Hospital Discharge Research Articles

Evaluation of a complex intervention: the Latch On randomized controlled trial of multicomponent breastfeeding support for women with a raised body mass index.

Latch On's objective was to achieve improved breastfeeding rates in women with raised body mass indices using a multicomponent breastfeeding support intervention. A hybrid type 1 implementation-effectiveness trial with mixed-methods process and health economics analyses were conducted. Data collection included stakeholder questionnaires, interviews, focus groups, fidelity data, participant and health system costs. The intervention was delivered with fidelity but the high breastfeeding rates at 3months were not different between intervention and usual care. Participants receiving the minimum intervention dose were more likely to initiate breastfeeding (P=0.045) and be breastfeeding at hospital discharge (P=0.01) compared with participants below the threshold. Participant exit interview themes highlighted the importance of improving breastfeeding support to women, the effect of COVID-19 on the breastfeeding experience, and found that the intervention improved the experience of establishing breastfeeding. The intervention cost €157 per participant, with no other cost difference between groups. Process analysis found that follow-up breastfeeding services continued in half of sites after study completion. This low-cost intervention resulted in a more enjoyable breastfeeding experience for participants and changed practice in some study sites. The intervention dose received may impact effectiveness, but further research is needed to provide definitive evidence of clinical and cost effectiveness.

Abstract Su1202: The utility of post cardiac arrest temperature control protocol according to the severity of hypoxic encephalopathy based on amplitude-integrated electroencephalography findings

Introduction: The TTM2 trial showed that active fever prevention below 37.5°C and hypothermia at 33°C had similar outcomes in out-of-hospital post cardiac arrest patients. However, the patients in the trial had mild hypoxic encephalopathy, and the effects of hypothermia may vary with its severity. We previously reported that amplitude-integrated electroencephalography (aEEG) findings after the return of spontaneous circulation can be used to categorize the severity of hypoxic encephalopathy (Crit Care. 2018;22:226). In September 2022, we adopted a new temperature control protocol wherein the target temperature was set based on aEEG findings. This study examined changes in outcomes before and after implementing this new protocol. Methods: We assessed out-of-hospital cardiac arrest patients who received post cardiac arrest care in our emergency intensive care unit between March 2021 and February 2024. We divided the patients into two groups: before (B) and after (A) the introduction of the new protocol. We classified the patients into categories 1 (C1) to 4 (C4) based on the severity of hypoxic encephalopathy (Figure 1). All patients in group B were treated with hypothermia at 34°C. In group A, patients in C1 were treated with active fever prevention, and those in C2–C4 received hypothermia at 34°C (Figure 2). Primary outcome was favorable neurological outcomes (cerebral performance categories of 1 or 2) at hospital discharge. Secondary outcome was the duration of mechanical ventilation. Results: A total of 160 patients were included. The median age was 62 years and 105 (66%) patients had cardiac etiology. Fifty-five (34%) patients underwent extracorporeal cardiopulmonary resuscitation. The median cardiac arrest time was 29 min. Groups B and A comprised 57 and 103 patients, respectively. C1 category comprised 20 and 28 patients in groups B and A, respectively. The rate of favorable neurological outcomes was 35% in both B and A groups (p=1.00). Regarding C1 patients, the rates were 90% and 86% in B and A groups (p=1.00). Median duration of mechanical ventilation was 5 and 3 days in group B and A, respectively (p=0.11). Conclusion: Neurological outcomes before and after introducing the new protocol were similar. Management of patients with mild hypoxic encephalopathy can be simplified with active fever prevention. A temperature control protocol based on the severity of hypoxic encephalopathy using aEEG findings is feasible for emergency physicians.

Abstract 4138635: The Association of Perioperative Statins and Cardiac Surgery Associated Acute Kidney Injury in Patients Undergoing Coronary Artery Bypass Grafting

Backgrounds: Cardiac surgery associated acute kidney injury (CSA-AKI) is a prevalent and detrimental complication following cardiac surgery, with significant effects on both in-hospital and long-term morbidity and mortality. The renal protective effect of statins for patients undergoing cardiac surgery remains unclear. Purpose: This study aims to evaluate the association between perioperative statin therapy and the risk of CSA-AKI following coronary artery bypass grafting (CABG). Methods: This retrospective cohort study included consecutive patients undergoing CABG between 2013 and 2022, with one year follow-up after hospital discharge. Any usage of statin initiated from admission to 72 hours after surgery was defined as perioperative statin therapy. The primary outcome was in-hospital postoperative AKI according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The secondary outcomes were composite measures including all-cause mortality and dialysis at 30 days and one year. Multivariate Cox proportional hazards regression models were constructed to assess the association between perioperative statin and pre-defined outcomes. Results: Among the included 36288 patients, 22272 (61.3%) patients received perioperative statin therapy, with a total of 19683 (54.2%) patients developing CSA-AKI. For the primary outcome, perioperative statin was associated with a significantly decreased risk of CSA-AKI (52.8% vs. 56.5%; adjusted Odds Ratio [OR], 0.865 [95% CI, 0.829-0.904]; p < 0.001). Additionally, the occurrence of a composite measure including all-cause mortality and dialysis was statistically lower in patients who underwent perioperative statin therapy at 30 days (0.7% vs. 1.6%; OR, 0.485 [95% CI, 0.394-0.597]; p < 0.001), as well as at one year (adjusted Hazard Ratio [HR], 0.632 [95% CI, 0.543-0.737], p < 0.001). For the subgroup analysis, the association between perioperative statin and reduced CSA-AKI risk was greater among patients with chronic heart failure and undergoing on-pump CABG. Conclusions: Perioperative statin therapy was associated with significantly lower risks of CSA-AKI following CABG, and a composite measure including all-cause mortality and dialysis at both 30 days and one year. The preventive effect of perioperative statin was more pronounced in patients with chronic heart failure and undergoing on-pump CABG.

