bluuebunny/crossref_metadata_2025_split huggingface dataset:
Abstract 176: Is Measuring Blood Pressure All That Simple? An Investigation of Medical Staff’s Proficiency in Blood Pressure Measurement
Authors: Mehlman Andrew , Batra Nakul , Moreland Spencer 
Published: March 2022

Hypertension is a very common medical condition, affecting millions of adults worldwide. Consequently, blood pressure measurement is a universally performed clinical procedure. However, studies have shown that errors in measurement may occur as often as 63% of the time. This study sought to determine whether improper blood pressure measurement techniques occur in our clinic, and to assess our medical staff’s knowledge of the procedure.
A single-blinded observational study was conducted at an academic tertiary referral center’s cardiology clinic. Criteria for proficiency in blood pressure measurement were assessed with a 15-point checklist based on American Heart Association guidelines. All observers received hands-on training in BP measurement prior to evaluating medical staff. After the observational period, medical staff were asked to complete a multiple-choice questionnaire regarding BP measurement technique.
In total, 72 different BP measurements were observed, and 25 members of the medical staff completed the post-observation questionnaire. A mean of 69% (10.35 of 15, SD of 13%) of AHA guidelines were followed when obtaining BP measurements. In no encounter were all 15 measured guidelines completed. The most commonly overlooked criteria included inquiry about recent exercise or tobacco/alcohol consumption (completed in 5.6% [4 of 72] of encounters), instruction not to speak (27.8% [20 of 72]), and absence of communication during testing (51.4% [37 of 52]). While cuff size was selected appropriately 87.5% (63 of 72) of the time, in ~24% (17 of 72) of encounters, the cuff was not properly placed on the patient’s arm. The post-observational questionnaire demonstrated less significant deviation from guideline recommended techniques compared to the observed clinical practice. For example, greater than 92% (23 of 25) of medical staff answered that they should ask patients about recent exercise, tobacco, or alcohol use. The most commonly incorrect answers regarded cuff selection, communication with patient, and patient positioning.
The data demonstrates that nearly a third of AHA guidelines for proper BP measurement are not followed. Differences between our observational and questionnaire results suggest that guidelines are either largely ignored, or more easily remembered when given in multiple-choice format. As most of these improper techniques lead to falsely elevated BP recordings, further research is needed to evaluate for possible overdiagnosis of hypertension and unnecessarily aggressive treatment.
Abstract P52: Epidemiology of Heart Valve Repair and Replacement Procedures in the United States: A 15-Year Perspective
Authors: Ong Kevin L , Lau Edmund , Patel Jasmine , Ochoa Jorge 
Published: March 2022

Open heart valve repair/replacement is widely used to treat various valvular pathologies. The development of percutaneous valve replacement technology may pave the way for less invasive treatment options. This study characterized the epidemiology of valvular repair and replacement procedures in the U.S.
The Nationwide Inpatient Sample (NIS) was used to identify closed and open heart valvotomy, heart valve replacement, annuloplasty, and percutaneous valvotomy procedures between 1993 and 2007. NIS is an annual survey of ∼1,000 hospitals and contains 20% of the U.S. inpatient hospitalizations. The prevalence of these procedures was calculated as a function of age, gender, race, census region, and type of hospital.
3,342 closed heart valvotomy, 191,141 closed heart valvotomy, 1,078,388 heart valve replacement, 106,110 annuloplasty, and 35,071 percutaneous valvotomy procedures were identified. Heart valve replacements included 302,932, 89,249, 13,828, and 4,680 aortic, mitral, pulmonary, and tricuspid valve procedures with tissue graft, respectively, and 479,168, 253,804, 3,904, and 7,494 prosthetic aortic, mitral, pulmonary, and tricuspid valve procedures, respectively. In contrast to valvotomy procedures, the majority of heart valve replacements (64.0%) and annuloplasty (57.7%) were performed on elderly patients (>=65 years). Most repair/replacement procedures were performed on men, except for percutaneous valvotomy (41.9%). Regional variations were found; for example, closed valvotomy were disproportionately performed in South (44.2%). The vast majority of procedures were performed in urban, non-teaching and large hospitals.
Databases such as the NIS allow the characterization of the epidemiology for heart valve repair/replacement patients in a large, nationally representative patient sample. Our study demonstrates that these procedures vary considerably by patient demographics and geographic region. Additional research will help assess if the epidemiology will change over time, as the use of new technologies such as percutaneous heart valve devices grows. In the future, longitudinal administrative databases, such as Medicare, provide a mechanism to evaluate the comparative effectiveness of these procedures.
Abstract 238: Utilization and Safety of a Heparin Nomogram in Treating Thrombotic Comorbidities in Stroke Patients
Authors: Grantz Matthew R , Proctor Pamela , Skalabrin Elaine , Pendleton Robert C , Majersik Jennifer J 
Published: March 2022

