Although a fibrinolytic pharmacoinvasive strategy is recommended for patients with ST elevation myocardial infarction (STEMI) unable to undergo timely primary percutaneous coronary intervention ...(PCI), there are limited data addressing outcomes specific to those with successful or unsuccessful pharmacologic reperfusions. Accordingly, we evaluated a contemporary pharmacoinvasive strategy for failed and successful reperfusions within the STrategic Reperfusion Early After Myocardial infarction study. Of 1,823 per-protocol–treated patients with STEMI, we examined clinical outcomes and angiographic and electrocardiographic metrics in 3 groups as follows: fibrinolysis requiring rescue (rescue, n = 348), fibrinolysis with scheduled angiography (scheduled, n = 516), and primary PCI (n = 927). Compared with pharmacoinvasive patients undergoing scheduled angiography, rescue patients were more likely to have anterior wall myocardial infarction, more baseline ST-segment elevation and deviation, as well as Q waves in the distribution of their ST elevation. Residual ST elevation ≥2 mm 30 minutes after angiography occurred in 27.9%, 7.9%, and 24.8% of patients who underwent rescue, scheduled, and primary PCI, respectively. Thirty-day composite event rates (all-cause death, cardiogenic shock, heart failure, and reinfarction) were 18.7%, 5.5%, and 13.9%; all-cause death: 6.1%, 2.1%, and 3.9%; cardiogenic shock: 7.5%, 2.0%, and 5.4%; heart failure: 11.8%, 2.3%, and 7.6%; and reinfarction: 1.5%, 1.4%, and 2.2%, for rescue, scheduled, and primary PCI, respectively. Compared with successfully reperfused patients undergoing scheduled angiography, the adjusted relative risk of the primary outcome was 2.92 (95% confidence interval 1.92 to 4.45) in rescue patients. In conclusion, pharmacoinvasive-treated patients requiring rescue angiography had greater baseline risk with more co-morbidities and worse 30-day outcomes compared with successful fibrinolytic-treated patients. Residual ST elevation after reperfusion assists in defining prognosis.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Once considered a childhood disease, the number of adults living with congenital heart disease has now exceeded the number of pediatric patients. The landscape of percutaneous intervention ...for adult congenital heart disease (ACHD) has evolved over the last decade and has yet to be characterized in Canada. The aim of this study was to begin to understand the current infrastructure underlying ACHD interventions in Canada and to characterize the type and number of interventions being carried out across the country. A cross-sectional national survey was distributed via email to all Cardiac Catheterization Laboratory Directors in 2015. All Canadian laboratories involved in ACHD interventions responded, encompassing 19 institutions spanning 69 cardiac catheterization laboratories. A total of 1,451 percutaneous interventions were recorded. Nationwide, the most common simple ACHD interventions were atrial septal defect and patent foramen ovale closures. The most common ACHD interventions of increased complexity were coarctation stenting and transcatheter pulmonary valve implantation. There was a marked clustering of procedures in Ontario, Quebec, British Columbia and Alberta, in keeping with Canada’s population density distribution. A total of 23 ACHD operators were identified, half of which had ACHD-specific fellowship training. This data can be used as a starting point to inform the present state of affairs in the area and lays the groundwork for further work to assess resource allocation and human resource planning for the care of ACHD patients in Canada.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background There are limited contemporary data on the early use of clopidogrel or glycoprotein (Gp) IIb/IIIa inhibitors, alone versus combination therapies, in non–ST-elevation acute coronary ...syndrome (NSTE-ACS). Methods This study included 5,806 Canadian NSTE-ACS patients with elevated cardiac biomarker and/or ST deviation on presentation in the prospective GRACE between 2003-2007. We stratified the study population according to the management strategy (non-invasive vs invasive) and into low-(GRACE risk score ≤108), intermediate- (109-140), and high-risk groups (≥141). Results Overall, 3,893 patients (67.1%) received early (≤24 hours of admission) antiplatelet therapy; the rates of use were 76%, 