Ottawa Heart Institute Research Articles

Abstract 18131: Canadian Multi-center Experience With WATCHMAN for Percutaneous Left Atrial Appendage Closure

Background: There is limited data with WATCHMAN for left atrial appendage (LAA) closure in patients with nonvalvular atrial fibrillation (AF) and contraindications to anticoagulation. The purpose of this study was to evaluate the safety and efficacy of WATCHMAN in our early Canadian experience. Methods: We report our consecutive series of patients who underwent WATCHMAN implantation at 4 Canadian centers (Vancouver General Hospital, Montreal Heart Institute, Hamilton General Hospital and Ottawa Heart Institute). Indications for LAA closure were CHADS2≥1, and contraindication/intolerance to or failure on anticoagulation. All cases were done under general anesthesia and TEE guidance. Majority of patients received dual antiplatelet therapy (DAPT) for 3-6 months after implant. Follow-up TEE was typically performed at 1-6 months post-procedure. Results: Ninety patients underwent LAA closure with WATCHMAN from May 2013 to June 2015. The mean age was 75.0 ± 7.9. The mean CHADS2 score was 2.9 ± 1.2, CHADS-VASc score was 4.4 ± 1.5, and HASBLED score was 3.2 ± 1.2. Permanent AF was present in 66.7% and paroxysmal AF in 33.3%. Indications for LAA closure were prior bleeding in 81 patients (90.0%; 74 major bleeding, and 7 minor bleeding), 9 were deemed high-risk for bleeding (renal failure, cirrhosis, labile INR, esophageal ulcers, on DAPT), and 1 with recurrent strokes on warfarin. Procedural success was 97.8% (88/90), with one device embolization (snared percutaneously) and one implant failure due to inadequate LAA depth. There was no procedural stroke/TIA, death, MI, or cardiac tamponade. There were 3 major bleeding that required transfusions. Mean hospital stay was 1.4 ± 1.8 days. Antithrombotic therapy post-implant included DAPT in 66/90 (73.3%), anticoagulant in 21/90 (5 warfarin, 16 direct anticoagulant), and aspirin alone in 3/90. Follow-up TEE was available in 53 patients, there was 1 device-associated thrombus (treated successfully with anticoagulation), and 18 peri-device leaks (all <5mm). Mean follow-up was 173.8 ± 117.3 days, with no stroke or death, but there was 1 TIA and 3 major bleeding. Conclusion: In our early Canadian experience, WATCHMAN for LAA closure in patients contraindicated to anticoagulation is safe and effective.

IMPACT OF A STRUCTURED REFERRAL ALGORITHM ON THE ABILITY OF AN ECHOCARDIOGRAPHY LABORATORY TO MONITOR ADHERENCE TO APPROPRIATE USE CRITERIA FOR TRANSTHORACIC ECHOCARDIOGRAPHY

Monitoring adherence to appropriate use criteria (AUC) for echocardiography (echo) referrals is an important requirement of echo laboratories by accrediting organizations and health care insurers. However, we have previously demonstrated that a large proportion of free-form-text referral requisitions do not provide sufficient information to allow an echo laboratory to monitor adherence to AUC or identify potentially inappropriate studies. Structured referral requisitions requiring AUC-relevant information have the potential to allow real-time monitoring of AUC adherence by an echo laboratory. We created a structured referral algorithm using requisition deficiencies identified retrospectively in a derivation cohort of 1303 transthoracic echocardiography (TTE) referrals. The purpose of this study was to evaluate the performance of this algorithm in a consecutive series of cardiology outpatient TTE referrals. The validation cohort consisted of 286 consecutive referrals from the outpatient Cardiology clinic at the University of Ottawa Heart Institute over a two-week period. The relevant 2011 American College of Cardiology Foundation (ACCF) AUC indication was identified from information extracted from the free-form-text requisition. The structured algorithm was then applied prospectively to the same cohort using information from the free-form-text requisition, electronic medical record, and ordering clinician. Referrals were classified as AUC adherent (appropriate), uncertain, non-adherent (inappropriate) or unclassifiable. For patients with an indication outlined in the ACCF 2011 AUC, only 28.0% of free-form-text referrals provided adequate information to identify the relevant indication. However, the relevant AUC indication could be identified in 94.4% of referrals using the structured algorithm (p<0.001). The algorithm improved identification of the relevant indication in the AUC categories of general evaluation of cardiac structure and function (100% vs. 43.0%, p<0.001); evaluation of valvular function (100% vs. 23.0%, p<0.001); evaluation of hypertension, heart failure or cardiomyopathy (100% vs. 20.3%, p<0.001); and evaluation of adult congenital heart disease (100% vs. 0%, p<0.001). The structured algorithm failed to identify the relevant AUC indication in 5.6% of referrals. Overall, 9.9% of requests were found to be non-adherent based on AUC criteria. In a consecutive population of 286 cardiology outpatients referred for TTE, our structured algorithm successfully identified the relevant AUC indication in 94.4% of referrals as compared to only 28.0% using standard free-form-text referral requisitions. Use of this structured algorithm could potentially allow echocardiography laboratories to monitor the vast majority of their TTE referrals for AUC adherence.