INTRODUCTION:
AHA guidelines discourage anticoagulation in acute ischemic stroke (AIS) patients to prevent stroke recurrence. However, some AIS patients have concurrent thrombotic states, such as DVT/PE, that require anticoagulation to prevent further morbidity. Little is published on the safety and efficacy of heparin titration nomograms used for thrombotic comorbidities in stroke patients. Our aim was to assess the utilization and safety of a heparin stroke infusion nomogram at a single, tertiary, academic hospital.

METHODS:
The heparin stroke nomogram contains no heparin bolus, a goal aPTT of 60-85, and stable “steady state” dose with 2 consecutive aPTT values at goal. Patients were identified via a retrospective, computerized order entry review for the heparin nomogram. Exclusion criteria were: baseline aPTT > 50s, a hypercoagulable state, and short usage (< 24 hrs) or interrupted nomogram prior to 2 consecutive “goal” aPTT values. Demographic data and aPTTs were determined from the prospectively-populated enterprise data warehouse. The aPTTs were divided into 6 hr time bins from initiation. Indication and outcomes were determined by source document review by a stroke neurologist.

RESULTS:
From 1/2010 - 6/2011, a heparin nomogram for any indication was initiated in 2,016 patients with 144 (7%) of these utilizing the “stroke” heparin nomogram, The nomogram was ordered by neurology (72%, n=103 ), neurosurgery (8%, n=11), other surgical specialties (9%, n=13), internal medicine (7%, n=10), and other (5%, n=7). After excluding those as above, the “stroke” heparin nomogram was used in 86 patients (40% female; mean 55 yrs SD 17), 74 with AIS, 2 with ICH, 1 with SAH, 2 with craniectomy, and 3 other. The indication for heparin included large artery near total occlusion (30%, n=26), cardiac thrombus (suspected (26%, n=22) or visualized (9%, n=8)), cerebral sinus venous thrombosis (10%, n=9), DVT/PE (5%, n=4), artery dissection (17%, n=15), and other (7%, n=6).

Percent of “at-goal” aPTTs by 6 hr time bins were: 6-12 hrs: 24% (n=21/86); 12-18 hrs: 36% (n=31/ 86); 18-24 hrs: 48% (n=40/84); 24-48 hrs: 55% (n=42/77); 48+ hrs: 65% (n=29/45). At the 42-48 hrs time point, 4% of patients had aPTT>150.
There were 4 non-bleeding related deaths. Repeat AIS occurred in 3 patients of the 74 patients with primary AIS. Asymptomatic ICH occurred in 1 patient with primary AIS; symptomatic hemorrhage occurred in 2 patients (epistaxis, GI). Discharge anticoagulation was prescribed in 56 patients (65%). Ninety day readmission occurred in 15% of patients (n=13), 5 for bleeding.

CONCLUSION:
The heparin stroke nomogram appears safe in that it does not increase risk of ICH. However, therapeutic aPTTs are not reached quickly with less than half of patients therapeutic at 24 hours, nor are they maintained at steady state. This nomogram could be too conservative in cases where clinical situation requires rapid anticoagulation.
Abstract 313: Rates of All-cause Mortality, Myocardial Infarction and Coronary Revascularization Stratified by Appropriate Use Criteria in Coronary Artery Disease Patients Managed with Optimal Medical Therapy
Authors: Saini Vikas , Mamuya Wilfred , Carolan Padraig , Aggarwal Deepa , Bilchik Brian , Blatt Charles , Ravid Shmuel 
Published: March 2022

