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Background: More than 450,000 patients receive outpatient hemodialysis in the United States. Patients on hemodialysis are at high risk of bloodstream infections (BSIs), which are associated with significant morbidity and mortality. National prevention efforts targeting hemodialysis facilities have resulted in widespread changes in practice, including modifications to central venous catheter (CVC) maintenance procedures. We analyzed dialysis event surveillance data submitted to the CDC NHSN to describe changes in BSI rates among hemodialysis outpatients from 2014 to 2018. Methods: Outpatient hemodialysis facilities report BSIs (ie, positive blood cultures collected in the outpatient setting or within 1 calendar day after hospital admission) and the number of hemodialysis outpatients treated during the first 2 working days of each month to the NHSN. For each BSI, the suspected source (ie, vascular access, another site, contamination, or uncertain) and vascular access type are indicated: CVC, arteriovenous fistula (AVF) or arteriovenous graft (AVG). Pooled mean rates (per 100 patient months) were calculated for BSIs, access-related BSIs (ARBSIs), and BSIs and ARBSIs were stratified by vascular access type. Annual BSI rate trends were evaluated using a negative binomial regression model, which treated patient months as an offset variable and included access type, year, and an access-year interaction variable. Results: More than 6,000 outpatient hemodialysis facilities reported 134,961 BSIs from 2014 to 2018. Of these BSIs, 102,505 (76%) were categorized as access related. CVCs were present in 63% of BSIs and 70% of ARBSIs. Pooled mean BSI rates decreased 27% from 0.64 to 0.47 per 100 patient months; rates of ARBSIs decreased 27% from 0.49 to 0.36 per 100 patient months. Significant decreases in event rates occurred across vascular access strata (Fig. 1). The reduction in BSI and ARBSI burden was most pronounced among patients with CVCs. BSI rates in patients with CVCs decreased 32% from 2.16 per 100 patient months to 1.46 (annual average decrease, 9.5%), and ARBSI rates in patients with CVCs decreased 32% from 1.83 per 100 patient months to 1.24 (annual average decrease, 9.4%). Conclusions: Substantial reductions in BSI and ARBSI rates among hemodialysis outpatients occurred during this 5-year period, and these reductions appear to be most prominent among CVC and AVF patients. Improvements in infection prevention and control practices, including CVC care, have likely contributed to these reductions. Additional efforts to increase the uptake of known prevention practices and to identify new strategies for prevention might contribute to continued decreases in infections among this highly vulnerable population.Funding: NoneDisclosures: None

A shared understanding of medical conditions between patients and their health care providers may improve self-care and outcomes. In this study, the concordance between responses to a medical history self-report (MHSR) form and the corresponding provider documentation in electronic health records (EHRs) of 19 select co-morbidities and habits in 230 patients with heart failure were evaluated. Overall concordance was assessed using the κ statistic, and crude, positive, and negative agreement were determined for each condition. Concordance between MHSR and EHR varied widely for cardiovascular conditions (κ = 0.37 to 0.96), noncardiovascular conditions (κ = 0.06 to 1.00), and habits (κ = 0.26 to 0.69). Less than 80% crude agreement was seen for history of arrhythmias (72%), dyslipidemia (74%), and hypertension (79%) among cardiovascular conditions and lung disease (70%) and peripheral arterial disease (78%) for noncardiovascular conditions. Perfect agreement was observed for only 1 of the 19 conditions (human immunodeficiency virus status). Negative agreement >80% was more frequent than >80% positive agreement for a condition (15 of 19 [79%] vs 8 of 19 [42%], respectively, p = 0.02). Only 20% of patients had concordant MSHRs and EHRs for all 7 cardiovascular conditions; in 40% of patients, concordance was observed for ≤5 conditions. For noncardiovascular conditions, only 28% of MSHR-EHR pairs agreed for all 9 conditions; 37% agreed for ≤7 conditions. Cumulatively, 39% of the pairs matched for ≤15 of 19 conditions. In conclusion, there is significant variation in the perceptions of patients with heart failure compared to providers’ records of co-morbidities and habits. The root causes of this variation and its impact on outcomes need further study.