73%, and 57% in the low-, intermediate-, and high-risk groups, respectively ( P for trend < .001). Only 54% of the conservatively managed patients and 12% of the invasively managed patients received early clopidogrel and GpIIb/IIIa inhibitors, respectively. High-risk patients were less likely (adjusted odds ratio = 0.48, 95% CI 0.39-0.59, P < .001) to receive early clopidogrel or GpIIb/IIIa inhibitors, whereas in-hospital catheterization was an independent positive predictor (adjusted odds ratio = 2.02, 95% CI 1.74-2.34, P < .001) of use. Conclusions In this contemporary NSTE-ACS population, both clopidogrel and GpIIb/IIIa inhibitors were targeted toward patients treated with an invasive strategy but paradoxically toward the lower-risk group. In particular, clopidogrel appeared to be underused among conservatively managed patients despite its proven efficacy, whereas GpIIb/IIIa inhibitors were administered to only a minority of the high-risk patients with elevated cardiac biomarkers. Our findings emphasize the ongoing need to promote the optimal use of evidence-based antiplatelet therapies among high-risk patients with NSTE-ACS.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Antiplatelet agents are a cornerstone of therapy for patients with atherosclerotic vascular disease. There is presently a lack of comprehensive guidelines focusing on the use of antiplatelet ...drugs in patients currently manifesting or at elevated risk of cardiovascular disease. The Canadian Antiplatelet Therapy Guidelines Committee reviewed existing disease-based guidelines and subsequently published literature and used expert opinion and review to develop guidelines on the use of antiplatelet therapy in the outpatient setting. This Executive Summary provides an abbreviated version of the principal recommendations. Antiplatelet therapy appears to be generally underused, perhaps in part because of a lack of clear, evidence-based guidance. Here, we provide specific guidelines for secondary prevention in patients discharged from hospital after acute coronary syndromes, percutaneous coronary intervention, or coronary artery bypass grafting; patients with a history of transient cerebral ischemic events or strokes; and patients with peripheral arterial disease. Issues related to primary prevention are also addressed, in addition to special clinical contexts such as diabetes, heart failure, chronic kidney disease, pregnancy or lactation, and perioperative management. Recommendations are provided regarding pharmacologic interactions that may occur during combination therapy with warfarin, clopidogrel, and proton-pump inhibitors, or aspirin and nonsteroidal anti-inflammatory drugs, as well as for the management of bleeding complications. The complete guidelines document is published as a supplementary issue of the Canadian Journal of Cardiology and is available at http://www.ccs.ca/.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Over the last decade, there have been major changes in the treatment of ST-elevation myocardial infarction (STEMI). Whether these have resulted in changes in sex differences in time to ...treatment is unknown. We examined temporal trends in time to reperfusion therapy among men and women with STEMI. Methods The study includes 2 cohorts of STEMI patients presenting to a large metropolitan region during the periods August 24, 2000, to August 20, 2002 (Cohort1, n = 753), and August 25, 2006, to December 31, 2008 (Cohort2, n = 885). Results In both cohorts, compared with men, women were significantly older and had more comorbidities. Rate of emergency medical services use among women increased from 55% in Cohort1 to 66% in Cohort2 ( P = .02). Median time from symptom onset to first medical contact was 84 minutes among men and 121 minutes among women ( P < .01) in Cohort1 and 59 minutes among men and 81 minutes among women ( P < .01) in Cohort2. Median door-to-balloon time was significantly longer among women compared with men in Cohort2. After multivariable adjustment, female sex was associated with a 34% (or 27-minute) increase in time from symptom onset to first medical contact and with a 23% (or 13-minute) increase in time from hospital arrival to reperfusion therapy. Conclusions In the last decade, there have been significant reductions in patient and system delay, especially among women. However, women continue to have longer presentation and treatment times, suggesting that there continue to be opportunities for improvement.