Appropriate use criteria (AUC) have been developed for guiding clinical decision-making for coronary revascularization (revasc). We studied a prospective cohort of 693 pts initiated in 1992 and managed with optimal medical therapy (OMT). AUC scores could be calculated using noninvasive test results and coronary angiographic data in 230 pts, which constitute the study group. When non-invasive findings were discordant, patients were put in the higher risk stratum. Revasc status and myocardial infarction (MI) events were ascertained as of June 2005. Mortality status was ascertained as of December 31, 2008. Based on AUC scores, pts were classified as Appropriate (A), Inappropriate (I), or Uncertain (U) for revasc. Decisions to pursue invasive evaluation and revasc were based solely on stability of symptoms, LV function, and exercise duration. Survival analysis and stepwise Cox modeling was used to assess AUC class as a predictor of outcomes.

Results:
The majority of pts, 53% (121 of 230), were AUC Class A, with almost all the remainder in Class U, 34% (79 of 230). The mean age of the study group was 66.0 years. The annual incidence of all-cause mortality over a mean follow up period of 12.1 years was 3.6%. A total of 99 deaths occurred. There were no significant differences in the mortality curves of the 3 AUC classes.

The annual incidence of non-fatal MI over a mean follow up of 6.45 years was 2.2%. AUC class A was not a predictor of non-fatal MI.
The annual incidence of revasc over a mean follow up period of 5.38 years was 6.5%. Multivariate stepwise Cox models showed AUC class A was a significant predictor of revasc, along with diabetes mellitus. Beta-blocker therapy at entry was protective. Kaplan-Meier curves confirmed the findings for revasc and nonfatal MI.

Conclusions:
In an OMT cohort initiated in 1992, 53% of pts in whom AUC scores were calculable were deemed appropriate for revasc but were managed with OMT alone. Low annual incidence of mortality and rates of eventual revascularization were observed. Retrospective stratification showed no adverse mortality experience with OMT by AUC class.

AUC Class A pts had a significantly higher rate of revasc during OMT, reflecting the goals of the AUC system, yet the annualized rates of death and MI in this class were comparable to the rates in the medical arms of recent RCT’s of OMT.
These findings suggest that contemporary AUC classification may permit revasc in OMT pts without distinguishing that subset with a future mortality risk on OMT alone. AUC Classification of pts for revasc may require further refinement to enhance the selection of mortality benefit over OMT.
Abstract 341: The Revascularization Heart Team: Feasibility and Cross-sectional Patient Profile in a Large Academic Center
Authors: Dota Anthony P , Badhwar Vinay , Sanchez Carlos , Lee Joon S , Marroquin Oscar C , Smith Anson J , Chu Danny , Wei Lawrence , Toma Catalin , Khandhar Sameer J , Bhama Jay , Esper Stephen , Rapsinski Rosalyn , Mulukutla Suresh 
Published: March 2022

The American College of Cardiology guidelines assign a Class IC recommendation for the use of a Heart Team approach in the treatment of complex coronary artery disease (CAD). However, doubts remain regarding the practical application and functionality of this method in providing routine cardiovascular care. We sought to assess the feasibility of the Heart Team approach to adjudicate complex CAD through analyzing personnel participation, as well as anatomic and comorbid patient characteristics.
From May to October, 2012 we convened a daily Heart Team meeting to discuss evidence based management of patients with complex CAD. All cases were comprehensively reviewed by a team of interventional cardiologists, non-invasive cardiologists, cardiac surgeons, and anesthesiologists within 72 hours of angiography in our health system.
Meetings occurred on average 3.5 days per week and included an average of 4 physicians from the multidisciplinary team. Patient profiles are detailed in Table 1. Recommendations for treatment were made based on a consensus decision amongst the group, and ultimately 20% of patients received medical therapy, 26.4% underwent percutaneous coronary intervention (PCI), 38.2 % had coronary bypass with or without valve repair or replacement, 0.9% went for minimally invasive direct coronary artery bypass, and 2.7% were treated with a hybrid procedure including PCI followed by surgery.
We found a structured Heart Team approach to be feasible, and effective in formulating revascularization strategies for individual patients. This represents a successful model for the implementation of the Heart Team in routine care, which has great potential to positively influence quality of care. Further analyses are being explored to evaluate the impact of the Heart Team on patient outcomes.
Abstract 353: Variations in Implantable Cardioverter Defibrillator (ICD) Utilization in the Louisiana Health System
Authors: Ferguson Tekeda F , Zhang Lu , Brashear Meghan M 
Published: March 2022