Category: 24. Myocardial Function/Heart Failure—Clinical Nonpharmacological TreatmentSession-Poster Board Number: 1160-25Authors: Catherine Norton, Vasiliki Georgiopoulou, Andreas Kalogeropoulos, Lucy Fike, Grigorios Giamouzis, Sonjoy Laskar, Robert Cole, Andrew Smith, Wilson W.H. Tang, Sandra Dunbar, Javed Butler, Emory University School of Medicine, Atlanta, GA, Cleveland Clinic Foundation, Cleveland, OH Background: Cumulative adherence with self-care recommendations and association with outcomes is not well described in heart failure (HF) patients.Methods: We used self-report to evaluate adherence to eight HF self-care recommendations (exercise, medications, alcohol and smoking habits, diet, weight and symptom monitoring) among 286 patients with HF (age, 56±11.6 years; 34.3% female; 46.2% black). Adherence was defined as optimal (overall ≥80%) or ideal (≥80% adherence to each recommendation). Outcomes included death or transplant or ventricular assist device placement; rates of emergency department visits, hospitalizations, and length of stay; health status using the Kansas City Cardiomyopathy Questionnaire.Results: Mean follow-up was 525±295 days. Adherence to individual recommendations ranged from 89% for medication to 26% for exercise. Optimal adherence was reported by 34% of patients whereas only 11% indicated ideal adherence. Education was the only sociodemographic variable associated with adherence (odds ratio [OR] 1.15; 95% confidence interval [CI] 1.05-1.25 for optimal; and OR 1.15; 95% CI 1.02-1.30 for ideal adherence per year of education). Patients with optimal or ideal adherence had better clinical outcomes (Table); however, only ideal adherence was associated with better quality of life.Conclusions: In this HF cohort, better adherence with self-care recommendations was associated with improved clinical outcomes. However, adherence was suboptimal for most patients. Optimal AdherenceDeath/Left Ventricular Assist Device/Transplant, % 8.0 9.2 0.73All cause hospitalizations, per 1000 patient-days 2.8 2.0 0.07HF hospitalizations, per 1000 patient-days 1.2 0.9 0.12Emergency department visits, per 1000 patient-days 1.3 0.8 0.02Hospital length of stay, per 1000 patient-days 13.8 8.8 0.06Hospital length of stay - HF only, per 1000 patient-days 8.5 5.5 0.13Kansas City Cardiomyopathy Questionnaire Overall Summary Score 65.2±23.2 67.9±24.3 0.37Ideal AdherenceDeath/Left Ventricular Assist Device/Transplant, % 8.3 9.4 0.83All cause hospitalizations, per 1000 patient-days 2.7 1.5 0.09HF hospitalizations, per 1000 patient-days 1.2 0.4 0.08Emergency department visits, per 1000 patient-days 1.2 0.8 0.33Hospital length of stay, per 1000 patient-days 13.6 3.0 0.02Hospital length of stay - HF only, per 1000 patient-days 8.3 0.8 0.04Kansas City Cardiomyopathy Questionnaire Overall Summary Score 65.1±23.5 74.3±23.5 0.04

Background Although oxidative stress is considered a key pathogenic step in mediating vascular dysfunction and atherosclerosis development, their association has not been evaluated in human coronary circulation in vivo. Accordingly, we hypothesized that higher oxidative stress would be associated with abnormal coronary epicardial structure and microvascular function. Methods We measured coronary flow velocity reserve (CFVR) and hyperemic microvascular resistance (HMR) as indices of microvascular function, and epicardial plaque volume and necrotic core using intravascular ultrasound (IVUS) in 47 patients undergoing cardiac catheterization. Plasma glutathione, cystine and their ratio served as measures of oxidative stress while high-sensitivity C-reactive protein (hs-CRP) served as a measure of inflammation. Results Lower glutathione, a measure of increased oxidative stress was associated with impaired microvascular function [CFVR ( r =0.39, p =0.01) and HMR ( r =−0.43, p =0.004)], greater plaque burden ( r =−0.32, p =0.03) and necrotic core ( r =−0.39, p =0.008). Similarly, higher cystine/glutathione ratio was associated with impaired microvascular function [CFVR ( r =−0.29, p =0.04)] and greater necrotic core ( r =0.37, p =0.01). In comparison, higher hs-CRP was associated only with greater necrotic core ( r =0.45, p =0.003). After multivariate adjustment for age, gender, hypertension, diabetes, acute coronary syndrome presentation, body mass index, tobacco abuse, statin use and hs-CRP, glutathione remained an independent predictor of CFVR, HMR and necrotic core ( p Conclusions Lower plasma glutathione level a measure of increased oxidative stress, was an independent predictor of impaired coronary microvascular function and plaque necrotic core.

ObjectivesThe primary objective of this study was to elucidate mechanisms underlying the link between vitamin D status and cardiovascular disease by exploring the relationship between 25-hydroxyvitamin D (25-OH D), an established marker of vitamin D status, and vascular function in healthy adults.BackgroundMechanisms underlying vitamin D deficiency-mediated increased risk of cardiovascular disease remain unknown. Vitamin D influences endothelial and smooth muscle cell function, mediates inflammation, and modulates the renin-angiotensin-aldosterone axis. We investigated the relationship between vitamin D status and vascular function in humans, with the hypothesis that vitamin D insufficiency will be associated with increased arterial stiffness and abnormal vascular function.MethodsWe measured serum 25-OH D in 554 subjects. Endothelial function was assessed as brachial artery flow-mediated dilation, and microvascular function was assessed as digital reactive hyperemia index. Carotid-femoral pulse wave velocity and radial tonometry-derived central augmentation index and subendocardial viability ratio were measured to assess arterial stiffness.ResultsMean 25-OH D was 31.8 ± 14 ng/ml. After adjustment for age, sex, race, body mass index, total cholesterol, low-density lipoprotein, triglycerides, C-reactive protein, and medication use, 25-OH D remained independently associated with flow-mediated vasodilation (β = 0.1, p = 0.03), reactive hyperemia index (β = 0.23, p < 0.001), pulse wave velocity (β = −0.09, p = 0.04), augmentation index (β = −0.11, p = 0.03), and subendocardial viability ratio (β = 0.18, p = 0.001). In 42 subjects with vitamin D insufficiency, normalization of 25-OH D at 6 months was associated with increases in reactive hyperemia index (0.38 ± 0.14, p = 0.009) and subendocardial viability ratio (7.7 ± 3.1, p = 0.04), and a decrease in mean arterial pressure (4.6 ± 2.3 mm Hg, p = 0.02).ConclusionsVitamin D insufficiency is associated with increased arterial stiffness and endothelial dysfunction in the conductance and resistance blood vessels in humans, irrespective of traditional risk burden. Our findings provide impetus for larger trials to assess the effects of vitamin D therapy in cardiovascular disease.