Abstract Su804: Use of Machine Learning Models to Predict Neurologically Intact Survival for Advanced Age Adults Following Out-of-hospital Cardiac Arrest

Background: We recently published a multivariable logistic regression model that successfully predicted neurologic outcomes in advanced age adults (≥ 65 years old) who achieve return of spontaneous circulation following out-of-hospital cardiac arrest (OHCA). Prior to externally validating this model, we sought to compare the predictive performance of our logistic regression model against common machine learning (ML) algorithms using the same dataset. Methods: We performed a retrospective observational analysis of the Cardiac Arrest Registry to Enhance Survival database from 2013-2021. All non-traumatic OHCA occurring in adults (≥65 years) who survived to hospital admission were included. The primary outcome measure was neurologically intact survival defined as a cerebral performance category (CPC) score of 1 or 2 at hospital discharge. Our original logistic regression model was compared to Boosted Trees and Decision Tree ML algorithms and assessed using accuracy, Area Under the Receiver Operating Characteristic Curve (AUC-ROC) and Area Under the Precision-Recall Curve (AUC-PR). The model variables included age, gender, race/ethnicity, location, witnessed status, who initiated cardiopulmonary resuscitation, whether an automated external defibrillator was applied prior to emergency medical services arrival, and first monitored rhythm. Results: A total of 83,561 OHCA were included. Median age was 75 years (IQR 69-82), 58.9% were male, 53% were White, 67% experienced an OHCA at home, 52% were witnessed by a bystander, 44% received bystander CPR, and 34% were found in shockable rhythm. Neurologically intact survival (CPC 1 or 2) occurred in 23% of patients. The logistic regression model had an accuracy of 79.6%, AUC-PR 0.542, and AUC-ROC of 0.774. The Boosted Trees model had an accuracy of 79.2%, AUC-PR 0.555, and AUC-ROC of 0.774. The Decision Tree Model had an accuracy of 79.3%, AUC-PR 0.490, and AUC-ROC of 0.717. Conclusion: Boosted Trees and Decision Tree ML models performed comparably to the logistic regression model in predicting favorable versus unfavorable neurological outcomes following successful resuscitation from OHCA in advanced-age adults. Given their similar performance, logistic regression may be preferred for its simplicity and interpretability over alternative ML models. Future efforts to improve and ultimately externally validate the model are warranted.

Abstract Su902: Ability of Composite Magnetic Resonance Brain Imaging Scores to Predict Functional Outcomes in Survivors of Cardiac Arrest

Background: Brain magnetic resonance imaging (MRI) has been examined for neuroprognostication (NP) after out-of-hospital cardiac arrest (OHCA). However, studies have focused on predicting poor outcomes of non-awakening and/or death. Recommendations for utilization of brain MRI in NP remain weak due to its subjective interpretation. Aim: We modified a previously published brain MRI score and examined our quantitated NP scores’ ability to predict good functional outcomes in OHCA survivors. Methods: We screened OHCA cases (2017-2023, Seattle Medic One registry) for patients who survived to hospital discharge and had brain MRIs performed 25 hours-7 days after arrest. Each MRI was reviewed by two adjudicators; a third reviewer served as tie-breaker. Reviewers were blinded to patient outcomes. Diffusion Weighted Imaging and Fluid Attenuated Inversion Recovery sequences were reviewed to score 35 neuroanatomical regions. Graded severity for estimated affected area (0 = zero; 1= < 25%; 2 = 25-50%; 3 = 50-75%; 4 = >75%) and binary (0 = not affected, 1 = affected) scores were tallied. Points were summed for a composite brain MRI score, “ NP score ”, possible range 0-214. Primary outcome was Cerebral Performance Categories (CPC) at hospital discharge (1-2: “independent”, 3: “dependent”, 4: “vegetative state”). Computational modeling employed folded normal distributions and Maximum Likelihood Estimation. Statistical analyses were Pearson’s, Spearman’s, ANOVA, Fisher LSD, t-tests. Results: Forty-two (42) adult patients were included (74% men, 55% Caucasian). Median NP score was 11.5 (IQR 41.5, n=42) overall, 2 (IQR=10, n=21) for independent versus 25.5 (IQR 36.5, n=10) for dependent patients, and 92 (IQR=81, n=11) for those in a vegetative state. NP scores strongly correlated with CPC [ r s (40) = .69, p< .001 ], and were significantly different between CPC groups [F(2,39) = 32.66, p< 0.001 ]. Interrater concordance for NP score was high (Pearson) r = .88 [r = .96; .95; .90; .71]. Conclusions: Our NP score correlated well with good functional outcomes in OHCA survivors, and (1) identified distinct thresholds that well-separate functional outcome groups and (2) had very strong concordance rate among four pairs of adjudicators. NP score-based predictive modeling differentiates functional outcomes beyond good versus poor dichotomy and may help providers and family anticipate recovery potential.