ASSESSING PSYCHOSOCIAL DISTRESS IN PATIENTS WITH PULMONARY ARTERIAL HYPERTENSION

Pulmonary arterial hypertension is a rare chronic illness with no known cure. Little attention has been given to the psychosocial burdens patients face daily. Identified in the literature includes burdens with emotions, finances, personal relationships, social relations and physical and practical activities. Researchers agree that assessing this population for psychosocial distress is important yet no formal tool exists to guide health care professionals in assessing and providing support for this populationThe aim of this project was to implement a distress-screening tool in the pulmonary hypertension clinic at the University of Ottawa Heart Institute.The distress-screening tool chosen for this pilot project comprised of the Edmonton Symptom Assessment System, the Canadian Problem Checklist and the Distress Thermometer. Statistical data was collected for 17 distress tools collected. A semi-structured interview was conducted to assess for a change in practice in the clinic.The ESAS trends demonstrated that a greater significance needs to be focused on fatigue, shortness of breath, well being and appetite. Many patients experienced mild anxiety. The Canadian Problem Checklist identified physical burdens, lack of sleep, emotional fears and intimacy problems. The distress scale demonstrated a range of mild to moderate emotional distress.The tool improved communication in the clinic and identified high-risk clients in need of psychosocial supportClinical implications include increased patient-centered care and assisting patients in maintaining healthy coping skills. Limitations of this clinical project include low effect size. This pilot project demonstrates the greater need to emphasize psychosocial support for this patient population. Pulmonary arterial hypertension is a rare chronic illness with no known cure. Little attention has been given to the psychosocial burdens patients face daily. Identified in the literature includes burdens with emotions, finances, personal relationships, social relations and physical and practical activities. Researchers agree that assessing this population for psychosocial distress is important yet no formal tool exists to guide health care professionals in assessing and providing support for this population The aim of this project was to implement a distress-screening tool in the pulmonary hypertension clinic at the University of Ottawa Heart Institute. The distress-screening tool chosen for this pilot project comprised of the Edmonton Symptom Assessment System, the Canadian Problem Checklist and the Distress Thermometer. Statistical data was collected for 17 distress tools collected. A semi-structured interview was conducted to assess for a change in practice in the clinic. The ESAS trends demonstrated that a greater significance needs to be focused on fatigue, shortness of breath, well being and appetite. Many patients experienced mild anxiety. The Canadian Problem Checklist identified physical burdens, lack of sleep, emotional fears and intimacy problems. The distress scale demonstrated a range of mild to moderate emotional distress. The tool improved communication in the clinic and identified high-risk clients in need of psychosocial support Clinical implications include increased patient-centered care and assisting patients in maintaining healthy coping skills. Limitations of this clinical project include low effect size. This pilot project demonstrates the greater need to emphasize psychosocial support for this patient population.

TCT-727 Canadian Multi-Center Experience with WATCHMAN for Percutaneous Left Atrial Appendage Closure

Background: There is limited data with WATCHMAN for left atrial appendage (LAA) closure in patients with nonvalvular atrial fibrillation (AF) and contraindications to anticoagulation. The purpose of this study was to evaluate the safety and efficacy of WATCHMAN in our early Canadian experience. Methods: We report our consecutive series of patients who underwent WATCHMAN implantation at 4 Canadian centers (Vancouver General Hospital, Montreal Heart Institute, Hamilton General Hospital and Ottawa Heart Institute). Indications for LAA closure were CHADS2≥1, and contraindication/intolerance to or failure on anticoagulation. All cases were done under general anesthesia and TEE guidance. Majority of patients received dual antiplatelet therapy (DAPT) for 3-6 months after implant. Follow-up TEE was typically performed at 1-6 months post-procedure. Results: Ninety patients underwent LAA closure with WATCHMAN from May 2013 to June 2015. The mean age was 75.0 ± 7.9. The mean CHADS2 score was 2.9 ± 1.2, CHADS-VASc sc...

