bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 365: Improving Hospital Adherence to The Appropriate Use Criteria; A Successful Multidisciplinary, Multipronged Approach
Authors: Wilbert Lisa A , Lawson William E , Horbatuk Elisa , Boudreau Susan , Hastings Deneen , Dorney Anna , Leonard Theresa , Sokoloff Lisa , Gruberg Luis , Jeremias Allen , Mani Anil
Published: July 2021

Background:
New York State (NYS) began monitoring and reporting back hospital’s adherence to the Appropriate Use Criteria for Coronary revascularization (AU) in 2010. NYS plans to publicly report as well as decrease payments for procedures deemed rarely appropriate based on these data. Utilizing the data in these reports on AU, our hospital made strenuous efforts to improve documentation and decrease inappropriate procedures. Results from NYS data from 2011 through 2013 were continuously tracked and charted to monitor progress and to identify areas to focus on for needed remediation.

Methods:
2010 data from NYS was utilized as the baseline. A multipronged approach was taken to improve appropriateness. A monthly multidisciplinary task force was organized to review opportunities, change policies and procedures, and review ongoing results. A worksheet was developed and used to provide education and data collection. The electronic catheterization report was changed to incorporate appropriateness criteria documentation previously missing from the chart. Challenges included education and achieving compliance from a diverse group of faculty captive and private cardiology groups supported by a large and constantly changing group of support staff. The summary of data from NYS was compared from 2010 through 2013 against the hospitals results and NYS as a whole.

Results:
Cases rated appropriate increased from 26% (102 of 391) in 2010 to 62% (75 of 121) in 2013. Cases rated inappropriate decreased from 24.8% (97 of 391) in 2010 to 8.3% (10 of 121) in 2013. The cases rated uncertain also decreased from 49% (192 of 391) in 2010 to 29.8% (36 of 121) in 2013. This is statistically significant with p < 0.05 by chi-square.

Conclusions:
Appropriate use dramatically improved with the effective implementation of a multipronged strategy utilizing: a task force, AU worksheet, electronic documentation tools, data review, practitioner feedback and education. Compliance with appropriate use metrics is assuming increasing importance with QHIP in 2015 designating 2 AU measures (unclassifiable and inappropriate) as determinants of hospital payments. Our effective improvement of AU results serves as an institutional template for other ongoing quality improvement efforts.
Abstract 377: The China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE) Prospective Study of Percutaneous Coronary Intervention: Study Design
Authors: Du Xue , Pi Yi , Dreyer Rachel P , Li Jing , Li Xi , Downing Nicholas S , Li Li , Feng Fang , Zhan Lijuan , Zhang Haibo , Guan Wenchi , Xu Xiao , Li Shu-Xia , Lin Zhenqiu , Masoudi Frederick A , Spertus John A , Krumholz Harlan M , Jiang Lixin
Published: July 2021

Background:
The volume of percutaneous coronary intervention (PCI) in China has increased more than 20-fold over the last decade. Consequently, there is a need for national-level information to characterize indications for PCI and its long-term outcomes, including health status improvement, which is the principal goal of PCI in stable patients.

Objectives:
To conduct a nationwide prospective study of patients receiving PCI and follow them to 1) measure long-term clinical outcomes, patient-reported outcomes (PROs), risk factor control and adherence to medications for secondary prevention; 2) determine patient- and hospital-level factors associated with these outcomes; and 3) assess indications for and appropriateness of the PCI procedures performed.

Methods:
The China PEACE Prospective Study of PCI, conducted from December 2012 to December 2014, has recruited 5000 consecutive patients undergoing PCI for any indication from 36 representative hospitals across China and followed them for 1-year. The follow-up rate at 12 months was 94%. After obtaining informed consent from each patient, we abstracted details of their medical history, treatments, and in-hospital outcomes from medical charts. We conducted baseline interviews to characterize patient demographics, risk factors, clinical presentation, and healthcare utilization. In addition, we used several validated instruments to measure PROs describing quality of life, symptoms, mood and sleep. The primary outcome, a composite measure of death, myocardial infarction and/or revascularization, was assessed at follow-up interviews conducted at 1-, 6- and 12-months after discharge. In addition, we measured PROs, medication adherence and risk factor control at these interviews. Blood and urine samples were collected at the 1- and 12-month interviews and stored for future analysis. To establish the appropriateness of PCI, the angiograms of 2000 randomly selected patients were reviewed by independent “core” labs in China and the United States. To complement these patient-level data, we surveyed participating hospitals to characterize their facilities, processes and organizational learning culture.

Conclusion:
This study will generate novel, high-quality, and comprehensive national data characterizing the patient experience after PCI in China.
Abstract 381: Clinical Outcomes Following Transcatheter Aortic Valve Replacement Among US Hospitals
Authors: McCarthy Fenton , McDermott Katherine M , Kini Vinay , Kobrin Dale , Desai Nimesh D , Groeneveld Peter W
Published: July 2021

Background:
Transcatheter Aortic Valve Replacement (TAVR) demonstrated excellent outcomes in clinical trials of inoperable/high-risk patients. Subsequent approval by the Food and Drug Administration and National Coverage Determination by the Centers for Medicare and Medicaid Services established unique volume requirements for institutions and physicians to perform TAVR. Diffusion of prior cardiovascular interventions has involved less stringent policies and exhibited significant institutional variation in clinical outcomes. Our objective is to compare risk-standardized procedural outcomes across US hospitals performing TAVR to identify hospitals with outlying post-procedure mortality rates.