Influence of sleep on seizures and interictal epileptiform discharges in epilepsy.

Sleep significantly influences seizure occurrence and interictal epileptiform discharges (IEDs) in patients with epilepsy. Sleep-related epilepsy, where seizures occur exclusively or predominantly during sleep, has been observed in various epilepsy syndromes. Understanding the influence of sleep on seizures and IEDs is crucial in the diagnosis, classification, and management of epilepsy. Although there is a bidirectional relationship between sleep and epilepsy, this review focuses on the influence of sleep on seizures and IEDs in epilepsy. Seizures are more common during non-rapid eye movement (NREM) sleep, particularly during stage N2, and are suppressed during rapid eye movement (REM) sleep. Sleep also activates IEDs, increasing the diagnostic yield of EEG recordings. The rate of IEDs increases during NREM sleep, reaches its maximum during stage N3, and decreases during REM sleep. Sleep affects the electrical field of IEDs, with an increase of spiking fields during NREM sleep and a decrease during REM sleep. In the localization of epileptogenic foci, REM sleep is less sensitive but more specific than NREM sleep. Thalamocortical EEG synchronization during NREM sleep and desynchronization during REM sleep underlie their opposing effects on seizures and IEDs. Accumulating evidence has suggested an antiseizure effect of orexinergic antagonism in animal studies. Interventions that promote REM sleep, including orexinergic antagonists, should be studied in the future as novel treatment strategies for epilepsy.

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.

Abstract 4143262: Unlocking Value: Revealing the Hidden Cost of Outpatient Interstage Care

Background: Interstage programs decrease morbidity and mortality and are potentially resource intensive. The accurate cost of these programs is unknown. Understanding cost and outcomes of care is necessary to provide high-value care for this population. Time-driven activity-based costing(TDABC) provides an accurate way to understanding costs that occur at the level of the patient. Research Question: What is the outpatient cost of the interstage period to the health care system? Methods: Single-center study of outpatient interstage care. Direct observation (over 9 months) and retrospective review were utilized to develop process maps. Outpatient interstage and pediatric visits were timed by 5 observers. Cost of personnel was calculated in dollars per minute utilizing median national health system salary data. Results: Patients attended a median of 13 cardiology, 5 pediatric, 3 physical therapy(PT), 4 occupational therapy(OT), and 7 speech therapy(SLP) visits while interstage. Total cost of interstage visit personnel was $258.18[$208.59-$389.24] and equipment cost was $1457.79. Total cost of a pediatric visit was $123.55[$130.80-$167.12]. Total cost of outpatient PT, OT, and SLP was $70.58, $66.68 and $72.43, respectively. Total cost of the outpatient interstage period was $6417.38[$5808.94-$8338.96] per patient.(Table) In interstage clinic, patients spent 132[89-165] minutes with providers and 64[41-66] minutes waiting.(Figure) In pediatric clinic, patients spent 73[71-76] minutes with providers and 9[6-13] minutes waiting. Conclusion: This work demonstrates that while challenging, TDABC analysis can be applied to complex interstage care to understand costs and move to deliver high-value care for this population. While caring for a child during the interstage period is time and resource intensive, it carries a relatively low cost to the health care system with a total cost of $6417.38 per patient. Additional work is needed to understand costs of inpatient interstage care.

Abstract Su707: Sex Differences in Bystander Cardiopulmonary Resuscitation and Survival to Hospital Discharge for Public Out-of-Hospital Cardiac Arrests in North Carolina and Singapore

Introduction: Although it is known that women are less likely than men to receive bystander cardiopulmonary resuscitation (BCPR) in public, few studies have examined differences in receipt of BCPR and survival to hospital discharge for public out-of-hospital cardiac arrests (OHCAs) by patient sex between distinct regions. Objectives: We assessed if patient sex was associated with BCPR (primary outcome) and survival to hospital discharge (secondary outcome) for public OHCAs in North Carolina (NC) and Singapore (SG). We hypothesized that females in both regions would have lower receipt of BCPR and were less likely to survive to hospital discharge compared with men. Methods: We conducted a retrospective cohort study of the Cardiac Arrest Registry to Enhance Survival dataset (NC, 2013-2022) and Pan-Asian Resuscitation Outcomes Study (SG, 2010-2020). We excluded pediatric, traumatic, emergency medical services (EMS) witnessed cases, arrests in healthcare facilities and residential cases. Using logistic regression, we examined the association of sex with BCPR and survival to hospital discharge controlling for potential confounding variables such as age, race and the year of arrest. Results: There were 65,627 OHCAs in NC; upon exclusion 6,828 remained (78% males; mean age: 57±15, males, 54.7±18, females). In SG, there were 24,177 OHCAs; upon exclusion 3,617 cases remained (87% males; mean age: 57±14, males, 61±16.4, females). In NC, public BCPR rates were 48% for males and 44% for females. Females had a 13% adjusted lower odds of receiving less BCPR (adjusted OR 0.87 (CI 0.77, 0.99)). In SG, BCPR rates were 59% for males and 52% for females. Similarly, females had a 22% lower adjusted odds of receiving BCPR (adjusted OR 0.78 (CI 0.62, 0.98)). In NC, survival to hospital discharge rates for public OHCAs were 24% for males and 26% for females. Females had a 17% lower adjusted odds ratio of survival to hospital discharge compared to males (adjusted OR 1.17 (95% CI 1.01, 1.35)). In SG, public survival to hospital discharge rates were 12% for males and 9% for females. Females had a 36% adjusted lower odds of survival to hospital discharge compared to males (adjusted OR 0.64 (95% CI 0.43, 0.94)). Conclusion: In public OHCAs, females were less likely to receive BCPR than males in both regions. However, females were less likely to survive to hospital discharge in SG, whereas the opposite was seen in NC. Further research is needed to elucidate factors for these differences.

