High-risk Patients Research Articles

HPB SO65 - An audit of the day-case rate of laparoscopic cholecystectomies at a busy district general hospital and factors affecting this

Abstract Background The target day case rate of laparoscopic cholecystectomies at a busy district general hospital is 75%, as per Model Hospital Guidelines. The current rate at which day cases are achieved is 55%. This audit aims to identify factors relating to the DGH not reaching their day case target and explore potential solutions for these, with the intention to reduce patient’s hospital stay and, therefore, overall costs. Method 119 patients had undergone a laparoscopic cholecystectomy in the first five months of 2024. Exclusion criteria included hot cholecystectomies, common bile duct explorations and planned admissions. The remaining 85 patients were included in this audit. The data proforma included age, ASA, BMI, co-morbidities, Nassar grade, scheduled and actual time of operation and any reasons for delay. Results Of the 85 patients included in this audit, 34% (29) were not daycases. 11 remained an inpatient due to post-operative nausea or pain, 3 due to requiring an MRCP, 9 were kept in for monitoring, 2 had intraoperative bleeding, 3 had social issues and 1 required IV antibiotics. 58% of the 29 had afternoon operations. 48% of the 29 had a Nassar grade of greater than 1. 38% of the 29 had a BMI greater than 30. Conclusion Various reasons for a case to not achieve daycase status were found, with the most common being post-operative pain or nausea. It would prove beneficial to educate patients on common post-operative symptoms and focus on managing these symptoms effectively. Pre-operative appointments should aim to explore a patients home setting at the time of the operation and ensure to book inpatient stays for those who require it, in advance. Theatre lists should be optimised by giving high-risk patients morning slots.

Impact of induction agents and maintenance immunosuppression on torque teno virus loads and year-one complications after kidney transplantation

BackgroundTorque teno virus load (TTVL) is gaining importance as a surrogate parameter to assess immunocompetence in kidney transplant recipients. Although the dynamics of TTVL have been investigated before, the impact of different induction agents and variations in immunosuppressive maintenance therapies on TTVL remain unknown.MethodsIn this retrospective study, TTVL was quantified in 537 plasma or serum samples from 134 patients transplanted between 2018 and 2021. TTVL was examined pre-transplantation and 30-, 90-, 180-, and 360-days post-transplant. To assess the influence of induction therapy on TTVL, 67 patients receiving anti-thymocyte globulin (ATG) induction were matched with 67 patients receiving an interleukin-2 receptor antagonist (IL2-RA) induction in terms of age, sex, and donor modality.ResultsFollowing transplantation, there was a steep increase in TTVL post-transplant for all patients with peak viral loads at 90 days post-transplant (median TTVL [IQR] 7.97×106, [4.50×105–1.12×108]) followed by subsequently declining viral loads. Compared to patients receiving IL2-RA as induction therapy, patients receiving ATG had significantly higher peak viral loads 3 months post-transplant (median TTVL [IQR] 2.82×107 [3.93×106–1.30×108] vs. median TTVL [IQR] 2.40×106 [5.73×104–2.60×107]; P<0.001). Throughout all post-transplant time points, patients receiving additional rituximab for induction along with higher tacrolimus target levels exhibited the highest TTVL.Patients whose TTVL 3-months post-transplant exceeded the currently proposed cutoff to predict infections within the first year post-transplant [6.2 log10] showed a trend towards a higher risk of being hospitalized with an infection in the following 9 months, albeit without being statistically significant (HR=1.642, P=0.07).ConclusionsHigher TTVL reflects the greater immunosuppressive burden in immunological high-risk patients receiving intensive immunosuppression. The choice of induction agent and intensified immunosuppressive maintenance therapy notably affects TTVL at 3 months post-transplant and beyond, necessitating careful consideration when interpreting and applying TTVL cutoffs to monitor immunocompetence post-transplant.

A generalized health index: automated thoracic CT-derived biomarkers predict life expectancy.

To identify image biomarkers associated with overall life expectancy from low-dose computed tomography and integrate them as an index for assessing an individual's health. Two categories of CT image features, body composition tissues and cardiopulmonary vasculature characteristics, were quantified from LDCT scans in the Pittsburgh Lung Screening Study cohort(n = 3,635). Cox proportional-hazards models identified significant image features which were integrated with subject demographics to predict the subject's overall hazard. Subjects were stratified using composite model predictions and feature-specific risk stratification thresholds. The model's performance was validated extensively, including 5-fold cross-validation on PLuSS baseline, PLuSS follow-up examinations, and the National Lung Screening Trial (NLST). The composite model had significantly improved prognostic ability compared to the baseline model (p < 0.01) with AUCs of 0.774 (95% CI: 0.757-0.792) on PLuSS, 0.723 (95% CI: 0.703-0.744) on PLuSS follow-up, and 0.681 (95% CI: 0.651-0.710) on the NLST cohort. The identified high-risk stratum were several times more likely to die, with mortality rates of 79.34% on PLuSS, 76.47% on PLuSS follow-up, and 46.74% on NLST. Two cardiopulmonary structures (intrapulmonary artery vein ratio, intrapulmonary vein density) and two body composition tissues (SM density, bone density) identified high-risk patients. Body composition and pulmonary vasculatures are predictive of an individual's health risk; their integrations with subject demographics facilitate the assessment of an individual's overall health status or susceptibility to disease. CT-computed body composition and vasculature biomarkers provide improved prognostic value. The integration of CT biomarkers and patient demographic information improves subject risk stratification.

