.

Methods:
In order to find an equation that includes all relevant risk factors, a literature search was conducted to update a review (published 2008) of 70 pre-2005 primary cardiovascular risk equations. Once an equation was selected, a relative risk was calculated from the ratio of estimated one-year CV risks of the modeled population versus the population in the selected equation. An initial assumption of independence of risk factors was made. The resulting ratio is adapted as a risk multiplier to estimate risk when modeling specific trial populations or subpopulations.

Results:
None of the original 70 equations included all of the six factors of interest, and only two contained kidney disease. In addition to updates and modifications of the 70 equations, four new studies were identified, including the UK-based QRISK2 which was the only prognostic equation that uses all six factors. QRISK2 was developed using over 16 million person-years’ worth of observations with 140,000 cardiovascular events, and was validated against the UK THIN population. The adapted QRISK2 equation estimates the first-year CV risk for a population adjusted for the six additional risk factors to be 7.1%. However the subset with diabetes and/or kidney disease, which makes up about 43% of the population, has an estimated risk of about 11%. If a treatment is assumed to reduce CV risk by 15% in both the entire and subset populations, then the number needed to treat to avoid one event is reduced from 93 for the entire population to 61 for the diabetes and/or renal impairment subset.

Conclusions:
Estimating the ratio of absolute risks for specific populations and subsets using QRISK2 can help a model to predict the value of targeting relevant subpopulations for a new treatment. When this risk adjustment is included in a lifetime model, additional benefits from secondary prevention, and increased likelihood that a treatment is cost effective in a UK context, can also be estimated. For non-UK populations, calibration of QRISK2 is needed or an alternative equation must be used.
Abstract 69: Defining Futility in Transcatheter Aortic Valve Replacement
Authors: Arnold Suzanne V , Spertus John A , Lei Yang , Green Philip , Kirtane Ajay J , Kapadia Samir , Thourani Vinod H , Herrmann Howard C , Beohar Nirat , Zajarias Alan , Mack Michael J , Leon Martin B , Cohen David J
Published: July 2021

Background:
Transcatheter aortic valve replacement (TAVR) has emerged as a less invasive option for valve replacement for patients with severe aortic stenosis. Although it has been recommended that TAVR not be offered to patients who will not improve functionally or derive meaningful survival benefit from the procedure, no guidance exists on how best to identify such patients. The first step in this process is to define a poor outcome that can then be used as a foundation for subsequent case identification and risk model development. Accordingly, we sought to evaluate potential definitions of a poor outcome after TAVR that combine both mortality and quality of life (QoL) components.

Methods:
Using data from 463 patients who underwent TAVR as part of the PARTNER Trial, we evaluated 6M mortality and QoL outcomes using the Kansas City Cardiomyopathy Questionnaire (KCCQ) to explore 5 potential definitions (DEFs) of a poor outcome. We then examined the strengths and weaknesses of each potential definition by examining the relationship between baseline and 6M KCCQ scores for each patient.

Results:
We considered 5 alternative definitions for a poor outcome (Table). DEFs #1 and #2 were not optimal as they preferentially identified patients at the high end of baseline KCCQ values as having a poor outcome--many of whom were likely to have undergone TAVR primary for its mortality benefit. DEF #3 incorporates a threshold for the KCCQ score, thereby implying that a patient should achieve a certain level of functional capacity after a successful TAVR. However, it ignores patients with high pre-TAVR KCCQ scores whose health status declines after treatment. We argue that DEFs #4 and #5 best reflect a failure to achieve the therapeutic goals of TAVR, which are a combination of improved quality and extended quantity of life, and we prefer DEF #4 for its simplicity.

Conclusion:
Using empiric data on a large number of patients enrolled in the PARTNER trial, we propose a definition for poor outcome after TAVR that combines both mortality and QoL measures into a single composite endpoint. Using this definition, patients at low risk for this poor outcome can be preferentially selected for TAVR and those at high risk can be given appropriate expectations of functional recovery after TAVR.
Abstract 70: Participation in Cardiac Rehabilitation Is Associated with Reduced Rehospitalization Following Acute Myocardial Infarction
Authors: Dunlay Shannon M , Zysek Victoria N , Pack Quinn R , Thomas Randal J , Killian Jill M , Roger Veronique L
Published: July 2021

Background:
Participation in cardiac rehabilitation (CR) has been shown to decrease mortality following acute myocardial infarction (MI), but its impact on rehospitalizations requires examination.