Abstract 4134957: Survival and Cardiac Recovery in Pediatric Dilated Cardiomyopathy: A Long-term Cohort Study of Risk Factors, Prognosis, and Health Outcomes Followed into Adulthood

Background: Dilated cardiomyopathy (DCM) is the most common cause of pediatric heart failure (HF), but there is limited literature on its long-term prognosis and treatment outcomes. We examined risk factors for long-term morbidity and mortality and outcomes of care in childhood-onset DCM. Methods: Electronic medical records from a tertiary care pediatric hospital (SickKids, Toronto, Canada) were used to retrospectively follow children ages 0–18 years with DCM from January 1, 2001 to July 1, 2017. Provincial healthcare administrative data was used to monitor outcomes recorded outside of SickKids, following patients during the same time period and into adulthood (age >18 years) until August 31, 2023. We compared DCM cases, with or without echocardiographic recovery (LVEDD z score < 2 and LVEF ≥ 55%), and controls matched on sex, age, and urban/rural residence on a range of health and health service outcomes. Primary outcomes included all-cause mortality, heart transplant (HT), and inpatient admission for HF. Among cases, Cox proportional hazards regression with backwards selection was used to identify demographic, disease, and treatment characteristics associated with each primary outcome, with candidate variables selected based on univariate analysis and clinical judgment. Results: We studied 156 patients with DCM and 780 controls for a median of 14.8 years. Median age at the end of follow-up was 16.2 years. Compared with controls, DCM cases had higher rates of all-cause death, HT, and HF admission (all P <0.001), as well as chronic kidney disease ( P <0.001) and diabetes ( P =0.002). Compared to cases with recovered DCM (n=53), non-recovered cases had higher rates of death, HT, and HF admission (all P <0.001). On multivariable analysis, beta blockers were associated with reduced mortality risk (HR 0.343, 95% CI 0.162–0.727). Using any HF medication (HR 0.205, 95% CI 0.102–0.412) and living in an urban versus a rural area (HR 0.166, 95% CI 0.048–0.573) decreased HT risk. Idiopathic (HR 4.16, 95% CI 1.42–12.2) or sarcomeric mutation-related (HR 9.86, 95% CI 2.30–42.3) DCM were associated with higher HT risk than myocarditis-related DCM. Conclusions: While childhood DCM is associated with long-term adverse health and increased health care utilization, patients who recover have improved morbidity and mortality. Treatment (e.g. medication or access to urban specialist care) was associated with lower mortality and HT risk in DCM.

Abstract 4136762: Association Between Circadian Rest/Activity Rhythms and Incident Dementia in Older Adults: The Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Alterations in circadian rest/activity rhythms (RARs) are common among older adults. RARs can be derived from accelerometry data and are routinely used as proxy measures. Evidence suggests that altered (e.g., fragmented, delayed) RARs may be risk factors for dementia. However, results have been mixed. Using data from the ARIC Study, a community-based cohort, we assessed the association between RARs and incident dementia. Methods: ARIC participants without dementia who wore the Zio XT ECG Patch in 2016-17 for > 3 days were included. RARs were obtained from an accelerometer within the Zio XT ECG Patch and measures of interdaily stability (IS; consistency), intradaily variability (IV; fragmentation), and relative amplitude (RA; strength) were derived. Dementia cases were identified through 2020 using in-person and phone-based cognitive assessments, hospitalization discharge codes, or death certificates. Cox proportional hazards models were used. Results: Of the 2,183 participants (mean [SD] age 79 [4.5] years, 58% female, 24% identified as Black), 176 (8%) developed dementia. Median follow-up time was 3 years and mean Zio XT ECG Patch wear time was 12 days. After multivariable adjustment, lower RA and higher IV were associated with incident dementia (HRs [95% CIs] per 1-SD increment: 0.65 [0.56-0.76], 1.19 [1.02-1.38]). No significant association between IS and dementia was noted; however, there was an interaction by race (p=0.03). Stratified results were not significant, but effect estimates were in opposite directions: (HRs [95% CIs] per 1-SD increment in IS: 0.78 [0.59-1.02] in Black participants and 1.17 [0.96-1.41] in white participants, respectively). No interactions by sex or APOEε4 were noted (p>0.10). Conclusion: In this community-based cohort of older adults, weaker circadian rhythm strength and fragmentation were associated with dementia risk. The association between IS and dementia may differ by race; however, this needs to be further examined in future research. Overall, measures of circadian RARs may be risk factors for dementia. Additional research is warranted to determine whether they can be novel targets for dementia prevention.