Heart Failure Related Hospitalization and Mortality after Aortic Valve Replacement

Patients undergoing surgical aortic valve replacement (AVR) are at risk for developing subsequent heart failure (HF) related events that can be predicted using a multivariate model. Based on the model age, preoperative NYHA class, left ventricular grade, atrial fibrillation, coronary artery disease, smoking, and redo AVR status predicted HF after surgery. Increased transprosthesis gradients were associated with HF after AVR while larger prosthesis size and effective orifice area were independently associated with freedom from HF. Select patient and prosthetic valve characteristics may be used to predict the incidence of HF related hospitalization and mortality after AVR. A semiparametric Cox proportional hazards model was developed based upon 1563 patients who underwent AVR at the University of Ottawa Heart Institute between 1976 and 2001. To validate the model a Kaplan-Meier analysis for the composite endpoint of HF related hospitalization or HF related death beyond 30 days post AVR was performed on an independent cohort of 1014 patients who underwent AVR in 2007-2009 as part of the IDE Trifecta trial. The HF endpoint occurred in a total of 41 subjects during 5 years of follow up. These events were driven by 34 HF hospitalization (83%) and 7 HF deaths (17%). Repeat HF hospitalizations occurred in 7 patients (20.6%). At baseline patients with HF events were older (79±8 vs 72±9 years; p<0.0001), had more females (63.4% vs 34.7%; p=0.0002), had a higher proportion of patients with left ventricular ejection fraction <50% (30% vs 12.8%; p=0.0018), and a higher proportion of patients with NYHA Class III or IV (78.1% vs 48.1%, p=0.0012). At 1-year post AVR patients with HF events had a higher trans-valvular gradient (10±4 vs 8±4 mmHg; p=0.004). The table compares the HF-free survival per Kaplan-Meier analysis of the Trifecta™ valve recipient cohort vs that predicted by the model over 5 years post-AVR. The HF-free survival values predicted by the model were well within the confidence intervals of the Kaplan-Meier analysis, confirming the accuracy of the predictive model over the 5-year time interval.Table 1Time post AVR30 days1 year2 years3 years4 years5 yearsCHF-free survival per Kaplan-Meier analysis of Trifecta cohort, % (95% Confidence Interval)100% (N/A)98.2 (97.2 - 98.9)97.0 (95.7 - 97.9)96.0 (94.3 - 97.1)94.7 (92.6 - 96.1)94.4 (92.3 - 95.9)CHF-free survival per Ruel predictive model customized to reflect Trifecta cohort100%98.7%97.4%96.0%94.4%92.7% Open table in a new tab A model for predicting HF events after AVR was validated. While patient characteristics cannot be improved at the time of surgery, a lower valve gradient and/or a larger EOA may be achieved with better valve selection, and thereby result in significantly reduced HF events. Moreover, referral of patients to AVR before advanced symptoms and LV dysfunction develop can result in lower HF recurrence.

Safety and Efficacy of Staged Percutaneous Coronary Intervention During Index Admission for ST-Elevation Myocardial Infarction With Multivessel Coronary Disease (Insights from the University of Ottawa Heart Institute STEMI Registry)

The optimal management strategy for patients with ST-elevation myocardial infarction (STEMI) and multivessel disease has not been well established. In the present cohort study, we sought to examine the safety and efficacy of inhospital staged PCI for patients with STEMI and multivessel disease. We identified all patients with STEMI referred for primary PCI who were found to have multivessel disease (stenosis ≥50% in nonculprit vessel) and compared clinical outcomes in relation to the management strategy, staged versus culprit-only PCI, for nonculprit vessel disease. The primary outcome was mortality at 180days, and secondary outcomes included mortality during the index hospitalization and at 30days, myocardial infarction, stent thrombosis, stroke, and bleeding. Of the 1,038 patients with STEMI meeting inclusion criteria, 259 (25%) underwent staged PCI and 779 (75%) culprit-only PCI during the index admission. Mortality at 180days was 0.8% in patients with staged PCI and 5.0% in patients with culprit-only PCI (p= 0.003). The association between staged PCI and reduced mortality persisted after adjusting for baseline differences in patient characteristics and angiographic variables between the 2 cohorts (odds ratio 0.2, 95% confidence interval 0.04 to 0.77, p= 0.02). The rates of inhospital reinfarction in the staged and culprit-only PCI cohorts were 0.8% versus 1.3% (p= 0.50), respectively, stent thrombosis 0.8% versus 1.3% (p= 0.50), and stroke 0.4% versus 1.3% (p= 0.31). There were no inhospital adverse events related to acute occlusion of a nonculprit vessel in either cohort. Staged PCI during index admission is a safe and effective revascularization strategy for patients with STEMI and multivessel disease.