A novel nomogram for predicting non-infectious fever in patients following laparoscopic myomectomy.

This study aimed to develop and validate a novel nomogram to predict the risk of non-infectious fever (NIF) in patients following laparoscopic myomectomy. A retrospective analysis was conducted on data from patients who underwent laparoscopic myomectomy between 2019 and 2023. Pertinent variables before, during, and after surgery were collected. Multivariate logistic regression analysis identified independent risk factors for postoperative NIF, from which a nomogram was constructed. The study included 576 patients, among whom 64 (11.1%) developed postoperative NIF. Multivariate analysis identified leiomyoma size, number of leiomyomas, preoperative hemoglobin levels, operative time, and estimated blood loss as independent risk factors for postoperative NIF. A predictive nomogram model incorporating these factors demonstrated good accuracy following internal validation. The developed nomogram represents the first tool tailored for predicting NIF after laparoscopic myomectomy. Its implementation can assist clinicians in early identification of high-risk patients, facilitating timely preventive and management strategies.

Abstract 4132875: Living Address Environmental Biotope Affects the Risk of Coronary Obstruction and Myocardial Ischemia Detected by Coronary Computed Tomography

Background: Several studies reported positive associations between air and noise pollution exposure and coronary artery calcification, but environmental effects on coronary obstruction and flow remain largely unknown. Hypothesis: Distance to road and airport, air pollution, and residential green space are linked to coronary artery obstruction and myocardial ischemia. Low CV-risk patients develop coronary obstruction due to environmental factors, while high-risk patients are more prone to develop myocardial ischemia. Methods: Consecutive patients screened by coronary CT angiography for stable chest pain between 01/01/2019 and 31/12/2020 were included in a registry. Distance to airport and major road, and exposure to PM2.5, NO 2 and normalized difference vegetation index (NDVI) were modelled at patients’ living address. Risk of obstructive coronary artery disease (OCAD, stenosis ≥50%) and abnormal fractional flow reserve (FFR CT &lt;80%) was assessed using propensity score (PS)-adjusted logistic regression. Subgroup analysis was performed according to gender and Framingham CV-risk categories. Results: We enrolled 2620 patients, including 420 (16%) FFR CT analyses. OCAD was reported in 518 (20%) patients and abnormal FFR CT in 276 (11%). People with OCAD lived closer to the airport (10.841 [7.869-19.022] km vs. 12.297 [8.691-22.843] km, p&lt;0.001). Distance to airport decreased OCAD risk (OR 0.983, 95%CI 0.974-0.992, per 1 km) in univariate analysis, with the association present in male, female, and low-risk patients. After PS-adjustment, a trend of association was present between airport distance and abnormal FFR CT risk (OR 0.986, 95%CI 0.969-1.003, per 1 km). Road distance tended to decrease OCAD risk in univariate and PS-adjusted analysis, in the general (OR 0.928, 95%CI 0.808-1.309; and OR 0.928, 95%CI 0.840-1.021, per 1 km) and high-risk population. NO 2 exposure tended to increase OCAD risk in univariate analysis (OR 1.012, 95%CI 0.997-1.027, per 1 µg/m 3 ), with the association only present in female patients, and disappearance after PS-adjustment. PM2.5 exposure showed no associations, while NDVI tended to increase OCAD risk in low-risk patients after PS-adjustment. Conclusion: Residential distance to airport is the major risk component compared to other urban exposome factors studied in this epidemiological observation. Green space tends to exert a cardioprotective effect in low-risk patients, whereas living close to major road worsens the risk in high-risk patients

Abstract 4137922: Cardiovascular Prognosis of Statin Users Developing Diabetes in Secondary Prevention: A Prospective Multicenter Study

Background: In primary prevention, statin use with new-onset diabetes mellitus (DM) was associated with increased atherosclerotic cardiovascular disease (ASCVD) risk. In high-risk and secondary prevention settings, the cardiovascular prognosis of statin users progressing to new-onset DM remains unclear. Methods: We collected data from inpatients with or without baseline ASCVD from four medical centers affiliated to Qingdao University. Patients were categorized into 4 phenotypes: (1) statin non-users without diabetes; (2) statin users with incident diabetes; (3) statin users with pre-existing diabetes; and (4) statin users without diabetes. The primary outcome was ASCVD events. The stratified Cox proportional hazard model was used to investigate the association between the four distinct phenotypes and the risk of ASCVD. Results: Among 12,800 high-risk patients, over a median follow-up of 118 days (interquartile range, 48-379 days), 1447 ASCVD events were documented. Compared with statin non-users without diabetes, statin users without diabetes (hazard ratio [95% confidence interval], 0.77 [0.65, 0.91], P=0.001) and statin users with pre-existing diabetes (0.80 [0.66, 0.99], P=0.035) were associated with lower risk of ASCVD, whereas statin users with new-onset diabetes were not (0.91 [0.70, 1.19], P=0.50), overall P for trend =0.013.( Figure 1 ) In patients with baseline ASCVD (i.e., secondary prevention settings), we observed similar findings ( Figure 2 ) Conclusions: In high-risk patients with pre-existing ASCVD, new-onset diabetes after statin use was likely associated with compromised cardiovascular benefits of statins.