Abstract 4119129: PREDICTING 30-DAY ALL-CAUSE READMISSION AFTER STROKE: THE APPLICATION OF MACHINE LEARNING TO LINKED REGISTRY DATA

Background: Thirty-day readmission following hospital discharge for stroke is an important quality measure for US hospitals. Current US prediction models for post stroke readmission based on electronic medical records from single healthcare systems or hospitals have modest discrimination (AUC range 0.64 - 0.74). Aim: To develop 30-day all-cause readmission prediction model using a machine learning (ML) based method trained on linked stroke registry and administrative claims data. Methods: Using probabilistic linking, we matched acute stroke (ICD-10 I61-I63) discharges from 31 hospitals participating in the Michigan Acute Stroke registry between 2016-2020 to multipayer administrative claims data provided by the Michigan Value Collaborative for Medicare and Blue Cross Blue Shield of Michigan commercial beneficiaries. Stroke registry data included patient demographics, clinical characteristics, past medical history, and treatments. Claims data was used to identify readmissions within 30 days of discharge. We used multivariable LASSO logistic regression- a simple ML technique to predict 30-day all-cause-readmission and evaluated the prediction accuracy using a hospital-split internal validation scheme to generate hospital-specific and pooled AUC estimates with 95% confidence intervals (Figure 1). Results: Of 19,382 linked stroke discharges, 2,724 (14.1%) were readmitted within 30-days. Readmitted patients were older, more likely to be male, black, and have higher stroke severity (NIHSS >5). Registry hospitals were either primary (64%) or comprehensive (26%) stroke centers. Hospital-specific 30-day readmission ranged between 9.9%-23.1% ( P <.001) with an average of 14.1% (95% CI:13.6%-14.5%) (Figure 2). Hospital specific AUC estimates ranged between 0.60-0.80 with a pooled AUC of 0.68 (95% CI:0.65-0.70) (Figure 2). Conclusions: ML prediction model fitted to linked registry data can be used to predict hospital-specific and statewide readmissions post stroke.

Abstract 4136724: Early Adoption of Sodium-Glucose Cotransporter-2 Inhibitor Among Patients Hospitalized with Heart Failure and Preserved Ejection Fraction in the United States

Introduction: In August 2021, the Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Preserved Ejection Fraction (EMPEROR-Preserved) found that empagliflozin reduced rates of cardiovascular death and hospitalization by 21% in patients with heart failure with mildly reduced ejection fraction of 41-49% (HFmrEF) and with preserved ejection fraction of > 50% (HFpEF). National trends in Sodium-Glucose Cotransporter-2 Inhibitors ( SGLT2i) use among patients with HFmrEF and HFpEF following this trial are unknown. Methods: We identified patients hospitalized for HFmrEF and HFpEF in the AHA Get With The Guidelines-Heart Failure registry between July 2021 and September 2023. We examined temporal trends in SGLT2i prescriptions at discharge after the publication of the EMPEROR-Preserved trial using the Cochran-Armitage trend test. Results: Among 158,849 hospitalizations with an EF > 40% across 557 hospitals, 27,712 (17.4%) had HFmrEF, and 131,137 (82.6%) had HFpEF. Overall, 22,126 (13.9%) patients were discharged with a prescription for SGLT2i, with higher rates among those with HFmrEF (18.5% vs. 13.0% in those with HFpEF). Patients prescribed SGLT2i were more likely to be younger, male, of Black race, have type II diabetes, have Medicaid insurance, and be discharged from large hospitals. After publication of the EMPEROR-Preserved trial during Q3 2021, rates of SGLT2i prescription at hospital discharge increased from 4.2% in Q3 2021 to 23.5% in Q3 2023, with a 29% relative increase in the rate of SGLT2i prescription for each quarter (adjusted OR, 1.29 [95% CI: 1.28, 1.29]; P<.001). Prescription rates increased from 6.1% in Q3 2021 to 31.6% in Q3 2023 among patients with HFmrEF and from 3.8% to 21.9% for patients with HFpEF (Figure). Conclusion: In the U.S., the use of SGLT2i at discharge has increased for patients hospitalized with HFmrEF and HFpEF following the publication of the EMPEROR-Preserved trial. However, the majority of eligible patients hospitalized for decompensated HF remain untreated with SGLT2i, indicating the need for further efforts to apply the scientific findings into clinical practice.