Short-term risk of arrhythmias among emergency department syncope patients with non-sinus rhythm

a Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada b Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada c Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada d Division of Cardiology, University of British Columbia, BC, Canada e Faculty of Medicine, University of Montreal, Montreal, QC, Canada f Department of Medicine, University of Calgary, Calgary, AB, Canada g Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada

Editorial introductions

Current Opinion in Cardiology was launched in 1985. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of cardiology is divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Thierry MesanaThierry MesanaDr Mesana is the President and Chief Executive Officer of the University of Ottawa Heart Institute. He received his medical degree in 1985 at the Université de la Méditerranée, Marseille, France, where he trained in thoracic and cardiovascular surgery. In 1990, he received his PhD in biophysics and biomechanics from the Université de la Méditerranée after extensive experimental work and design development on artificial hearts and ventricular assist devices. In 1991, Dr Mesana was, at the time, the youngest cardiac surgeon in France to receive a full Professorship. He then became the Chair of Thoracic and Cardiovascular Surgery at La Timone University Hospital, France, the largest hospital in Marseilles, where he introduced a number of advanced techniques in valve surgery, thoracic aorta surgery and ventricular assist devices and greatly expanded their cardiac surgery program, doubling its size in a 10-year period. Dr Mesana was appointed Chief of Cardiac Surgery at the University of Ottawa Heart Institute in 2001. Under his leadership, the Institute's surgical program became a leading Canadian and International program and his valve repair program has become recognized as one of the best in the world. His emphasis on repairing failing heart valves helped to establish this approach as a gold standard for treatment. He is a strong advocate of basic science research in the field of myocardial regeneration. In the last few years, his group in Ottawa has published papers extensively on studies in basic research related to stem cells and angiogenesis, clinical research papers on long-term follow-up of patients with heart valve prosthesis, as well as studies on aortic prosthesis mismatch and predictors of long-term outcome such as stroke, heart failure and reoperation. In addition, he has encouraged the development of minimally invasive surgical procedures for coronary bypass grafting and complex cardiac arrhythmias, and utilization of miniaturized rotary blood pumps as bridge to transplantation. During his tenure at the Institute, he marked the milestone of its 500th heart transplant. Haissam HaddadHaissam HaddadDr Haddad received his BSc from Tichreen University in Syria in 1980 and graduated from Medical School at Tichreen University in 1983. Following a family medicine practice in Syria, Dr Haddad immigrated to Canada and trained in internal medicine at Dalhousie University, Canada, and successfully completed his Cardiology training at the University of Alberta, Canada. In July 1997, Dr Haddad joined the Division of Cardiology, Queen Elizabeth II Health Sciences Centre, Dalhousie University in Halifax, Nova Scotia and was Medical Director of the Heart Transplant Program and Director of the Cardiac Rehabilitation Program. In September 2001, Dr Haddad joined the University of Ottawa Heart Institute, Canada; he is Professor of Medicine, Division of Cardiology, Director of the Heart Failure Program, and Medical Director of Heart Transplant Program (2001–2013). He is also the Vice President of Medical Staff, The Ottawa Hospital and member of The Board of Directors. Dr Haddad was a member of the Primary Panel of the Canadian Cardiovascular Society's consensus conferences on the management of heart failure (2001–2010), on heart transplantation in adults (2003) and on heart transplantation in pediatrics (2005). He also chaired the Society's consensus conference for heart transplant in 2008–2009. Dr Haddad was the chair of The Canadian Cardiac Transplant Group, 2006–2008. He is the vice president, Canadian Heart Failure Association. He is the founder of the annual educational meeting for The Canadian Cardiac Transplant programs (Ottawa 2008, Calgary 2009, Quebec City 2010). Dr Haddad has earned numerous prestigious awards, namely the Anemia Institute for Research and Education Award in 2005, and the 1st Award Prize in the International Competition of the American College of Physicians in 2000.

Limitations of free-form-text diagnostic requisitions as a tool for evaluating adherence to appropriate use criteria for transthoracic echocardiography.