Methods:
All Medicare fee-for-service beneficiaries who underwent TAVR between January 1, 2011 and November 30, 2012 were identified. Thirty-day risk-standardized mortality rates (RSMR) were calculated using the Hospital Compare statistical method, a well-validated hierarchical generalized linear model.

Results:
Claims were examined from 5044 patients undergoing TAVR at 199 hospitals, with a crude 30-day mortality rate of 5.97%. RSMRs modeled using patient-level predictors varied from 4.5 % to 9.0 % (Figure 1). One hospital had a RSMR statistically lower than the national mean (4.5%, P<0.05), and two hospitals had RSMRs statistically higher than the national mean (8.5% and 6.9%, P<0.05).

Conclusions:
Clinical outcomes among TAVR hospitals in high-risk/inoperable patients demonstrated very little variability, few outliers, and excellent outcomes comparable to pre-approval clinical trials. This may be the result of the unique policy and regulatory environment governing the CMS coverage determination for TAVR institutions. As TAVR disseminates to additional hospitals and other new cardiovascular interventions are inevitably introduced, risk-standardized outcome comparisons across hospitals may facilitate ongoing surveillance to ensure high quality outcomes at all active centers.
Abstract 383: Quality of Weight Measurement Practices Among Heart Failure Inpatients
Authors: Nanna Michael , Murphy Terrence E , Wong Risa , Bazylevska Vlada , Bellumkonda Lavanya , McNamara Robert L
Published: July 2021

Background:
Regular weight measurement is the standard of care among patients hospitalized for heart failure (HF) for monitoring response to diuretic therapy. While recent guidelines recommend routine daily weights in decompensated HF inpatients, the quality of weight measurement in clinical practice has not been well characterized.

Methods:
We conducted a retrospective single-center observational cohort study of consecutive adults with decompensated HF (N = 658) who were admitted from June 2012 through February 2013. We collected demographic, clinical, laboratory, imaging and weight measurement information during the hospitalization. Daily weights were defined as daily weights between day 2 of the hospitalization and the day prior to discharge. Discharge weights were defined as a weight on the day prior to or the day of discharge. We qualified whether weights were standing weights or not standing. We performed multivariable logistic regression analyses to assess association between documentation of weights and 30-day HF specific readmission.

Results:
The majority of patients were weighed on admission and discharge, though less than half of patients had daily weights and even fewer patients had admission, daily and discharge weights measured (Table). A small minority of patients had standing admission and discharge weights along with any daily weights (3.6%, 24 of 658). Although not meeting statistical significance, in multivariable logistic regression analyses patients who had admission, daily and discharge weights measured showed a tendency toward lower 30-day HF specific readmission (OR = 0.665, CI = 0.354-1.249, P = 0.20).

Conclusion:
In our single-center study, measurement of admission, discharge and daily weights among HF inpatients was inconsistent. A small minority of patients received daily weights and even fewer received ideal assessment - standing weights on admission and discharge with daily weights. Further study is needed to determine whether the quality of weight measurement seen in this study is generalizable to other institutions, to identify potential barriers to consistent inpatient weight measurement, and to perform a more robust assessment for the association of weight measurement with short-term clinical outcomes.
Abstract 105: A 360 Degree Perspective on the Timing of Patient Discharge: A Multidisciplinary Survey of Patients, Physicians, and Nurses on Discharge Practices Within a Cardiovascular Service Line at a Tertiary Academic Institution
Authors: Avula Harshith , Adusumalli Srinath , Telukuntla Kartik , Kolansky Daniel M , Moran Leah , Wald Joyce
Published: July 2021

Background:
Early hospital discharge for patients has been linked to improved post-discharge outcomes. Health systems continue to struggle with early discharges and past interventions have centered around provider perspectives of the discharge process, with no identifiable studies focusing on patient perspectives. We sought to examine the discharge process from a comprehensive perspective, obtaining simultaneous patient and healthcare provider beliefs to improve our institution’s discharge process.

Methods:
Our study was approved by the Institutional Review Board at the University of Pennsylvania and all participants provided informed consent. Physicians and nurses who took part in discharges from our inpatient cardiology services participated in an electronic survey regarding discharge processes over a six-month period. Patients being discharged from these services also completed anonymous surveys at the time of discharge from the hospital.

Results:
The survey was completed by 476 patients, 47 nurses, and 44 physicians. Approximately 54% of physicians and 43% of nurses reported that the ideal time of discharge is between 8:00 AM and 12:00 PM. A vast majority (85%) of patients reported that discharges before 2:00 PM are best, with 60% of patients reporting that discharges should ideally occur before 12:00 PM. Nearly half (46%) of patients, 64% of physicians, and 75% of nurses reported that the discharges they participated in occurred after 2:00 PM, which was consistent with the mean discharge times reported by institutional data taken during the survey period. Less than half (40%) of patients also reported that they were informed of their discharge before 12:00 PM on their day of discharge. The majority of healthcare providers reported that they do not believe early discharges would reduce the rate of 30-day readmissions (physicians 87%, nurses 88%) or lead to safer discharges (physicians 78%, nurses 69%). More than one-third (36%) of patients reported that a delay in coordination of transitional care (e.g. medication delivery, transportation issues, and inadequate communication with primary team) contributed to a later discharge time.

