bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 282: The Effect of State Medicaid Expansions on Acute Myocardial Infarction Care Quality and Outcomes
Authors: Wadhera Rishi K , Bhatt Deepak L , Wang Tracy Y , Lu Di , Lucas Joseph , Garratt Kirk N , Yeh Robert W , Joynt Maddox Karen E
Published: July 2021

Background:
Despite considerable progress in the treatment of acute myocardial infarction (AMI), major disparities in care remain for the uninsured. Lack of insurance is associated with delays in seeking emergency care for AMI, and uninsured patients are less likely to receive guideline-directed medical therapy, invasive cardiac procedures, and have higher mortality rates than their insured counterparts. In 2014, Medicaid eligibility was expanded under the ACA, and millions of low-income adults gained insurance coverage in over 30 states. However, little is known about Medicaid expansions’ impact on the quality and outcomes of inpatient care for AMI.

Methods:
We studied 325,343 MI patients under 65 years of age treated at 860 hospitals in the ACTION-GWTG Registry between 2012 and 2016. Expansion states were those that implemented ACA Medicaid expansion during 2014. Our pre-expansion period included the two years prior to expansion (1/1/2012 to 12/31/2013) and our post-expansion period included the two years following expansion (1/1/2015 to 12/31/2016). We first characterized trends in AMI hospitalizations by insurance status during the study period in expansion and non-expansion states. We then identified a low-income cohort, defined as being covered by Medicaid or uninsured, and assessed the association between state expansion status and quality and outcome measures stratified by time periods using hierarchical logistic regression models.

Results:
In our overall cohort, from 2012 to 2016, the proportion of hospitalized AMI patients insured by Medicaid increased by 6.9% in expansion states (7.5% to 14.4%) and 0.4% in non-expansion states (6.2% to 6.6%). Uninsured hospitalizations also declined more in expansion states (18% to 8.4%) than in non-expansion states (25.6% to 21.1%). Our low-income cohort included 55,737 patients - 38,786 were uninsured and 16,951 were insured with Medicaid. Prior to expansion, states that eventually expanded Medicaid were more likely to provide defect free AMI care (all performance measures followed for eligible patients) compared with non-expansion states (aOR 1.26, 95% CI 1.10-1.45, p<0.001). In the post-expansion period, there was no significant difference in defect free AMI care (aOR 1.02, 95% CI 0.89-1.16, p=0.83, p for interaction<0.001). In addition, patients in expansion and non-expansion states had similar rates of in-hospital death both during the pre-expansion period (aOR 0.95, 95% CI 0.79-1.13, p=0.56) and the post-expansion period (aOR 1.03, 95% CI 0.87-1.24, p=0.71, p for interaction=0.48).

Conclusions:
States that elected to expand Medicaid did not experience significant improvements in AMI care quality or in-hospital mortality compared with non-expansion states.
Abstract 6: What Fundamental Factors Underlie Measures of Socio-Economic Status?
Authors: Buchanan Donna M , Jones Philip G , Bennett Kymberley K , Spertus John A
Published: July 2021

Background:
Numerous studies have examined socio-economic (SES) disparities in cardiovascular outcomes. However, these studies often use different metrics to quantify SES (e.g. zip code, income, education, questionnaires). Consequently, the field suffers from the lack of a unifying conceptual model through which these different assessment techniques can be integrated. We sought to explore what fundamental factors may be present in a number of SES items collected within an MI registry.

Methods:
In the 19-center PREMIER registry of 2481 post-MI patients, we collected data on 9 items measuring different aspects of patients' SES and used exploratory factor analysis to identify underlying constructs measured by these items.

Results:
Two factors emerged (see figure), “general SES” (GSES) and “healthcare-related SES” (HSES), which explained 63% of the variability among the 9 items. Four items loaded on GSES, 6 loaded on HSES and one (end-of-month financial reserves) was shared by both factors. Although wide in range, all loadings were very strong and highly significant. There was a strong correlation between the 2 factors (r = .49).

Conclusion:
SES is primarily comprised of 2 distinct factors and different modes of assessing SES are variably associated with these constructs. The commonly used SES measures of zip code median income and insurance status had some of the weakest associations with these factors. Future work is needed to validate these factors, to correlate these with outcomes, and to define the most efficient method for measuring these factors so that researchers can more consistently explore SES disparities in outcomes and develop interventions to overcome them.
Abstract P101: Short and Long-Term Outcomes in Aspirin Treated PCI Patients Using NSAIDs
Authors: Alimohammad Rizwan , Tariq Sayed , Elkharbotly Ali , Timm Ed , Torosoff Mikhail
Published: July 2021

Background:
NSAIDs may exert direct deleterious effects on CV system, while non-selective (NS) -NSAIDs may also diminish cardio-protective effect of low-dose aspirin. On another hand, NSAIDs may decrease CRP levels and ameliorate systemic inflammation. We have investigated short and long-term outcomes associated with NSAIDs use in post-PCI patients.

Methods and Material:
NSAID utilization, hospital and long-term outcomes of 2933 percutaneous coronary revascularizations (PCI) were collected and analyzed. Patients not on aspirin, or treated with rofecoxib and valdecoxib were excluded. ANOVA, Chi-square, Kaplan-Meyer analysis with log-rank test, and logistic regression were utilized. The study was approved by the Institutional IRB.

Results:
Patients treated with NS-NSAIDs, but not celecoxib, experienced longer length of stay, higher incidence of peri-procedural myocardial infarction, and mildly increased post-PCI mortality (Table). These effects were unchanged after adjustment for age (p=0.001), ejection fraction (p<0.001), and history of previous MI (p<0.001). There was a trend towards lower long-term (50+/-15 months) mortality in NS-NSAIDs (9%) and celecoxib (6.7%) treated patients, when compared to the rest of the cohort (11.3%, Table).