Abstract 4136463: Novel Systemic Inflammatory Biomarkers Can Predict Significant Coronary Disease in High Risk Patients

Background: Coronary artery disease (CAD) is a major cause of morbidity and mortality worldwide. Chronic inflammation is a known risk factor for atherosclerosis, plaque formation, disease progression, and plaque instability. Novel inflammatory biomarkers have been recently linked to excess risk of adverse cardiovascular events, including incident myocardial infarction. Elevated inflammatory biomarkers may help identify patients at higher risk for severe CAD. Aim: This study aimed to evaluate the use of novel systemic inflammatory markers in predicting the pretest probability of severe CAD in patients referred to diagnostic coronary angiography in a single tertiary care center. Methods: This was a prospective observational cohort study enrolling consecutive patients referred to diagnostic coronary angiography in a tertiary care center. Preprocedural laboratory results were obtained from medical charts, including complete blood counts with differentials. Three novel systemic inflammatory markers were computed using existing mathematical formulas: systemic immune-inflammation index (SII = neutrophil count*platelet/lymphocyte); systemic inflammation response index (SIRI = neutrophil*monocyte/lymphocyte); and systemic immune inflammatory response index (SIIRI = neutrophil*monocyte*platelet/lymphocyte). The primary study outcome was severe CAD defined as the presence of ≥70% stenosis in one of three main coronary arteries requiring percutaneous coronary intervention). The outcome was adjudicated by an independent reviewers blinded to computations of biomarkers. Result: The sample included 264 patients (age 59.3±10.8, 47% Females). Overall, 84 patients (32%) met the primary study outcomes. In univariate analysis, those with severe CAD had significantly higher SIRI (2.9±0.7 vs. 2.6±0.6, p = 0.001) and SIIRI (8.4±0.8 vs. 8.1±0.7, p = 0.015) compared to their counterparts. In multivariate analysis adjusted for age and sex, only SIRI was an independent predictor of severe CAD. Using SIRI &gt; 20.8 (upper quartile) was associated with nearly three-fold excess risk of severe CAD (OR = 2.72, 95% CI 1.45-5.09). Conclusion: Elevated SIRI, a marker of ongoing systemic inflammatory response, could be indicative of severe CAD. As an inexpensive biomarker based exclusively on complete blood count, SIRI can be used to prioritize patients referred for diagnostic angiography and potentially expedite treatments in those at higher risk for coronary events.

Abstract 4134309: From Heartache to Headache: Cryptococcal Meningitis Post-Heart Transplant in a Chronic Hepatitis B and Sarcoidosis Patient

Introduction: We report the case of a heart transplant patient on chronic immunosuppression diagnosed with cryptococcal meningitis. Up to 5% of solid organ transplant patients develop cryptococcosis, carrying a 50% mortality rate in central nervous system involvement. Case Presentation: This is a 57-year-old male with a past medical history of heart failure with reduced ejection fraction (HFrEF) status post orthotopic heart transplantation (on prednisone 7.5 mg daily, mycophenolate, tacrolimus and sirolimus), pulmonary sarcoid, and chronic hepatitis B (on tenofovir and entecavir) who presented with headache, nausea, vomiting and seizure-like activity. The patient’s heart rate was 129 beats per minute, blood pressure 188/92 mmHg, but was afebrile. He eventually underwent a lumbar puncture with the cerebrospinal fluid (CSF) positive for cryptococcal antigen (1:2560). The patient was started on liposomal amphotericin B and flucytosine. Mycophenolate and sirolimus were held in the setting of his infection. The patient’s hospital course was complicated by acute kidney injury likely secondary to elevated tacrolimus levels while on fluconazole. He was ultimately discharged with plans to repeat CSF studies as an outpatient. Discussion: Here we report a case of cryptococcal meningitis in a heart transplant patient in the context of pulmonary sarcoidosis, chronic hepatitis B and quadruple immunosuppression. Of note, as part of rejection surveillance, the patient undertook serial AlloSure and AlloMap testing. Sirolimus was added to his regimen due to persistently elevated AlloSure scores. Indeed, immunosuppressive agents are the leading risk factor for cryptococcosis in organ transplant patients. Our patient also has two important risk factors for cryptococcal infection. Firstly, sarcoidosis is associated with T-cell dysregulation, compromising cell-mediated immunity. Additionally, hepatitis B carriers have an increased predisposition for cryptococcal infections, notwithstanding that our patient had been on dual antiviral therapy. Conclusion: Quadruple immunosuppression in heart transplant patients, especially in the context of risk factors such as sarcoidosis and hepatitis B infection, can result in cryptococcal meningitis and should be considered in patients with suggestive symptoms. Effective prophylactic regimens for such higher risk patients may be a potential area for further investigation.