Conclusion:
Our data reveal that both patients and providers believe that the optimal time for discharge is prior to 12:00 PM, despite the fact that most discharges occur after 2:00 PM. Patients cite delays in coordination of transitional care as the most common reason for delayed discharge times, and were typically informed of their formal discharge after noon on the day of discharge. Although most healthcare providers do not believe that early discharge improves outcomes, additional studies are needed to investigate outcomes associated with early discharge time.
Abstract 110: A Novel Method for Estimating the Optimal Contrast Amount Needed to Minimize Acute Kidney Injury After Percutaneous Coronary Intervention
Authors: Shafiq Ali , Pokarel Yashashwi , Qintar Mohammed , Kennedy Kevin , Spertus John A , Amin Amit P
Published: July 2021

Introduction:
Risk models are the foundation of personalized medicine. Converting risk into clinically actionable strategies to improve care, however, can be difficult. Acute kidney injury (AKI) after percutaneous coronary intervention (PCI) occurs in 7% of cases and contrast use has a linear relationship with risk. As the amount of contrast use is readily modifiable, we developed a novel approach to convert the National Cardiovascular Data Registry (NCDR) AKI risk model into an actionable guide for defining ‘safe contrast limits’.

Methods:
Because some patients are at low risk for AKI and the amount of contrast does not markedly increase their absolute risk, we reasoned that only patients with an above average pre-PCI risk (>7%) for AKI would be targets for contrast minimization. Providers could then define the magnitude of risk reduction they wanted to achieve (e.g. 5%, 10% or 15%). Given this target, we were able to back-calculate the safe contrast limits to achieve the respective magnitude of risk reductions.

Results:
25% of patients were estimated to have above average risk (>7%) for developing AKI after PCI. The safe contrast limits for alternative magnitudes of relative risk reduction (RRR), across the range of patients’ pre-procedural risk, and the percentage of patients are shown (Figure-A). The number needed to treat (NNT) to prevent 1 AKI episode was <50 for patients with baseline risk of ≥14% for a 15% RRR and for patients with baseline risk of ≥21% for a 10% RRR, however it was never <50 for a 5% RRR (Figure-B).

Conclusion:
We were able to convert a complex prediction model into a clinically-actionable guide for prospectively improving treatment. Testing whether prospective targets of safe contrast limits (achieved through avoiding left ventriculograms, staging multi-vessel PCI or using bare wire lesions/injection minimization) could improve safety and costs should be prospectively tested.
Abstract 12: Heart Failure Medications Prescribed at Discharge for Patients With Left Ventricular Assist Devices
Authors: Baras Shreibati Jacqueline , Sheng Shubin , Fonarow Gregg C , DeVore Adam D , Yancy Clyde W , Bhatt Deepak L , Peterson Eric D , Hernandez Adrian , Heidenreich Paul A
Published: July 2021

Background:
The longitudinal success of the heart failure (HF) patient with a left ventricular assist device (LVAD) depends on medications to maintain the device, such as antithrombotic agents to prevent pump thrombosis and antihypertensives to reduce stroke risk. However, the role of traditional, evidence-based HF medications for patients with concurrent LVAD support is not well known. This study aimed to determine use, temporal trends, and factors associated with prescription of HF medications at discharge among patients with advanced HF with and without LVADs, and to examine patient and hospital-level factors associated with HF medication prescription among LVAD recipients.

Methods:
We conducted a retrospective, observational analysis of 4,580 advanced HF patients from 215 hospitals participating in the Get With The Guidelines-Heart Failure registry from January 2009 to March 2015. We examined patterns of HF medication use at hospital discharge among patients with an in-hospital (n=258) or prior (n=326) LVAD implant, and those with advanced HF without an LVAD, as defined by a reduced left ventricular ejection fraction and intravenous inotrope or vasopressin antagonist receipt (n=3,996).

Results:
For beta-blocker and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACE/ARB), discharge prescriptions were 58.9% and 53.5% for new LVAD recipients, 62.9% and 51.4% for prior LVAD recipients, and 78.7% and 60.7% for patients without LVAD support, respectively (p<0.0001 and p=0.0005). There was no significant difference in aldosterone antagonist use among the three groups (p=0.23) but its use quadrupled among LVAD patients during the study period (p<0.0001, see figure). Approximately 54% of new and prior LVAD patients and 66% of patients without an LVAD were discharged on two of the three HF medications (p<0.0001). In the multivariable analysis of LVAD patients, patient age was inversely associated with beta-blocker, ACE/ARB, and aldosterone antagonist use.

Conclusion:
Traditional HF therapies are commonly prescribed to LVAD recipients, although less frequently than to advanced HF patients without LVAD support. Aldosterone antagonists are prescribed increasingly to LVAD patients. Further research is needed on the optimal medical regimen for patients with LVADs.
Abstract 128: Changes in Left Ventricular Ejection Fraction Predict Survival and Hospitalization in Heart Failure With Reduced Ejection Fraction
Authors: Breathett Khadijah , Allen Larry A , Udelson James , Davis Gordon , Bristow Michael
Published: July 2021

Background:
Left ventricular remodeling, as commonly measured by left ventricular ejection fraction (LVEF), is associated with clinical outcomes. Although change in LVEF over time would be anticipated to reflect response to therapy and subsequent clinical course, systematic serial measurement of LVEF is inconsistent in observational settings, and has not been systematically reported in large-scale clinical trials. Thus the incremental prognostic value of change in LVEF has not been well characterized.

Methods:
The Beta-Blocker Evaluation of Survival Trial (BEST, 1995-1999) collected LVEF by radionuclide ventriculography at baseline and at 3 and 12-months after randomization. Change in LVEF was defined as change from baseline to 12-month unless that value was missing, in which case the 3-month value was used. We built a series of multivariable models including 16 commonly used clinical parameters plus change in LVEF for predicting the following time to first event endpoints: all-cause mortality (ACM), cardiovascular mortality (CVM), heart failure hospitalization (HFH), and ACM or HFH.