BackgroundMonitoring the adherence to Appropriateness Use Criteria (AUC) has been identified as an important component for the accreditation of echocardiography laboratories. Referral requisitions are a logical tool to rapidly determine the appropriateness of transthoracic echocardiography (TTE) referrals, however data is lacking. We investigated whether standard free-form-text TTE referral requisitions can be used to evaluate AUC adherence.MethodsConsecutive TTE referral requisitions to the University of Ottawa Heart Institute echocardiography laboratory were reviewed over a four-week period. Indication on the requisition was matched with the relevant indication on the 2011 American College of Cardiology Foundation (ACCF) AUC. Requisitions that did not provide sufficient information to identify the relevant AUC indication were identified as inadequate. For inadequate requisitions, reason for the referral was clarified through medical records and referring physicians.ResultsOf the 1303 requisitions, 26.2% did not provide adequate information to determine adherence to AUC, despite a non-adherence (inappropriate) rate of only 6.1% in the referral population. Indication for referral, physician specialty, outpatient status, and prior echocardiogram were independent predictors of inadequate requisitions (p < 0.001, respectively). The most common reasons for inadequate requisitions were a failure to report: 1) change in clinical status, 2) date of a prior echocardiogram, and 3) type and/or severity of a valve lesion. Inclusion of this information would have decreased the inadequacy rate by 56%.ConclusionIn a large, academic echocardiography laboratory, over one quarter of free-form-text TTE requisitions are inadequate to evaluate AUC adherence. Structured requisition formats requiring AUC-relevant information are needed to facilitate the practical application of AUC in the echocardiography laboratory.Electronic supplementary materialThe online version of this article (doi:10.1186/1476-7120-13-4) contains supplementary material, which is available to authorized users.

The Cardiac Imaging Fellowship Training Program at the University of Ottawa Heart Institute

The Cardiac Imaging Fellowship Training Program at the University of Ottawa Heart Institute

Ezetimibe: rescued by randomization (clinical and mendelian).

Since its market launch in the early 2000s, ezetimibe has had a stormy history of acceptance and use by the clinical community. Ezetimibe’s initial approval by regulatory bodies was based primarily on its low side effect profile together with its ability to consistently reduce low-density lipoprotein (LDL) cholesterol by ≈20% either as monotherapy or as an additive to statin therapy. Notably, approval was granted despite the absence from ezetimibe’s portfolio of studies, demonstrating reductions in hard clinical cardiovascular outcomes, such as myocardial infarction or stroke. By 2006, ezetimibe accounted for >15% of all prescriptions for lipid-lowering medications in the United States,1 reflecting that era’s stout faith in the reliability of LDL cholesterol as a surrogate marker for clinical end points, together with practitioners’ positive real-world experiences with ezetimibe’s biochemical efficacy and good tolerability. It was tacitly anticipated that the pending cardiovascular outcome studies would be positive, eventually vindicating the early confidence that clinicians placed in the drug. However, the waters grew rough for ezetimibe in 2008. First, the Ezetimibe and Simvastatin in Hypercholesterolemia Enhances Atherosclerosis Regression (ENHANCE) trial conducted for 24 months in 720 patients with familial hypercholesterolemia showed that combined therapy with ezetimibe and simvastatin did not significantly change carotid intima–media thickness when compared with simvastatin alone, despite decreased levels of LDL cholesterol.2 Next, the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) trial conducted for 52 months in 1873 elderly nondiabetic patients with aortic stenosis showed that ezetimibe plus simvastatin did not reduce the composite outcome of combined aortic valve events and ischemic events.3 To add insult to injury, the 2009 Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol-6-HDL and LDL Treatment Strategies in Atherosclerosis (ARBITER 6-HALTS) study demonstrated that when combined with a statin, extended-release niacin caused a significant …

Editorial introductions

Editorial introductions

Quantification of Myocardial Blood Flow in Absolute Terms Using 82Rb PET Imaging: The RUBY-10 Study

ObjectivesThe purpose of this study was to compare myocardial blood flow (MBF) and myocardial flow reserve (MFR) estimates from rubidium-82 positron emission tomography (82Rb PET) data using 10 software packages (SPs) based on 8 tracer kinetic models. BackgroundIt is unknown how MBF and MFR values from existing SPs agree for 82Rb PET. MethodsRest and stress 82Rb PET scans of 48 patients with suspected or known coronary artery disease were analyzed in 10 centers. Each center used 1 of 10 SPs to analyze global and regional MBF using the different kinetic models implemented. Values were considered to agree if they simultaneously had an intraclass correlation coefficient >0.75 and a difference <20% of the median across all programs. ResultsThe most common model evaluated was the Ottawa Heart Institute 1-tissue compartment model (OHI-1-TCM). MBF values from 7 of 8 SPs implementing this model agreed best. Values from 2 other models (alternative 1-TCM and Axially distributed) also agreed well, with occasional differences. The MBF results from other models (e.g., 2-TCM and retention) were less in agreement with values from OHI-1-TCM. ConclusionsSPs using the most common kinetic model—OHI-1-TCM—provided consistent results in measuring global and regional MBF values, suggesting that they may be used interchangeably to process data acquired with a common imaging protocol.

