tbuckley/cabot-search huggingface dataset:
Abstract 14451: Switching From Warfarin to Direct Oral Anticoagulants (DOACs) in Medicine Clinic at a Safety Net Hospital in New York City: A Quality Improvement Project
Authors: Wael Abdelmottaleb, Mustafa Ozbay, Kuldeep Ghosh, Poojitha Pathakamudi, Victor Delgado Lazo, Mohammed T Al-Juboori, Savi Mushiyev
Journal: Circulation (2023)

Introduction: Many patients are still using warfarin for thromboembolic prevention, even though Direct-Acting Oral Anticoagulants (DOACs) have replaced it in most indications to decrease the need for frequent dose adjustments and minimize drug interactions. Methods: This study is a clinic patient-based observational quality improvement project to review warfarin use in adult patients following at the anticoagulation clinic at Metropolitan Hospital. Electronic medical records were screened, and TTR was calculated over 3 months. STATA was used for statistical analysis, including Histograms, Skewness-Kurtosis tests for normality, student-T tests for continuous variables, and χ2 tests for categorical variables. The P-value of less than 0.05 was considered statically significant. Results: A total of 45 patients were included; the mean age was 61, of whom 23 (51.1%) were males. The comorbidities observed were hypertension (HTN), diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), and obesity. The time in therapeutic range (TTR) was less than 65% in 22 patients (48.9%). Warfarin was indicated in 28 patients (62.2%) and not indicated in 17 patients (37.8%), out of which 6 patients (36.3%) agreed to switch to direct oral anticoagulants (DOACs) (Figure 1). Conclusions: Our project revealed a significant number of patients are still using warfarin despite being suitable for DOACs. 60% prefer warfarin due to perceived safety with frequent clinic visits. Socioeconomic status affects the transition. The PINNACLE Study identified practice and provider variations, Practices with high-volume clinics, more electrophysiologists, and those located in the western region are more likely to switch to DOACs. Based on our findings, we recommend the following: - Physicians should engage in shared decision-making with patients on warfarin use. - Physicians may need to discuss the available DOACs options with insurance companies due to coverage limitations.
Abstract 14806: Rate of In-Hospital Initiation of SGLT2 Inhibitors Remains Low Despite Reduction in Rate of 30-Day Readmission From Heart Failure Exacerbation
Authors: Massoud Saleki, Juvena Hitt, Peter Van Buren
Journal: Circulation (2023)

Introduction: Heart failure (HF) management guidelines recommend starting SGLT-2 inhibitors (SGLT2i) for symptomatic HF to reduce rates of HF hospitalization and cardiovascular mortality. However, in-hospital initiation of SGLT2i for titration has yet to be strongly recommended. In this study, we sought to evaluate the effect of in-hospital initiation of SGLT2i on the rate of 30-day HF-related readmission from an index admission for HF exacerbation at the University of Vermont Medical Center (UVMMC). Hypothesis: Patients who are admitted for an HF exacerbation who are discharged on SGLT2i from their index admission are less likely to be readmitted from an HF-related cause within 30 days of discharge compared to patients who are not started on an SGLT2i, though a minority of eligible patients will be started on SGLT2i during this time. Aims: The aims of this study are to 1) compare 30-day HF-related readmission rates between patients discharged on SGLT2i during their index admission, and patients not on SGLT2i, and 2) describe the proportion of patients not currently on SGLT2i who appear to be eligible. Methods: We conducted a chart review of 122 patients admitted to UVMMC from July to December 2022 with an HF exacerbation. We recorded patient and index admission descriptors, including ejection fraction, other GDMT (BB, RAASi, MRA), comorbidities, demographics, and admission duration. We then determined if 1) an HF-related readmission occurred within 30 days, 2) the patient was an acceptable candidate for SGLT2i, and 3) SGLT2i was present on discharge. Results: Among 122 patients admitted with an HF exacerbation at UVMMC, the 30-day HF-related readmission rate of patients discharged on SGLT2i was 3.7%, compared to 8.5% for patients not started on SGLT2i. Of these 122 patients, while 116 (95.1%) were acceptable candidates for SGLT2i, only 27 (23.3%) were discharged on SGLT2i, with 8 more (6.9%) eventually started on SGLT2i. Conclusions: Our review affirms guidelines that recommend starting SGLT2i in patients with symptomatic HF to reduce rates of HF hospitalization. Despite these guidelines, adoption rates remain low due to a variety of factors. Improving in-hospital SGLT2i initiation rates would benefit HF patients and the healthcare systems that support them.