Methods:
We included patients who were hospitalized with first-ever MI in Olmsted County Minnesota from 1987-2010 and survived to hospital discharge. Participation in CR within the first 30 days following MI was determined using billing data and was analyzed as a time-dependent covariate. The association between CR participation and all-cause rehospitalization was analyzed using Andersen-Gill models to account for repeated events. As CR participation is a non-randomized intervention, we adjusted for propensity to participate after fitting a logistic regression model using 13 factors significantly associated with participation on univariate analysis. Patients were censored at the time of death or last follow-up.

Results:
Among 2991 patients (mean age 67 years, 59% male, 31% ST elevation MI), 1480 (49%) participated in CR following acute MI hospital discharge (first session occurred at a mean of 9 days post-discharge). Most patients (75%) were rehospitalized at least once during a mean follow-up of 7.6 years, and CR participation was associated with reduced risk of rehospitalization. The rehospitalization rates were 39% and 59% at one year for participants and non-participants, respectively. In unadjusted analysis, CR participation was associated with a markedly decreased risk of rehospitalization (HR 0.51, 95% CI 0.49-0.53, p<0.001). After adjusting for propensity to participate, the association between CR participation and all-cause rehospitalization persisted (HR 0.70, 95% CI 0.67-0.73, p<0.001).

Conclusions:
CR participation is associated with a markedly reduced risk of rehospitalization after incident MI. In addition to reducing mortality, improving CR participation rates may have a large impact post-MI healthcare resource use.
Abstract 77: Statin Adherence and Persistence Among Japanese Patients With High Risk Vascular Disease: A Japan Claims Database Analysis
Authors: Zhao Zhenxiang , McCollam Patrick L , Davis Keith L , Meyers Juliana , Murakami Masahiro
Published: July 2021

BACKGROUND:
High risk vascular disease (HRVD defined as cerebrovascular disease [CVD], coronary artery disease with diabetes [CADD], history of acute coronary syndrome [ACS], or peripheral artery disease [PAD]) is among the biggest health problems affecting Japanese, with CVD and coronary artery disease (CAD) being the 2nd and 3rd most common causes of death. Despite proven efficacy of statins in reducing CV mortality, limited research is available to systematically study statin adherence and persistence for HRVD patients in Japan.

OBJECTIVE:
Examine statin adherence and persistence in HRVD patients.

METHOD:
A retrospective cohort study was conducted using the Japan Medical Data Center (JMDC) database, a large Japanese administrative claims database with 10 insurance societies (payers), and integrated inpatient, outpatient, and pharmacy claims of approximately 0.8 million covered lives from 2006-2011. Patients
>
18 years with HRVD (CVD, PAD, CADD or history of ACS [≥30days through 365 days after discharge for ACS]) between 01/01/2008 to 12/31/2009, were identified for this study with minimum 12-month pre- and 24-month post-index insurance eligibility. Statin use was measured during the 12-month baseline period and the 24-month follow-up period. The date of the first HRVD claim(s) satisfying the above inclusion criteria was defined as the index date. Statin use was examined for the overall HRVD group as well as subgroups of patients with CVD only, PAD only, CADD only, history of ACS only, and patients with multiple HRVDs. Statin adherence, calculated using the medication possession ratio [MPR], and statin persistence, assessed with survival analysis techniques using a ≥30-day gap to define discontinuation, were measured in the 24-month follow-up period for the overall HRVD patient group.

RESULTS:
There were 10,400 HRVD patients identified in the JMDC database. Mean age was 52.8 and 57.1% were male. Statin use during the baseline period showed 12.1% of HRVD patients taking statins (CVD only: 10.2%; PAD only: 9.6%; CADD only: 14.6%; history of ACS only: 46.7%; CADD and a history of ACS: 48.3%; 2 affected artery beds: 17.8%; 3 affected artery beds: 19.5%). Statin use increased to 32.9% during the 24-month follow-up period (CVD only: 27.6%; PAD only: 26.6%; CADD only: 45.1%; history of ACS only: 54.4%; CADD and a history of ACS: 58.3%; 2 affected artery beds: 49.3%; 3 affected artery beds: 45.5%). For Japanese HRVD patients who used a statin, mean/median MPR was 0.89/0.94 and 82.1% of statin users were adherent (MPR ≥80%) to their statin therapy during the 24-month follow up period. The median time to statin discontinuation was 679 days during the 24-month follow up period.