Conclusion:
Non-selective NSAIDs, but not Celecoxib, are associated with prolonged hospital stay and increased peri-procedural myocardial infarction in PCI patients. Long-term mortality does not appear to be affected by the NSAIDs use at the time of PCI. Randomized studies of this important clinical question are needed.
Abstract P162: Has LDL Cholesterol (LDL-C) and Non-HDL Cholesterol (Non-HDL-C) Goal Attainment Improved 7 Years After Adult Treatment Panel III (ATP III) Guidelines Were Published?
Authors: Virani Salim S , Woodard Lechauncy , Robinson Cassie , Pietz Kenneth C , Urech Tracy H , Ballantyne Christie M , Petersen Laura A
Published: July 2021

Background
In coronary heart disease (CHD) patients, ATP III guidelines (2001) recommended LDL-C goal of <100 mg/dl, with optional goal of <70 in a 2004 update, and in patients with triglycerides (TG) ≥ 200mg/dl, non-HDL-C goal of <130 mg/dl with optional goal of <100. In a 2003 survey (NEPTUNE II), 62% of CHD patients achieved LDL-C goal of < 100 mg/dl but only 33% achieved both LDL-C and non-HDL-C goals.

Methods
To assess whether goal attainment has improved, we analyzed data from 7 Veterans Affairs (VA) medical centers. In patients with ICD-9 codes for CHD and a primary care visit in 2008, we assessed LDL-C and (in patients with TG ≥200 mg/dl) non-HDL-C (calculated as total cholesterol - HDL-C), to compare goal attainment for LDL-C and non-HDL-C in the VA system with NEPTUNE II.

Results
We analyzed 24,769 CHD patients. Significantly more VA patients (
table
) attained LDL-C goals per ATP III guidelines. Attainment of optional LDL-C goals per the 2004 update was statistically better than NEPTUNE II, but still low (34%). A major treatment gap was noted in patients with TG ≥ 200, with poor attainment for both LDL-C (primary goal) and non-HDL-C (secondary goal) per both ATP III (51%) and the update (12%), although goal attainment was better in the VA patients compared to NEPTUNE II. Controlling for facility clustering and patient's illness severity, non-physician providers (p=0.07), care at a teaching facility (p=0.09), patient's age > 55 years (p= 0.001) and diabetes (p=0.005) were positively associated with goal attainment, whereas African American patients were less likely to achieve lipid goals (p=0.04).

Conclusion
LDL-C goal attainment per ATP III guidelines has improved, but attainment of <70 mg/dl in CHD patients remains low. CHD patients with elevated TG continue to have poor attainment of non-HDL-C goals, which recent data indicate is as important as LDL-C goal attainment. We also identify factors associated with goal attainment which have implications for future interventions.
Abstract P177: The Impact of Triple Therapy (3T) as Secondary Prevention for Recurrent Acute Coronary Syndrome Patients With Prior Myocardial Infarction
Authors: Cheng Alexander C , Stahlbaum Danielle , Salata Brian , Olomu Ikponmwosa , Kosteva Adam , Froehlich James B
Published: July 2021

Background:
We determined if use of aspirin, beta-blocker, and statin, or triple therapy (3T), on admission for recurrent acute coronary syndromes (ACS) improved outcomes in patients with history of myocardial infarction (MI).

Methods:
A total of 1442 patients with history of MI who presented with ACS between January 1999 and December 2006 were identified. Data on baseline demographics, clinical presentation, and in-hospital management were collected, and patients with contraindications to any of the three drugs were excluded. Patients were then separated into two groups based on presence or absence of 3T in admission medications. The impact of 3T on in-hospital, 6-month, and 2-year mortality and adverse cardiovascular events was then analyzed using Pearson Chi-Square tests, Student's t-tests, and multivariate logistic regression.

Results:
Only 42.3% (610 of 1442) patients were found to be taking 3T upon admission. These patients were more likely to be younger and to have a history of previous PCI or CABG, hypertension, and hyperlipidemia, as well as higher LV EF%, lower pulse, and lower initial serum LDL values. They were also less likely to present with STEMI and more likely to be managed in-hospital with aspirin, beta-blockers, or statins.

Conclusion:
Recurrent ACS patients with prior MI who were taking 3T on admission were found to have lower rates of mortality and adverse cardiovascular events at each time point. These trends were sustained when controlling for age, and further confirmed when looking at the effects of 3T on discharge. Further studies should be done to determine why so few patients were taking 3T both on admission and on discharge.

Mortality and Adverse Events

3T [+]
3T [-]
p-value

N (%)

n = 610 (42.3%)
*

n = 832 (57.7%)
*

In-hospital

Death
12 (2.0)
35 (4.3)
.017

MACE
**

67 (11.1)
143 (17.4)
.001

6-month

Death
36 (6.4)
74 (9.9)
.025

MACE
**

108 (25.8)
172 (33.0)
.017

2-year

Death
89 (17.7)
151 (25.9)
.001

MACE
**

141 (35.8)
199 (44.0)
.015

*

n = number of patients in category on admission

**

MACE = Major Adverse Cardiovascular Event

Age-Adjusted Mortality

Odds Ratio (OR)
CI
p-value

3T on admission

Death, In-hospital
.47
(.24, .92)
.028

Death, 6 months
.69
(.45, 1.05)
.079

Death, 2 years
.68
(.50, .92)
.013

3T on discharge

Death, 6 months
.69
(.51, .94)
.019

Death, 2 years
.49
(.33, .74)
.001
Abstract P189: Cardiac Repolarization and Resting Energy Expenditure in Patients Hospitalized With Severe Anorexia Nervosa
Authors: Krantz Mori J , Sagar Utpal N , Long Carlin S , Barbey Jean T , Gaudiani Jennifer L , Sabel Alison , Mehler Phillip S
Published: July 2021

Background and Objectives:
Anorexia nervosa (AN) carries the highest mortality among psychiatric illnesses and disproportionately impacts women. QTc prolongation is believed to underlie this risk but is a subject of controversy as ECG data among patients with advanced AN is inadequately characterized. Moreover, previous studies have utilized non-digitized ECG data and therefore have limited measurement precision. We sought to determine the prevalence of QTc prolongation and assess its relationship to body mass index (BMI) and resting energy expenditure (REE) within a national AN referral center.

