AHA Guidelines Research Articles

P020: Post-return of spontaneous circulation care and outcomes a single centre experience

Introduction: Out of hospital cardiac arrest (OHCA) continues to carry a very high mortality rate, with approximately 10% surviving to hospital discharge. In 2015, the American Heart Association release updated guidelines dictating best practices in post-return of spontaneous circulation (ROSC) care, advocating for more liberal utilization of emergent coronary angiography. We sought to determine if the post-ROSC care at our centre during our study period adhered to the previously published (2010) guidelines. Methods: We performed a retrospective analysis (Sept. 2011 - June 2015) of the Resuscitation Outcomes Consortium (ROC) database, which contains pre-hospital, hospital and outcomes data on adult, EMS-treated, non-traumatic OHCA. Patients under 18 years, with missing age data or with obvious non-cardiac causes of arrest were excluded. Key variables included rates of post-ROSC emergent angiography, survival to hospital discharge and survival to hospital discharge with favourable neurologic outcome (modified Rankin score 2). Results: During the study period, there were a total of 997 OHCA; 86 met exclusion criteria. Of the 911 remaining patients, 557 (61.1%) were transported to a local ED. Of those transported to the ED, 262 (47.0%) achieved sustained ROSC, defined as survival to ED discharge. Of those who achieved sustained ROSC, median age was 65 years (IQR=21.75), 66.8% were male. ECG interpretation data was available on 214 patients, of whom 56 had definite STEMI, and 135 had definite absence of STEMI. 37/56 (66.1%) definite STEMI patients received coronary angiography within 24 hours of presentation, as per AHA guidelines. 58/262 (22.1%) post-ROSC patients overall received coronary angiography within 24 hours of presentation to the ED. Of those 58 patients who received emergent angiography, 38 (65.5%) underwent percutaneous coronary intervention (PCI). No patients received fibrinolysis. Of post-ROSC patients who received emergent coronary angiography, 40/58 (69.0%) survived to hospital discharge and 37/58 (63.8%) survived with good neurologic outcome. In comparison, 55/204 (27.0%) who did not receive emergent angiography survived to hospital discharge and 18.8% survived with good neurologic outcome. Conclusion: Only 22.1% of patients with OHCA, and only 66.1% with ECG-proven STEMI underwent emergent coronary angiography post-ROSC. Further investigation into causes for delay or the withholding of emergent angiography is necessary.

NewsCAP: New AHA guidelines include extending time to treatment for ischemic stroke.

NewsCAP: New AHA guidelines include extending time to treatment for ischemic stroke.

Did Prasugrel and Ticagrelor Offer the Same Benefit in Patients with Acute Coronary Syndromes after Percutaneous Coronary Interventions Compared to Clopidogrel? Insights from Randomized Clinical Trials, Registries and Meta-analysis.

According to ACC/ AHA guidelines, a minimum of 1 year of dual anti- platelet therapy (DAPT) consisting of aspirin and a platelet ADP-receptor antagonist (P2Y12 inhibitor) is recommended for patients presenting acute coronary syndromes (ACS), regardless of which type of revascularization is performed during the acute event. The purpose of this presentation was to review the present data either from a direct randomized comparison among the three compounds and also large prospective observational registries and meta-analysis were analyzed in detail. With this aim, we performed an extensive large search from PubMed/Medline Journals identifying studies comparing fashion the new P2Y12 inhibitors in patients with ACS including ST elevation myocardial infarction (STEMI) in direct and indirect manner. Pivotal large randomized clinical trials (RCT) in patients with ACS including STEMI, comparing clopidogrel, a first generation P2Y12 inhibitor against the newer prasugrel and ticagrelor showed major efficacy advantages of the latters although both drugs had more bleeding risk than clopidogrel. Direct comparisons of prasugrel and ticagrelor from large RCT are not yet available, however, several observational registries and metaanalysis reported results from an indirect comparison between both compounds. Major findings and limitations of each of these studies were identified, highlighted and discussed. Prasugrel and ticagrelor are both more effective than clopidogrel to prevent adverse cardiac events in patients with ACS. Compared to ticagrelor, prasugrel appears to be more effective in patients with STEMI, although lack of randomized data didn't allow to draw definitive conclusions.