Abstract Su501: Feasibility and Implications of Electrocardiogram-based Prediction of Incessant Refractory Ventricular Fibrillation

Background: Refractory ventricular fibrillation (R-VF) patients, defined as requiring ≥ 3 shocks during resuscitation of OHCA, have relatively poor outcomes. Prior studies have predicted R-VF using the ECG, suggesting potential to guide early patient-specific treatment for R-VF. However, R-VF comprises multiple phenotypes with distinct defibrillation response profiles: Incessant VF (no shocks terminate VF), recurrent VF (all shocks terminate VF but VF recurs), or mixed VF (shocks variably terminate VF). These phenotypes may have distinct prognoses, and may also respond differently to R-VF treatments such as early antiarrhythmics, modified vasopressor dosing, alternative defibrillation strategies, or expedited invasive interventions. Early prediction of specific R-VF phenotype could potentially improve outcome through preemptive targeting of treatment to individual phenotype. Aim: We sought to predict incessant R-VF using machine learning analysis of the defibrillator ECG. Methods: We performed a retrospective study of adult VF OHCA treated by EMS from 2006–2019 in King County WA. We linked a clinical OHCA registry with defibrillator recordings to evaluate ROSC and survival to hospital discharge by VF type (non-refractory; or incessant, recurrent, or mixed R-VF prior to the third shock). To predict incessant R-VF specifically, we used a series of four 2-s ECG segments from each patient within 60s surrounding the first shock. Patients were randomized 65%/35% for training/test. A support vector machine classifier was trained to predict subsequent incessant R-VF using ECG scalograms. Algorithm performance was assessed by area under the receiver operating characteristic curve (AUC) and by sensitivity at >75% specificity. Results: Of 1111 included VF patients, median age was 62, 241 (22%) were female, 658 (59%) were refractory (≥ 3 shocks), 800 (72%) achieved ROSC, and 520 (47%) survived. The incessant R-VF phenotype accounted for 10% (N=116) and had worse ROSC and survival compared to recurrent R-VF and non-refractory patients (Table). Training and test AUCs to predict incessant R-VF were 0.77 (95% CI: 0.72–0.82, N=723) and 0.76 (95% CI: 0.66–0.82, N=388) respectively. Test sensitivity and specificity were 64% and 76%. Conclusion: Refractory VF comprises distinct phenotypes with disparate outcomes. Incessant R-VF has notably poor prognosis. Machine learning may be able to predict incessant R-VF, potentially guiding preemptive, patient-specific treatments to improve outcome.

Abstract 4137942: Comparing Outcomes in Low versus High Activated Partial Thromboplastin Time-guided Anticoagulation Monitoring during Extracorporeal Membrane Oxygenation

Introduction: Systemic anticoagulation in Extracorporeal Membrane Oxygenation (ECMO) aims to reduce the risk of patient and circuit thrombosis, but requires monitoring due to risk of bleeding. Activated partial thromboplastin time (aPTT) is one of many tests utilized for this purpose. However, it lacks validation in ECMO patients and its clinical utility necessitates further analysis. Aim: We aim to elucidate associations between low versus high aPTT-guided anticoagulation monitoring and total time, survival, bleeding, and thrombotic events during ECMO. Methods: A retrospective review was conducted on 93 patients requiring ECMO at our institution between January 2020 and March 2021. Study inclusion required more than 2 days on ECMO and maintenance on anticoagulation with aPTT targets predominantly greater (>) or less than (<) 60 seconds (s). Final cohort was 74 subjects; 30 subjects with majority aPTT targets <60s composed the control “low” aPTT group and 44 subjects with aPTT targets >60s composed the “high” aPTT group. Primary outcomes were survival to decannulation, survival to discharge, average time on ECMO, and incidence of bleeding and thrombotic events during ECMO. Bleeding and thrombotic events were classified into subtypes and incidence of each was recorded. Statistical analyses were performed with Fisher’s exact, Pearson’s chi-square, and Student’s t-tests with an alpha level of .05 on IBM SPSS software. Results: The high group required a longer average time on ECMO (29.5 days versus 14.3 days; p = .002; 95% CI [5.5; 24.7]). Chi-square tests did not show an association between the low versus high groups and survival to decannulation (22/30 and 35/44; p = .533), survival to hospital discharge (17/30 and 30/44; p = .312), or overall incidence of bleeding (18/30 and 20/44; p = .219) and thrombotic events (7/30 and 14/44; p = .427). Regarding subtypes of events, Fisher’s exact test showed an association between aPTT target >60s and severe epistaxis (1/30 in the low and 9/44 in the high group; two-tailed p = .042). Though not significant, a greater incidence of oxygenator failure and circuit thrombosis was recorded in the high group. Conclusions: Our findings did not establish a relationship between aPTT target <60s or >60s and survival, bleeding, or thrombotic events. However, aPTT target >60s was associated with longer average ECMO time and severe epistaxis. Further investigation of aPTT-guided anticoagulation monitoring in ECMO patients is needed.

Abstract Su502: Is 80% a Reasonable Minimal Goal for Defibrillation Efficacy of Out-of-Hospital Cardiac Arrest ?