Methods and analysis:
We identified 34 patients hospitalized with severe AN. ECGs were obtained on admission then digitized and read with high-precision calipers by a single blinded electrophysiologist. We evaluated the proportion of patients with marked QTc prolongation defined as exceeding 0.500 seconds. Descriptive statistics were used to summarize continuous normally distributed data. Categorical variables were summarized with frequencies and percentages. Pearson's and Spearman's correlation coefficients were used to determine if there was an association between QTc and admission BMI and REE calculated using the Harris Benedict equation.

Findings:
A total of 31 of 34 (91.2%) patients were women, and median age was 27 years. The median weight on admission was 81.4 pounds and median BMI was 13.5 kg/m
2
(interquartile range 11.8 - 14.5) Mean heart rate was 58 bpm and mean QTc calculated by the Fridericia formula was 0.421 seconds. A QTc interval exceeding 0.500 seconds was seen in only one patient (4.8%). There was no significant correlation between QTcF and either BMI (-0.20, p=0.39) REE (+0.19, p=0.40) on hospital admission.

Conclusions:
QTc interval prolongation occurs infrequently among patients with severe anorexia nervosa; most exhibit normal cardiac repolarization even at the height of their illness. Disease severity as assessed by admission BMI and REE is not significantly correlated with the QTc interval. Beyond the need for larger studies, these findings suggest that other markers of sudden death should be investigated within this vulnerable population.
Abstract P206: Changes in Social Support Within the Early Recovery Period and Outcomes After Acute Myocardial Infarction
Authors: Leifheit-Limson Erica C , Reid Kimberly J , Kasl Stanislav V , Lin Haiqun , Jones Philip G , Buchanan Donna M , Peterson Pamela N , Parashar Susmita , Spertus John A , Lichtman Judith H
Published: July 2021

Background:
Baseline social support is associated with outcomes after AMI. However, little is known about changes in social support during the early AMI recovery period and whether changes influence outcomes over the first year.

Methods:
Using data from 1951 AMI patients enrolled in the 19-center PREMIER study, we longitudinally examined whether changes in social support between baseline (index hospitalization) and 1 month post-AMI were associated with health status and depressive symptom outcomes. Using 5 items from the ENRICHD Social Support Inventory, we categorized patients into low (score <=18) and high (score >18) support and examined changes between these categories during the first month of recovery. Health status and depressive symptoms were assessed at baseline, 6, and 12 months using the Seattle Angina Questionnaire (SAQ), Short Form-12 (SF-12), and the Patient Health Questionnaire-9 (PHQ-9). Associations were evaluated using hierarchical repeated-measures regression, adjusting for site, baseline health status, depressive symptoms, and other sociodemographic and clinical factors.

Results:
During the first month of recovery, 5.6% of patients had persistently low support, 6.4% had worsened support, 8.1% had improved support, and 80.0% had persistently high support. In risk-adjusted analyses, patients with persistently low or worsened support (versus those with persistently high support) had greater risk of angina, worse SAQ quality of life (QOL), worse SF-12 mental component summary (MCS), and more PHQ-9 depressive symptoms (
table
). Patients with improved support had outcomes consistent with those of patients with persistently high support (
table
). Similarly, patients with worsened support had outcomes comparable to patients with persistently low support (p>0.50 for all comparisons).

Conclusion:
Changes in social support within the early recovery period are not uncommon and are important for predicting patient-centered outcomes.

Outcome
Social Support Status at 1 Month

Persistently Low
Worsened
Improved
Persistently High

SAQ Angina
*

1.39 (1.09, 1.78)

1.46 (1.08, 1.97)

1.13 (0.89, 1.43)

reference

SAQ QoL

†

-7.63 (-10.96, -4.30)

-7.44 (-10.54, -4.34)

-0.85 (-3.49, 1.80)

reference

SF-12 PCS

†

-0.14 (-2.20, 1.91)
-0.20 (-2.14, 1.73)
-0.44 (-2.07, 1.18)
reference

SF-12 MCS

†

-5.63 (-7.33, -3.92)

-4.82 (-6.42, -3.22)

-1.54 (-2.88, -0.20)

reference

PHQ-9

†

2.29 (1.51, 3.06)

1.94 (1.22, 2.66)

0.81 (0.19, 1.43)

reference

*

Estimates correspond to relative risks (95% confidence intervals) of any angina (SAQ Angina Score <100).

†

Estimates correspond to beta values (95% confidence intervals).
Abstract P212: How Much Do Psychosocial Factors Mediate the Association Between Socioeconomic Status and 1-Year Angina After Myocardial Infarction?
Authors: Buchanan Donna M , Bennett Kymberley K , Jones Philip G , Lichtman Judith H , Spertus John A
Published: July 2021

Background:
Low socioeconomic status (SES) is associated with worse cardiovascular (CV) outcomes. The Reserve Capacity Model (RCM) is a published, but not yet fully tested, framework linking SES, psychosocial factors and health outcomes. “Reserve capacity” is one's inter-/intrapersonal resources for managing stress. We tested the RCM to determine what portion of the association between SES and angina frequency 1 year post-MI is attributable to psychosocial factors.