CONCLUSION:
Statin use after HRVD diagnosis was modest and highest in ACS patients and patients with multiple affected vascular beds. Statin adherence was high among patients with HRVD in Japan.
Abstract 84: Thirty-day Mortality of Patients with ST-Elevation Myocardial Infarction (STEMI) According to Hospital Reperfusion Strategy: The Importance of Examining Outcomes of Both Treated and Not Treated Patients
Authors: Lambert Laurie J , Xiao Yongling , Kouz Simon , Rinfret Stéphane , Segal Eli , Ross Dave , L’Allier Philippe L , Vanasse Alain , Maire Sébastien , Nasmith Jim , Bogaty Peter
Published: July 2021

BACKGROUND:
In Quebec (Canada), patients with STEMI present to 1 of 4 types of hospitals: 1) primary percutaneous coronary intervention (PPCI) centers; 2) non-PPCI centers that systematically transfer patients for PPCI; 3) ‘mixed centers’ that transfer some patients for PPCI and treat others with fibrinolysis; and 4) centers that exclusively treat with fibrinolysis. In all centers, substantial proportions of STEMI patients do not receive any reperfusion therapy for a variety of reasons. Overall STEMI outcomes may vary by type of reperfusion strategy and who is selected to receive it.

METHODS:
All acute care centers that annually treated ≥ 30 acute myocardial infarctions participated in 2 field evaluations (n=80 in 2006-7; n=81 in 2008-9). All patients had a final diagnosis of myocardial infarction, characteristic symptoms and STEMI confirmed by centralized ECG interpretation. Clinical factors and comorbidities were compared across type of center for all patients, and by reperfusion therapy status. Odds ratios (OR) of 30-day mortality were estimated separately for treated, untreated and all STEMI patients.

RESULTS:
Of the 3731 STEMI patients, 29.7% presented to PPCI-capable centers, 33.0% to exclusive PPCI transfer centers, 26.7% to mixed centers (66% transferred for PPCI, 34% received fibrinolysis) and 10.6% to exclusive fibrinolysis centers. The proportion of untreated patients increased with decreasing PPCI access: 16.7% in PPCI centers, 21.4% in transfer PPCI centers, 24.9% in mixed centers and 29.8 % in fibrinolysis centers. Mixed center patients transferred for PPCI had the longest treatment delays (only 17% within guidelines). For treated patients, there were no significant differences in adjusted OR across type of center (see Table). However, for untreated patients, risk of death was significantly higher in transfer PPCI and mixed centers compared to PPCI centers. Risk was significantly higher in mixed centers for all STEMI patients combined.

CONCLUSION:
These findings suggest that in centers that transfer for PPCI, treatment selection bias may mask important disparities in STEMI outcomes, especially in centers with long transfer delays. When evaluating hospital outcomes for STEMI, it is important to examine not only those who are treated but also patients who do not receive reperfusion therapy.
Abstract 9: The Relationship Between Patient Diversity and Warfarin Use in Atrial Fibrillation: A Ten-Year Perspective (2000-2010) on Cardiovascular Outcomes
Authors: Kim Michael H , Puckrein Gary , Cai Qiang , Xu Liou
Published: July 2021

Background:
Anticoagulants are effective in stroke prevention in patients with atrial fibrillation (AF). Warfarin’s comparative effectiveness in AF Medicare beneficiaries by race/ethnicity and gender is not well described.

Methods:
Medicare claims data for years 2000-2010 were used to calculate: 1) AF per annum prevalence (N > 1.9 million); and 2) rates of new AF cases (first Medicare reimbursement for AF), hospitalization, and mortality. Three 20 % samples of AF beneficiaries for years 2000 (n=266K), 2005 (n=316K), and 2007 (n=311K) were used to calculate warfarin use and stroke (ischemic) rates. Consistent with prior study methods, INR test claims were used as a surrogate for warfarin use with a greater than 95 % precision rate and specificity. New AF cases were extracted from each of the three sample cohorts (mean 72K cases each) and continuous survival analyses conducted to assess warfarin’s relationship to stroke, mortality, and hospitalization after adjustment for CHADS2 score, age, gender, and race/ethnicity.

Results:
AF prevalence and warfarin use increased while stroke and mortality rates declined across gender and race/ethnicity from 2000 to 2010. Survival analysis comparing Blacks, Hispanics, and Asians to Whites showed: 1) even when adjusted for warfarin use, Blacks were 40 % (p<0.0001) more likely to have a stroke; 2) in 2007 Hispanics had a 35 % (p<0.01) higher prevalence of stroke and warfarin use did not reduce their stroke risk; and 3) Asians had better outcomes. Warfarin did not reduce stroke risk in women as well as in men, but women using warfarin had a lower risk of death and hospitalization than men. While there was a >70% (p<0.0001) reduction in mortality for warfarin users (Blacks still had a 25 % (p<0.0001) higher mortality risk than Whites after adjusting for warfarin use). 5-year survival rate for all AF beneficiaries was about 50 %.