Abstract 13223: Assessing Cardiomediastinal Abnormalities Through Quantitative Evaluation of Chest X-rays: A Multicenter Validation in Various Clinical Cohorts
Authors: June-Goo Lee, Tae Joon Jun, Cherry Kim, Young Joo Suh, Marly Van Assen, Carlo N De, Iksung Cho, Young-Hak Kim, Dong Hyun Yang
Journal: Circulation (2023)

Objective: The ADC study, entitled 'Quantitative A nalysis of Chest X-ray for D iagnosing C ardiomediastinal Abnormality,' is aiming to establish the normal reference values for cardiovascular borders (CB) using Chest X-ray (CXR) and to investigate its clinical application. Methods: The normal reference values of CBs, including right upper/lower, aortic knob, pulmonary conus, left atrial appendage [LAA], and, left lower were determined by pre-validated deep learning from 71,494 'normal' CXRs, as defined by echocardiography. All CBs were standardized into age-and gender specific z-score and underwent validation using three distinct normal external datasets (n=25,429). Subsequently, the clinical relevance was investigated across different disease cohorts - coronary artery disease (CAD, n=34,251), valvular heart diseases (VHD, n=9,893), and mediastinal mass (Mass, n=109). Results: External normal cohorts aligned with the normal CBs established by this study, with a low range of z-scores (-0.49 - 0.40). After adjusting for cardiovascular risks in CAD cohorts, an increased pulmonary conus (z-score &gt; 2.5) on CXR was found to be independently linked to adverse outcomes (HR 1.56 - 3.76, p &lt; 0.001). The pattern of cardiomegaly varies depending on the type of VHDs. In mitral stenosis (MS), the LAA are broader than in aortic stenosis (AS) (1.73 vs. 0.55), while the ascending aorta is more expansive in AS (1.20 vs. 0.47). The subgroup of MS with significant TR demonstrated worse CXR measurements as opposed to MS in isolation (LAA diameter 62.2mm vs. 57.4mm). Among 109 mediastinal masses, the borders of 66 tumors (60.6%) were merged with the CBs and consequently detected via CB analysis. Conclusion: This fully automated, deep learning-guided chest X-ray analysis may contribute to various clinical tasks such as detection, classification, and risk stratification of cardiomediastinal abnormalities.
Abstract 14926: Case of Severe Myocarditis Associated With Nivolumab-Relatlimab
Authors: Levindo Jose Garcia Quarto, Thalys Sampaio Rodrigues, Rinat Nuriev, Michael Maysky
Journal: Circulation (2023)

Introduction: Immune checkpoint inhibitors (ICIs) are the standard of care for cancer but can cause immune-related adverse events (irAEs). Nivolumab/Relatlimab combination was approved in March 2022 for unresectable or metastatic melanoma. Cardiac toxicity associated with ICIs is rare but can be fatal. Prompt recognition is key. Description: We present a case of an 84-year-old with no cardiac history who experienced worsening fatigue a week after Nivolumab/Relatlimab infusion. This was followed by myalgia, double vision, shortness of breath, and chest heaviness. Her symptoms worsened, and she sought medical care. Tests showed elevated high-sensitivity troponin T and total creatine kinase levels of 1100 and 6000, respectively. Her first EKG revealed first degree AV block. Within hours, she developed a complete AV block. Her initial LVEF was 75%. She was diagnosed with “triple M" syndrome (myositis, myocarditis, and myasthenia) and received pulse-dose steroids and IV immunoglobulin. She developed myasthenic crisis with respiratory failure requiring intubation. Repeat echocardiogram revealed a drop in LVEF to 43% with new regional wall motion abnormalities attributed to worsening myocarditis. Considering fast progression and poor prognosis, the patient and her family chose comfort measures over escalation of care. Discussion: Myocarditis is a known but rare irAE with reported incidence of less than 1%. It can be associated with myositis and/or myasthenia. Clinical presentation varies, but rapidly progressive conduction disease is one of the most commonly described conditions. Direct T-cell cytotoxicity is the proposed mechanism. Cardiac irAEs can fully resolve if treated early. However, mortality remains elevated. Conclusion: This is one of the few reported cases of severe myocarditis from Nivolumab/Relatlimab. As the combination is still in phase IV development, more cases may emerge in the future and early recognition is vital.