Introduction: There is no clear goal defined by standards or learned societies on clinical performance related to defibrillation efficacy. In literature, monophasic shocks defibrillation efficacy is mainly >70% whereas biphasic is >80%. Resuscitation guidelines define efficient defibrillation as cessation of shockable rhythm at 5s post-shock and proceed to state that beyond 5s, shock outcomes are biased by known confounders (call to AED connection time (CallAEDTime), bystander, cardio-pulmonary resuscitation (CPR), drugs…). Thus, it is consistent that automated external defibrillator (AED) performance should be assessed in terms of defibrillation efficacy right after the shock rather than in terms of restoration of a spontaneous circulation or survival to hospital discharge. This study aimed to define an acceptable goal for validation of defibrillation efficacy. Method: In this observational retrospective study, we included AED tracings of adult non-traumatic out-of-hospital cardiac arrest (OHCA) patients with initial ventricular fibrillation (VF) rescued by basic life support teams (Paris Fire Brigade) from 01/2017 to 02/2022. Cardiac rhythm was examined during the 10 first minutes of connection of the AED (DGT7, Schiller Médical, France). Shockable rhythm is defined as coarse-VF with at least 200µV peak-to-peak amplitude (ptpA). Efficient defibrillation was defined as cessation of shockable rhythm at 5s post-shock. We fitted a linear mixed model to predict defibrillation efficacy using the 4s ptpA of pre-shock VF. The model included the patient as random effect and a p-value <0.05 was considered statistically significant. Results: We analyzed 1333 shocks from 547 patients, with: median age of 59 (interquartile range, IQR[49-71]), 78% male, 36% in public places, 72% with bystander CPR and median[IQR] CallAEDTime of 13min [10-15]min. The effect of the pre-shock ptpA of VF on the defibrillation efficacy is statistically significant: OR=1.023, 95% Confidence Interval (CI) [1.010,1.036], p<0.001. That means that for each 100µv increment in VF amplitude pre-shock, the probability of success at 5s post-shock increases by 2.3%. Adjusting for age, sex, location, CPR and CallAEDTime does not change the results. The logistic regression of Figure1, shows a defibrillation efficacy at 200µV ptpA of 79%, CI [75,82]%. Conclusion: Based on 1333 OHCA biphasic shocks, this study suggests defining 80% as a reasonable minimal goal for validation of the AED defibrillation efficacy.

Abstract 4119094: Claims-Based versus Registry-Reported Stroke Events in the NCDR Left Atrial Appendage Occlusion Registry

Background: Administrative claims data are increasingly used for post-marketing surveillance of drugs and medical devices, though data reliability remains uncertain. Given their associated morbidity and mortality, stroke events are particularly important to monitor for cardiovascular therapies such as transcatheter left atrial appendage occlusion (LAAO). However, there are limited data comparing stroke events in contemporary claims data to events reported in large nationwide registries with comprehensive data collection. Aim: To compare stroke events in Medicare claims data with adjudicated registry-reported events in the National Cardiovascular Data Registry Left Atrial Appendage Occlusion (LAAO) Registry. Methods: LAAO Registry data were linked with 2016-2022 Medicare inpatient claims. Primary diagnosis ICD-10 codes from inpatient hospitalizations were compared to adjudicated registry-reported ischemic and hemorrhagic stroke events occurring after discharge with up to two years of follow-up. In multiple secondary analyses, primary and secondary diagnosis codes were counted as events in claims data and patients with prior history of stroke were also excluded. Results: The cohort included 71,043 adults ≥65 years old in the LAAO Registry with inpatient Medicare data. Following LAAO hospitalization discharge, there were 1405 claims-based and 1308 registry-reported total stroke events. Sensitivity and positive predictive value (PPV) of claims for identifying registry-reported events were 60.8% and 50.5% for ischemic stroke (kappa statistic 0.55), 42.7% and 50.5% for hemorrhagic stroke (kappa 0.46), and 58.1% and 54.1% for all stroke (kappa 0.55), respectively. Inclusion of secondary diagnosis codes improved sensitivity of claims (70.3% for ischemic stroke, 53.9% for hemorrhagic stroke and 67.0% for all stroke), but PPV decreased (44.8% for ischemic stroke, 34.8% for hemorrhagic stroke and 47.8% for all stroke). Specificity and negative predictive values of claims data were >98% for all stroke types. Findings were similar after excluding patients with prior history of stroke ( Table ). Conclusions: Among Medicare patients in the LAAO Registry, administrative claims data had moderate agreement with adjudicated registry-reported stroke events. Claims data may not reliably capture all stroke events in real-world practice, and additional event ascertainment methods may be needed to ensure accurate assessment of stroke in post-marketing surveillance efforts.

Abstract Su505: Impact of a Targeted Automated External Defibrillator (AED) Program on Survival After Ventricular Fibrillation Cardiac Arrest in the Sao Paulo Metropolitan Subway System: A Landmark Initiative in Latin America

The targeted Automated External Defibrillator (AED) program in the Sao Paulo Metro has yielded promising results in improving survival rates for individuals experiencing out-of-hospital cardiac arrest (OHCA) due to ventricular arrhythmias. A longitudinal observational study conducted from September 2006 to November 2023 assessed the program's impact on survival outcomes. The implementation of the full program led to a significant improvement in survival to hospital discharge with minimal neurological impairment (0% vs. 43%, P=0.001). These findings underscore the importance of a targeted AED program in improving survival outcomes for OHCA, particularly in densely populated urban environments such as the Sao Paulo Metro. The short interval between arrest and defibrillation emerged as a critical factor in achieving favorable long-term, neurologically intact survival rates. The success of this program advocates for the strategic expansion of targeted AED initiatives in other large Latin American cities, emphasizing the potential to save lives and enhance public health outcomes through proactive emergency medical response measures.