The emergence of implantable cardiac device technology has rapidly changed the way in which patients with chronic ventricular dysfunction are evaluated and medically treated. Effectiveness of cardioverter defibrillator (ICD) devices across patient subgroups such as age needs more evaluation. Several clinical variables have been associated with lack of survival benefit despite the overall 5-7% mortality rate over a period of 2- 4 years.
The overall objective of this Quality Improvement Initiative is to investigate the prevalence and variation in ICD utilization by hospital characteristics, income, or cardiovascular risk factor prevalence, as well as the related survival outcome among heart failure patients in the Louisiana State University health system.
All patients diagnosed with chronic heart failure between 1999 through June 30, 2012 within Louisiana State University Health Care Services Division (LSUHCSD) were selected from the Disease Management Evaluation Database (DMED). Seven hospitals in Louisiana contribute to the patient population. Prevalence was calculated for heart failure and ICD utilization; chi square test were used to explore the variation of ICD utilization by hospital characteristics and multiple cardiovascular risk factors.
There have been approximately 39,830 patients diagnosed with heart failure in the LSUHCSD hospitals over the last 13 years. Among heart failure patients identified, 3.6% have an ICD. There is slightly higher proportion of females than males with heart failure in the population; however, ICDs are higher among men (p-value <0.001). African-Americans have a higher rate of heart failure in the population and receipt of ICD than Whites (p-value = 0.005). Approximately 67% of the population has 2 or more listed comorbidities, with 12% having 5 or more comorbidities. The incidence of heart failure patients in LSU HCSD has decreased; however, the rate of ICD has increased over the last decade. The facility with the most heart failure and ICD patients identified is the largest facility, the Public Hospital in New Orleans, LA. However, the rate of ICD among heart failure patients is highest at the Medical Center, in Bogalusa, LA (17.3% compared to 12.4%). This facility has the highest proportion of Medicare patients.
Underutilization of ICDs can be identified in the LSUHCSD system. Variability for medical care including interventions can have multiple causes including market factors that reflect hospital attributes such as the type of cardiac services provided, managed care penetration, socioeconomic status and disease burden including risk factors such as those for cardiovascular disease (like obesity and tobacco use). This area holds much potential for gaining an understanding about allocation of resources in Louisiana in heart failure care and as a consequence to policy development for standardized patient treatment and improved care.
Abstract 316: Arm Exercise Heart Rate, Stress Test Findings and Outcome
Authors: Marshall Cynthia , Xian Hong , Chandiramani Pooja , Bainter Emily , Martin Wade 
Published: March 2022