Abstract 16730: Neighborhood Deprivation and Left Ventricular Mass in Women, NGHS Longitudinal Cohort Analysis
Authors: Carissa M Baker-Smith, Jessica G Woo, Elaine M Urbina
Journal: Circulation (2023)

Left ventricular hypertrophy is an independent predictor of cardiovascular disease. Neighborhood level deprivation is a risk factor for increased morbidity and mortality for a variety of diseases and conditions. However, to date, no study has assessed the relationship between neighborhood level deprivation and left ventricular hypertrophy. Methods: The NHLBI National Growth and Health Study (NGHS) is a 36-year longitudinal study of 871 women (50% white/50% Black). All participants were enrolled between 9-10 years of age in 1987. Annual assessments of anthropometric, echocardiographic and neighborhood level deprivation data, between the ages of 20-28 years (visits 11-17), were analyzed. We assessed the relationship between quartiles of deprivation index (DI) (high/worst, moderately high, moderately low, low/best) at ~age 20 years with levels of systolic blood pressure (SBP), body mass index (BMI) and indexed left ventricular mass (LVMI, g/m 2.7 ), between ages 20-28, adjusting for race. Results: Data from 531 (55% Black) women were examined. Compared to the lowest DI quartile, the highest DI quartile exposure at ~20 years was associated with a 3.37 [1.34, 8.44] greater odds of BMI &gt; 30 (obesity) at age 28, p=0.01 . An interaction between visit and DI quartile was significant, such that women in the highest DI quartile at age 20 had greater increases in BMI by age 28 than those in lower DI quartiles ( p=0.001 , Figure 1). There was no significant relationship between SBP and DI quartile in this cohort (data not shown). Compared with women who resided in the lower 2 DI quartiles at age 20, the LVMI of women exposed to higher (worse) DI was significantly greater after age 23 (visit 14 , p&lt;0.05 , Figure 2). Conclusion(s): In summary, increased deprivation is associated with increased BMI in young adult women, adjusting for race. In addition, increased deprivation is also associated with greater indexed left ventricular mass, an independent predictor of cardiovascular disease.