Methods:
In 2481 post-MI patients enrolled in the 19-center PREMIER registry, we used confirmatory factor analysis to create latent variables of health-related SES and reserve capacity (including social support, optimism, and internal health locus of control). Structural equation modeling was used to test the associations between baseline SES, 1-month psychosocial factors (perceived stress, reserve capacity, and depressive symptoms) and 1-yr angina, adjusting for age, sex, and baseline angina.

Results:
The overall correlation between SES and 1-yr angina was significant (r = -.21*). Of this, 37% was explained by psychosocial factors. (See figure.) Higher SES was associated with greater reserve capacity (r = .43*), which was strongly and inversely associated with stress (r = -.68*) and depressive symptoms (r = -.36*). Depressive symptoms were directly associated with angina (r = .12*). (*p < .05)

Conclusion:
These results validate the RCM, showing that perceived stress, reserve capacity, and depressive symptoms partially mediate the link between SES and 1-yr angina post-MI. This identifies possible areas for intervention to reduce SES-related disparities in angina and potentially other CV outcomes.
Abstract P216: The Utility of Specific Measure for Heart Failure Patient in Web-Based Management: Reliability of Kansas City Cardiomyopathy Questionnaire
Authors: Gupta Ankur , Kashem Abdul , Gonzalez Jorge , Alkhouli Mohamad , Homko Carol , Santimore William , Bove Alfred A
Published: July 2021

[Background]
Internet-based disease management program is known to reduce heart failure (HF) patients' re-hospitalization. Health-related quality of life (QoL) is often omitted in the web-based management of HF patients. We explored whether Kansas city cardiomyopathy questionnaire (KCCQ) can correlate QoL among HF patients while using web-based telemedicine communication system.

[Method]
48 HF patients >50 years of age were enrolled into a clinical trial of telemedicine communication system for 12 month. KCCQ was given to the HF patients at the beginning and end of the study at 12 month.

[Results]
Mean age was 53.2; 72.2% were male; 38.9% were African-Americans; and the mean New York Heart Association class was 2.3. 50% HF patients used telemedicine and 50% served as control. KCCQ symptom stability was reduced in control patients when compared with web-communicated patients (C-28.1%; Web-32.0%; p=0.12). Overall quality of life was reduced in both group and higher in control group (16.3% vs. 2.2%; p=0.02). Overall clinical summary was improved in web-communicated patients (↑0.64% vs. ↓3.47%; p=0.01).

[Conclsuion]
These cross-sectional data highlight the potential utility of specific measure for HF patients in web-based communication system and disease management. KCCQ has significance of social and behavioral factors in HF-specific QoL.
Abstract P255: Should Models of Hospital Outcomes Include Race as a Covariate?
Authors: Hebert Paul L , Ross Joseph , Goldstein Nathan , Howell Elizabeth
Published: July 2021

Objective:
There remains controversy about whether models of hospital performance should account for patient race. We used simulated data to explore the effects on hospital rankings of including or excluding race as a covariate in risk-standardized hospital outcome models, using hospitalizations for heart failure as a case study.

Methods
We simulated three scenarios by which patient race might affect heart failure hospital outcome: a) a treatment bias simulation in which non-white patients were 20% less likely to receive optimal treatment regardless of hospital quality performance; b) an allocative bias simulation in which non-white patients systematically received care from lower performing hospitals that lower quality care to all patients uniformly; and c) a survival bias simulation in which nonwhite patients were 10% less likely to survive than white patients regardless of hospital quality performance. We evaluated the concordance in estimated hospital rank between models that did and did not include race for a simulation of 100,000 patients hospitalized at 1,000 hospitals. We also present the extent to which each model over- or under-predicted hospital quality for hospitals that treat a high percentage of nonwhite patients.

Results
When allocation or treatment bias scenarios were simulated, the model results were highly consistent (kappa>0.9) regardless of whether or not patient race was included in risk-standardization models; models were most disparate for the survival bias scenario (kappa =0.689). In both the allocative bias and the treatment bias scenarios, models that include race overestimated the quality of hospital care at hospitals that treat a higher percentage of nonwhite patients (beta =91.9 and 78.9, respectively; p<0.001) while models that excluded race did not (beta=31.5; p=0.184, and 2.5; p=0.916, respectively). In the survival disparity scenario, the model that included race performed well (beta=-36.7 p=0.15), whereas the model that excluded race significantly underestimated quality at highly nonwhite hospitals (beta= -326.6; p<0.001).

Conclusion
The impact of including race in risk standardization models of hospital performance depends on causal pathways by which race impacts clinical outcomes.
Abstract P268: Telephone Counseling to Activate Peripheral Arterial Disease Patients Toward Improved Low Density Lipoprotein Cholesterol Levels: A Randomized Controlled Clinical Trial
Authors: McDermott Mary M , Reed George , Greenland Philip , Mazor Kathy , Pagoto Sherry , Ockene Judy , Graff Rex , Merriam Philip A , Leung Kathy , Manheim Larry , Kibbe Melina , Olendzki Barbara , Pearce William H , Ockene Ira
Published: July 2021

BACKGROUND:
Patients with lower extremity peripheral arterial disease (PAD) have high rates of cardiovascular events but are less likely to achieve ideal low density lipoprotein cholesterol (LDL-C) levels than coronary artery disease patients. We determined whether a telephone counseling intervention, designed to activate PAD patients to request more intensive LDL-C lowering therapy from their physician, can help PAD patients achieve lower LDL-C levels compared to two control groups.

METHODS:
Three hundred fifty-five participants with PAD and baseline LDL-C ≥ 70 mg/dl were randomized to one of three parallel arms: telephone counseling intervention, attention control condition, and usual care. The primary outcome was change in LDL-C level at twelve- month follow-up. The secondary outcome was the percent of PAD participants with an LDL-C < 100 mg/dl at 12 month follow-up. The intervention consisted of eight patient-centered telephone counseling calls that encouraged PAD participants to request more intensive lipid-lowering therapy from their physician. The attention control group consisted of eight telephone calls providing knowledge about PAD. The usual care group participated in baseline and follow-up testing only.