Abstract 4124065: Clonal Hematopoiesis of Indeterminate Potential (CHIP) in Chronic Coronary Artery Disease: A Report from the ISCHEMIA Trials Biorepository

Introduction: CHIP is associated with CAD and mortality. The prognostic relevance of CHIP for high-risk patients with confirmed CAD is unknown. Hypothesis: CHIP variants are associated with cardiovascular (CV) events and mortality in high-risk patients with known CAD in the ISCHEMIA Trials Biorepository. Methods: 895 ISCHEMIA and ISCHEMIA-CKD (hereafter, ISCHEMIA Trials) participants with moderate-severe ischemia and next-generation sequencing performed for CHIP variant allele fractions of ≥2% (CHIP) and ≥10% (large CHIP) were included. Unadjusted and multivariable adjusted (age, sex, diabetes, eGFR not on HD, HD, and LVEF) associations of CHIP and large CHIP with a) ISCHEMIA Trials initial phase primary endpoint (CV death, myocardial infarction (MI), or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest, RCA) and b) ISCHEMIA Trials combined initial and extended follow-up phase (hereafter, Cumulative) endpoint of all-cause death . Results: Median (IQR) age of sequenced participants was 67 (56 – 79) years, 19% were female, 83% white, and 6% Hispanic. Hypertension (84%), diabetes (45%) and obesity (47%) were common, 26% had an eGFR &lt;60 ml/min/1.73m 2 . The prevalence of CHIP and large CHIP was 23% and 7%, and both increased with age ( Figure 1a ). CHIP mutations in DNMT3A were detected in 106 (12%), TET2 CHIP in 44 (5%), and ASXL1 CHIP in 21 (2%) participants ( Figure 1b ). DNMT3A, TET2, and CREBBP mutations collectively comprised 199 (52%) of overall CHIP mutations, including individuals with multiple mutations in the same gene (N overall = 385); 67 participants (7%) had mutations in &gt;1 gene. Over 3.1 years of RCT follow-up there were 135 (20%), 32 (16%) and 15 (18%) primary endpoints for no CHIP, CHIP and large CHIP, respectively. Over 6.8 years of EXTEND follow-up, there were 126 (18%), 47 (23%) and 24 (29%) deaths in the no CHIP, CHIP and large CHIP groups, respectively. After multivariable adjustment there was no association between CHIP or large CHIP and CV events or mortality ( Figure 1c ). Conclusion: Neither CHIP nor large CHIP was associated with adverse outcomes in 895 high-risk individuals with confirmed CAD, despite a high prevalence of these mutations.

Abstract 4137165: Changes in Contrast Volume among Patients Undergoing Percutaneous Coronary Intervention: a Report from NCDR CathPCI registry

Background: Acute kidney injury (AKI) is the most common complication after percutaneous coronary intervention (PCI) and can be mitigated by using less iodinated contrast. The National Cardiovascular Data Registry (NCDR) supports quality improvement initiatives by providing quarterly, risk-adjusted, institutional AKI rates. However, it remains uncertain whether these efforts have reduced procedural contrast volume, particularly in high-risk patients. Aims: Examine temporal trends in contrast volume during PCI across different pre-procedural AKI risk strata. Methods: Within the NCDR CathPCI Registry, we identified PCIs performed between April 1, 2018, and December 31, 2022, and examined changes in mean contrast volume over time across different pre-procedural AKI risk strata defined by the validated NCDR AKI risk model. A multivariable hierarchical model, with the physician as a random effect, was constructed to assess the trend in contrast volume use over time. Results: Among 3,126,559 patients undergoing PCI (mean age = 66.8 ± 11.7 years, 69.4% men, and 39.9% elective procedures), contrast volume declined from a mean of 168.1±77.6 ml in Q2 2018 to 149.8±71.2 ml in Q4 2022 ( p &lt; 0.001 for trend) with the trend being consistent across AKI risk strata ( Figure ). After adjusting for patient and pre-procedural characteristics, the contrast volume declined by 18.9 ml (95%CI 19.1 to 18.6, P &lt;0.001) between 2018 and 2022. Despite marked physician variability in mean contrast use, the lowest mean contrast doses were observed in patients at greatest AKI risk (&gt;15%). Conclusions: PCI contrast administration has declined over time, and the average exposure was lowest in patients at highest risk for AKI, suggesting improved efforts to reduce AKI over time.

Abstract 4138294: Medicare Utilization and Associated Spending on Icosapent Ethyl

