Suarez, Audry Chacin

Introduction: The Community Practice Center (CPC) in North Philadelphia serves a community with significant socioeconomic barriers leading to inability to access care necessary for management of hypertension (HTN). Prior studies have shown the efficacy of SMBP programs in improving blood pressure (BP) control. Methods: All sequential patients presenting to the CPC with stage 2 HTN were screened for eligibility. Upon enrollment, patients received a Bluetooth-enabled BP cuff connected to a mobile health app and HTN education. Patients completed validated social and behavioral assessments including social determinants of health (SD)H) assessment via WellRx screen, depression screening (PHQ-9), and self-efficacy screening ( Self-Efficacy to Manage Chronic Disease Scale ). A behavior change plan was created using Brief Problem Solving Therapy based on the aforementioned assessments. Staff continuously monitored usage, BP, and provided individualized interventions. We conducted a cross-sectional quality improvement study using daily BP data from June 2022 - April 2023 to assess the correlation between baseline sociodemographic characteristics and Time in Target Range (TTR) through multivariable linear regression. We calculated TTR, defined as the percentage of time with systolic BP within 100-130 mmHg, through linear interpolation. Results: A total of 133 patients were enrolled in the program. We analyzed data from 78 patients with ≥3 days of readings (average 33; SD 49) and complete baseline characteristics (Table 1). Female sex and non-smoking status were associated with TTR, while diabetes, positive depression screening, positive SDOH screening, and self-efficacy were not (Table 2). Conclusions: In a socioeconomically disadvantaged population participating in a comprehensive SMBP program, depression, SDOH, and self-efficacy screening at time of enrollment did not predict TTR. Participation in a SMBP program may be valuable in these populations.

Background: Meta-analyses have shown the success of SMBP in BP control. We aim to describe an SMBP QI program at our primary care clinic and assess its impact on BP. The Einstein CPC is a safety net practice that serves a socially and economically disadvantaged population facing many HTN management barriers. Methods: This program utilized a QI approach for BP control and patient-provider connection. Patient demographics, clinical features, and SDOH were assessed at baseline. Patients with uncontrolled HTN (SBP >140 mmHg) were asked to participate. To date, 111 patients enrolled. Patients were given a Bluetooth-enabled BP monitor connected to a mobile health app, HTN education, DASH diet recommendations, and orientation to SMBP protocols. Those reporting social needs or depression were referred to behavioral resources. Health staff continuously telemonitored patient usage, BP, and individualized interventions. We evaluated the difference in BP from baseline BP and estimated the change in time using a linear multilevel model with random intercept and random slope for each patient. We also calculated time in target range defined as time in SBP 100-130 and DBP 70-80 in mmHg. Results: Patient characteristics (Table 1). Those with at least 3 d of BP readings - 93% (103/111) were included in the BP analysis (Figure 1); mean follow-up 69±67 d and BP readings 42±52. Over 90 d, SBP, and DBP decreased by 11 (95% CI: 4-17) and 5 (95% CI: 3-8) mmHg, respectively. Conclusions: A QI-based SMBP program with robust telemonitoring and individualized interventions may effectively promote short-term adherence to remote BP monitoring and BP control in a socially and economically disadvantaged population.

Background: The body Mass Index (BMI) is commonly used in clinical practice to screen for obesity and resulting cardiometabolic conditions. Nonetheless, BMI has limited utility as it cannot differentiate body fat (BF). Hypothesis: We tested the hypothesis that BF content measured by air displacement plethysmography (Bod-Pod®) had a stronger association with prevalent hypertension (HTN), diabetes mellitus (DM) and dyslipidemia (DLP) when compared to BMI. Methods: We performed a community-based cross-sectional study on adults attending an employee wellness center from January 2007-December 2011 who had had a body composition assessment with Bod-Pod®. We excluded subjects with history of myocardial infarction, coronary artery disease, congestive heart failure, stroke at baseline. The prevalence of HTN, DM and DLP was assessed across quartiles of BF% and BMI categories. Their association with BF% and BMI was evaluated using linear regression models that adjusted for age, sex, and white race. Results: We included 3,052 individuals; 68 % were women, and the mean age ± SD was 42.09±12.8, BMI was 27.9±6.2; BF% 31.88±10.69, 892 (29.2%) were obese by BMI. Cardiometabolic conditions were prevalent in 496 (16.2%) with HTN, 378 (12.4%) with DM and 743 (24.4%) with DLP. While the prevalence of DM, HTN and DLP increased across BF% quartiles (all p for linearity>0.01), this was not always the case across BMI categories (p for linearity<0.05 for HTN and DLP, and 0.04 for DM) see Figure A . Elevated BF %, better identified individuals with HTN (AUC 0.766 vs 0.625; p<0.001), DM (AUC 0.643 vs. 0.568; p<0.001), DLP (AUC 0.758 vs. 0.593; p<0.001). Conclusion: BF content is better associated with a higher prevalence of HTN, DM, and DLP. Highlighting the role of body composition assessment in primary prevention. Dyslipidemia.