Abstract 176: Is Measuring Blood Pressure All That Simple? An Investigation of Medical Staff’s Proficiency in Blood Pressure Measurement

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 239: The Effect of an Interdisciplinary Simulation Training Program on Translational Outcomes for In-Hospital Cardiopulmonary Arrests

Purpose: High-quality cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest (IHCA) is the primary component influencing return of circulation (ROSC) and survival to hospital discharge, but few hospitals regularly track these metrics. Other studies have demonstrated significant improvements in survival after IHCA events following implementation of a dedicated code team training program. Therefore, we developed a unique curriculum for a Code Team Training (CTT) course, and evaluated its post-implementation effect on CPR quality and post-IHCA patient outcomes at our institution. Methods: CPR quality data was prospectively collected for quality improvement purposes once our institution had that capability, with 12-months pre-CTT and 21 months post-CTT. Pre-CTT data shaped the elements of the four-hour CTT course that included didactics, small group sessions, and high-fidelity simulation exercises. A total of 456 multi-professional code team members were trained in 22 courses. Data collection included CPR quality and translational outcomes for events where CPR was performed, except the ED. CodeNet® software was used for CPR quality measures, cardiac rhythm, defibrillation metrics, use of continuous waveform capnography, and pauses in compressions. Target metrics for CPR quality were based on 2015 AHA guidelines. Key translational outcomes measures included event location, ROSC, and survival to hospital discharge. Results: CPR quality was obtained from 140 of 230 (61%) in- and out-of-hospital pulseless adult cardiac arrest events over 33 months (50 [36%] before CTT and 90 [64%] following the first course). There was no significant difference between groups in terms of event location within the hospital nor initial event rhythm. A total of 116,908 chest compressions were evaluated. Median compressions in target rate improved from 32% before CTT to 49% after CTT (p<0.05). When accounting for target rate and depth, the median compressions rate improved to 38% post-CTT compared to 31% pre-CTT (p<0.05). While compression depth had a non-statistically significant decline (90.8% pre-CTT and 83.4% post-CTT), mean rate and median rate-in-target improved from 119.99 +/- 15.6 cpm and 32.4% pre-CTT to 113.7 +/- 16.1 cpm and 48.6% post-CTT (p<0.05). The rate of ROSC improved from 60% (30 of 50) to 78% (70 of 90) after implementation of CTT (p=0.003), excluding IHCA in the ED. Index IHCA survival rate for our institution improved from 26% to 33% before and after CTT [p-value NS], which far surpasses the national average (23.8%). Conclusions: After the initiation of a CTT course that targets key code team member personnel, CPR quality significantly improved, which was associated with an increase in ROSC and a trend towards increased survival for in-hospital cardiac arrest patients.

Variability in the time to initiation of CPR in continuously monitored pediatric ICUs

AimTo study the influence of patient characteristics and unit ergonomics and human factors on the time to initiation of CPR. MethodsA single center study of children, 0 to 21 years old, admitted to an ICU who experienced cardiopulmonary arrest (CPA) requiring >1 min of chest compressions. Time of CPA was determined by analysis of continuous ECG, plethysmography, arterial blood pressure, and end-tidal CO2 (EtCO2) waveforms. Initiation of CPR was identified by the onset of cyclic artifact in the ECG waveform. Patient characteristics and unit ergonomics and human factors were examined including CPA cause, identification on the High-Risk Checklist (HRC), existing monitoring, ICU type, time of day, nursing shift change, and outcome. ResultsThe median time from CPA to initiation of CPR was 50.5 s (IQR 26.5 to 127.5) in 36 CPAs. Forty-seven percent of patients experienced time from CPA to initiation of CPR of >1 min. There was no difference in CPA cause, ICU type, time of day, or nursing shift change. ConclusionNearly half of pediatric patients who experienced CPA in an ICU setting did not meet AHA guidelines for early initiation of CPR. This is an opportunity to study the recognition phase of CPA using continuous monitoring data with the aim of improving the understanding of and factors contributing to delays in initiation of CPR.