RESULTS:
At 12-month follow-up, the telephone counseling intervention was associated with lower LDL-C levels as compared to attention control (-18.4 mg/dl vs. -6.8 mg/dl, p= 0.010) but not as compared to usual care (-18.4 mg/dl vs. -11.1 mg/dl, p= 0.208). Both attention control and the usual care condition were less likely to achieve an LDL-C < 100 mg/dl, compared to the intervention (odds ratio = 0.34, 95% Confidence Interval (CI) = 0.17-0.69, p=0.003 and odds ratio = 0.42, 95% CI = 0.20-0.86, p=0.018, respectively). Participants in the intervention were more likely to start a new statin medication than the attention control arm (18.6% vs. 5.5%, p=0.008) and usual care arm (18.6% vs. 5.5%, P=0.005).

CONCLUSION:
Among patients with PAD, a telephone counseling intervention designed to activate patients to request more intensive LDL-C lowering therapy from their physician resulted in lower LDL-C levels and higher rates of initiating cholesterol-lowering drugs, compared to control groups.

1
Abstract P287: Clinical Characteristics, Management, and Hospital Outcomes in Patients With CVA and Type 2 Myocardial
Authors: Khawaja Hussain , Makarian Alexandre , Fatima Maheen , Torosoff Mikhail
Published: July 2021

Background:
We have investigated clinical correlates of elevated troponin and studied contemporary management of patients with stroke and evidence suggestive for Type 2 myocardial infarction (MI).

Material and Methods:
Restrospective chart review was performed on 380 consecutive stroke patients referred for an echocardiographic evaluation. Of these 342 had troponin tested for chest pain and/or abnormal ECG. Patients were further divided into 3 groups according to the troponin level: Group I - 253 (74%) with normal, Group II - 72 ( 21% ) with intermediate, and Group III - 17 (5%) with level consistent with MI diagnosis. ANOVA and chi-square tests were employed. Study was approved by the institutional IRB.

Results:
Mortality and prolonged length of stay both strongly correlated with highest achieved troponin level (4% mortality in Gr I, 10% in Gr II, and 29% in Gr III, p<0.001). Patients with CVA and Type 2 MI (Group III) had lower hematocrit (p<0.001) and higher creatinine (p=0.009) then the rest of the cohort. However, there was no correlation between elevated troponin and patients' age, gender, history of CAD, diabetes, hypertension, dyslipidemia, peripheral vascular disease, or chronic renal failure/hemodialysis. ECG abnormalities (mostly negative T waves) were slightly, but not significantly more prevalent in Type 2 MI patients (18% vs. 9% in Gr I and 14% in Gr II, p=0.37). Prevalence of decreased ejection fraction was significantly higher in Type 2 MI, but only at initial evaluation (p=0.0001), while the follow-up echocardiograms showed no such difference (p=0.842). Abnormal, ischemic stress test result were equally common in all groups (p=0.427).

Conclusion:
CVA patients with abnormal troponin incur increased mortality and protracted hospital stay. Traditional CAD risk factors are poor predictors of abnormal troponin in CVA patients. Cardiac testing in this population appears to be of limited utility. Randomized studies of this important subject are needed.
Abstract P298: The Impact of JNC VII Recommendations for Controlling Blood Pressure in a Heart Failure Disease Management Program
Authors: Marzouka George R , Julian Elyse , Dias Andre , Tamariz Leonardo , Trahan Pat , Arcement Lee , Hebert Kathy
Published: July 2021

Background:
A significant correlation between hypertension (HTN) and long-term risk for heart failure (HF) exists. The aim of this study was (i) to assess what percent of patients enrolled in a heart failure disease management program (HFDMP) reach the JNC VII target goals for blood pressure control; (ii) to assess if there is a disparity in HTN control by race or ethnicity; (iii) and to assess the impact of reaching JNC VII targets for blood pressure control on survival.

Methods:
Patients with an ejection fraction ≤40% were enrolled into HFDMPs and screened for HTN, defined as blood pressure (BP) ≥ 130/80. Patients were titrated to beta blocker therapy and ace inhibitor therapy following the ACC/AHA HF guidelines. Final BP was measured after one year.

Results:
Mean baseline systolic BP (SBP) (N = 648) was 149.9 mmHg and mean baseline diastolic BP (DBP) was 90.5 mmHg. At one year, mean SBP decreased to 138.0 mmHg, DBP to 81.8 mmHg. There was no significant increase in survival for patients with BP ≤130 and ≤80 versus patients with HTN. There was a significant disparity in BP control in Blacks and Hispanics compared to whites (p<0.001)

Conclusion:
Disease management programs are an effective way to reduce BP in hypertensive patients, as well as keeping normotensive patients within JNC VII guidelines however health disparities persisted by race and ethnicity.

Mean SBP and DBP of cohort at baseline Vs. 12 Month Follow up

Blood pressure ≤ 130/80 mmHg

Baseline Visit
Last Visit
P-Value

SBP,m sd
110.9 (12.6%)
120.9 (22.2%)
<0.001

DBP
, m sd

67.1 (8.6%)
72.4 (13.7%)
<0.001

Blood pressure > 130/80 mmHg

Baseline Visit
Last Visit
P-Value

SBP
, m sd

149.9 (21.4%)
138.0 (24.6%)
<0.001

DBP
, m sd

90.5 (16.3%)
81.8 (16.8%)
<0.001
Abstract P30: Disparities in Geographic Access to Emergency Stroke and Myocardial Infarction Care
Authors: Pedigo Ashley , Odoi Agricola
Published: July 2021

Stroke and myocardial infarction (MI) are serious health conditions that require emergency care; thus, geographic access to appropriate care facilities is critical. However, little is known regarding disparities in timely geographic access to stroke and MI care based on actual travel time, instead of distance to the healthcare facility. Current methods for determining access can be inaccurate since they typically do not include road characteristics and driving restrictions. Therefore, the objective of this study was to identify disparities in access to appropriate and timely stroke and MI care in East Tennessee utilizing a novel epidemiological method.