Introduction: Arrhythmias commonly occur during clinical exercise stress testing (EST), however there are limited data on prognostic significance, particularly differences between individuals with minor versus significant arrhythmia burden. Hypothesis: We hypothesized that significant but not minor arrhythmia burden during EST would be predictive of future all-cause mortality. Methods: Adults who underwent clinically indicated EST at Mayo Clinic Rochester between September 1993 and April 2017 were included and followed-up until March 2021 using the National Death Index to ascertain survival status. Expert clinician coding pertaining to arrhythmia burden during EST were used to group individuals (see Table 1 ). Cox proportional hazard models adjusted for known predictors of exercise-induced arrhythmias, were used to test the association of arrhythmia burden with all-cause mortality. Results: A total of 30796 individuals were included (age: 55±14yrs; female: 36%; Table 1 ). Mean follow-up was 8.8±3.6yrs, with a total of 2516 deaths. Arrhythmia during EST was associated with all-cause mortality compared with no arrhythmia (HR: 1.72; 95% CI: 1.58-1.88; p<0.001), however significant arrhythmia showed greater association compared with minor arrhythmia (HR: 2.07; 95% CI: 1.81-2.38; p<0.001). Both minor and significant arrhythmia during EST were significant predictors of all-cause mortality compared with no arrhythmia ( Figure, Table 2 ), however, after model adjustments, only significant arrhythmia was associated with all-cause mortality (HR: 1.40; 95% CI: 1.21-1.63; p<0.001) ( Table 2 ). Conclusions: After multivariate adjustment, significant arrhythmia burden during EST showed a 40% increased future risk of all-cause mortality, Conversely, adjusting for age and sex attenuated the effect of minor arrhythmia burden during EST on incidence of death. These results highlight the clinical significance of arrhythmia burden during exercise testing.

Introduction: Cardiac rehabilitation (CR) is a comprehensive secondary cardiovascular disease (CVD) program which integrates structured lifestyle interventions to reduce morbidity and mortality. The Life’s Simple 7 (LS7) is an objective measure of cardiovascular health (CVH) which incorporates health-promoting behaviors and clinical factors however, it has not been rigorously evaluated in the CR setting. Methods: Retrospective cohort study of 937 patients who attended center-based CR at Mayo Clinic from Jan 2018 -Sept 2020. Patient characteristics and LS7 component metrics at baseline (pre-CR) and completion (post-CR) were collected: 3 clinical factors (blood pressure [BP], cholesterol, and hemoglobin A1c [HbA1c]), and 4 health behaviors (smoking, body mass index [BMI], physical activity [PA] and diet). LS7 score was computed as a composite of each LS7 component by assigning 2-points for ideal, 1-point for intermediate, or 0-points for poor CVH ranging from 0-14 points. LS7 score was further categorized as poor 0-6, intermediate 7-8 and ideal 9 -14. Results: Patients were 64±13 years old, 34% were female, and attended a mean of 11±12 CR sessions, Table 1. At baseline, the LS7 components with the highest proportion within the poor category were HbA1c (201/495, 41%) and BMI (465/936, 50%), Table 2. From pre to post-CR, there was a reduction in proportion of patients classified within the poor category for each LS7 component except HbA1c ( Figure 1 ), and the proportion of patients with LS7 scores in the ideal range increased from 6.4% to 19% (P<0.001). There was a statistically significant improvement in LS7 score from 5.5±1.8 to 6.7± 2.4 (+Δ1.6±2.4, P<.0001), Table 2 . Conclusions: Patients attending CR demonstrated an improvement in LS7 score and almost all LS7 components suggesting an overall positive impact of CR on CVH. Further research is needed to better understand the impact of the individual LS7 components on CV outcomes in diverse populations participating in CR.