Results:
Among 2,484 patients with a mean follow-up of 2-years, serial improvement in LVEF by ≥5% was the second most significant predictor (behind baseline creatinine) of outcomes (Table). LVEF change ≥5% correlated with a modest increase in C-index compared to traditional predictors (Table).

Conclusions:
Serial evaluation for change ≥5% LVEF predicts both survival and HFH. Further validation of the incremental prognostic value of change in LVEF for important clinical decisions, including frequency of cardiac imaging, across various heart failure populations is needed.
Abstract 129: Chest Pain Characteristics of Myocardial Infarction With Non-Obstructive Coronary Arteries (MINOCA) in Comparison to Myocardial Infarction With Coronary Artery Disease (MI-CAD)
Authors: Pasupathy Sivabaskari , Tavella Rosanna , Arstall Margaret , Chew Derek , Worthley Matthew , Zeitz Christopher , Beltrame John
Published: July 2021

Background:
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is being increasingly recognized with the frequent use of angiography following Acute Myocardial Infarction (AMI); yet there is little evaluation of these patients in the literature. The current study is a prospective, contemporary analysis of clinical features and chest pain characteristics between patients with MINOCA and Myocardial Infarction with coronary artery disease (MI-CAD).

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

Results:
From 3,431 angiography procedures undertaken for AMI, 359 (11%) were classified as MINOCA. MINOCA patients were younger (59 ± 15 vs. 64 ± 13, p <0.01) and more likely to be female (60% vs. 26%, p<0.01), with age adjusted analysis revealing less cardiovascular risk factors in MINOCA compared to MICAD: current smoker (21% vs. 35%, p< 0.01), hypertension (56% vs. 65%, p<0.01), dyslipidaemia (46% vs. 61%, p<0.01), and diabetes (20% vs. 32%, p<0.01). Analysis of presenting chest pain characteristics showed no significant differences between MICAD and MINOCA for the presence of retrosternal pain (81% vs. 82%, p>0.05,) or shoulder pain (27% vs. 26%, p>0.05) respectively, however MINOCA patients were less likely to experience arm pain (33% vs. 40%, p<0.01). In regards to precipitating factors, emotional stress was more common (14% vs. 5%, p<0.001) and exertion related chest pain was less common (27% vs. 40%, p<0.001) in MINOCA patients. Quality of pain for MINOCA and MICAD was similar with the most frequent descriptors being burning (11% vs. 9%, p>0.05), sharp 21% vs. 23%, p>0.05) and tightness (41% vs. 44%, p>0.05). In addition, there were no significant differences observed between groups in relieving factors and duration of chest pain

Conclusions:
In contemporary cardiology practice, MINOCA presentation is more common than previously appreciated, with younger women frequently implicated. Delineating a MINOCA patient from MICAD on the basis of chest pain characteristics is not feasible.
Abstract 134: Comparison of Emergency Department Risk Scores for Efficient Triage of Patients with Chest Pain
Authors: Thangavel Sarumathi , Kim David , Poornima Indu G
Published: July 2021

Background:
Efficient triage of patients presenting to the Emergency Room (ER) with chest pain (CP) is imperative for appropriate delivery of care, decreased length of stay, and reducing cost of care. Several studies have demonstrated the low yield of hospital admission and further testing in the majority of low-risk patients with chest pain. Identification of low-risk patients that could be discharged with outpatient follow-up is the goal. We sought to identify the risk score that maximally identifies low-risk patients and examined the rate of follow-up testing and cardiovascular events in these patients.

Methods:
We retrospectively enrolled 300 consecutive patients who presented to the ER for evaluation of CP. We compared the number of patients stratified as low risk by 3 individual risk scores- the Emergency Department Assessment of Chest Pain Score (EDACS), the HEART (History, ECG, Age, Risk factors and Troponin) score and the TIMI (Thrombolysis in Myocardial Infarction) score and compared their ability to predict major adverse cardiovascular events (MACE) defined as myocardial infarction (MI), percutaneous or surgical coronary revascularization or death, in a 6 week follow-up period. Based on published validation studies, an EDACS score< 16, a HEARTS score≤ 3 and a TIMI score =0 have been identified as the threshold for low-risk. Patients that had a diagnosis of MI on initial presentation or with incomplete records were excluded.

Results:
Among the 300 study patients (mean age 57±5years, 46% male) 45% were smokers, 45% had hyperlipidemia, 60% had hypertension, 22% were diabetic and 27% had a family history of CAD. The EDACS score classified significantly more patients as low risk compared to HEARTS (202/300 vs 150/300-OR of 2.06, CI-1.48-2.86; p<0.0001) and TIMI scores (202/300 vs 127/300- OR 2.80, CI-2.01-3.9; p<0.001). In the study population, 30 patients (10%) underwent coronary CTA, 201 patients (67%) underwent stress testing and 69 patients (23%) were admitted to the observation unit and discharged without further testing. A low-risk EDACS score was present in 93%, 66% and 59% of those undergoing CTA, stress testing and observation admission respectively, suggesting increased use of CTA in low-risk patients. MACE (MI) occurred in one patient identified as high-risk by all scoring systems.