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Traditional time-to-event analysis assigns equal weight to the first event in the composite end point. This is counterintuitive to many stakeholders. Methods We constructed weights for ...components of a composite efficacy end point and a net clinical outcome by including metrics of safety and efficacy and compared the weighted with the traditional approach. Through an externally validated, clinician-investigator Delphi panel, the relative severity of individual components of a composite end point (30-day death, recurrent myocardial infarction, cardiogenic shock, and congestive heart failure) was determined. The net clinical outcome was assessed through the incorporation of risk thresholds for safety events (intracranial hemorrhage and major systemic bleeding). These weights were then applied to a modified analysis of the ASSENT-3 trial. Results The weights for the efficacy composite were as follows: death, 1.0; shock, 0.5; congestive heart failure, 0.3; and recurrent myocardial infarction, 0.2. The traditional time-to-first-event approach demonstrated a comparable advantage for both enoxaparin (enox) and abciximab (abx) over unfractionated heparin ( P = .05), whereas the weighted efficacy analysis suggested an advantage for enox and similar outcomes between unfractionated heparin and abx ( P = .2). The apparent advantage of enox was attenuated when the net clinical outcome was examined; the apparent efficacy of abx combination therapy was also diminished by an elevated major systemic bleeding rate ( P < .001). Conclusion This novel approach adds an alternative dimension to treatment evaluation by more efficiently incorporating the differential value of all events in each patient. Further development and application of this approach to future trial design and analysis are warranted.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background The CAPTIM trial suggested a survival benefit of prehospital fibrinolysis (FL) compared to primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial ...infarction (STEMI) with a presentation delay of <2 hours. We examined the relationship between reperfusion strategy and time from symptom onset on 1-year mortality in a combined analysis of 1,168 patients with STEMI. Methods Individual patient data from CAPTIM (n = 840, 1997-2000) and the more recent WEST trial (n = 328, 2003-2005) were pooled. Results Median age was 58 years, 81% were men, and 41% had anterior myocardial infarction; 640 patients were randomized to FL versus 528 patients to PCI. Both arms received contemporary adjunctive medical therapy. Presentation delay (ie, symptom onset to randomization) was similar in FL and PCI patients (median 105 72-158 vs 106 74-162 minutes, P = .712). Rescue PCI after FL occurred in 26% and 27%, and 30-day PCI, in 70% and 71% in CAPTIM and WEST, respectively. Mortality was not different between FL and PCI (4.6% vs 6.5%, P = .263); however, the interaction between presentation delay and treatment was significant ( P = .043). Benefit with FL was observed with time <2 hours (2.8% FL vs 6.9% PCI, P = .021, hazard ratio HR 0.43, 95% CI 0.20-0.91), whereas beyond 2 hours, no treatment difference was observed (6.9% FL vs 6.0% PCI, P = .529, HR 1.23, 95% CI 0.61-2.46). Conclusions A strategy of early FL demonstrated a reduction in 1-year mortality compared to primary PCI in early presenters. Time from symptom onset should be a key consideration when selecting reperfusion therapy for STEMI.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Following the occurrence of an acute coronary syndrome (ACS), patients are at high risk for subsequent cardiovascular events. Therapies to lower the level of low-density lipoprotein (LDL) cholesterol ...remain a pillar in secondary prevention approaches following ACS. Significant variability remains in the application of therapies to lower cholesterol level in clinical practice.
A cross-sectional, online survey was conducted of 200 cardiovascular and lipid specialists across Canada who routinely care for patients following the occurrence of ACSs. The survey consisted of 50 multiple-choice questions with opportunities for free-text entry exploring knowledge of lipid guidelines and recent clinical trials, and in-hospital and outpatient management of lipids and familial hypercholesterolemia.