Introduction: The COVID-19 pandemic imposed significant constraints to delivery of cardiac rehabilitation (CR) with many programs relying on delivery of home-based cardiac rehabilitation (HBCR). We sought to compare the effects of HBCR vs conventional center-based CR (CBCR) on clinical metrics, health-related quality of life, and modifiable risk factors in CR patients. Methods: Retrospective cohort study comparing 511 HBCR patients (March 2020-April 2021; COVID-19 pandemic) and 765 age and sex matched CBCR patients (Jan 2018-Jan2020; immediately pre-pandemic) from the Mayo Clinic Health System. We assessed changes in clinical outcomes before and after CR. HBCR included 12 sessions (one in-person assessment + weekly education and exercise monitoring phone/video calls). Conventional CBCR included 36 sessions (3 sessions per week for 12 weeks). Continuous data were described as mean±SD, and comparisons of change between groups were assessed with linear regression adjusting for baseline value, in complete cases. Results: HBCR and CBCR patients were 65±14 yrs old (68% male) and 65±14 yrs old (67% male) respectively. HBCR patients demonstrated greater improvement in exercise days/week whereas CBCR patients had greater improvement in exercise min/day. HBCR patients had greater improvement in blood glucose with a trend towards greater improvement in non-HDL cholesterol. Both groups demonstrated similar improvement on nutrition, depression, health-related quality of life surveys and total, LDL and HDL cholesterol, as well as HbA1c between the groups. Conclusions: Collecting clinical metrics during the COVID-19 pandemic proved challenging due to the initial closure of out-patient services. For patients in whom data was captured, HBCR appears to be similarly effective at improving several intermediate outcomes compared to CBCR. HBCR may be an effective alternative for improving clinical outcomes in patients who are unable to participate in CBCR.

Introduction: Many center-based cardiac rehabilitation programs were forced to close during the pandemic resulting in a programmatic shift to delivering cardiac rehabilitation remotely in the home-based setting. This study examined sex differences in the change of exercise frequency and exercise capacity in patients participating in home-based cardiac rehabilitation (HBCR) during the COVID-19 pandemic. Methods: Retrospective cohort study of 567 HBCR patients between March 2020 and May 2021. Patients who completed the Duke Activity Status Index questionnaire before and after HBCR were included. We calculated the number of reported exercise days/ week, exercise min/day, and VO 2 peak estimated. Patients were divided into two groups according to sex (Male/Female). Continuous data are described as mean±SD and baseline data compared with a two-sample t-test. The delta change from pre-post between groups also are compared with a two-sample t-test. Results: Of 567 HBCR patients, 118 patients completed both pre and post HBCR questionnaires (Male, n=82, 66±12 yo vs Female, n=36, 65±12 yo, p=0.80). There were no differences between groups for baseline exercise days/week or exercise min/day pre HBCR (4.0±2.8 vs 4.1±3.0 days, p=0.87; 22±20 vs 18±20 min, p=0.33); however, VO 2 peak at baseline HBCR was higher in males than females (22.3±8.1 vs 18.9±5.9 ml/kg/min, p<0.05). Both groups improved exercise days/week (4.0±2.8 to 5.7±1.5 vs 4.1±3.0 to 5.7±1.4 days, p<0.05 for both), exercise min/day (22±20 to 40±15 vs 18±20 to 37±21 min, p<0.05 for both), and VO 2 peak (22.3±8.1 to 27.8±8.0 vs 18.9±5.9 to 22.7±6.5, ml/kg/min, p<0.05 for both). In addition, there was no significant difference for the delta change of the three outcomes between groups (1.7±2.7 vs 1.6±2.5 days; 18±19 vs 19±18 min; 5.5±6.5 vs 3.8±4.5 ml/min/kg, p>0.05 for all). Conclusions: Female patients entering HBCR during the COVID-19 pandemic demonstrated lower exercise capacity compared to males; however, both female and male patients increased exercise frequency (days/week and min/day) and exercise capacity (estimated VO 2 peak) similarly after attending HBCR during the COVID-19 pandemic.

Introduction: The COVID-19 pandemic resulted in the closure of many center-based cardiac rehabilitation programs leading many institutions to rely on home-based cardiac rehabilitation (HBCR) to provide critical secondary cardiovascular disease prevention and rehabilitation. The impact of age on the change of exercise frequency and exercise capacity as a result of HBCR during the COVID-19 pandemic remains unknown. Methods: Retrospective cohort study of 567 HBCR patients between March 2020 and May 2021. Patients who completed the Duke Activity Status Index questionnaire at enrollment and completion of HBCR were included. We calculated the number of reported exercise days/week , exercise min/day, and VO 2 peak estimated. Patients were divided into two groups according to age (Younger<65 y.o; Older≥65 y.o). Continuous data are described as mean ±SD and baseline data compared with a two-sample t-test. The delta change from pre-post between groups also are compared with a two-sample t-test. Results: Of 567 HBCR patients, 118 patients completed both pre and post HBCR questionnaires (Younger, n=54, 56±8 years old vs Older, n=64, 74±7 y.o, p<0.05). Both groups improved exercise days/week (4.4±2.8 to 5.8±1.3 vs 3.8±2.9 to 5.6±1.6 days, p<0.05 for both), exercise min/day (21±20 to 41±17 vs 20±20 to 37±17 min, p<0.05 for both), and VO 2 peak (20.5±7.1 to 27.6±8.0 vs 21.9±8.1 to 25.1±7.7 ml/min/kg, p<0.05 for both). The delta change for exercise days/week and exercise min/day were not significantly different between groups (1.4±2.7 vs 1.9±2.7 days and 19±19 vs 17±18 min, p>0.05); however, the Younger patients significantly increased their VO 2 peak more than the older patients (7.1±6.1 vs 3.2±5.3 ml/min/kg, p<0.05). Conclusions: During the COVID-19 pandemic, exercise frequency (days/week and min/day) and exercise capacity (estimated VO2peak) increased in all patients participating in HBCR. With this, the increase in estimated exercise capacity was greater in younger patients compared with older patients. These findings suggest that additional work is needed to explore factors potentially limiting improvement and strategies to maximize improvement in exercise capacity in older patients participating in HBCR.