EFFICACY OF AN EARLY INVASIVE STRATEGY FOLLOWING FIBRINOLYSIS IN ST-ELEVATION MYOCARDIAL INFARCTION IN RELATION TO THE ANGIOGRAPHIC EXTENT OF CORONARY ARTERY DISEASE

benefit as compared to mild therapeutic hypothermia by inhibiting multiple deleterious pathways. OBJECTIVE: We sought to determine the feasibility of cooling and maintaining comatose post-cardiac arrest patients with ROSC at a target temperature of 31 degrees Celsius over a 24 hour interval. The ability to achieve and maintain moderate therapeutic hypothermia (31 degrees Celsius) in a clinical setting has never been studied in post-cardiac arrest patients. METHODS: The University of Ottawa Heart Institute (UOHI) is currently conducting a randomized controlled therapeutic hypothermia trial, CAPITAL CHILL. Patients presenting with out-of-hospital cardiac arrest, whose treatment includes therapeutic hypothermia, are randomly allocated to mild (34 degrees Celsius) or moderate (31 degrees Celsius) hypothermia through the use of an endovascular cooling device. We identified the first 20 patients who were randomized to 31 degrees Celsius. We examined the ability to achieve and maintain a target temperature of 31 degrees Celsius during a 24 hour interval. RESULTS: Between August 2013 and April 2014, we identified the first 20 consecutive patients randomized to 31 degrees Celsius: the mean age was 60 16 yr. A complete temperature dataset was available on 18 patients, however, out of these patients, 2 expired 12 and 16 hrs following randomization. The figure depicts the mean temperatures with standard deviations evaluated during a 24 hour period at the following time points; 0, 2, 4, 8, 12, 16, 20 and 24 hours. The zero time point was defined as the temperature at randomization.

SEX DIFFERENCES AND CHANGES IN HEALTH STATUS OF YOUNG ADULTS DURING THE FIRST YEAR FOLLOWING ACUTE MYOCARDIAL INFARCTION

Bivalirudin for primary percutaneous coronary interventions in patients with cardiogenic shock: Outcome Assessment in the CAPITAL STEMI registry. BACKGROUND: Data from randomized clinical trials have demonstrated superiority of bivalirudin to heparin with or without routine use of glycoprotein (GP) IIb/IIIa inhibitors in patients undergoing primary percutaneous coronary intervention (PPCI). However the performance of bivalirudin in PPCI without the use GPIIb/IIIa inhibitors, in patients with cardiogenic shock remains unknown. METHODS AND RESULTS: We screened 2536 patients who underwent PPCI for ST elevation myocardial infarction (STEMI) at the University of Ottawa Heart Institute between June 2004 to June 2011. From this cohort, we identified 91 patients who developed cardiogenic shock and who received either bivalirudin (n1⁄434) or Heparin (n1⁄457), with no GP IIb/IIIa inhibitors. The primary outcome was a composite of cardiovascular death, myocardial infarction and stroke. The secondary endpoints were the rate non-coronary artery bypass graft related TIMI major bleeding, any major bleeding, reinfarction and stent thrombosis and in-hospital mortality. The primary outcome was similar in both groups, occurring in 44% of patients receiving bivalirudin vs. 58% in patients treated with heparin alone (OR 0.76 CI 0.36 to 1.60, P1⁄40.47). Compared with the heparin group, a reduction in non-CABG related TIMI major bleeding (18% vs. 16%, P1⁄40.72), any major bleeding (18% vs. 19%, P1⁄40.87) or inhospital mortality (38% vs. 52%, P1⁄40.18) with bivalirudin could not be demonstrated. Notably, the use of bivalirudin was associated with a 6.8 fold increased risk of stent thrombosis and re-infarction (11.7% vs. 1.7%, P1⁄40.043). CONCLUSION: In patients with cardiogenic shock, undergoing PPCI with dual antiplatelet therapy with no GP IIb/IIIa inhibitors, the use of bivalirudin appears to be a safe anticoagulation strategy when compared to heparin. Bivalirudin was however associated with a potential risk of increased stent thrombosis and re-infarction in the setting of cardiogenic shock. Larger clinical studies are needed to either confirm or refute these findings.