Conclusions:
Among patients presenting to the ER with CP, the EDACS score identifies a larger number of low-risk individuals than other scores. This group may not need inpatient admission or immediate testing. As shown in previous studies, the MACE rate in this ER population is low. Prospective studies comparing these scores in larger populations are warranted.
Abstract 147: ECG to Decision Time - Small Delays Deciding to Transfer a STEMI Patient Adds Much Larger Delays to Reperfusion Time
Authors: Mullvain Richard , Rostvedt Ashlee
Published: July 2021

Background:
Non-PCI capable facilities are faced with a time critical challenge to transfer a STEMI patient to a PCI capable hospital for Primary PCI within 120 minutes of first medical contact. Once a 12-Lead ECG is obtained and printed, a period of time elapses before STEMI is recognized, and a decision is made to transfer the patient for Primary PCI. It seems logical that the ECG-to-Decision time should not impact the subsequent Decision-to-PCI time. We evaluated the impact of the time spent from ECG-to-Decision time on the subsequent Decision-to-PCI time.

Methods:
Data was combined, and retrospectively analyzed on 157 consecutive STEMI cases first identified at 32 non-PCI capable facilities, and transferred to one of two different PCI capable hospitals located in either Duluth, Minnesota, or Fargo, North Dakota. There were 124 cases from September 2013 through February 2015 at one hospital, and 33 cases from May 2013 through February 2015 at the other. Decision time was defined by the call time for inter-facility transport for Primary PCI, or the call time to the PCI capable hospital to request activation of the Cath Lab.

Findings:
30% of patients had an ECG-to-Decision time of less than 5 minutes, with mean & median Decision-to-PCI times of 93 min. & 86 min. (range 38-231; SD = 34.8). Another 30% of patients had an ECG to Decision time between 5 to 9 minutes, with mean & median Decision-to-PCI times of 102 min. & 103 min. (range 46 - 158; SD = 23.3). 40% of patients had an ECG-to-Decision time of 10 minutes or greater, with mean & median Decision-to-PCI time of 131 & 124 minutes (range 58 - 239; SD = 47.9). For a 5-9 minute delay in ECG-to-Decision time, an additional 17 minute delay was added to the median Decision-to-PCI time. If the ECG-to-Decision time was delayed 10 minutes or more, an additional 38 minute delay was added to the median Decision-to-PCI time.

Conclusion:
We observed an escalating impact of delay on Decision-to-PCI time as the result of smaller increases in delay of ECG-to-Decision time. Our data suggests that a realistic goal for ECG-to-Decision time of under 5 minutes should be considered for non-PCI capable facilities, to avoid escalating delays in Primary PCI time for STEMI patients.
Abstract 155: Evaluation of Dyslipidemia Control and Its Risk Factors of Cardiac Outpatients
Authors: Talib Al-Ani Iman Nazar , AbdulRazzaq Al-Ani Hadeer Akram , Hussein Hanan , Syed Sulaiman Syed Azhar , Abdulameer Al-Hashimi Aseel Hadi , Mansoor Sarab M
Published: July 2021

Objective:
is to assess the dyslipidemia control and demographic differences in lipid patterns among dyslipidemic cardiac patients.

Method:
data based a retrospective analysis of 504 persons (age mean 58.16 ± 11.119 years) was conducted in Malaysia which estimated the lipid abnormalities in statin-treated patients. Demographic data including age, race, alcoholic and smoking status were collected. Lipid profiles including triglyceride (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) were measured.

Results:
a desirable level of (TC) and (TG) were 62.2% and 54.4% respectively, optimal level of (LDL-C) was 66.5% and the normal level of (HDL-C) was 54.2%. Risk factor analysis of dyslipidemia was done with a primary focus on the possible impact of statin type, gender, race and dyslipidemia type. Atorvastatin was significantly more effective for primary dyslipidemia than simvastatin and lovastatin in HDL cholesterol (
p
< 0.002), while in LDL cholesterol (p = 0.001) and total cholesterol (p < 0.03) simvastatin was significantly found more effective for primary dyslipidemia. A significant correlation emerged between gender and statin type in HDL cholesterol (p < 0.02) and total cholesterol TC (p < 0.001), atorvastatin is found more effective to be used by males than females. A correlation was also significant between gender and dyslipidemia type in HDL cholesterol (p < 0.01). Results for triglyceride reported a significant relationship between age, race and statin type (p < 0.001), atorvastatin was found to be more effective among Chinese while lovastatin was more effective among Indians. Finally 18.2% abnormality of HDL was explained by interactions of risk factors: first statin type and dyslipidemia type, second for gender and dyslipidemia type and the third was gender and statin type.

Conclusions:
more than 50% of cardiac outpatients were in an acceptable range of lipid profile evaluation. This could support the need for increasing attention to basic monitoring of cardiovascular risk factors in these dyslipidemic patients particularly in Asian population.
Abstract 164: Home-Based Cardiac Rehabilitation Improves Access for Rural Veterans
Authors: Schopfer David W , Whooley Mary A
Published: July 2021

Objective:
Referral to cardiac rehabilitation (CR) is one of nine performance measures for patients with ischemic heart disease (IHD), but fewer than 10% of eligible Veterans participate. Home-based CR programs may improve participation in CR, particularly for rural Veterans who do not live near traditional facility-based programs. We sought to compare referral to, participation in, and completion of CR in rural and urban Veterans.