Abstract P133: Epigenome-Wide Association Study of Moderate-Vigorous Physical Activity in Adult African Americans Identifies Loci Near HCCA2

Regular moderate-vigorous physical activity (MVPA) reduces the risk of cardiovascular and other chronic diseases, among other important benefits at all life stages. It is hypothesized that physical activity may alter disease risk via epigenetic modifications, including potentially long-standing changes in DNA methylation as previous research has shown epigenetic changes following exercise interventions. Most existing reports examine global methylation or study acute exercise effects on DNA methylation. To our knowledge, there are no published epigenome-wide association studies (EWAS) of habitual MVPA. In this analysis, we tested associations between leisure time MVPA and genome-wide variation in CpG methylation, an epigenetic mark, in 2,601 African American participants (1,663 women; mean age 56.6 years) in the Atherosclerosis Risk in Communities (ARIC) study. The Illumina HM450K Bead Chip was used to measure methylation in 471,035 CpG sites in stored frozen leukocyte samples, from visit 2 (1990-1992) or 3 (1993-1995). Linear regression models tested the cross-sectional association of DNA methylation M-value with self-reported leisure time MVPA at the visit of sample collection, modeled as minutes of MVPA per week and by category based on the AHA guidelines for physical activity in adults (none, less than 150, or at least 150 minutes MVPA per week), adjusting for age, sex, body mass index, education, alcohol use in grams per week, smoking status, cancer status, white blood cell count, imputed cell-type proportions using the Houseman method, and batch effects with the top 30 HM450K built-in nonnegative control probe principal components. Three CpGs, cg08269485, cg20272155, and cg08966208, upstream of the cathepsin D encoding gene, CTSD, were observed to be significantly inversely associated (q<0.05, FDR) with MVPA minutes/week. This is a strongly imprinted genomic region (chr11p15.5) and the region has also been reported to include DNA methylation variants that changed in response to an exercise training intervention. Additionally, 163 CpGs that we identified in the literature to be associated with habitual MVPA were also tested using the same models. One CpG, cg07863043, upstream of the adenomatosis polyposis coli gene, APC, in the 5q22.2 genomic region, was observed to be significantly positively associated with achieving at least 150 minutes of MVPA per week compared to none (q=0.0001, FDR). APC encodes a tumor suppressor protein that is an antagonist of the Wnt signaling pathway, and is involved in carcinogenesis and embryonic development. Replication in other populations is ongoing to confirm these findings as well as to identify additional physical activity-related DNA methylation variants.

Treatment Modality and Quality Benchmarks of Aneurysmal Subarachnoid Hemorrhage at a Comprehensive Stroke Center.

Aneurysmal subarachnoid hemorrhage (aSAH) is the most severe type of stroke. In 2012, the Joint Commission, in collaboration with the American Heart Association/American Stroke Association (AHA/ASA), launched the Advanced Certification for Comprehensive Stroke Centers (CSCs). This new level of certification was designed to promote higher standard of care for patients with complex stroke. The goal of this study was to examine the treatment modality and quality benchmarks of aSAH at one of the first five certified CSCs in the United States. Consecutive patients with aSAH at Cedars-Sinai Medical Center between April 1, 2012 and May 30, 2014 were included for this retrospective study. The ruptured aneurysm was treated with coiling or clipping within 24 h. All patients were managed per AHA guidelines. Discharge outcomes were assessed using modified Rankin Scale (mRS). The rate of aneurysm treatment, door-to-treatment time, rate of posttreatment rebleed, hospital length of stay (LOS), discharge outcome, and mortality rates were evaluated as quality indicators. The median age (interquartile range) of the 118 patients with aSAH was 55 (19). Among them, 84 (71.2%) were females, 94 (79.7%) were transfers from outside hospitals, and 74 (62.7%) had Hunt and Hess grades 1-3. Sixty patients (50.8%) were treated with coiling, 52 (44.1%) with clipping, and 6 (5.1%) untreated due to ictal cardiac arrest or severe comorbidities. The rate of aneurysm treatment was 95% (112/118) with median door-to-treatment time at 12.5 (8.5) h and 0.9% (1/112) posttreatment rebleed. The median ICU and hospital LOS were 12.5 (7) and 17.0 (14.5) days, respectively. Coiling was associated with significantly shorter LOS than clipping. There were 59 patients (50%) with favorable outcome and 19 deaths (16.1%) at hospital discharge. There was no significant difference in discharge outcome between coiling and clipping. Care of aSAH at one of the early CSCs in the United States was associated with high rate of aneurysm treatment, fast door-to-treatment time, low posttreatment rebleed, excellent outcome, and low mortality rate. Coiling was associated with significant shorter LOS than clipping. There was no significant difference in discharge outcomes between treatment modalities.

