Medina‐Inojosa, José R.

Abstract Funding Acknowledgements Type of funding sources: None. Background Falls are the leading cause of injury-related morbidity and mortality among older adults in the United States, including those with cardiovascular disease. Cardiac rehabilitation (CR) helps to optimize functional capacity, strength, and balance in patients with cardiovascular disease and, in theory, may reduce the risk of falls. However, little evidence has been published in this regard. Purpose The purpose of this study was to assess the association between CR participation and risk of falls in a community-based sample of individuals 65 years of age and older with cardiovascular disease who were eligible for CR participation. Methods Individuals from Southeastern MN and Western WI, USA, 65 years of age and older who had experienced a cardiovascular event that qualified them for CR (MI, PCI, CABG, Valve Surgery, Transplant) between January 1, 2000, and December 31, 2018, were included in this study. Participation in CR (≥1 sessions, CR-group) and subsequent falls (moderate or severe, using the Campbell classification system) were ascertained using the Rochester Epidemiology Project records-linkage system. Logistic model to create propensity weighting were used to test the association between CR participation and falls after adjustment for potentially confounding factors. Results A total of 5004 individuals met inclusion criteria for the study, with 2183 (44%) included in the CR group and 2821 (56%) in the non-CR group (CR was indicated, but the individual did not participate). Overall, 1122 patients experienced a fall within the first 5 years (16% of those in the CR-group, 23% of those in the non-CR group). After adjustment, CR participation was not associated with falls, but older individuals, females, and those with a history of falls were more likely to have had a fall, compared to young individuals, males, and those without a history of a fall. Conclusions While CR is beneficial for patients with cardiovascular disease, our study did not find evidence of an association between CR participation and fall risk in individuals 65 years of age and older who have cardiovascular disease. Additional research is needed to evaluate the role of CR components that may potentially reduce modifiable risk factors for falls and thereby reduce the risk of falls.

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiac rehabilitation (CR) is a key component in the continuum of care for patients with CVD that reduces mortality, morbidity and rehospitalization. Clinical practice guidelines strongly recommend and encourage CR participation for eligible patients with CVD. Although there are multiple studies on barriers and solutions to improve the initiation rates of CR, a limited number of studies have explored the barriers and solutions to increase the degree of adherence to CR. Purpose The aim of this study was to define those characteristics that predict adherence to CR with special focus on women and employed patients, since these groups are generally understudied. Methods We performed a retrospective electronic medical record review of the Mayo Clinic CR program, Rochester to identify patients who had started the Mayo Clinic program between January 1, 2014 and September 30, 2015. Among patients who met the inclusion criteria, we conducted a telephone survey with the aim of defining barriers to participation and possible solutions proposed by patients to increase CR adherence. The survey included factors previously identified in the literature as possible barriers, as well as other hypothetical factors; including closed and open-ended questions. The study was approved by the Mayo Clinic institutional review board. Results 376 patients met the inclusion criteria. 257 patients completed the survey. 240 (63.8%) returned the HIPAA (Health Information Use Authorization) document. 72 (30%) were women with a mean age of 66.4 ±12.4 years. Forty-seven percent (n = 113) of the participants did not complete the recommended course of 36 sessions of CR. Among the most important barriers, we found that schedule conflicts were more frequently noted to be a barrier to CR participation among employed patients compared to non-employed patients (p=0.04). Lack of motivation and an inadequate awareness of the importance of completing CR were significantly reported as barriers from employed and non-employed patients. Among the proposed solutions, the participants suggested the potential benefit of alternative delivery models for CR programs; as well efforts to improve awareness of the importance of CR adherence among patients and professionals. Conclusions This study has great relevance because it addressed barriers and potential solutions to CR adherence. Barriers such as mental stress and motivation, as well as a lack of knowledge about CR benefits highlight the role of patient counseling and education as keys to help improve CR adherence. Alternative CR delivery models are attractive options to help facilitate participation, with special focus on the employed population and women, as they more frequently report logistical barriers to CR compared to non-employed patients and men. Further research and advocacy work are needed to help identify and implement strategies that address barriers to CR adherence and completion.