Methods:
We established The Healthy Heart Program, a home-based CR program, to increase participation in CR programs and provide an alternative to facility-based CR programs for Veterans with IHD. Between August 2013 and May 2015, 574 patients were referred to CR during hospitalization for myocardial infarction, coronary revascularization, valve surgery, angina, or as an outpatient with heart failure. We used the Rural-Urban Commuting Areas (zip code) system to categorize urban and rural Veterans. We then compared the proportions of urban vs. rural Veterans who were referred to, enrolled in, and completed home-based CR.

Results:
Overall, 52% (94/181) of rural and 51% (202/393) of urban Veterans agreed to enroll in CR. Rural Veterans were more likely to be married (50% vs. 41%, p=0.02) and have undergone coronary artery bypass surgery (30% vs. 20%, p=0.03). Among 296 patients who agreed to enroll, 82% chose home-based and 18% chose facility-based CR (p<0.001). Rural Veterans were more likely than urban Veterans to choose home-based CR (95% vs. 76%; p<0.001). Among 243 patients who enrolled in home-based CR, rural Veterans were more likely to complete at least 9 weeks of home-based CR (67% vs. 53%; p=0.031) and less likely to withdraw (33% vs. 47%, p=0.031). After adjustment for demographics and clinical indication, rural Veterans had 49% greater odds of enrolling in (odds ratio 1.49, 95% confidence interval 1.03, 2.14; p=0.034) and 80% greater odds of completing home-based CR (OR 1.80, 95% CI 1.20, 2.71; p=0.004).

Conclusion:
The majority of Veterans who were interested in CR chose a home-based over a facility-based program. Rural Veterans were more likely to choose home-based CR and to complete CR. Home-based CR is an effective way of engaging patients who may otherwise decline to participate in CR, especially for rural Veterans.
Abstract 167: Impact of a Pharmacist-Led Outpatient Direct Oral Anticoagulation Service
Authors: Barnes Geoffrey D , Ashjian Emily , Yeshe Robert , Kurtz Brian , Renner Elizabeth
Published: July 2021

Background:
Direct oral anticoagulants (DOACs) represent novel alternatives to vitamin K antagonists but present new challenges for appropriate prescribing and ongoing patient adherence. We assessed the impact of a pharmacist-led DOAC service on prescription appropriateness and patient adherence as compared to usual care.

Methods:
We performed a retrospective, observational, matched cohort analysis of patients prescribed a DOAC at a large academic medical center between September 20, 2013 and December 31, 2014. We compared a group of patients (n=129) who participated in a pharmacist-led DOAC service to a matched group (n=129) who received usual care using coarsened exact matching based on prescriber specialty, DOAC prescribed, indication for anticoagulation and age. Co-primary endpoints included the percentage of patients who had appropriate DOAC therapy (FDA-approved medication and dose based on indication and renal function) prescribed at baseline and at 3-6 month follow up after initiating the medication. Secondary endpoints included mean medication possession ratios (MPR) for patients who received at least 3 months of DOAC therapy and had available pharmacy records (n=171). We performed multivariable logistic regression modeling for appropriate prescription and multivariable linear regression modeling for MPR.

Results:
Patients in the two groups were well balanced across multiple demographic and comorbid factors. Patients in the pharmacist-led DOAC service were significantly more likely to have an appropriate combination of DOAC and dose prescribed for their indication at baseline as compared to usual care (92.2% vs. 77.5%; adjusted odds ratio [aOR] 3.02, p=0.006). This finding persisted at follow up (93.7% vs. 81.1%; aOR=2.92, p=0.016). There was no significant difference between groups in the number of patients determined to have an appropriate DOAC prescribed for an FDA-approved indication (independent of dose) in the pharmacist-led service (95.3%) vs usual care (93.0%) at baseline (aOR 0.93, p=0.901). Patients in the pharmacist-led service had a mean adjusted MPR of 91.8% compared to 79.3% with usual care (p=0.001) over a median follow up of 248 days.

Conclusions:
A pharmacist-led DOAC service increases appropriate dosing of DOACs at baseline and follow up as well as patient adherence to therapy. Associated costs and clinical event rates associated with pharmacist-lead DOAC management remain to be investigated.
Abstract 168: Impact of Continuing Medical Education on the Treatment of Hypertriglyceridemia with Omega-3 Fatty Acids
Authors: Larkin Amy , LaCouture Michael , Boutsalis George , Bays Harold
Published: July 2021

Introduction:
The less prominent role of triglycerides in determining cardiovascular risk keeps these lipids from being top-of-mind for practicing clinicians, yet epidemiologic data affirm that hypertriglyceridemia contributes to atherosclerotic disease development and progression. We sought to determine if online continuing medical education (CME) could improve the clinical knowledge and competence of primary care physicians (PCPs) and cardiologists regarding hypertriglyceridemia and the use of omega-3 fatty acids in its treatment.

Methods:
The effects of two educational interventions about advances in hypertriglyceridemia treatment (activity 1) and educating patients about omega-3 fatty acid products (activity 2) were analyzed to determine efficacy of online education presented in the form of online video-based roundtable discussions. The activities launched online in May and June, 2015 respectively, and data were collected through July, 2015. The effects of education were assessed using knowledge- and case-based matched pre-assessment/post-assessments. The effect sizes were calculated with Cohen’s d (> 0.8 is large, 0.8-0.4 is medium, and < 0.4 is small).