CPR feedback/prompt device improves the quality of hands-only CPR performed in manikin by laypersons following the 2015 AHA guidelines

PurposeWe investigated the effects of a cardiopulmonary resuscitation (CPR) feedback/prompt device on the quality of chest compression (CC) during hands-only CPR following the 2015 AHA guidelines. MethodsA total of 124 laypersons were randomly assigned into three groups. The first (n=42) followed the 2010 guidelines, the second (n=42) followed the 2015 guidelines with no feedback/prompt device, the third (n=40) followed the 2015 guidelines with a feedback/prompt device (2015F). Participants underwent manual CPR training and took a written basic life support examination, then required to perform 2min of hands-only CPR monitored by a CPR feedback/prompt device. The quality of CPR was quantified as the percentage of correct CCs (mean CC depth and rate, complete recoil and chest compression fraction (CCF)) per 20s, as recorded by the CPR feedback/prompt device. ResultsSignificantly higher correct ratios of CC, CC depth, and rate were achieved in the 2010 group in each minute vs the 2015 group. The greater mean CC depth and rate were observed in the 2015F group vs the 2015 group. The correct ratio of CC was significantly higher in the 2015F group vs the 2015 group. CCF was also significantly higher in the 2015F group vs the 2015 group in the last 20s of CPR. ConclusionsIt is difficult for a large percentage of laypersons to achieve the targets of CC depth and rate following the 2015 AHA guidelines. CPR feedback/prompt devices significantly improve the quality of hands-only CPR performance by laypersons following the standards of the 2015 AHA guidelines.

Abstract WP125: Pathologic Changes in Carotid Artery Lesions in Relation With Intensity of Statins Therapy

Introduction: Due to its lipid lowering and pleiotropic effects, statins are part of the standard medical treatment of carotid artery disease. Nevertheless, scarce medical information can be found relating intensity of its use and arterial pathologic changes. The aim of our research was to study the relationship between intensity and temporal patterns of statins therapy (ST) with pathologic changes of carotid lesions (CLs) obtained from carotid endarterectomies (CAE). Methods: 236 consecutive patients undergoing CAE from 01/01/2012 to 06/30/2017 were retrospectively analyzed. Intensity of the ST was categorized according to the 2013 AHA Guidelines as High (HI); Moderate (MI) or Low (LI). The CLs samples were described blindly by a pathologist with no clinical information. Vulnerability of the CLs were classified according to the AHA Guidelines into types IV; V (Va, Vb ,Vc) and VI (VIa, VIb , VIc). Findings as fibrosis, Myofibroblastic hiperplasia, lipid core, calcification, inflammation, hemorrhage and thrombosis were cuantified as absent, mild, moderate and intense. Angiogenesis was graded in a scale from 0 to 3. Spearman correlation; X 2 , t test and logistic regression were used for statistical significance. Results: We studied 236 CAEs (55% right sided) with a mean age of 69,5 years; 41% women; 32,3% symptomatic . In 83% of the cases, statins were being used (HI in 48,4%, MI in 50% and LI in 1.6%; Duration of ST previous to CAE was > 6 months; 63%; < 6 months: 29.8% and <1 month in 7.8%. Complicated plaques (type VI) were shown in 50.8%. An inverse correlation was found between statins dosing and stenosis grading ( p <.05) and fibrosis scores ( p =.03). No association between histopathologic changes and ST was found. A correlation between complicated plaques and symptomatic lesions was found. (p=.01). Conclusions: No association was found between the pathologic findings of the CLs and the intensity and duration of the statins therapy evn though in our population a low percentage of patients received HI and long duration ST.

Abstract 111: Endovascular Therapy for Mild Strokes: How Low Should We Go?