Abstract 14514: Hypertrophic Cardiomyopathy - Genotype Distribution and Genotype-Phenotype Correlations - A Unique Perspective From a Single Center Study
Authors: Muddasir Ashraf, M F Jan, Arshad Jahangir, Stacie Kroboth, Sara Walczak, Heather Sanders, A. Jamil Tajik
Journal: Circulation (2023)

Background: The role of genotype in risk stratification of hypertrophic cardiomyopathy (HCM) is unclear. Hypothesis: Genotype status affects phenotype and associated outcomes. Aims: To evaluate genotype-phenotype correlations in all adult HCM patients seen at our Cardiac Specialty Center over 13 years and associated outcomes. Methods: We evaluated genotype-phenotype correlations, all-cause mortality, and a composite outcome, including mortality, stroke, implantable cardioverter-defibrillator placement, heart failure hospitalization, LV assist device implantation, heart transplant, septal myectomy, and alcohol septal ablation. Results: Of 827 HCM patients, genotyping was completed in 754 (91.2%), which included 27% genotype-positive (Gen-P), 22% variants of unknown significance (VUS), and 51% genotype-negative (Gen-N) patients with a mean age of 47, 57, and 58 years, respectively. The most common gene implicated was MYBPC3 (63%). LV hypertrophy on electrocardiogram was more frequent in Gen-N than Gen-P patients. Gen-P patients had more frequent non-sustained ventricular tachycardia on Holter monitoring (25% vs 10%), grade III diastolic dysfunction (12% vs 7%), elevated ProBNP (71% vs 61%), and lower ejection fraction (66% vs 69%) than Gen-N patients (P &lt;.05 for all comparisons). All heart transplantations (N=5) were performed in Gen-P patients. LVOT obstruction was more frequent in Gen-N than Gen-P patients (48% vs 26%, P &lt;.01). Distribution of outcomes is shown in Panels A-H. The composite outcome was worse in Gen-P vs Gen-N patients (HR 1.84, P &lt;.01). The other independent predictors of poor composite outcome were old age, male sex, obesity, and atrial fibrillation. A separate analysis of mortality showed similar survival in all groups. Conclusion: Differences exist in phenotype and outcomes based on the genotype status, with more severe phenotype and poorer outcomes in Gen-P patients in our single-state single-center experience.
Abstract 15691: Permanent Pacemaker Implantation After Aortic Valve Surgery for Infective Endocarditis Was Associated With an Increased Risk of Heart Failure
Authors: Lisa O Bearpark, Michael Dismorr, Anders Franco-Cereceda, Ulrik Sartipy, Natalie Glaser
Journal: Circulation (2023)

Background Surgery for infective endocarditis (IE) is associated with a high risk of receiving a new permanent pacemaker. The clinical impact of permanent pacemaker implantation in these patients is unknown. Research question Does permanent pacemaker implantation after aortic valve surgery for IE affect long-term clinical outcomes? Aims To analyze the risk of mortality, heart failure hospitalization, and prosthetic valve endocarditis in patients who received a permanent pacemaker within 30 days of aortic valve surgery for IE. Methods: In this nationwide, population-based, observational cohort study based on the SWEDEHEART register, we included all patients who underwent primary aortic valve replacement for IE in Sweden from 1997 to 2022. Patients with a preoperative cardiac implantable electronic device were excluded. The primary outcome was all-cause mortality. Secondary outcomes were heart failure hospitalization and prosthetic valve endocarditis. Follow-up was complete. Inverse probability of treatment weighting was used to account for intergroup differences and flexible parametric models were used to estimate cause-specific hazards and cumulative incidences. Results: Among 2110 patients, 131 patients (6%) received a new permanent pacemaker, and 1979 patients (94%) did not. The mean age was 59 years, and 433 patients (21%) were female. During a mean follow-up time of 8.5 years (maximum 26 years), 873 patients (41%) died. The cumulative incidence of all-cause mortality and heart failure hospitalization at 20 years was 66% (95% CI 46%-79%) versus 61% (95% CI 58%-64%) and 45% (95% CI 33%-58%) versus 32% (95% CI 29%-34%) in the pacemaker versus the non-pacemaker group, respectively. After adjustment, there was no difference in the risk of mortality (HR 1.14, 95% CI: 0.82-1.59) or reinfection (HR 1.00, 95% CI 0.63-1.59), but the risk of heart failure was increased in the pacemaker group (HR 1.67, 95% CI: 1.11-2.52). Conclusion Permanent pacemaker implantation after aortic valve surgery for IE was associated with an increased risk of heart failure, but there was no difference in the risk of long-term mortality or prosthetic valve endocarditis. These results suggest that patients who receive a pacemaker after surgery for IE warrant careful observation.