Abstract Su703: Racial/Ethnic Disparities in Bystander Cardiopulmonary Resuscitation after Witnessed Out-of-Hospital Cardiac Arrest: A NEMSIS Database Study

Introduction: Out of hospital cardiac arrest (OHCA) is a leading cause of death in the United States, with upwards of 360,000 OHCAs annually. Receiving bystander cardiopulmonary resuscitation (CPR) almost doubles an individual’s odds of survival compared to those who don’t receive bystander CPR. Unfortunately, in the US, bystander application of CPR only occurs in 40% of OHCA. Improving the rate of bystander CPR and AED use will improve survival rates for OHCA. Minoritized populations experience worse outcomes from OHCA. Compared to non-Hispanic whites, they are less likely to survive to hospital discharge. A cross-sectional study of witnessed OHCA patients found that Black and Hispanic patients had lower rates of bystander CPR. Less is known about disparities in care for Asian American persons who experience OHCA. Studies using the Resuscitation Outcomes Consortium Epidemiologic Registry (ROC) and the Cardiac Arrest Registry to Enhance Survival (CARES) have concluded discrepant results, with ROC finding that Asian Americans were less likely to receive bystander CPR and CARES finding that they were just as likely to receive bystander CPR compared to non-Hispanic Whites. To that end, we sought to evaluate the association between bystander CPR and Asian race after witnessed OHCA. Objective: To evaluate the association between race/ethnicity and the odds of receiving bystander cardiopulmonary resuscitation (bCPR) after witnessed out-of-hospital cardiac arrest (OHCA). Methods: Data were obtained from the National Emergency Medical Services Information System (NEMSIS) database for adults (≥18 years) with a witnessed non-traumatic OHCA in the year 2022. Patients were separated into two groups: Non-Hispanic White and Asians. The primary outcome was the odds of receiving bCPR. Exclusions included traumatic etiology, do-not-resuscitate orders, and arrests witnessed by healthcare providers. Pearson’s chi-square test was used to test significance. Results: A total of 73,215 witnessed OHCA activations were included in this study. Overall, bystander CPR rates were lower for the Asian group (59.8%) compared to the Non-Hispanic White group (65.0%). Pearson’s chi-square test showed a statistically significant difference between the bCPR rates of the Asian group and Non-Hispanic White group, with a p-value of less than 0.001. Conclusion: Racial/ethnic disparities exist for Asian individuals in the odds of receiving bCPR after a witnessed non-traumatic OHCA.

Abstract Su301: Longer Chest Compression Intervals Between Pulse Checks in Patients with Non-Shockable Rhythms are Associated with Increased Subsequent Return of Spontaneous Circulation Events

Background: Chest compressions are a cornerstone of cardiopulmonary resuscitation (CPR), and evidence shows that fewer interruptions and higher chest compression fractions improve outcomes in cardiac arrest. Interruptions in chest compression are important in patients with shockable rhythms to assess the need for defibrillation; however, in pulseless electrical activity (PEA) or asystole, a pause in chest compressions every 2 minutes may be detrimental, as it decreases chest compression fraction and reduces myocardial, cerebral, and systemic perfusion. Hypothesis: We hypothesize that patients with non-shockable rhythms on whom chest compression intervals were greater than 2 minutes have better odds of achieving return of spontaneous circulation (ROSC). Objective: Our primary objective is to determine if longer chest compression intervals are associated with improved subsequent ROSC in patients with initial PEA or asystole rhythms. Methods: We conducted a retrospective cohort study of video-recorded adult atraumatic cardiac arrest resuscitations in a quaternary care Emergency Department from 1/30/2018 to 2/20/2024. We only examined patients in PEA or asystole and determined the duration of all chest compression intervals for each patient. We grouped the chest compression interval durations into 3 groups (<1min 45sec, 1min 45sec to 2 min 14sec, ≥2min 15 sec) and determined the odds of subsequent ROSC for each chest compression interval duration. We assessed the association between chest compression interval duration and ROSC episodes using a logistic regression model. Results: Out of 326 video-reviewed patients, 235 patients had an initial rhythm of PEA or asystole of which 44 (18.7%) survived to admission and 9 (3.8%) to hospital discharge. The 235 patients yielded 1724 chest compression intervals and 151 ROSC episodes. The ROSC rate for the chest compression intervals <1:45sec was 7.3% (49 out of 673) versus 8.1% (51 out of 632) for intervals 1:45 to 2:14 versus 12.2% (51 out of 419) for intervals ≥2 min 15sec. In a logistic regression model, using the 1min 45 sec to 2min 14 sec interval as the reference group, the <1min 45sec group had 10% lower odds of ROSC (OR: 0.90; 95% CI: 0.60, 1.35) and the ≥2min 15 sec group had 58% higher odds of ROSC (OR: 1.58; 95% CI: 1.05, 2.38). Conclusion: In cardiac arrest patients presenting with non-shockable rhythms, chest compression intervals ≥2 min15sec are associated with higher odds of achieving ROSC.