Conclusions:
Significant differences in key metrics between race/ethnicity and gender exist. Across all metrics, Blacks had worse outcomes with less warfarin use and comparatively worse outcomes even when on warfarin. Patient diversity should be a focus for future trials in AF-related cardiovascular outcomes.
Abstract 101: Association Of Cardiovascular Disorder Requiring Intubation To In-hospital Mortality And Discharge Status Of The Patients: Analysis Of 17,128 Hospitalizations
Authors: Aggarwal Sourabh , Attaway Amy , Gupta Vishal
Published: July 2021

Introduction:
Endotracheal intubations are a vital cornerstone of care for critically ill patients. The decision to intubate a critically ill patient is often complicated secondary to long term prognosis of underlying illness and extent of aggressive treatment a patient would desire. This study was done to identify association of cardiovascular disorder requiring endotracheal intubation to in-hospital mortality and discharge status of the patients.

Methods:
Nationwide Inpatient Sample data (which represents 20% of all the hospitals data in US) was used for the study and data related to all the intubations for the year 2011 was extracted. Patients with complete data on endotracheal intubations associated with primary cardiovascular diagnosis of acute myocardial infarction (MI), cardiac arrest and ventricular fibrillation (CA/VFib), congestive heart failure (CHF), acute cerebrovascular accident (CVA) and cardiac dysrhythmia were included in the study. Statistical analysis was done using SPSS.

Results:
A total of 17,128 intubations associated with primary cardiovascular diagnosis were identified. In-hospital mortality for endotracheal intubations secondary to cardiovascular etiology was significantly higher than intubations secondary to non-cardiovascular etiology (58.5 % vs 29.43%, p value <0.001). CA/VFib (84.39%), MI (61.74%) and CVA (60.67%) were associated with significantly higher in-hospital mortality than cardiac dysrhythmia (49.44%) and CHF (42.11%) (p value <0.001). Patients with CHF were associated with significantly higher routine discharges (15.33%) or transfer to another short term hospital (12.53%) and patients with CVA were associated with discharge to another health care institution (23.42%) (p value <0.001).

Conclusions:
Our study reports that patients who are intubated secondary to cardiovascular etiology have higher in-hospital mortality. Among these patients, patients having cardiac arrest/ventricular fibrillation have high in-hospital mortality and patients with CHF have higher routine discharges. This data can help clinicians to have well informed discussion with the family and weigh the risk and benefits of aggressively treating certain populations of critically ill cardiac patients with endotracheal intubation.
Abstract 103: Determinants of Quality of Life in Permanent Pacemaker Patients: a Cross-Sectional Analysis
Authors: Cardoso Rhanderson N , Garcia Daniel , Benjo Alexandre , Macedo Francisco , Benjo Cesar , Motta Taina , Motta Isabela , Rezende Junior Maury , Tamariz Leonardo , Batista Sa Luiz
Published: July 2021

Background:
Permanent pacemakers (PPM) have improved cardiovascular outcomes and quality of life (QoL) in patients with a wide variety of cardiac rhythm disturbances. Nevertheless, misperceptions about the safety of daily activities (SODA) and associated factors can compromise patients’ absolute well-being. We aimed to study factors associated with worst QoL in PPM patients.

Methods:
PPM patients from a tertiary hospital answered an 18-question questionnaire about their perception on the SODA, which was scored based on misperception rate. Patients also answered SF-36, a validated QoL questionnaire which is scored from 0 to 100 on each of its 8 scales. Baseline characteristics were compared to average on SF-36 scales in a cross-sectional model by t-test for categorical variables and by univariable regression for continuous variables. Statistical analysis was done with Stata software 10.0 (Texas).

Results:
A total of 75 PPM patients aged 65.3±12 years were included, of which 31 (41%) were males. Most common reason for PPM was 3rd degree atrioventricular block (44%). Body mass index (p=0.019) and misperception rate on SODA (p=0.003) presented a significant negative regression coefficient with SF-36 average. Age, gender, average income, Chagas disease etiology, diabetes, hypertension, ejection fraction, NYHA classification, previous myocardial infarction (MI), smoking history and peripheral vascular disease were not significantly associated with SF-36 QoL results.