Introduction: Patients undergoing cardiac rehabilitation (CR) exhibit various degrees of illness severity and high prevalence of chronic conditions (CC). Cardiorespiratory fitness (CRF) is a key predictor of outcomes in patients with cardiovascular disease. Participation in CR is associated with increased CRF, reduced future cardiovascular events, and mortality. Peak oxygen uptake (VO 2 ) is the gold-standard method to evaluate CRF; however, the burden of multimorbidity and its impact on CRF improvement has not been extensively studied. Methods: We included 618 patients who were ≥ 18 years old and underwent cardiopulmonary exercise testing prior to and after CR at Mayo Clinic. Using the Rochester Epidemiology Project records- linkage system, we assessed the prevalence of 18 CC defined by the US Department of Health and Human Services. To evaluate changes in peak VO 2 in patients with multimorbidity (categorized as ≥6 CC), we created logistic regression models adjusting for age, sex, and baseline peak VO 2 . Results: Mean age was 61.5 ± 11.0 years and 75.5% were male. Most patients (81.2%) attended ≥18 CR sessions. Half (50.4%) of patients had at least 6 CC (median 6; range 0-13). Overall, peak VO 2 at baseline was 20.7 ± 6.3 mL/kg per min and the percent change in peak VO 2 following CR was 11.4% ± 21.6%, Figure 1A . Multimorbidity was associated with lower improvement in peak VO 2 following CR compared to patients with <6 CC (7.5% vs 11.4%, p=0.0001). Furthermore, across categories of CRF improvement (i.e., 1%, 5%, and 10% percent change in peak VO 2 ) lower multimorbidity was associated with a 1.5-2-fold increase in CRF when compared to those with higher multimorbidity (≥6 CC), Figure 1B . Conclusions: Patients entering CR have a high multimorbidity burden. Our results suggest that multimorbidity in CR patients attenuates improvement in peak VO 2 . Individualized interventions should focus on managing and reducing multimorbidity to minimize the negative impact on CRF improvement.

Introduction: Multimorbidity is associated with physical disability, increased health care utilization, reduced quality of life, and mortality. Whereas most literature has focused on the co-occurrence of somatic conditions, we aim to (i) establish the prevalence of combined somatic and mental health multimorbidity (SMM) in cardiac rehabilitation (CR) patients, and (ii) determine the most prevalent co-occurrence of cardio-metabolic conditions (CMC) with other somatic or mental health conditions in CR patients. Methods: Using the Rochester Epidemiology Project records-linkage system, we identified residents of Southern MN and Western WI who attended (≥1) CR sessions from 1995 to 2019. The prevalence of 18 chronic conditions defined by the US Department of Health and Human Services was electronically extracted. Heat maps were created to assess the pairwise prevalence of cardio-metabolic (CMC; n=6) with mental (n=5) and other somatic (n=7) chronic conditions (Table 1) . Results: We included 13,056 patients; 68.5% were male. Patients were 65.5±12.5 years old with 44.7% ≤65 years old. Median number of conditions was 7 (Range 0-18) with 52.6% of patients having ≥7 conditions. Hyperlipidemia (89.3%), hypertension (79.5%), and arrhythmias (72.4%) were the most prevalent CMC. The prevalence of combined SMM (≥2 conditions) was 44.9% and was higher in those <65 years ( p <.0001). Depression (26.8%) and anxiety (24.7%) were the most common mental conditions involved in SMM and frequently co-occurred with CMC. Among other prevalent somatic conditions, arthritis (51.7%), chronic obstructive pulmonary disease (33.5%), and cancer (29.3%) co-occurred with CMC (Figure 1). Conclusions: Half of patients in CR have ≥7 chronic conditions. Somatic and mental health multimorbidity (SMM) is highly prevalent and is more frequent in those younger than 65 years old. Our results highlight the critical need to better understand the clinical burden of SMM in patients undergoing CR.