Background: We developed a deep learning algorithm that detects coronary artery calcium (CAC) score using 12-lead electrocardiograms (CAC- ECG). We tested the hypothesis that the output from the CAC-ECG algorithm would be associated with incident atherosclerotic cardiovascular disease (ASCVD) events and that the CAC- ECG would refine the AHA/ACC Pooled Cohort Equation’s (PCE) predictive capabilities. Methods: A community-based cohort of consecutive patients seeking primary care in Olmsted County, MN, between 1998-2000 with passive follow-up via record linkage. Inclusion was identical to the PCE. The original CAC-ECG was developed in 43,210 subjects yielding an AUC of 0.83. Herein, we used the CAC-ECG output to predict a high CAC (≥ 300). Primary outcome was ASCVD defined as fatal and non-fatal myocardial infarction and ischemic stroke, secondary outcome was Major Adverse Cardiovascular Events (MACE) further including PCI, CABG, and mortality. Events were validated in duplicate. Cox proportional hazard models adjusted for variables included in the PCE and were stratified to evaluate the effect of the CAC-ECG on PCE-predicted risk. Follow-up was truncated at 10 years for PCE analyses. Results: We included 24,793 subjects, mean ± SD age 53.9 ± 12.1, 52% women, 95% white. After 16.7±3.7 yrs follow-up, 2,366 (9.5%) had ASCVD and 3,401 (13.7%) had MACE. Risk of ASCVD and MACE increased with CAC-ECG probability quintiles, independent of risk factors, p for trend <0.001 ( Fig. A-B ). The CAC-ECG enhanced the predicted capabilities of the PCE across all ASCVD risk groups ( Fig. C ). Net reclassification improved 13.7% with comparable C-statistic from 0.77 vs. 0.78 for PCE and CAC-ECG. Conclusions: CAC-ECG was associated with ASCVD and MACE and improved PCE predicted risk. The CAC-ECG algorithm could identify individuals at risk in primary prevention; Unlike the PCE, the CAC-ECG can be applied without chart review or performing a computer tomography and may be reliably used retrospectively in cohorts with digitally stored ECGs.

Background There is a scarcity of validated rapid dietary screening tools for patient use in the clinical setting to improve health and reduce cardiovascular risk. The Healthy Eating Index (HEI) 2015 measures compliance with the 2015 to 2020 Dietary Guidelines for Americans but requires completion of an extensive diet assessment to compute, which is time consuming and impractical. The authors hypothesize that a 19‐item dietary survey assessing consumption of common food groups known to affect health will be correlated with the HEI‐2015 assessed by a validated food frequency questionnaire and can be further reduced without affecting validity. Methods and Results A 19‐item Eating Assessment Tool (EAT) of common food groups was created through literature review and expert consensus. A cross‐sectional survey was then conducted in adult participants from a preventive cardiology clinic or cardiac rehabilitation and in healthy volunteers (n=661, mean age, 36 years; 76% women). Participants completed an online 156‐item food frequency questionnaire, which was used to calculate the HEI score using standard methods. The association between each EAT question and HEI group was analyzed by Kruskal‐Wallis test. Linear regression models were subsequently used to identify univariable and multivariable predictors for HEI score for further reduction in the number of items. The final 9‐item model of Mini‐EAT was validated by 5‐fold cross validation. The 19‐item EAT had a strong correlation with the HEI score ( r =0.73) and was subsequently reduced to the 9 items independently predictive of the HEI score: fruits, vegetables, whole grains, refined grains, fish or seafood, legumes/nuts/seeds, low‐fat dairy, high‐fat dairy, and sweets consumption, without affecting the predictive ability of the tool ( r =0.71). Conclusions Mini‐EAT is a 9‐item validated brief dietary screener that correlates well with a comprehensive food frequency questionnaire. Future studies to test the Mini‐EAT's validity in diverse populations and for development of clinical decision support systems to capture changes over time are needed.

Abstract Background Little is known about clinical outcomes in patients with bicuspid aortic valve (BAV) and ascending aortic diameters ≥50 mm where the elective surgical-indication zone begins. Purpose To assess incident aortic dissection (AoD), post-surgical survival and guideline implementation. Methods Multi-center retrospective study of BAV patients (≥18 years) with maximal root or tubular-ascending aortic diameters ≥50mm detected by transthoracic echocardiography at baseline. Ascertainment of aortic surgery, AoD and death was carried-out at their respective institutions. The primary outcome was AoD: “confirmed” AoD by surgery or death certificate, or “possible” AoD defined as sudden cardiac death of unknown cause by death certificate. Secondary outcomes were aortic surgery, post-surgical survival and guideline implementation. Results We included 506 consecutive BAV patients, mean age 61±14 years, 83% men, mean maximal aortic diameter 52±2 mm at baseline, ascending aorta was the most common segment ≥50mm (85%). During a median follow-up of 7.7 years, 356 (71%) underwent elective surgery (89% of class 1 patients). Early-surgery (≤6 months from baseline) occurred in 195 patients and 311 patients remained “under-surveillance”. Surgery under-surveillance (&gt;6 months from baseline) occurred in 161/311 (52%) patients at 2.6 [IQR: 1.5–4.7] years of follow-up. Surgical mortality was 1.4%. Ten-year post-surgical survival was &gt;90% and similar between early-surgery and surgery under-surveillance (p=0.8). Of 8 AoD events, 3 confirmed and 5 possible (all occurring in unoperated patients under-surveillance), 5 events occurred with maximal aortic baseline diameter ≥55 mm and/or &gt;1 year without clinical follow-up; therefore, under guideline non-compliance. Incidence of confirmed plus possible aortic dissection was 0.37% per year with size 50–54mm, 1.13% per year between 55–59mm, and 10.41% per year with size ≥60mm. Aortic stenosis was associated with AoD (p=0.04) and all-cause death in unoperated patients (p=0.001). Conclusions Our results suggest that BAV patients can be safely followed as per guidelines after aortic diameters enter the elective surgical zone (≥50mm), with excellent post-surgical survival regardless of whether surgery is early- or under-surveillance. Appropriate guideline implementation for surgical thresholds and interval clinical follow-up could have prevented most AoD events. Valvular disease guideline should also be followed to prevent AoD and improve survival in these patients. Funding Acknowledgement Type of funding sources: None.