Attainment of 85% age-predicted peak heart rate (APPHR) during leg exercise is widely accepted and emphasized in clinical textbooks as a condition for adequate diagnostic stress test sensitivity. However, there is little direct evidence for this belief and relationships among peak heart rate, diagnostic sensitivity, coronary revascularization and mortality are poorly characterized. In addition, the prognostic significance of chronotropic incompetence as a predictor of mortality is underappreciated and there is almost no data relating arm exercise heart rate responses to abnormal stress test results and mortality.
Thus, the purpose of this study was to investigate relationships among arm exercise heart rate responses, abnormal stress tests findings, coronary revascularization and mortality in patients who could not perform leg exercise. From 1997 to 2002, we conducted arm cycle ergometer stress tests on 446 veterans aged 64±11 years, of whom 253 underwent myocardial perfusion imaging (MPI). We evaluated associations of quartiles of %APPHR and heart rate reserve (%HRR) with an abnormal electrocardiographic (ECG ST depression ≥ 1 mm) or MPI stress test, coronary revascularization and all-cause mortality during follow-up ≥ 10 yrs. An abnormal arm exercise ECG occurred in 62/427 (14.5%) of patients with an interpretable ECG. MPI was abnormal in 157/253 (62.1%). Over 12.0±1.3 yrs. follow-up, there were 256 deaths (57.4%) and 105 patients (23.5%) underwent coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). An abnormal arm exercise ECG was directly associated with quartile of %APPHR (p = 0.009) and %HRR (p = 0.02) but an abnormal arm exercise MPI exhibited an inverse trend (p = 0.10 and 0.12, respectively). There was a sharp upward inflexion point for increased percent of abnormal arm exercise ECG tests at 69%APPHR. Results for abnormal ECG and MPI tests were similar for patients taking beta blockers. Both %APPHR and %HRR were inversely related to all-cause mortality (p = 0.02 and p = 0.004, respectively) after adjustment for significant demographic and clinical variables. CABG and PCI were each predicted by an abnormal arm exercise ECG (p < 0.04) and PCI alone by abnormal MPI (p= 0.02) with no interaction of %APPHR or %HRR. We conclude that higher %APPHR and %HRR are associated with greater likelihood of an abnormal arm exercise ECG, particularly above 69%APPHR, but borderline reduced likelihood of abnormal arm exercise MPI in patients unable to perform leg exercise. An abnormal arm exercise ECG predicts CABG and PCI and MPI predicts PCI with no apparent influence of %APPHR or %HRR. Higher arm exercise %APPHR and %HRR are related to lower all-cause mortality.
Abstract 362: Presentation, Management, and Outcomes of Infective Endocarditis at a Tertiary Medical Center
Authors: Kashef Mohammad Amin , Hernandez Jaime , Atreya Auras , Friderici Jennifer , Lagu Tara 
Published: March 2022

Background:
Infective endocarditis (IE) has historically caused significant morbidity and mortality, but there are few descriptions of contemporary cohorts of IE patients.

Methods:
We conducted a retrospective cohort study of adult patients admitted to a single tertiary medical center with diagnosis of IE between 2007-2011. Using medical record abstraction and administrative databases, we collected demographic data, comorbidities and clinical data indicating IE severity, management and outcome.

Results:
We identified 180 hospitalizations with a primary or secondary discharge diagnosis of IE and clinical criteria confirming IE diagnosis; 66% were male and 79% were white. Mean patient age was 60 years (SD=18 years) and 29% (52 of 180) of patients were admitted to critical care or step down unit. Risk factors for IE were common: 9% (17 of 180) had previous history of IE, 25% (45 of 180) had prosthetic valve IE, 17% (30 of 180) had intra cardiac devices, 12% (21 of 180) had long term central lines and 14% (25 of 180) were intravenous drug users.

Half of the sample had an infected native mitral valve (90 of 180) and 40% had an infected native aortic valve (72 of 180). Nearly all patients (93%: 173 of 180) had at least 2 sets of blood cultures drawn before starting antibiotics. The most common microorganism detected in blood culture was
Staphylococcus aureus
(41%: 69 of 180), followed by
Streptococcus.viridans
(17%: 29 of 180). Cultures were negative for 4% (7 of 180). Infectious disease consultation was completed in 83% (150 of 180) and cardiac surgery consultation in 45% (81 of 180) of patients.

Echocardiography was performed in 89% (161 of 180) of patients, transthoracic in 69% (125 of 180), and transesophageal in 56% (100 of 180). Among patient who had echocardiography, 17% (28 of 180) had a left ventricular ejection fraction of <50%; 52% (94 of 180) had insufficiency of the infected valve. Perivalvular abscess was reported in 8.9% (16 of 180) and valve perforation in 11% (19 of 180).
The median length of stay was 13 days (interquartile range 9-21days), inpatient mortality rate was 15% (27 of 180; 95% CI: 11.2%-21.2%), and 6-month readmission rate was 10.5% (19 of 180; 95% CI: 6.0%-15.1%).

Conclusions:
In a single academic medical center, IE patients presented with high degree of acuity and found to have frequent complications in echocardiogram. Despite recent advances in medical, surgical, and critical care, many patients had a long hospitalization with relatively high inpatient mortality and readmission rate.