Abstract 15068: Connexin43 Concerns Arrhythmias Through Changes in Mitochondrial Ca <sup>2+</sup> and ROS
Authors: Tsuyoshi Okumura, Kao Takeda, Sana Koyama, Shiori Akazawa, Chiyohiko Shindoh, Haruka Sato, Masahito Miura
Journal: Circulation (2023)

Introduction: Connexin43 (Cx43) is a connexin that forms gap junctions in hearts and exists as hemichannels in the inner mitochondrial membrane (mCx43). It is still unknown whether mCx43 is involved in the occurrence of arrhythmias. Thus, we examined whether deficiency of Cx43 increases arrhythmias and what roles mitochondrial Ca 2+ and ROS play in the occurrence of arrhythmias. Methods: Cardiac-specific Cx43-deficient ( Cx43 -/- ) mice were generated by crossing Cx43 flox/flox mice with α-myosin heavy chain cre +/- mice. The resulting offspring, Cx43 -/- mice and their littermates ( Cx43 +/+ mice), were used. Trabeculae were dissected from mouse hearts. Force was measured with a strain gauge, mitochondrial Ca 2+ with rhod-2, and mitochondrial ROS with MitoSox Red. The spatial distribution of rhod-2 and MitoSox Red imaged with confocal microscopy was similar to that of MitoTracker Green within trabeculae, meaning that rhod-2 and MitoSox Red are loaded within mitochondria. MitoSox Red fluorescence was measured before (Fl) and after the addition of 10 mM H 2 O 2 (FlH 2 O 2 ), and the ratio of Fl to FlH 2 O 2 was calculated. To estimate arrhythmogenesis, the minimal extracellular Ca 2+ concentration (Cao), at which arrhythmias were induced by electrical stimulation (0.3-s stimulus intervals for 30 s), was determined (Cao min ). Results: Cx43 -/- mice died within 8 weeks (p&lt;0.01). Cx43 was present in the inner mitochondrial membrane in Cx43 +/+ mice but not in Cx43 -/- mice. In Cx43 -/- mice, rhod-2 fluorescence was higher than that of Cx43 +/+ mice (n=7, p&lt;0.01), while developed force of Cx43 -/- mice was similar to that of Cx43 +/+ mice. The Cao min in Cx43 -/- mice was lower than that in Cx43 +/+ mice (n=5, p&lt;0.01), suggesting that Cx43 -/- mice shows increased arrhythmogenesis. In Cx43 -/- mice, Ru360 (5 μM), a mitochondrial calcium uniporter inhibitor, increased the Cao min , that is, decreased arrhythmogenesis, with decreases in rhod-2 and MitoSox Red fluorescence (n=6, p&lt;0.05). Antioxidant peptide SS-31 (50 μM) and N-acetyl-L-cysteine (1 mM) increased the Cao min in Cx43 -/- mice (n=5, p&lt;0.05), and the ratio of Fl to FlH 2 O 2 in Cx43 -/- mice was larger than that in Cx43 +/+ mice. Conclusions: Deficiency of Cx43 increases arrhythmogenesis with increases in mitochondrial Ca 2+ and ROS.