Introduction: In 2019, Icosapent Ethyl became the first US Food and Drug Administration (FDA) approved medication for reducing cardiovascular risk beyond cholesterol-lowering therapy in high-risk patients. It was approved specifically as an adjunct to maximal tolerated statin therapy to reduce cardiovascular risk in adult patients with elevated triglyceride (TG) levels. The National Lipid Association now has a Class I recommendation for the use of icosapent ethyl (4 g/d) to reduce cardiovascular risk in patients with TG &gt; 150 mg/dl. Methods: We analyzed available data from Medicare Part D prescription drug events published from the year 2018 to 2022. All data were de-identified and made publicly available. All costs were adjusted for inflation and represented in 2022 US dollars. Results: The number of Medicare Part D beneficiaries prescribed Icosapent Ethyl increased from 141,336 to 303,971 (215%) between 2018 and 2022 (Fig. A) and the number of claims increased from 704,334 to 1,527,133 (216%) (Fig. B). The total spending increased from $278 million to $787 million (282%) within the same timeframe (Fig. C). The average spending per claim has increased from $396 to $515 (130%) (Fig. D) and the average spending per beneficiary has also increased from $1976 to $2591 (131%) (Fig. E) between 2018 and 2022. Discussion: We observed a marked increase in the use of icosapent ethyl from 2018 to 2022. We can see a sharp rise of 187% in beneficiaries from 2018 to 2019 following FDA approval. The total number of claims and total spending also increased by 181% and 200%, respectively, from 2018 to 2019. The average spending per claim and average spending per beneficiary has increased from 2018 to 2022. It also demonstrates the cost burden to Medicare with the use of such lipid-lowering agents. Many Medicare plans include icosapent ethyl as a Tier 4 drug, which is the second most expensive drug tier. Limitations: The pattern of data used may not be generalizable to other payer demographics. Policy changes can affect the comparability of data over different periods. Conclusion: Our data highlights the increasing use of icosapent ethyl as a cardiovascular risk-reduction medication in the Medicare population. There has been a steady increase in the number of claims and beneficiaries since the approval of icosapent ethyl with an increase in average spending from 2018 to 2022.

Abstract 4135270: Clinical and Procedural Outcomes after Transcatheter Aortic Valve Replacement vs Surgical Aortic Valve Replacement in Severe Aortic Stenosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Introduction: A growing body of evidence from randomized controlled trials (RCTs) has demonstrated the superiority of transcatheter aortic valve replacement (TAVR) over surgical aortic valve replacement (SAVR) irrespective of surgical risk in patients with severe aortic stenosis (SAS). Given the rise in TAVR procedures, analyzing trends in outcomes over time is critical to aid clinical decision-making. Hence, we pooled RCT data for a robust assessment of clinical and procedural outcomes in SAS patients undergoing TAVR and SAVR. Methods: PUBMED and SCOPUS were queried until April 2024. Trials were classified into high and low-risk groups based on surgical risk. The outcomes were analyzed at 30 days (short-term), 1 year (mid-term), and 5 years (long-term). Estimates were calculated as random effects risk ratios (RRs) with 95% confidence intervals (CI). Results: 10 RCTs with a total of 10,252 patients were included. There was no significant association between TAVR and SAVR in reducing all-cause mortality at 30 days (RR: 0.84 [0.64, 1.10]; Figure 1a). While TAVR was associated with a significantly lower all-cause mortality at 1 year (RR: 0.82 [0.68-0.97]; Figure 1b), it was linked with a significantly higher all-cause mortality at 5 years (RR: 1.14 [1.07-1.21]; Figure 1c). Myocardial infarction and stroke were similar in both groups up to 5 years. TAVR was associated with a lower risk of acute kidney injury for up to 1 year and atrial fibrillation for up to 5 years but a higher risk of new permanent pacemaker implantation and aortic valve re-intervention for up to 5 years. In low-risk patients, TAVR showed no significant differences from SAVR for all-cause mortality at 30 days and 5 years, but it was significant at 1 year. In high-surgical-risk patients, all-cause mortality was comparable between TAVR AND SAVR at 30 days and 1 year, with a higher rate observed with TAVR at 5 years. Conclusion: Compared with SAVR, TAVR was superior in reducing all-cause mortality at 1 year in low-risk patients and inferior in reducing all-cause mortality at 5 years in high-risk patients. A thorough evaluation of anatomical, clinical, and procedural factors is crucial to tailor the optimal intervention for each patient.

Abstract 4137718: Coronary Artery Calcium for Risk Stratification of Heart Failure Mortality

Background: There is increasing interest in predicting heart failure (HF), a major cause of morbidity and mortality that exerts a significant financial burden. The role of coronary artery calcium (CAC), an accessible and inexpensive test, in predicting long-term HF mortality amongst asymptomatic adults remains unknown. Objectives: To determine if CAC burden is associated with HF-related mortality in the primary prevention population. Methods: The study included 66,636 primary prevention patients from the Coronary Artery Calcium Consortium. Multivariable competing risks regression was used to assess the association between CAC and HF-related mortality adjusting for demographics and traditional risk factors. Results: The mean age was 54.4 years, 67% male, 89% white, and 55% had CAC &gt;0. A total of 260 HF-related mortality events were observed during a median follow up of 12.5 years, 75.3% of which occurred among those with a baseline CAC score &gt;100. Compared with a CAC = 0, there was a stepwise higher risk (P &lt; 0.005) of HF mortality for CAC 1-100 (subdistribution hazard ratio [SHR]: 2.27; 95% CI: 1.3-3.99), 100-400 (SHR: 3.68; 95% CI 2.1-6.43), and &gt;400 (SHR: 7.05; 95% CI 4.05-12.29). This increasing risk of HF mortality across higher CAC scores persisted across age groups, sex, and in the intermediate and high-risk groups as calculated by the pooled cohort equation (PCE) and the PREVENT equation. Conclusions: Higher CAC is associated with increasing incidence of long-term HF-related mortality in the primary prevention population, particularly intermediate and high-risk patients. Early preventive approaches in patients with high CAC must focus on preventing heart failure and ASCVD with lifestyle changes and medications.