Background: Endovascular therapy (EVT) is the standard of care for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) with NIHSS ≥ 6. LVO patients may present with mild (NIHSS <6) but disabling deficits and were not well represented in RCTs resulting in a NIHSS cutoff of ≥ 6 on AHA guidelines. Milder deficits may not justify EVT risk-benefit ratio. To generate practice level data, we evaluated EVT treatment effect in mild stroke. Methods: A retrospective cohort from 8 USA and Spain centers of AIS with LVO in the anterior circulation with NIHSS ≤ 6 presenting within 24 hrs (1/12 to 3/17) was pooled. EVT patients were compared with those only treated with medical management (MM). 90 day mRS (0-1 excellent) was chosen as the primary outcome as an appropriate goal for mild stroke. Multivariable analyses compared the treatment effects and their interactions with NIHSS, both as an ordinal and dichotomized (0-3 vs 4-5) variable. Adjustment was made for age, time LSN to EVT center arrival, IV-tPA, occlusion site and ASPECTS. Within center correlation was accounted for. Results: 223 patients were included (EVT 105, MM 118). The two groups had similar baseline age (65.7 and 66.3 yrs, p=0.73), ASPECTS (9.4 and 9.3 p=0.53), %IV t-PA (39% and 36% p=0.65) and median (IQR) time mins to EVT center 156(66.5-301) and 212(90-387) p=0.09, EVT and MM respectively. There was no difference in outcomes (54.6% EVT vs 53.4% MM) when all patients (NIHSS 0-6) were assessed (aOR 0.94, 95% CI 0.62-1.40, p=0.94); same for NIHSS 0-5 (55.1% EVT vs 55.6% MM), (aOR 0.95, 95% CI 0.71-1.26, p=0.95). For NIHSS 0-3, MM had better outcomes (51.9% EVT vs 74.6% MM), (aOR 0.39, 95% CI 0.25-0.61, p<0.01). For NIHSS 4-5, results favored EVT (57.1% EVT vs 22.2% MM), (aOR 4.04, 95% CI 2.56-6.38, p<0.01). Fig 1, 2 show CIs of EVT and MM as related to NIHSS. Conclusion: Though limited by a non-randomized comparison, the data suggest a possible benefit for EVT in mild strokes with NIHSS 4-5. In NIHSS ≤3, the intervention had no additive benefit.

Abstract TMP68: ACT-FAST Algorithm: Paramedic Validation Of A 3-Step Algorithmic Approach to Large Vessel Occlusion Identification

Introduction: Large vessel occlusion (LVO) triage scales facilitate prehospital bypass to endovascular centers, avoiding time consuming inter-hospital transfers. However, there are concerns that current scales lack specificity when used by paramedics, leading to erroneous bypass. The 3-step ACT-FAST Algorithm was designed for high specificity and reliability. First, arm fall to stretcher <10s is assessed, followed by severe aphasia (if right arm weak) or abnormal shoulder tap response for gaze/neglect (if left arm weak), followed then by questions regarding endovascular eligibility. We prospectively validated the new algorithm with paramedics. Methods: Over 8 months, paramedics bringing suspected stroke or endovascular transfers to the Royal Melbourne Hospital assessed deficits contemporaneously with stroke doctors. For the first 100 patients (Phase 1), paramedics completed an assessment allowing derivation of several scales: ACT-FAST (exam steps), RACE, LAMS and FAST-ED. For remaining patients (Phase 2) paramedics scored only the ACT-FAST Algorithm with eligibility questions. LVO was defined as ICA/M1 occlusion on CTA with NIHSS ≥6 (AHA guidelines). Results: A total of 142 patients (29 LVO) were included. Table 1 compares scales in Phase 1. ACT-FAST showed a trend towards highest accuracy compared with other scales. In Phase 2, the full ACT-FAST Algorithm had 83.3% sensitivity and 100% specificity in identifying LVO accepted for endovascular treatment. Agreement on ACT-FAST classification between paramedics and doctors was excellent (kappa = 0.93). Conclusion: ACT-FAST combines the simplicity of a 3-step algorithm with items optimized for paramedic usability to create a simple LVO identification tool. Initial prospective validation shows excellent reliability and trends towards increased accuracy for LVO recognition compared to other scales. Future research will focus on implementing ACT-FAST in Victoria to determine efficacy of LVO bypass.