Travel times to stroke and cardiac specialty care centers were computed using network analysis in ArcGIS9.3, while adjusting for distance, speed limits, road connectivity, and turn impedances for each street segment. Neighborhoods represented by census tracts that were within 30, 60, or 90 minutes travel time were identified and described. Travel time by air ambulance was also calculated in ArcGIS9.3 using a 130 mph flying speed, a 3.5 minute warm-up delay, and a 20 minute patient preparation time delay.

Approximately 8% (66,379 of 857,138) and 15% (127,143 of 857,138) of the study area population do not have timely access to appropriate stroke and MI emergency care, respectively. The disparity was greatest for populations in rural areas. However, the entire study population had timely access to emergency stroke and MI care by air ambulance.

In conclusion, there are disparities in timely access to emergency stroke and MI care in East Tennessee. With specific time sensitive treatments, timely access to appropriate care is critical in improving stroke and MI outcomes. Use of air ambulance or telemedicine programs in the rural areas could play a vital role in addressing these disparities. This information is invaluable for evidence-based population health planning initiatives that seek to address disparities in access to care for stroke and MI.
Abstract P328: Complete vs. ‘Culprit’ Only Revascularization in STEMI Patients With Multivessel Coronary Artery Disease: Practice Patterns, Predictors of Complete Revascularization and Impact on Health Status Outcomes
Authors: Amin Amit P , Salisbury Adam , Tang Fengming , Reid Kimberly , McNulty Edward , Stolker Joshua , Cohen David J , Spertus John A , Grantham James A
Published: July 2021

BACKGROUND
One third of patients presenting with acute ST segment elevation myocardial infarction (STEMI) are found to have multivessel coronary artery disease (MVD). Several studies have described clinical outcomes after culprit only compared to complete revascularization. Little is known about the health status benefits of these competing strategies.

METHODS
The 26-center TRIUMPH registry was used to identify STEMI pts with MVD. CR was defined as revascularization of all significant coronary stenoses ≥70%. Numerous demographic and clinical factors were tested for their independent association with CR using multivariable, hierarchical Poisson regression models. The association of CR with 1-year mortality, and disease-specific and generic health status as assessed by the Seattle Angina Questionnaire (SAQ) and SF-12 Physical Component Scores (SF-12 PCS) were evaluated using hierarchical multivariable models.

RESULTS
Among the 664 STEMI pts with MVD (mean age 58 yrs, 74% male, 25% diabetic, 2.4 ± 0.7 mean diseased vessels), 231 (35%) underwent CR and 433 (65%) had ‘culprit’ revascularization. Among CR pts, 28 (12.1%) had CABG. Of the CR patients treated with PCI 71 (30.7%) occurred concurrent with primary reperfusion while the remainder were staged. Independent predictors of CR included greater number of diseased vessels (RR 1.33, 95% CI 1.17-1.51), LAD culprit (RR 0.63, 95% CI 0.48-0.81), and acute heart failure (RR 1.65, 95% CI 1.10-2.48). An inverse-U shaped relationship between age and CR was present, with pts age 50 most likely and young and old less likely to receive CR. At 1 year, CR was not associated with mortality [2.6% vs. 3.2%, p=0.66) and angina [30.6% vs. 25.9%, p=0.278], but was associated with improved health status - a 4.7 point increase in SAQ quality of life score (95%CI 0.53 - 8.84, p=0.03) and a trend in SF-12 PCS score (2 point increase, 95% CI 0.19 - 4.24, p=0.07).

CONCLUSION
CR during the index hospitalization for STEMI is common. While CR was not associated with improved 1 year survival, it was associated with improved health status. These patient centered benefits should be considered in future guidelines recommendations.
Abstract P342: Demographic and Risk Factor Profiling of Patients With Abnormally High and Low Ankle Brachial Index in a Nationally Representative Cohort
Authors: Rathod Ankit , Mohamad Tamam , Bharadwaj Aditya , Badheka Apurva , Patel Ruchir , Veeranna Vikas , Carrillo Antonio
Published: July 2021

Background:
Ankle Brachial Index (ABI) is widely used for diagnosis and prognostication in patients with peripheral vascular disease. Both abnormally high and low ABIs have been associated with increased risk of cardiovascular events. Although multiple demographic and other risk factors have been linked to high and low ABI, differences and distribution in a national cohort has not been described previously.

Methods:
We did a descriptive cross sectional analysis on the cohort of continuous National Health and Nutrition Examination Survey (NHANES) between the years 1999-2006 (n=31124). We included only those with baseline ABI data on both extremities (n= 6819). Chi-square test and ANOVA were used to measure the differences for categorical and continuous variables.

Results:
We found 6577 people with normal ABI (0.9 to 1.4), 214 with abnormally low ABI (<0.9) and 28 with abnormally high ABI (≥ 1.4). The demographic and risk factor distribution among all the 3 groups has been shown in
Table 1
.

Conclusion:
Patients with both high and low ABI have increased prevalence of risk factors compared to cohort with normal ABI. The prevalence and distribution of these differences could be helpful for targeted health interventions.