A total of 67.5% (n = 135) of participants stated that a lipid panel would routinely be obtained during the first 24 hours of an admission for an ACS, and 68.5% (n = 137) stated that their hospitals had standing orders for statin initiation at ACS presentation. In high-risk patients, the majority (75.5%; n = 151) of participants indicated that they target an LDL cholesterol level of <1.8 mmol/L. However, a subset (22%; n = 44) would target lower LDL cholesterol levels ranging from 0.5 to 1.7 mmol/L. Only 32.0% (n = 64) of participants stated that >70% of their ACS patients were at or below guideline-recommended LDL cholesterol levels. Respondents generally underappreciated the prevalence of familial hypercholesterolemia in both the general population and ACS patients.
There is significant variation in practice patterns involving therapies to lower LDL cholesterol level in the post–ACS onset period. To improve management of lipids in this high-risk population, changes to institutional policies, shared responsibility of lipid management across multiple disciplines, and physician education are required.
Après un syndrome coronarien aigu (SCA), le risque qu’un autre événement cardiovasculaire survienne est élevé. Les traitements visant à réduire le taux de cholestérol des lipoprotéines de basse densité (C-LDL) demeurent l’un des piliers de la prévention secondaire après un SCA. Dans la pratique clinique, l’utilisation de ces traitements varie considérablement d’un praticien à l’autre.
Nous avons mené une enquête transversale en ligne auprès de 200 spécialistes de la santé cardiovasculaire et des lipides de partout au Canada, qui traitent régulièrement des patients ayant subi un SCA. L’enquête comprenait 50 questions à choix multiples; les participants pouvaient aussi donner des réponses détaillées permettant d’évaluer leurs connaissances des lignes directrices en matière de maîtrise des lipides et des essais cliniques récents, ainsi que de la prise en charge de la lipidémie et de l’hypercholestérolémie familiale en contexte hospitalier et ambulatoire.
Au total, 67,5 % (n = 135) des participants ont déclaré demander systématiquement un bilan lipidique complet dans les 24 heures suivant l’admission d’un patient en raison d’un SCA, et 68,5 % (n = 137) des participants ont dit que la norme dans leur hôpital était d’instaurer un traitement par statine chez tous les patients ayant subi un SCA. Dans le cas des patients présentant un risque élevé, la majorité des participants (75,5 %, n = 151) ont indiqué qu’ils ciblaient un taux de C-LDL de moins de 1,8 mmol/l. Une partie de ces répondants (22 %; n = 4) ont dit cibler un taux de C-LDL encore plus bas, soit de 0,5 à 1,7 mmol/l. Seulement 32,0 % (n = 64) des répondants ont déclaré que plus de 70 % de leurs patients ayant subi un SCA avaient un taux de C-LDL à la limite ou en deçà du taux recommandé dans les lignes directrices. Les répondants ont en général sous-estimé la prévalence de l’hypercholestérolémie familiale dans la population générale et chez les patients ayant subi un SCA.
Les pratiques varient considérablement d’un praticien à l’autre en ce qui concerne les traitements visant à diminuer le taux de C-LDL après la survenue d’un SCA. Afin d’améliorer la prise en charge de la lipidémie dans cette population exposée à un risque élevé, il conviendrait de revoir les politiques des établissements, de répartir la responsabilité de la prise en charge de la lipidémie entre les intervenants de différentes disciplines et de mieux informer les médecins.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Cardiovascular disease encompasses coronary artery disease and valvular heart disease, and the prevalence of both increases with age. Over the past decade, the landscape of interventional ...cardiology has evolved to encompass a new set of percutaneous procedures outside the coronary tree, including transcatheter aortic valve implantation, transcatheter mitral valve repair, and left atrial appendage occlusion. These interventions have sparked a new discipline within interventional cardiology referred to as structural heart disease (SHD) intervention. The access to and numbers of such procedures performed in Canada is currently unknown. This “first of its kind” survey of structural interventions provides insight into the landscape of SHD intervention in Canada and the challenges faced by cardiologists to deliver this important care.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
PDF