Results:
In total, 842 PCPs and 75 cardiologists who completed all pre/post assessment questions in any of the two activities during the study period were included in analyses. Significant overall improvements were seen for PCPs (activity 1: n = 452,
P
<.05, effect d= 0.68; activity 2: n = 390,
P
<.05, effect d= 0.96) and cardiologists (activity 1: n = 35,
P
<.05, effect d= 0.77; activity 2: n = 40,
P
<.05, effect d= 0.9). Compared with baseline, specific areas of improvements include:

• 22% more PCPs and 31% more cardiologists identified weight loss as a nonpharmacological intervention that can effectively lower triglyceride levels for overweight/obese patients with hypertriglyceridemia, (both
P
< .05)

• 35% more PCPs and 32% more cardiologists identified the appropriate dosing of prescription omega-3 fatty acids (both
P
<.05)

• 23% more PCPs (
P
< .05) and 20% more cardiologists (
P
=.068 ) recognized that reducing the risk for pancreatitis is a primary medical objective in patients with severe elevations in triglyceride levels Areas identified as needing additional education include:

• 57% of all physicians remain unaware that omega-3 fatty acids reduce apolipoprotein C3

• 61% of PCPs and 60% of cardiologists did not demonstrate a thorough understanding of the differences between prescription omega-3 fatty acids and omega-3 supplements

Conclusion:
This study demonstrates the success of a targeted educational intervention with two educational components on improving knowledge, competence, and clinical decision-making of PCPs and cardiologists regarding hypertriglyceridemia treatment and the role of omega-3 fatty acid products in its treatment.
Abstract 2: Comparative Effectiveness and Safety of Anticoagulant Therapy With Warfarin, Dabigatran, Apixaban, or Rivaroxaban in Patients With Nonvalvular Atrial Fibrillation
Authors: Adeboyeje Gboyega , Sylwestrzak Gosia , White Jeff , Rosenberg Alan , Abarca Jacob , Crawford Geoffrey , Barron John
Published: July 2021

Background:
The efficacy and safety of novel oral anticoagulants (NOACs) as alternatives to warfarin therapy in nonvalvular atrial fibrillation (NVAF) patients have been studied in randomized trials. Given the increasing use of NOACs, additional data is required to assess the relative effectiveness and safety of anticoagulation with warfarin, dabigatran, apixaban, or rivaroxaban therapy in real-world settings in the United States (U.S).

Methods:
A retrospective cohort study design was used to analyze data from a U.S. commercial claims database of > 38 million members. Study population included new users of warfarin, dabigatran, apixaban, or rivaroxaban aged ≥ 18 years with ≥ 2 diagnoses of NVAF from November 2010 to February 2015. The primary effectiveness outcome was a composite of thromboembolic event or stroke; the primary safety outcome was major bleeding event requiring hospitalization. Cox proportional hazards models with inverse probability of treatment weighting (IPTW) were used to compare event rates between NOAC and warfarin users, and among NOAC users.

Results:
In the final NVAF cohort studied, there were 23,431 warfarin, 8,539 dabigatran, 3,689 apixaban, and 8,398 rivaroxaban users. A total of 7,022 primary outcome events and 3,264 safety events were identified. Warfarin users were older than dabigatran, apixaban, or rivaroxaban users (mean: 73 vs 66 vs 69 vs 67 years). After IPTW, all treatment groups were balanced on all baseline risk factors including stroke and bleeding risk.

Compared to warfarin, NOAC users had fewer thromboembolic events or strokes: dabigatran (hazard ratio HR, 0.77 [95% CI: 0.72 - 0.82]), apixaban (HR, 0.73 [CI: 0.65 - 0.82]), and rivaroxaban (HR, 0.80 [CI: 0.75 - 0.86]). Additionally, dabigatran ([HR], 0.67 [CI: 0.60 - 0.76]), and apixaban users (HR, 0.52 [CI: 0.41 - 0.67) experienced fewer major bleeding events compared to warfarin users. No significant difference was found in major bleeding risk between rivaroxaban (HR, 1.00 [CI: 0.89 - 1.12]) and warfarin users.

All three NOAC groups had similar risks for thromboembolic event or stroke: dabigatran vs rivaroxaban (HR, 0.96 [CI: 0.88 - 1.05]); apixaban vs rivaroxaban (HR, 0.91 [CI: 0.80 - 1.04]); dabigatran vs apixaban (HR, 1.05 [CI: 0.93 - 1.19]). However, compared to rivaroxaban users, major bleeding risk was 33% and 48% lower in dabigatran and apixaban users respectively (HR, 0.67[CI: 0.58 - 0.78]) and HR, 0.52 [CI: 0.40 - 0.68]).

Conclusions:
Our results demonstrated a lower risk of a thromboembolic event or stroke among dabigatran, apixaban, or rivaroxaban users compared to warfarin users. Among NOACs, risks of a thromboembolic event or stroke were similar. Further studies are needed to clarify the finding of a higher major bleeding risk in warfarin and rivaroxaban users.
Abstract 201: Are Patients With Atrial Fibrillation Willing to Consider New Strategies to Prevent Stroke? A Qualitative Analysis of Community-Based Focus Groups
Authors: O’Neill Elizabeth S , Grande Stuart W , Coylewright Megan
Published: July 2021

Introduction:
Atrial fibrillation (AF) is a common arrhythmia affecting nearly five million Americans and is the cause of one in six strokes. The FDA has approved new therapies to prevent stroke in patients with AF, including several medications and a procedural device, all shown to be equivalent to, or better than, warfarin. In light of these new options there is a renewed focus in the literature on the evaluation of thromboembolism versus bleeding risk. Determining optimal stroke prevention therapy is a preference-sensitive decision appropriate for shared decision making (SDM). However, values and preferences of patients with AF in this new context are unknown.