Abstract TP379: Stroke Survivors Achieve Good Blood Pressure Control with Nurse Practitioner Led Self-Blood Pressure Monitoring Program Following AHA Guidelines

Background: Hypertension is a leading risk factor for stroke affecting 33% of adults in the US with only 54% adequately controlled. National guidelines recommend blood pressure (BP) self-management at home; however the partnership with clinicians is necessary for education and coaching. BP self-monitoring in stroke survivors has not been widely reported. The purpose of this quality improvement project was to increase the provision of BP education and support stroke patients receiving outpatient rehabilitation services with BP self-management. Methods: Stroke patients treated in a community based multidisciplinary outpatient stroke rehabilitation program addressing medical, rehabilitation, psychosocial and vocational needs between 6/2016 - 3/2017 were included. Patients met with a Nurse Practitioner (NP) to receive a standardized educational program based on the American Heart Association’s Life’s Simple 7 addressing cardiovascular education, independence with medications and health maintenance. Additional training was provided during the first 3 NP visits related to the BP guidelines and self-measurement with a single wrist monitor. Manual and machine BPs measured by the NP were correlated with self BPs measured by each patient. Patients recorded their self BPs at a designated station prior to individual physical therapy sessions. The first 20 patients received pre- and post-assessment of BP knowledge and confidence to self-monitor. Results: Among 29 consecutive stroke patients (59% male; 14% hemorrhagic; 83% hypertensive) 100% performed self BP monitoring and recording. A total of 571 self BPs were recorded with an average of 20 per patient (range=2-77). Four patients with BPs <120/80mmHg self-monitored an average of 2.5 times/week; 22 patients with BPs 120/80-139/89mmHg self-monitored 1.4 times/week; and 3 patients with BPs 140/90-160/90mmHg self-monitored an average of 1.2 times/week (none >160/90 mmHg). Knowledge of AHA BP guidelines improved 90% and confidence to self-monitor improved 65%. 50% began to self-monitor at home. Conclusions: Community dwelling stroke survivors can perform BP self-monitoring with good BP control, improved knowledge of AHA guidelines with increased confidence and successful carry over to home.

Abstract WP353: Decreasing "Door to Admission" Times for Intravenous tPA Treated Patients: A Single Comprehensive Stroke Center Experience

Introduction: AHA’s Get with The Guidelines (GTWG) initiative has recommended “door to admission” time for patients receiving IV tPA to be <3 hours. In large tertiary hospitals like ours, complicated administrative steps and coordination required to admit patients often leads to delays. There has been a paucity of studies aiming to streamline this process for patients treated with IV tPA. Aim: To assess whether having a dedicated rapid response team (RRT) RN within the ED to coordinate care of patients receiving IV tPA reduces “door to admission” times. Methods: A policy of notifying RRT of all patients eligible for IV tPA was implemented in the ED. The responsibility of RRT was to coordinate care between neurology resident, ED nurse, acute stroke unit (ASU) charge nurse and admissions office to ensure timely completion of steps required for admission. “Door to admission” times were collected prospectively for 3 months before and after intervention. The compliance of recording neuro checks and vital signs per AHA guidelines for post tPA care were also measured. Wilcoxon two sample test was used to analyze time variables and compliance rates. Results: The post intervention group had significantly decreased “door to admission” and “bolus to admission” times (see table). Also, significantly fewer patients had >1 vital signs checks miss in post-intervention group (6% vs 38%; p=0.033). There was no significant increase in the compliance rate of neuro checks. Discussion: By adding RRT in coordination of care for IV tPA patients in the ED, we were able to drastically reduce our door to admission times. The improvement was because of faster placement and prioritized processing of the admission orders. RRT acted as a “control center” relaying vital information to admission office and ASU charge nurse. This also freed ED RN to improve compliance rate of recording vital signs in IV tPA patients. Similar interventions can be used by other centers to decrease their “door to admission” times.

Abstract TP4: Current Practices and Discharge Outcome of Endovascular Coiling and Clipping Amongst Hemorrhagic Stroke Patients