Abstract 4142792: VA Lipid Optimization Reimagined Quality Improvement Project (VALOR-QI) at the Dallas VA

The Dallas VA is one of the 50 VA sites participating in a national quality improvement initiative called VALOR-QI: VA Lipid Optimization Reimagined Quality Improvement Project. VALOR-QI is a collaborative project between the U.S. Department of Veterans Affairs (VA) and the American Heart Association (AHA) with the goal of positively impacting veterans’ cardiovascular (CV) health. As part of the program, VA sites work with an AHA QI Consultant to develop and deploy a local quality improvement plan to help overcome site specific barriers preventing veterans from achieving optimal cholesterol levels. We hypothesize that the QI strategies implemented will positively impact lipid levels and ultimately CV outcomes among high-risk patients. We aim to assess potential barriers to achieving LDL-C &lt;70 mg/dL and develop efficient ways to maintain LDL-C goal. Our approach to the VALOR-QI program at Dallas VA is by enrolling patients with established ASCVD and LDL-C &gt; 70 mg/dL from cardiology, vascular, diabetes, lipid, and independent PharmD clinics. These patients are followed by a health coach every 2- 6 months. Medical adherence is enforced by the health coach ensuring timely refills and reminders. Lifestyle modifications are encouraged via educational materials, referral to dieticians, recreation classes, and tobacco cessation. Patients are also encouraged to sign up for patient portal (my HealtheVet) to access electronic medical records and expedite communication with their healthcare team. The health coach provides individualized counseling regarding lipid lowering treatment and acts as liaison between patients and their providers. VALOR-QI was launched at Dallas VA in Jan 2023. As of May 17 th , 2024, an interim analysis showed that out of 132 veterans engaged, 49 (37.1%) achieved target LDL-C, 66 (50%) received educational material, 4 (3.03%) were referred to dieticians, 10 (7.58%) were referred to recreation programs, and 4 (17.4% of active smokers) were interested in quitting. In conclusion, our VALOR-QI strategy at Dallas VA showed encouraging results, but it is premature to make final conclusions. The support of a health coach showed improved medication adherence, health literacy, and lifestyle modification, thus achieving LDL-C target. Major barriers to achieving target LDL-C were health literacy about high cholesterol, challenges in navigating the health care system, and treatment inertia among patients and providers.

Abstract 4138446: Ceramides Surpass LDL-Cholesterol in Predicting Cardiovascular Mortality in Diabetic and Non-Diabetic Patients

The power of cardiovascular risk prediction is biased by comorbidities (including T2DM), medical treatment, and age, which impact cholesterol levels. Consequently, when applying LDL-C, the true cardiovascular risk of such confounded patients is often underestimated. However, it is not clear whether this constraint for risk prediction may likewise apply to other lipid risk markers in particular ceramides. In this observational cohort study, we recorded cardiovascular mortality for 16 years in 1195 patients. Their median age was 67 years, all of them had a high preexisting cardiovascular risk, 51% were taking statins, and 30% had T2DM. We found a U-shaped association between cardiovascular mortality and LDL-C. We thus stratified the population according to the vertex into high (≥150mg/dL) and lower LDL-C (&lt;150mg/dL) and also according to the T2DM status. A Cox regression analysis revealed that LDL-C failed to predict cardiovascular mortality in any subgroup. In contrast, no U-shaped but a linear association was found for ceramide-based markers. They were able to significantly predict cardiovascular mortality after stratification and even after multivariate adjustment. We thus propose that ceramide-based predictors rather than LDL-C should be applied for a more accurate cardiovascular risk prediction in diabetic and other high-risk patients.

Abstract 4120785: Differential Cardiovascular Impact of ω-3 Fatty Acid in Patients at High Cardiovascular Risk in Asians versus non-Asians: Sub-analysis of the STRENGTH Randomized Clinical Trial