Abstract 18794: Relationships Between Sex and Size and Morbidity and Mortality Among Patients Undergoing Cardiovascular Procedures
Authors: Nancy J Birkmeyer, Harold L Dauerman, Ansar Hassan, James T Devries, Cathy S Ross, Benjamin M Westbrook, John D Klemperer
Journal: Circulation (2023)

Background. Recent large studies reported improvements in outcomes of cardiovascular procedures over time but have not benefited women. Objective. To explore the role that smaller physical stature may play in explaining differential outcomes of these procedures among men and women. Methods. We used regional data (2003-17) to examine differences in in-hospital complications (bleeding, infection, stroke, low output failure, respiratory failure, RF), mortality and long-term survival among men and women of different body surface area (BSA) categories (&lt;1.6, 1.6-1.7, 1.8-1.9, &gt;=2) undergoing PCI (n=97,205), isolated CABG (27,128), or valve (17,414) while controlling for baseline age, comorbidity, disease severity, and year. Results. Smaller size was associated with worse outcomes among both men and women. In-hospital mortality rates were highest among the smallest men for CABG (5.1% versus 1.8% in largest men (OR=3.1; 95%CI=1.5-6.5; p=0.002)) and PCI (2.4% versus 1.1% (OR=2.5; 95%CI=1.4-4.3; p=0.002)) but not valve where smallest women had the highest mortality (9.3% versus 4.6% in the largest men (OR=2.3; 95%CI=1.7-3.2; p&lt;0.001)). In-hospital complications were highest among smallest men for CABG (18% versus 13% (OR=1.5; 95%CI=0.9-2.3; p=0.100)) and valve (29% versus 26% (OR=1.2; 95%CI=0.7-2.1; p=0.502)) but highest among smallest women for PCI (5.9% versus 2.4% in the largest men (OR=2.7; 95%CI=2.3-3.1; p&lt;0.001)). Long-term survival was worst among smallest men for CABG (HR=2.0; 95% CI=1.5-2.7; p&lt;0.001) and PCI (HR=1.9; 95% CI=1.7-2.2; p&lt;0.0001). Bleeding complications were significantly higher in smaller men (3.4% versus 1.6% (OR=2.2; 95%CI=1.4-3.6; p=0.001)) and women (4.8% versus 1.6% (OR=3.2; 95%CI=2.8-3.8; p&lt;0.001)) undergoing PCI. Conclusions. Peri-operative devices and/or processes of care better tailored to the size of the patient might help to improve outcomes of cardiovascular procedures among women as well as smaller men.
Abstract 15889: An Artificial Intelligence-Derived Pediatric Pulmonary Hypertension Risk Prediction Model From the Pediatric Pulmonary Hypertension Network (PPHNet) Registry
Authors: Megan Griffiths, Cedric Manlhiot, Bhargava K Chinni, Lynn A Sleeper, Steven Abman, Erika Rosenzweig, Lewis H Romer, Mary P Mullen, Shili Lin, raymond Benza, Allen D Everett
Journal: Circulation (2023)

Introduction: Risk prediction is fundamental to guiding pulmonary hypertension (PH) treatment and is a key part of PH guideline based care. Data-driven risk prediction in pediatric PH has been lacking, relying instead on expert opinion. Objective: Use the multi-center Pediatric Pulmonary Hypertension Network (PPHNet) registry to develop a pediatric PH risk model. Methods: Pediatric PH patients (WSPH 1/3) enrolled in the PPHNet were used in this study and randomly split into train (80%) and test cohorts (20%). 176 variables were suitable for analysis including demographics, imaging, hemodynamics, functional/exercise testing, laboratory values, symptoms, and comorbidities. Boruta feature selection with random forest classifier identified variables that predicted the composite outcome of time to death, transplant or reverse Potts shunt. 2 The prediction model was built using an extreme gradient boost classifier with parameter tuning using Bayesian optimization. Model performance was quantified using confusion matrices, calculated sensitivity, specificity, AUC-ROC, and calibration slope. Results: A total of 1232 patients (985 Train, 247 test) were appropriate for inclusion; 134 patients (10.9%) met the composite outcome) with follow-up to 4 years from diagnosis. 37 variables were isolated for the prediction model. The Model performed strongly in the test cohort with an AUROC of 87% (Figure 1A), sensitivity of 85%, and specificity of 77%. Predicted probabilities were stratified into 3 major risk groups based on 1-year risk of event (Figure 1B; low &lt;5%, medium 10-15%, high &gt;15%) with good agreement between predicted and observed outcomes. Conclusions: Using the multicenter PPHNet cohort, we developed a well calibrated 1-year risk prediction model for pediatric groups 1 and 3 PH. This model is uniquely trained on incident and prevalent pediatric patients and could enable accurate identification of high-risk patients in need of aggressive therapy.