Conclusions:
In a cross-sectional study, body mass index and misperceptions about the safety of daily-life activities were associated with worst quality of life in patients with permanent pacemaker. These results suggest that optimal physician education of patients and their families about the SODA for PPM patients may ultimately improve patients’ well-being.
Abstract 105: Chagas Disease: an Independent Mortality Risk Factor for Patients with Pacemakers?
Authors: Cardoso Rhanderson N , Garcia Daniel , Benjo Alexandre , Macedo Francisco , Motta Isabela , Motta Taina , Ghatak Abhijit , Tamariz Leonardo , Batista Sa Luiz , Mitrani Raul , Coffey James
Published: July 2021

Background:
Almost 25% of patients with Chagas disease (CD) have some degree of cardiac compromise, including rhythm disturbances, which ultimately may require permanent pacemaker (PPM) implantation. CD has been shown to be an independent risk factor for mortality in heart failure. In PPM patients the prognostic significance of CD seropositivity is yet to be determined.

Methods:
Patients from a highly endemic region for CD with a PPM were divided into two groups: those with CD confirmed by immunofluorescence and those without CD. Patients were followed for a 3-year period. Cox proportional-hazards model and Kaplan-Meier method with log-rank test for mortality were calculated.

Results:
A total of 75 patients aged 65.3±12 years were included, of which 31 (41%) were males and 49 (65%) had positive serology for CD. Age, gender, diabetes, hypertension, ejection fraction, reason for PPM implantation and prior myocardial infarction were not significantly different between groups. After a 3-year follow up, 8 patients in the CD group and 1 in the control group died. Although mortality rate was higher in patients with CD seropositivity, the difference was not statistically significant (HR 3.86; p=0.17). Kaplan-Meier survival plot is illustrated bellow.

Conclusions:
CD was associated with a non-significant increased mortality rate in PPM patients. Larger prospective studies may reveal a significant prognostic role for CD seropositivity in this population.
Abstract 106: Association between Insurance Status and Presentation Delay in Young Patients with Acute Myocardial Infarction: Insights from the VIRGO Study
Authors: Chen Serene I , Wang Yongfei , Dreyer Rachel , Strait Kelly M , Spatz Erica S , Xu Xiao , Smolderen Kim G , Desai Nihar , Lorenze Nancy P , Lichtman Judith H , Spertus John A , D'Onofrio Gail , Krumholz Harlan M
Published: July 2021

Background:
Lacking health insurance and having financial concerns are known barriers to emergency care access in patients with AMI. However we do not know whether being uninsured or underinsured is associated with increased prehospital delay among young adults specifically, and whether this relationship varies by gender.

Methods:
We used data from the VIRGO study, a multicenter prospective study of women and men aged 18-55y with AMI (3,572). We excluded non-US patients (587) and those with unknown prehospital delay time (32) or insurance status (2). Participants were divided into 3 groups by health insurance status: 1. uninsured; 2. underinsured (insured but avoided care or medications due to cost concerns); 3. adequately insured (insured and without the above concerns). Prehospital delay was defined as the time interval between symptom onset and hospital presentation. The association between insurance groups and prehospital delay of >12 hours was examined using chi-square test. A hierarchical logistic model was used to evaluate the independent effect of insurance groups on prehospital delay of >12 hours adjusting for site clustering, demographics, medical history and clinical characteristics.

Results:
Of the 2951 young individuals with AMI in our study, 1987 were women (67.3%); the median age was 48 (IQR= 44, 52); 38% were underinsured; and 23%, uninsured. While women were less likely than men to be uninsured (21.8 vs 25.4%, P=0.03), they were more likely to be underinsured (60.5 vs 53.6%, P12 hours of prehospital delay: 38% of women and 29% of men (P=0.0001; figure). Insurance status was not associated with delays of >12 hrs in women (P=0.10) or men (P=0.57). After adjustments, the underinsured (OR 0.99; 95%CI 0.81, 1.19) and uninsured (OR 1.11; 95% CI 0.88, 1.39) did not have higher odds of having >12 hrs of prehospital delay compared to the adequately insured.

Conclusion:
More than 1 in 3 young individuals with AMI presented to hospitals beyond 12 hours after onset of symptoms. Insurance status was not associated with prehospital delays in this population. Although women are more likely to have >12 hours of prehospital delay, this difference is not attributable to differences in insurance status. Factors beyond the provision of insurance will need to be addressed to reduce delays.