Table 1

Variable
ABI < 0.9(214)
ABI ≥ 1.4(28)
Normal ABI(6577)
p value

Age

71.9±10.3
61.4±12.5
59.1±12.7
<0.0001

Race White Black Other

57.9 21.9 20.1
67.9 3.5 28.6
54.1 17.6 28.3
0.01

Gender -Male

47.7
42.9
48.5
0.81

BMI
*

27.9±5.6
31.1±8.6
28.3±5.5
<0.001

Triglyceride

166±102
137±56
162±157
<0.001

Cholesterol

208±45
198±35
210±41
<0.001

LDL
#
- cholesterol

124±41
134±26
125±35
<0.001

HDL

†

-Cholesterol

51±16
49±12
53±16
0.09

Smoking

20
10.7
19.9
0.008

Homocysteine

12±4.6
9±2.8
9.5±4.8
<0.001

Creatinine

1.1±0.5
0.84±0.3
0.88±0.4
<0.001

Waist Circumference

101±14
107±18
99±14
<0.001

Hypertension

69.6
39.3
39.8
0.01

Myocardial Infarction

14
7.14
3.07
<0.001

Coronary Artery Disease

11.2
3.6
3.2
<0.0001

Angina

6.5
7.1
2.7
0.001

Diabetes Mellitus

25.2
17.9
11.7
<0.0001

Stroke

6.5
7.2
1.9
<0.0001

*

Body Mass Index, #Low Density Lipoprotein,

†

High Density Lipoprotein
Abstract P358: Do Cardiac Interventions Affect Noncardiac Mortality?
Authors: Bryg Robert , Yang Tae , Bryg David
Published: July 2021

Clinical trials of cardiovascular drugs and devices primarily assess benefit and risk in terms of cardiovascular mortality and other major adverse cardiovascular events. There is little data on how noncardiac mortality is impacted in clinical trials. In this study, we sought to determine how noncardiac mortality was affected in clinical trials that were published in the past 12 years in major general medicine journals. We calculated the standardized mortality ratio and its confidence intervals for cardiac, noncardiac and total mortality in all arms of 93 large clinical trials. Relative change and power to detect significant changes in all three components was calculated.

Twenty two studies had a decrease in cardiovascular mortality of at least 20%, while only 4 studies had an increase in cardiovascular mortality more than 20%. Only 7 studies had a statistically significant decrease in cardiovascular mortality. Noncardiac mortality was at least 5% higher in the treatment arm in 31 (33%) of all studies. In 4 of these studies, noncardiac mortality was at least 20% higher in the treatment arm. Noncardiac mortality was at least 5% lower in the treatment arm in 24 studies, with 3 of then having at least a 20% lower mortality rate. In only 1 study was there a significant difference in noncardiac mortality. Only 3 studies were adequately powered to detect a 20% difference in noncardiac mortality. None were powered to detect a 10% difference in noncardiac mortality. Overall, there was no difference in noncardiac mortality in these studies.

There is wide variation in differences in noncardiac mortality determined in clinical trials, with most studies showing at least a 5% difference in noncardiac mortality rates and over 1/3 of the studies demonstrating at least a 10% difference in noncardiac mortality. In primary prevention and hypertension studies, one would only need a 6-10% increase in noncardiac mortality to negate a 20% decrease in cardiac mortality. No studies were adequately powered to evaluate for this effect.

With the strong push to evidence based medicine, studies need to be adequately powered to demonstrate a lack of harm as well as benefit. The increased use of multiple endpoints will exacerbate the problem of assessment of risk in cardiovascular clinical trials.
Abstract P37: A Novel Emergency Stroke Alert System Reduces Door-to-CT And Door-to-Needle Time in Patients With Acute Ischemic Stroke
Authors: Pervez Muhammad A , Goldstein Joshua N , Rost Natalia S , Mclntyre Joyce , Fay Joseph , Copen William A , Santimauro Janine , Masrur Shihab , Lev Michael H , Viswanathan Anand , Schwamm Lee H
Published: July 2021

Background:
National guidelines recommend eligible acute stroke patients undergo neuroimaging within 25 min and IV tPA within 60 min. In order to reduce door-to-needle time, we implemented an “ED2CT” virtual group pager which allows ED staff to simultaneously activate the Stroke Team, neuroradiologists, CT technologists, nursing supervisors and pharmacists.

Methods:
We performed an IRB approved retrospective review of a prospectively acquired cohort of consecutive patients with ischemic stroke presenting to a single tertiary stroke center using our Get With the Guidelines Stroke (GWTG-S) database. We compared patients who received IV tPA within 3 hours of symptom onset pre- (March 2006-April 2008) to post-intervention (September 2008-December 2009) by Wilcoxon or Fisher's exact as appropriate.

Results:
Overall, there were 56 patients in the pre-intervention and 53 in the post-intervention groups. Patients were 50.5% male, median age was 76 [IQR 63, 85] years, median time to presentation was 50 [IQR 33, 87] min, and median initial NIHSS was 14 [IQR 8, 20]. None of these variables were significantly different between the pre- and post-intervention groups. Implementation of the ED2CT alert was associated with a reduction of 31% in door-to-CT time (29 [22, 40] vs. 20 [16, 29] min; p=<0.001) and 13.5% in door-to needle time (59 [42, 78] vs. 51 [35, 62] min; p=0.02). In addition, there was an increase of 55% in the proportion of patients undergoing CT within 25 min (42.9% vs.66.7 % p=0.01) and 39% in door-to needle within 60 min (51.8% vs. 72.0% p=0.03). Symptomatic intracerebral hemorrhage (sICH) was infrequent among patients receiving IV tPA with or without rescue IA reperfusion (n=109, 8.3%) and those with IV tPA only (n=83, 6.0%); there was a trend in reduced sICH rate post intervention (11.6% vs. 0%; p=0.06).