INSIGHTS INTO THE IMPORTANCE OF THE ECG IN PATIENTS WITH ACUTE HEART FAILURE

tween May 2010 and September 2013 with normal ejection fraction (EF>40%), no documented CAD and no regional perfusion defects (summed stress score <4) were included in the analysis. Data was obtained from the Rubidium PET-Alternative Radiopharmaceutical for Myocardial Imaging (Rb-ARMI) database at the University of Ottawa Heart Institute. Patients with a confirmeddiagnosis ofHF (adjudicated via chart reviewexamining clinical documents, discharge summaries, emergency department visits and echocardiographic data available through electronic medical records at theOttawaHospital; n1⁄4120)were compared to patients with no evidence of dyspnea or knownHF (n1⁄4350). The primary outcomeanalyzedwas global LVand regional (left anterior descending artery, LAD; left circumflex, LCx; right coronary artery, RCA) MFR measured as stress/rest myocardial blood flow. Secondary variables including age, gender, body mass index, smoking history, hyperlipidemia, hypertension, anemia (on the basis of haemoglobin, HgB), renal dysfunction (represented by creatinine level, Cr) and diabetes were also examined. RESULTS: The average age of this cohort was 63, with 57% females. Patients with HFpEF were more likely to be older, female and have comorbid hypertension, diabetes and anemia. HFpEF was associated with a significant reduction in global (2.70 in Controls vs 2.20 inHFpEF, p<0.001) and regionalMFR (LAD, 2.73 vs 2.22; LCx, 2.63 vs 2.15;RCA, 2.70 vs 2.20; all p<0.001). HFpEF remained a significant predictor of reduced global MFR after adjustment for age, gender, diabetes, Cr, HgB, BMI, smoking history, hypertension and hyperlipidemia (p<0.001). CONCLUSION: HFpEF is associated with reduced MFR independent of other risk factors and epicardial CAD. Whether this has prognostic value or may be a therapeutic target requires further study.

IMPROVING THE TRANSITION OF CARE FOR HEART FAILURE PATIENTS DISCHARGED FROM HOSPITAL

Despite optimal medical management, patients with heart failure (HF) have a high rate of readmission. One reason for this may be due to issues surrounding transition of care between hospital and home. Since the discharge summary is the primary mode of communication between the hospital care team and receiving practitioners, enhancing the quality of these reports can improve transition of care. Recently, a standardized discharge template was piloted at the University of Ottawa Heart Institute with the goal of improving the transitions of care from hospital to home for HF patients. This prospective cohort study compared the new standardized discharge summaries to discharge summaries in same four-month period in the year prior to the intervention (Oct 2012-Jan 2013 vs Oct 2013-Jan 2014). The effectiveness of this intervention was measured by (1) a survey of end-user discharge summary satisfaction, (2) the time from discharge to receipt of discharge summary, and (3) the proportion of HF discharge summaries that contain key recommended elements of information. Three independent raters reviewed the summaries with moderate agreement (κ=0.41). There were 187 discharge summaries (N=96 pre-intervention group vs N=91 post-intervention group). Most HF patients were male (60.4% vs 61.5%), of similar age (mean ± SD, 67.6±12.7 vs 70.3±12.8 years) and length of stay (14.5±11.5 vs 11.4±7.7 days). The results of the primary care discharge summary satisfaction survey, which had a response rate of 55% (12 out of 22), revealed a mean overall satisfaction of 3.25±1.13 out of 4.00. The time to delivery of the discharge summary decreased (median ± MAD, 1.0±1.0 vs 0.0±0.0 days). There was a trend for the overall compliance of discharge summaries containing the 14 key recommended elements to increase with the use of the template (71.5% vs 77.8%, p-value=0.16). The use of the template was associated with significantly greater reporting of current weight/target weight (12.5% vs 40.7%, p-value<0.0002), results of creatinine, electrolytes, and/or INR at discharge (38.5% vs 57.1%, p-value=0.0054), and a description and explanation for medication changes in hospital (38.5% vs 50.5%, p-value=0.0495). The use of a standardized hospital discharge template for HF patients was associated with a trend towards decreased time to delivery and improved quality of reporting key elements related to HF management. This strategy may be effective when bundled with multiple interventions aimed at improving transitions of care. Further studies are ongoing to determine if this will decrease hospital readmission rates.

BIVALIRUDIN FOR PRIMARY PERCUTANEOUS CORONARY INTERVENTIONS IN PATIENTS WITH CARDIOGENIC SHOCK: OUTCOME ASSESSMENT IN THE CAPITAL STEMI REGISTRY