Methods:
To identify patient values and preferences around the choice of strategy for stroke prevention in AF, focus groups were conducted. Demographic data were collected and a semi-structured interview guide was used. Transcripts of the audio-recorded focus groups were qualitatively evaluated and characterized into themes.

Results:
Five focus groups were completed in May of 2015: two in senior living facilities, one in a community-based senior resource center, and two in anticoagulation clinics. Of the participants, 60% (25 of 42) were women and the mean age was 82 years. The majority of participants (64%) (27 of 42) had a history of AF and 93% (39 of 42) took aspirin or another blood thinner. There was limited experience with major bleeding. Qualitative analysis revealed three main themes: 1) Participants described a fear of debilitating stroke, with varying willingness to accept inconveniences associated with blood thinners; 2) Some participants were reluctant to change long-term anticoagulation regimens and others were interested in exploring new strategies; and 3) In order to consider alternate therapies for stroke prevention, participants emphasized the importance of mutual respect and trust with their physicians.

Conclusion:
Focus group participants expressed a fear of debilitating stroke, with varying levels of acceptance of inconveniences and potential bleeding associated with blood thinners. Among a subset of participants, there was willingness to consider new stroke prevention therapies; however, this was preferred with a known, trusted physician. Subspecialized clinicians offering new therapies may be challenged to establish perceived mutual respect with patients, traditionally built over time, and this may be required for patients to consider new therapies. Future research is needed to determine best practices for both establishing mutual respect within a referral practice and incorporating patient values and preferences into stroke prevention decision making in the context of atrial fibrillation.
Abstract 213: Interplay of Health-Related Quality of Life, Cardiovascular Disease and Healthcare Costs: 2012 Medical Expenditure Panel Survey
Authors: Salami Joseph A , Valero-Elizondo Javier , Ogunmoroti Oluseye , Spatz Erica S , Rana Jamal S , Virani Salim S , Blankstein Ron , Blaha Michael J , Post Janisse , Arrieta Alejandro , Veledar Emir , Nasir Khurram
Published: July 2021

Background:
Cardiovascular disease (CVD), the leading cause of of death in the United States, has deleterious impact on health-related quality of life (HRQL). In this study we aim to examine the interplay of CVD, HRQL and healthcare costs.

Methods:
Adults aged 40 in the 2012 Medical Expenditures Panel Survey (MEPS) were examined. Their HRQL were determined using responses to the Short Form 12 (SF-12) Physical and Mental Component Scale (PCS-12 and MCS-12 respectively), and Visual Analogue Scale (VAS) questionnaires. ICD-9 diagnosis of CVD (410, 413, 414, 428, 433, 434, 435, 436, 437, 427, 440, 443, or 447) was used to classify them. The two-part econometric model was used to estimate the per capita health expenditure and, linear regressions to estimate the mean change in HRQL by CVD status.

Results:
An estimated 139.4 million adults (59+/-27 years; 52% female) were investigated. 13.4% had CVD, and cost $245 billion in healthcare. In adjusted analysis, participants with CVD spent an average of $8,104 (95% CI: $7,465 - 8,744) in health care vs. $5,550 (95% CI: $5,101 - 6,000) among those without it. The mean HRQL scores are statistically significantly reduced across all measuring scale by CVD, and by modifiable risk factors among Non-CVD participants. In adjusted analyses, both in the general population and among those with CVD, people with better HRQL spent less on health care. For instance, participants with CVD who perceived their health to be “very good” had -$13,347 (95% CI: -$17,129 to -9,565) average lower health care expenditure versus those who perceived their health to be “poor” (p<0.001).

Conclusion:
CVD significantly increases healthcare expenditures and lowers HRQL. However, those with better HRQL tend to spend less on health care, irrespective of CVD status. Measures directed at improving HRQL may significantly improve healthcare cost.
Abstract 222: Nerve Conduction Study in Postural Orthostatic Tachycardia Syndrome
Authors: Ashangari Chandralekha , Asghar Samreen F , Syed Sadaf , Butt Amna A , Suleman Amer
Published: July 2021

Background:
Postural orthostatic tachycardia syndrome (POTS) is an autonomic disturbance characterized by the clinical symptoms of orthostatic intolerance, mainly light headedness, fatigue, sweating, tremor, anxiety, palpitation, exercise intolerance and near syncope on upright posture. These are relieved on lying down. Patients also have a heart rate >120 beats/min (bpm) on standing or increase their heart rate by 30 bpm from a resting heart rate after standing for 10 min. A nerve conduction study (NCS) is a medical diagnostic test commonly used to evaluate the function, especially the ability of electrical conduction, of the motor and sensory nerves of the human body. The aim of this study is to demonstrate median, ulnar, peroneal, tibial nerve conduction results POTS patients.

Methods:
177 patients were selected randomly from our clinic with POTS. Nerve conduction results of median, ulnar, peroneal, tibial nerves were reviewed from electronic medical records.

Results:
Out of 177 patients, 151 patients are females (85%, n=151, age 32.07±11.10), 26 patients are males (15%, n=26, age 29.08±17.40).Median nerve conduction results are 57.83 m/sec ±7.58 m/sec, Ulnar nerve conduction results are 56.62 m/sec ±6.85 m/sec, Peroneal nerve conduction results are 49.96 m/sec ±6.85 m/sec, Tibial nerve conduction results are 50.70 m/sec ±6.86 m/sec.

Conclusion:
The nerve conduction velocities tend to be within normal range in Postural Orthostatic Tachycardia Syndrome (POTS) patients.