Conclusions:
A novel emergency alert system with which the ED attending directly activates multiple members of the acute stroke clinical and imaging team was associated with an improved door-CT time and improved door-tPA time without an increased risk of sICH. This approach aligns acute stroke care activation with trauma and emergency cardiac care and suggests that team-based approaches may be better than specialty -specific responses.
Abstract P42: Health Professional Shortage Areas, Insurance Status, and Cardiovascular Disease Prevention in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study
Authors: Brown Todd M , Parmar Gaurav , Durant Raegan W , Halanych Jewell , Hovater Martha , Muntner Paul , Prineas Ronald J , Roth David , Samdarshi Tandaw E , Safford Monika M
Published: July 2021

Background:
Uninsured individuals and those living in federally designated Health Professional Shortage Areas (HPSA) face considerable access barriers and, consequently, may receive less cardiovascular disease (CVD) preventive care.

Methods:
REGARDS is a national cohort of 30,239 African American (AA) and White community dwelling individuals >45 years of age recruited between 2003 and 2007. We investigated 5 CVD prevention guidelines: 1) aspirin in those with coronary heart disease (CHD), 2) beta-blockers (BB) following myocardial infarction, 3) angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers in those with diabetes or CVD and either hypertension or chronic kidney disease, 4) statins in those with diabetes or CHD, and 5) warfarin for atrial fibrillation. We compared use of these medications by insurance status and HPSA county residence, adjusting for sociodemographics, health behaviors, and health status. Counties with partial HPSA status were excluded.

Results:
Mean age of participants was 64±9 years, 42% were AA, 55% were women, 93% were insured; 2,548 participants resided in complete HPSA counties and 17,441 in non-HPSA counties, representing 340 of 842 complete HPSA and 1,145 of 1,792 non-HPSA counties nationally. The odds of receiving aspirin, BBs, and ACEI by were similar by HPSA county type and insurance status. However, the odds of receiving statin therapy were lower among uninsured participants, regardless of county type (Table).

Conclusions:
Residence in HPSA counties was not associated with less CVD prevention. However, a combination of lack of insurance and residence in a HPSA county defined those with the lowest recommended statin use, suggesting lack of access to newer, more expensive therapies among those with both financial and geographic barriers to primary care.

Adjusted OR
*
(95% CI) for Recommended Medications Compared to Insured Residents of non-HPSA Counties

Aspirin
Beta-Blockers
ACEI or ARB
Statin
Warfarin

Insured residents of HPSA counties
1.19 (0.79-1.80)
1.05 (0.75-1.47)
1.08 (0.90-1.30)
1.01 (0.84-1.21)
1.42 (0.93-2.17)

Uninsured residents of non-HPSA counties
1.33 (0.66-2.64)
1.47 (0.78-2.74)
0.98 (0.75-1.28)
0.74 (0.57-0.96)
1.44 (0.65-3.21)

Uninsured residents of HPSA counties
0.92 (0.26-3.24)
1.01 (0.31-3.25)
0.98 (0.58-1.65)
0.54 (0.33-0.90)

**

*

Adjusted for age, race, gender, education, income, percent of county population below poverty, medication adherence, functional capacity, and depressive symptoms. ACEI=angiotensin converting enzyme inhibitor, ARB=angiotensin receptor blocker, CVD=Cardiovascular Disease, HPSA=Health Professional Shortage Area.

**

Adjusted OR not available due to few available individuals; unadjusted OR=0.14 (0.02-1.08).
Abstract P47: Predicting Death and Stroke After Carotid Endarterectomy in Asymptomatic Patients: A Clinical Prediction Model
Authors: Calvillo-King Linda , Zhang Song , Xuan Lei , Halm Ethan A
Published: July 2021

Background and Purpose:
National AHA guidelines on carotid endarterectomy (CEA) for asymptomatic patients (Pts) stipulate that the long term benefit of surgery is dependent on having a ≤ 3% risk of perioperative death or stroke (D/S) due to the procedure. We developed and validated a multivariate model of risk of D/S within 30 days of CEA for asymptomatic disease and a clinical prediction rule based on the final model.

Methods:
We analyzed data from 6553 asymptomatic cases in the New York Carotid Artery Surgery (NYCAS) study, a population-based cohort of all Medicare beneficiaries having CEA in NY State from 1/98 to 6/99. Medical records were abstracted for: sociodemographics, neurological history, carotid imaging data, comorbidities, and D/S within 30 days. All events were adjudicated. Multivariate logistic regression with GEE was used to identify independent predictors of combined D/S. The final model was cross-validated with100 random splits. A CEA-8 Clinical Risk Score assigned 1 point to each risk factor except for disability which got 2 points.

Results:
The 6553 CEAs were performed by 435 surgeons in 157 hospitals. Mean age was 74 years, 3655 were male, 4152 had coronary artery disease (CAD), 873 valvular disease, 611 congestive heart failure (CHF), 1453 history of distant stroke or TIA, and 93 severe disability. Nearly all (6413) had 70-90% ipsilateral stenosis, and 2469 had ≥ 50% contralateral stenosis. The combined 30 day D/S rate was 3.0% (198 of 6553). Multivariable predictors of perioperative D/S were: female (OR, 1.5; 95% CI, 1.1-1.9), non-white (OR, 1.8; 1.1-2.9), severe disability (OR, 3.7; 1.8-7.7), CHF (OR, 1.6; 1.1-2.4), CAD (OR, 1.6; 1.2- 2.2), valvular heart disease (OR, 1.5; 1.1-2.3), distant history of stroke/TIA (OR, 1.5; 1.1- 2.0), and non-operated stenosis ≥50% (OR, 1.8; 1.3-2.3). The CEA-8 Risk Score stratified Pts from a D/S rate of 0.6% (3 of 509) to 10% (16 of 159).

Conclusions:
Several sociodemographic, neuroseverity, and comorbidity factors predicted risk of D/S in asymptomatic patients having CEA. A CEA-8 Risk Score of ≥ 4 identifies high risk Pts (predicted D/S rate of >7.5%) with 2.5 times the AHA guideline acceptable complication risk in asymptomatic Pts (≤ 3%).