Background: Racial differences in lipid and cardiovascular risk profiles are well-established including for Asians. The STRENGTH trial found that ω-3 carboxylic acid (CA) formulation of eicosapentaenoic acid and docosahexaenoic acid did not result in significant changes in cardiovascular event rates compared with corn oil in statin-treated patients at high cardiovascular risk, however drug efficacy may vary by race. We evaluated and compared the cardiovascular treatment effect of ω-3 CA between Asians and non-Asians in this sub-analysis of the STRENGTH trial. Methods: The STRENGTH trial was a double-blinded 1:1 randomized controlled trial of 13,078 high cardiovascular risk patients enrolled during 10/30/2014-6/14/2017 at 675 centers. Efficacy of ω-3 CA for Asians (n=1,355) and non-Asians (n=11,723) and interactions between race and treatment effect were assessed. The primary endpoint is a composite of cardiovascular death, non-fatal myocardial infarction, stroke, coronary revascularization and unstable angina hospitalizations. Results: Key differences in baseline characteristics include Asians having significantly higher prevalence of men, secondary prevention, and lower total cholesterol, LDL, apoB100, and hsCRP. In Asians, ω-3 CA was associated with significantly lower primary endpoint during follow-up, with 81/698 events [Kaplan-Meier (KM) Estimate: 14.8%] in the ω-3 CA group, 103/657 events (KM Estimate: 20.4%) in the corn oil group, and hazard ratio (HR) 0.72, 95% CI 0.54-0.96, P=0.026 (Figure A). In non-Asians, there was not a significant difference in primary endpoint rates between the two groups, with 704/5841 events (KM Estimate: 15.6%) in the ω-3 CA group, 692/5882 events (KM Estimate: 15.9%) in the corn oil group, and HR 1.03 95% CI 0.93-1.14, P=0.60 (Figure B). There were significant interactions between race (Asian versus non-Asian) and treatment group for the primary endpoint (P=0.021) and non-fatal stroke (P=0.016) and remained significant after adjusting for other covariates. Conclusion: ω-3 CA was associated with significant reduction in major adverse cardiovascular events compared with corn oil in Asians but not in non-Asian patients with high cardiovascular risk. Further research is necessary to elucidate the mechanisms for potentially beneficial effects of ω-3 CA unique to Asian race.

Abstract 4122080: Outcomes of Left Atrial Appendage Occlusion With and Without Concurrent Catheter Ablation for Patients at High Bleeding Risk: A Systematic Review and Meta-analysis

Introduction: The prevalence of non-valvular atrial fibrillation (NVAF) and stroke-related morbidity is rising. First-line therapy remains rate or rhythm control with anticoagulation, with catheter ablation (CA) also considered in suitable candidates. Left atrial appendage closure (LAAC) is increasingly used due to mounting evidence of non-inferiority compared to anticoagulation. Despite improved pre-procedural planning and patient selection reducing complications, adverse outcomes such as pericardial effusion and device-related thrombus occur in about 5% of patients. This study evaluates the outcomes of LAAC with CA versus standalone LAAC in NVAF patients with contraindications to anticoagulation. Methods: We searched PubMed, EMBASE, and Cochrane databases for all cohort studies comparing LAAC with CA to LAAC alone in patients with NVAF. Case series, reviews, and non-English language studies were excluded. The assessed outcomes included device compression rate at implant, device-related thrombosis, pericardial effusion, need for pericardiocentesis, and peri-device leak at 6 weeks. Statistical analysis was performed using Review Manager 5.1.7. Heterogeneity was assessed with I 2 statistics. Results: We included 6 studies with 51,545 patients, of whom 1,221 (2.3%) underwent both procedures. LAAC with CA and standalone LAAC cohorts had similar baseline demographics including age (68, 69 years), percentage of women (48%, 46%), CHA2DS2-VASc score (3.6, 3.7), and HAS-BLED score (3.1, 3.2). LAAC with CA was associated with a reduced incidence of device-related thrombosis (OR=0.18; 95% CI= 0.04-0.89; p=0.04) without an increase in pericardial effusion rates (OR=0.85; 95% CI= 0.48-1.51; p=0.59). There were no significant differences in device compression rates at implant (MD=0.34; 95% CI= -0.77-1.45; p=0.55), the need for pericardiocentesis (OR=1.01; 95% CI= 0.30-3.48; p=0.98), or rates of peri-device leak at 6 weeks (OR=0.61; 95% CI= 0.21-1.78; p=0.37). Conclusion: Concomitant LAAC with CA may reduce rates of device-related thrombosis compared to standalone LAAC without increasing the risk of pericardial effusion or peri-device leak at 6 weeks. These findings support the consideration of combining these procedures in the management of high-risk NVAF patients unable to tolerate anticoagulation.

Abstract 4148074: Radial Artery Pseudoaneurysm Following Transradial Cardiac Catheterization: A Systematic Review and Case Report

Introduction/Background: Transradial cardiac catheterization (TRC) is recommended for patients with acute coronary syndrome over femoral artery catheterization. Randomized controlled trials show TRC has significantly lower rates of bleeding, vascular complications, and mortality in high-risk acute coronary syndrome patients. However, vascular complications like radial artery spasm, occlusion, arteriovenous fistula, perforation, and pseudoaneurysm (PSA) can still occur. Despite TRC's widespread adoption, recent data summarizing radial artery pseudoaneurysm post-TRC is lacking. Research Question/Hypothesis This review aims to identify at-risk patients, present a case of catheterization-related radial artery pseudoaneurysm, and provide diagnostic and management insights. We hypothesize that older patients with hypertension are at higher risk and that early detection and management are associated with low complication rates. Methods/Approach: Systematic searches were conducted in PubMed, Web of Science, EMBASE, and CINAHL databases. Two researchers independently selected articles, extracted data, and evaluated study quality on RA PSA post-TRC (2003–2023). A third reviewer resolved conflicts. The Joanna Briggs Institute (JBI) tool was used to evaluate bias risk. Additionally, a case report is presented. Results: From 3,262 records, 43 studies were selected, involving 67 patients (58.8% female, median age 73.5 years). Hypertension (39.5%) and atrial fibrillation (27.9%) were the most common comorbidities. Percutaneous interventions like stenting and angioplasty caused 58.1% of cases; diagnostic catheterizations accounted for 37.2%. Ultrasonography diagnosed 83.7% of cases. Symptoms appeared a few hours to four months post-TRC, with pulsatile mass (21.4%) and swelling (14.3%) being the most common, and pain and ecchymosis at 2.4% each. More than half of the patients (51.2%) required surgical intervention, but 66.7% recovered without deficits. Severe complications were rare, affecting fewer than 5%. Conclusions: A literature review of 43 articles with 67 patients suggests older female patients with hypertension may be more prone to radial artery pseudoaneurysm post-TRC. It typically presents as a pulsatile, painful swelling detectable by ultrasound. This complication precludes the use of the radial artery as a conduit for coronary artery bypass grafting. The review highlights the importance of vigilant post-catheterization monitoring to enable early detection and treatment.