Background: 20% of strokes are hemorrhagic (HS), with subarachnoid hemorrhage (SAH) and intracerebral hemorrhage each accounting for 10%. Most SAHs are caused by ruptured saccular aneurysms. Therapeutic advances like endovascular coiling (EvC) and clipping have added to the armamentarium for treating this malignant process. Methods: Data from Nationwide Inpatient Sample (NIS) (years 2003-2013) was analyzed to identify HS (aSAH and ICH) hospitalization using ICD-9-CM codes. EvC and clipping patients were identified from the cohort. A retrospective analysis with multivariate survey logistic regression was done to evaluate the predictors of utilizations of EvC and clipping. Results: From years 2003 to 2013, total 1,004,736 patients with HS were hospitalized. Out of them, 47,999 (4.7%) patients had EvC and 55,900 (5.6%) patients had clipping. Predictors of higher EvC utilization were young 35-50 years patients (aOR: 1.20; 95%CI: 1.04-1.38), large hospitals (>100 beds) (aOR: 4.53; 95%CI: 3.54-5.81), and urban teaching hospitals (aOR: 4.66; 95%CI: 3.63-5.97). Clipping utilization was higher among age 65-80 years patients (aOR: 2.02; 95%CI: 1.73-2.37) and age >80 years (aOR: 5.15; 95%CI: 4.25-6.23), male (aOR: 2.02; 95%CI: 1.89-2.15), emergency admissions (aOR: 1.73; 95%CI: 1.52-1.97), and pre-existing co-morbidities like renal failure, solid tumor, hypertension, and diabetes. Utilization of EvC was associated with lower frequencies of in poor discharge disposition: transferred to short-term hospital/skilled nursing facility/intermediate care/long term care facility (45.86% vs. 49.75%; p<0.001) in comparison to clipping. Discussion: Historically, coiling was reserved for the treatment of high-grade subarachnoid bleed, has found to be not only safe but also favourable with better discharge disposition. The recent AHA guideline and multiple research trials have shown the same result.

Abstract TP323: Necessity of the Twenty-Four Hour Head Computed Tomography Scan After Administration of Intravenous Recombinant Tissue Plasminogen Activator Among Clinically Stable Patients With Acute Ischemic Stroke

Introduction: Current AHA guidelines recommend obtaining a brain imaging study usually a computed tomography scan of the head (CTH) at 24-hours after thrombolysis with intravenous recombinant tissue plasminogen activator (IV r-tPA) before starting anti-platelets (AP) or anticoagulant (AC) therapy due to concerns for intracerebral hemorrhage. Several studies argued against the utility of a 24-hour post-thrombolysis CTH in AIS patients especially if they recover early or are clinically stable, and suggested that it would not alter clinical management. Hypothesis: The authors hypothesize that new findings after the 24-hour post-thrombolysis CTH alter management decisions regardless of clinical stability in patients with AIS. Methods: Stroke patients admitted to the Neurocscience Critical Care Unit (NCCU) after thrombolytic therapy from January 2013 to June 2016 were identified retrospectively. Clinically stable patients with new 24-hour post-thrombolysis CTH findings were included. Patient characteristics and outcome were compared according to cohorts of “with management change”(with MC) versus “with no management change”(no MC). Primary outcome were types and frequencies of MC. Secondary outcomes were hospital length of stay (HLOS), discharge and 30-day NIHSS and MRS, in-patient mortality and discharge disposition. Results: A total of 223 AIS patients were admitted to the NCCU after thrombolysis. Forty-two patients were included for analysis. Based on new CTH findings, 28(67%) had MC. The most common types of MC were repeating CTH (24, 86%) followed by AC delay (18, 64%). Majority of the “with MC” cohort had CTH findings of ventricular compression due to mass effect (20, 71%). They also had longer HLOS (median[IQR] 7.5[13]vs 4[4],p-value=0.012) and higher 30-days NIHSS (9.5[11]vs 2[3],p=0.042) and MRS on discharge (4[3]vs 1.5[2],p=0.002) compared to the “no MC” group. Conclusion: We showed that a 24-hour CTH after IV r-tPA is necessary prior to starting AP or AC therapies for AIS patients and affects management decisions regardless of the patients’ clinical stability. Patient outcome was worse among those with management change. Studies should be done to analyze long-term effect of these managements and their impact on healthcare costs.

Role of depression in secondary prevention of Chinese coronary heart disease patients receiving percutaneous coronary intervention.