Bivalirudin for primary percutaneous coronary interventions in patients with cardiogenic shock: Outcome Assessment in the CAPITAL STEMI registry. BACKGROUND: Data from randomized clinical trials have demonstrated superiority of bivalirudin to heparin with or without routine use of glycoprotein (GP) IIb/IIIa inhibitors in patients undergoing primary percutaneous coronary intervention (PPCI). However the performance of bivalirudin in PPCI without the use GPIIb/IIIa inhibitors, in patients with cardiogenic shock remains unknown. METHODS AND RESULTS: We screened 2536 patients who underwent PPCI for ST elevation myocardial infarction (STEMI) at the University of Ottawa Heart Institute between June 2004 to June 2011. From this cohort, we identified 91 patients who developed cardiogenic shock and who received either bivalirudin (n1⁄434) or Heparin (n1⁄457), with no GP IIb/IIIa inhibitors. The primary outcome was a composite of cardiovascular death, myocardial infarction and stroke. The secondary endpoints were the rate non-coronary artery bypass graft related TIMI major bleeding, any major bleeding, reinfarction and stent thrombosis and in-hospital mortality. The primary outcome was similar in both groups, occurring in 44% of patients receiving bivalirudin vs. 58% in patients treated with heparin alone (OR 0.76 CI 0.36 to 1.60, P1⁄40.47). Compared with the heparin group, a reduction in non-CABG related TIMI major bleeding (18% vs. 16%, P1⁄40.72), any major bleeding (18% vs. 19%, P1⁄40.87) or inhospital mortality (38% vs. 52%, P1⁄40.18) with bivalirudin could not be demonstrated. Notably, the use of bivalirudin was associated with a 6.8 fold increased risk of stent thrombosis and re-infarction (11.7% vs. 1.7%, P1⁄40.043). CONCLUSION: In patients with cardiogenic shock, undergoing PPCI with dual antiplatelet therapy with no GP IIb/IIIa inhibitors, the use of bivalirudin appears to be a safe anticoagulation strategy when compared to heparin. Bivalirudin was however associated with a potential risk of increased stent thrombosis and re-infarction in the setting of cardiogenic shock. Larger clinical studies are needed to either confirm or refute these findings.

The association between ambient air quality and cardiac rate and rhythm in ambulatory subjects

BackgroundAcute increases in ambient air pollution have been associated with increased hospitalization for cardiac diseases and stroke. Triggering of cardiac arrhythmia by changes in air quality could theoretically predispose individuals to cardiac arrest or heart failure, or stroke through precipitation of atrial fibrillation. We investigated the association between air quality and cardiac rate and rhythm characteristics measured by ambulatory cardiac monitoring. Methods and resultsDaily ambient 3-h maximum concentrations of ozone, nitrogen dioxide and fine particulate matter, and an index summarizing these pollutants called the Air Quality Health Index (AQHI) were compared to the results of 24-h ambulatory cardiac monitoring performed for clinical purposes in 8662 patients and analyzed at the University of Ottawa Heart Institute, Canada, between 2004 and 2009. An interquartile increase in the daily 3h- maximum AQHI was associated with a 0.9% (95% CI 0.3%, 1.5%) increase in the daily maximum heart rate and a 1.17% (95% CI 1.07%, 1.29%) increase in heart block frequency. An interquartile increase in NO2 was associated with an increase in the percentage of time in atrial fibrillation of 4.39% (−0.15, 9.15) among those ≤50years old, and 7.1% (0.24, 14.5) among males. ConclusionsWe found evidence that air pollution may affect cardiac rate and rhythm. This may be one mechanism partially explaining the increase in strokes and cardiac events observed on days of higher air pollution.

Editorial introductions

Current Opinion in Cardiology was launched in 1985. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of cardiology is divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Sherif F. NaguehSherif F. NaguehAfter graduating from the Cairo University Faculty of Medicine, Egypt, in 1986, Dr Nagueh emigrated to Houston, Texas, USA. He completed his medicine residency and cardiology fellowship at Baylor College of Medicine, USA. He is currently Professor of Medicine at Weill Medical College of Cornell University, USA; and Medical Director of the Echocardiography Laboratory at the Methodist DeBakey Heart Center in Houston, Texas, USA. Dr Nagueh has received several awards, including the Second Annual Feigenbaum Lecture at the American Society of Echocardiography meeting in 2001. He sits on the Editorial Boards of the Journal of the American College of Cardiology, Circulation, Journal of the American Society of Echocardiography, and Clinical Science; and has served as the Imaging and echocardiography Section Editor for Current Opinion in Cardiology since 2001. Andrew PipeAndrew PipeDr Andrew Pipe graduated from Queen's University, Canada in 1974. He is currently Chief of the Division of Prevention and Rehabilitation at the University of Ottawa Heart Institute, Canada, and is also a Professor in the Faculty of Medicine at the University of Ottawa, Canada. He is currently involved in clinical research assessing new approaches to smoking cessation, strategies designed to facilitate exercise adoption, and novel initiatives to prevent cardiovascular disease. Dr Pipe has addressed audiences in over 30 nations and is frequently consulted on issues related to tobacco use and smoking cessation, physical activity and health, and drug use in sport. Dr Pipe is the recipient of the International Olympic Committee's Award for “Sport, Health and Wellbeing” and honourary degrees from Queen's University (LLD), Brock University (DSc), Canada and the University of Guelph (DSc), Canada. He was the recipient of the Canadian Cardiovascular Society's Dr Harold N. Segall Award for distinguished contributions to the prevention of cardiovascular disease, and was named to the Order of Canada in 2002.