Abstract 4136819: Necrotizing Enterocolitis is More Common After Hybrid Stage 1 Palliation Than Norwood Without Clear Risk Factors

Background: Infants with congenital heart disease are at high risk of developing necrotizing enterocolitis (NEC), with increased morbidity and mortality compared to infants without heart disease who develop NEC. Shunted single ventricle patients are at even higher risk. The hybrid stage 1 palliation (HS1P) is an alternative to the Norwood procedure for high-risk single ventricle patients or as initial palliation for patients with future two ventricle repair, as bridge to transplant, or as destination therapy. Few small studies have shown similar or slightly higher rates of NEC after HS1P compared to after Norwood. Aims: To evaluate the incidence, risk factors, and outcomes of NEC in HS1P versus Norwood patients. Methods: This is a single-center retrospective cohort study of all neonates who underwent HS1P or Norwood procedure from 2011-2022. Demographic data and episodes of NEC (defined using modified Bell’s criteria) were collected. NEC incidences and risk factors were compared between HS1P and Norwood patients using Chi-square test. For HS1P patients, more extensive data were collected including planned and final physiologic outcomes (single ventricle palliation, biventricular repair, transplant, and destination) and primary patient risk factors that led to HS1P. Risk factors and clinical outcomes of HS1P patients with and without NEC were compared using standard univariate tests. Results: The cumulative incidence of NEC in the HS1P group was 53% versus 37% in the Norwood group (p=0.01) and HS1P patients had more NEC episodes than the Norwood group (median 2 vs 1, p=0.03). Suspected NEC (stage 1A/1B) accounted for 70-75% of NEC cases in both groups. Only two infants, both in the HS1P group, had surgical (stage 3B) NEC. We found no differences in baseline demographics between patients with and without NEC in both HS1P and Norwood groups. In the HS1P group, NEC was associated with longer hospital length of stay (LOS), (median 49 days vs 23 days, p&lt;0.0001) and greater need for tube feeds at 1 year (32% of the NEC group exclusively orally fed versus 43% of the non-NEC group, p=0.03). Final physiologic outcome was not associated with development of NEC in the HS1P group (p=0.38). Conclusions: While the exact risk factors or predictors are not clear, NEC is more common after HS1P compared to Norwoods and is associated with longer hospital LOS and late feeding difficulty. Further studies to better understand the physiologic causes of NEC in the HS1P population are needed.

Abstract 4116558: Navigator-driven Recommendations for Palliative Care Consults for Patients with Heart Failure and High Predicted Mortality

Background: Palliative care (PC) engagement can improve quality of life, reduce hospital costs, and enhance symptom control for individuals with heart failure (HF). For certain HF patients, PC can address symptoms and improve quality of life. However, referrals to PC often occur late, delaying benefits. Hypothesis: We hypothesize that a standardized recommendation for inpatient PC consultation will increase PC consultation rates and improve 30-day readmission without an impact on 30-day mortality rates. Methods: This interrupted time series study focused on high-risk HF patients at Atrium Health Wake Forest Baptist. The cohort included patients in the Golden Hearts Program, which is a local program to identify HF patients at elevated risk for 30-day readmissions and to accelerate resources to support their transitions. Baseline data were from patients 5 months before September 1, 2023, and the intervention group were from patients 5 months afterward. A standardized message recommending inpatient PC consultation was sent to attending physicians for patients with ESCAPE scores ≥4. Recommendations were also discussed at multidisciplinary rounds with senior residents. The primary outcomes were inpatient palliative care consultation and discharge to Hospice. Secondary outcomes were 30-day readmissions and 30-day mortality. Outcome measures were assessed post-discharge using Chi-square and T-test analyses. Results: The baseline group had 203 patients; the intervention group had 213. Post-intervention, PC consultation rates decreased from 12.3% to 8% (p=0.19), Discharge to hospice decreased from 2% to 0.9% (p=0.05), 30-day mortality decreased (8.4% vs 7%, p=0.74), and 30-day readmission dropped from 23.6% to 15% (p=0.04). The average length of stay remained 5.7 days in both groups. Limitations included provider buy-in and a limited time period. Conclusion: Though the intervention aimed at targeted PC consult recommendations for advanced HF patients led to reduced 30-day readmissions, there was a not a statistically significant impact on palliative care consultation or mortality.