IntroductionCoronary heart disease (CHD) patients who have undergone percutaneous coronary intervention (PCI) have higher rates of depression than the general population. However, few researchers have assessed the impact of depression on the secondary prevention of CHD in China.ObjectiveThe main purpose of this investigation was to explore the relationship between depression and secondary prevention of CHD in Chinese patients after PCI.MethodsThis descriptive, cross-sectional one-site study recruited both elective and emergency PCI patients one year after discharge. Data from 1934 patients were collected in the clinic using questionnaires and medical history records between August 2013 and September 2015. Depression was evaluated by the 9-item Patient Health Questionnaire. Secondary prevention of CHD was compared between depression and non-depression groups.ResultsWe found that depression affected secondary prevention of CHD in the following aspects: lipid levels, blood glucose levels, smoking status, physical activity, BMI, and rates of medication use.ConclusionsDepressive patients with CHD are at increased risk of not achieving the lifestyle and risk factor control goals recommended in the 2006 AHA guidelines. Screening should focus on patients after PCI because treating depression can improve outcomes by improving secondary prevention of CHD.

Contraindications with recombinant tissue plasminogen activator (rt-PA) in acute ischemic stroke population

BackgroundMost of the exclusion criteria in a stroke population are attributed to demographic, more specific or relative contraindications indicating that thrombolysis maybe beneficial more to a stroke population with less restrictive criteria. MethodsWe analyzed a three year data set from a large stroke registry on rt-PA administration based on the US Food and Drug Administration (FDA) package insert, explicitly for the use of tissue-type plasminogen activator in acute ischemic stroke. We identified absolute and relative contraindications including specific clinical rationales for exclusion. ResultsA total of 663 ischemic stroke patients were eligible to receive rt-PA. Out of the 663 acute ischemic stroke patients, 241 received rt-PA and 422 were excluded based on specific absolute and relative exclusionary contraindications. Patients older than 80 years and those with mild or rapidly improving stroke symptoms, and higher NIHSS significantly influenced the decision to exclude stroke patients from rt-PA. ConclusionContraindications differ with individual patients’ representing commonly encountered clinical situations that support most of the exclusion criteria in both the old FDA package insert and AHA guideline.

Changes in cardiac arrest patients\u2019 temperature management after the publication of 2015 AHA guidelines for resuscitation in China

A survey was performed to assess the current management of targeted temperature management (TTM) in patients following cardiac arrest (CA) and whether healthcare providers will change target temperature after publication of 2015 American Heart Association guidelines for resuscitation in China. 52 hospitals were selected from whole of China between August to November 2016. All healthcare providers in EMs and/or ICUs of selected hospitals participated in the study. 1952 respondents fulfilled the survey (86.8%). TTM in CA patients was declared by 14.5% of physicians and 6.7% of the nurses. Only 4 of 64 departments, 7.8% of physicians and 5.7% of the nurses had implemented TH for CA patients. Since the publication of 2015 AHA guidelines, 33.6% of respondents declared no modification of target temperature, whereas 51.5% declared a target temperature’s change in future practice. Respondents were more likely to choose 35∼36 °C-TTM (54.7%) after guidelines publication, as compared to that before guidelines publication they preferred 32∼34 °C-TTM (54.0%). TTM for CA patients was still in the early stage in China. Publication of 2015 resuscitation guidelines did have impact on choice of target temperature among healthcare providers. They preferred 35∼36 °C-TTM after guidelines publication.

Preference Of Dental Practitioner On Antibiotic Prophylaxis For Infective Endocarditis Guidelines: The Cohort Of Klang Valley

Introduction: Antibiotic prophylaxis guidelines for infective endocarditis have been regularly revised and modified based on current scientific evidence. These guidelines commonly regarded as standard of care and determine the medicolegal standards. The aim of this study was to elicit the current practice of prophylaxis antibiotic for Infective endocarditis among general dental practitioner in Klang Valley. Materials and Methods: A standardized questionnaire forms were distributed to the selected dental practitioners in Klang Valley by mail. Results: 43 out of 427 questionnaires was answered and posted back. 70.6% of the respondent claimed to be following guidelines that advocate antibiotic prophylaxis for the prevention of infective endocarditis (American Heart Association, British Cardiac Society, European Society of Cardiology) while others claimed to be following The National Institute for Health and Clinical Excellence guidelines (no antibiotic prophylaxis). However, majority of the respondent showed poor compliance towards the guideline. Several barriers have been identified. Conclusion(s): Majority of the respondent preferred to choose AHA guidelines for antibiotic prophylaxis. However, adherence to the guidelines seems to be low. Efforts to increase awareness of the guidelines among the dental practitioner should be taken.