Introduction: Limited validated rapid dietary screening tools are available for patient use for actionable goal setting to improve health and reduce cardiovascular risk. The Healthy Index (HEI) Score measures compliance with the 2015-2020 Dietary Guidelines for Americans but requires completion of an extensive food frequency questionnaire (FFQ) to compute, which is time consuming and impractical. Hypothesis: A 19-item dietary survey that assesses consumption of common food groups known to affect health is correlated to the gold standard FFQ and HEI score and can be further reduced without affecting validity. Methods: An evidence-based 19-item Eating Assessment Tool (EAT™) of common food groups was created through literature review and expert consensus. We then conducted a cross-sectional survey of adult patients from a preventive cardiology clinic or cardiac rehabilitation and of healthy volunteers (n=628, mean age= 37 y, 76% women). Participants completed an online 156-item FFQ which was used to calculate the HEI score using standard methods. The association between each EAT™ question and HEI score category was analyzed by Kruskal-Walis test. Linear regression models were used to identify univariable and multivariable predictors for HEI score. The final model of Mini-EAT™ was validated by 5-fold cross validation. Results: The 19-item EAT™ had good correlation with the HEI (r=0.77) and was subsequently reduced to the 8 items independently predictive of the HEI score: fruits, vegetables, whole grains, refined grains, legumes/nuts/seeds, low-fat dairy, high-fat dairy, and sweets consumption, without affecting the predictive ability of the tool (r=0.76). Conclusions: Mini-EAT™ is an 8-item validated brief dietary screener that correlates well with a comprehensive FFQ. Future studies to test the Mini-EAT™’s validity in diverse populations and for development of clinical decision support systems to capture changes over time are needed.

Introduction: Estimating body fat content has shown to better predict adiposity-related cardiovascular risk than the commonly used body mass index (BMI). The white-light 3D Body Volume Index Scanner (BVI) is a non-invasive device normally used in the clothing industry to asses body shapes and sizes. We assessed the hypothesis that volume obtained by BVI is comparable to the volume obtained by air displacement plethysmography (BodPod) (COSMED Concord, CA, USA) and thus capable of assessing body fat mass using the bicompartmental principles of body composition. Methods: We compared BVI to BodPod, a validated bicompartmental method to assess body fat percent that uses pressure/volume relationships in isothermal conditions to estimate body volume. Volume is then used to calculate body density (BD) applying the formula density= Body mass/Volume. Body fat mass percentage is then calculated using the Siri formula (4.95/BD – 4.50) х 100. Subjects were members of the Mayo Clinic Dan Abraham Healthy Living Center undergoing a wellness evaluation. Measurements from both devices were obtained the same day. A prediction model for total BodPod volume was developed using linear regression based on 80% of the observations (N=971), as follows: Predicted BodPod Volume (L) = 9.498 + 0.805*(BVI volume, L) - 0.0411*(Age, years) - 3.295*(Male=0, Female=1) + 0.0554*(BVI volume, L)*(Male=0, Female=1) + 0.0282*(Age, years)*(Male=0, Female=1). Predictions for BodPod volume based on the estimated model were then calculated for the remaining 20% (N=243) and compared to the volume measured by the BodPod. Results: Mean (SEM) age was 41.5(0.41) years, 39.4% were men, weight 81.6(0.67) kg, BMI was 27.8 (0.20) kg/m2. Average difference between volume measured by BodPod- predicted volume by BVI was 0.0 L, median: -0.4 L, IQR: -1.8 L to 1.5 L. Average difference between Body fat % measured - predicted was -1%, median: -2.7%, IQR: -13.2 to 9.9, R2 = 0.9845 (Figure 1-A, B). Conclusion: Body fat mass can be estimated using volume measurements obtained by a white- light 3D body scanner (Figure 1-A).

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.