Blair J. O’Neill

Canadian Cardiovascular Society Guidelines for the Diagnosis and Management of Stable Ischemic Heart Disease

This overview provides a guideline for the management of stable ischemic heart disease. It represents the work of a primary and secondary panel of participants from across Canada who achieved consensus on behalf of the Canadian Cardiovascular Society. The suggestions and recommendations are intended to be of relevance to primary care and specialist physicians with an emphasis on rational deployment of diagnostic tests, expedited implementation of long- and short-term medical therapy, timely consideration of revascularization, and practical follow-up measures.

Catheter thrombosis during primary percutaneous coronary intervention for acute ST elevation myocardial infarction despite subcutaneous low-molecular-weight heparin, acetylsalicylic acid, clopidogrel and abciximab pretreatment

BACKGROUND Subcutaneous enoxaparin is increasingly employed as the antithrombin of choice in non-ST elevation myocardial infarction and in conjunction with various fibrinolytic regimens in acute ST elevation myocardial infarction (STEMI). Few data exist describing the use of subcutaneous or intravenous enoxaparin as an anticoagulant in the highly thrombotic setting of primary percutaneous coronary intervention (PCI) for STEMI. METHODS The Which Early ST Elevation Therapy (WEST) study compared fibrinolysis (with and without early cardiac catheterization) with primary PCI in a setting that expedited both strategies on first medical contact. Patients assigned primary PCI are administered acetylsalicylic acid 325 mg, clopidogrel 300 mg and subcutaneous enoxaparin 1 mg/kg before transport to a PCI centre. Of 36 initial patients treated with primary PCI, three patients had procedures that were complicated by extensive thrombosis within coronary catheters and on PCI equipment. RESULTS Index cases were men aged 43 to 68 years who presented with confirmed STEMI and angiographically proven acute total or subtotal occlusion of a major epicardial coronary segment. During PCI, performed 76 min to 102 min following enoxaparin administration, a clot developed within the guide catheter or on the coronary guidewires and balloon catheter shafts, thus necessitating the replacement of all PCI equipment. In one case, there was evidence of continued intracoronary clot propagation and embolization. CONCLUSION A single, conventional, weight-adjusted dose of subcutaneous enoxaparin before expedited primary PCI for STEMI may not provide a reliable antithrombotic effect. Supplementary intravenous enoxaparin is now strongly recommended within the WEST study, and a substudy evaluating pre- and postprocedural antifactor Xa activity has been initiated.

Outcomes following percutaneous coronary intervention and coronary artery bypass grafting surgery in Chinese, South Asian and white patients with acute myocardial infarction: administrative data analysis

BackgroundLittle is known on whether there are ethnic differences in outcomes following percutaneous coronary intervention (PCI) and coronary artery bypass grafting surgery (CABG) after acute myocardial infarction (AMI). We compared 30-day and long-term mortality, recurrent AMI, and congestive heart failure in South Asian, Chinese and White patients with AMI who underwent PCI and CABG.MethodsHospital administrative data in British Columbia (BC), Canada were linked to the BC Cardiac Registry to identify all patients with AMI who underwent PCI (n = 4729) or CABG (n = 1687) (1999–2003). Ethnicity was determined from validated surname algorithms. Logistic regression for 30-day mortality and Cox proportional-hazards models were adjusted for age, sex, socio-economic status, severity of coronary disease, comorbid conditions, time from AMI to a revascularization procedure and distance to the nearest hospital.ResultsFollowing PCI, Chinese had higher short-term mortality (Odds Ratio (OR): 2.36, 95% CI: 1.12-5.00; p = 0.02), and South Asians had a higher risk for recurrent AMI (OR: 1.34, 95% CI: 1.08-1.67, p = 0.007) and heart failure (OR 1.81, 95% CI: 1.00-3.29, p = 0.05) compared to White patients. Risk of heart failure was higher in South Asian patients who underwent CABG compared to White patients (OR (95% CI) = 2.06 (0.92-4.61), p = 0.08). There were no significant differences in mortality following CABG between groups.ConclusionsChinese and South Asian patients with AMI and PCI or CABG had worse outcomes compared to their White counterparts. Further studies are needed to confirm these findings and investigate potential underlying causes.

Weekend compared with weekday presentation does not affect outcomes of patients presenting with non-ST elevation acute coronary syndrome

Aim: In non-ST elevation acute coronary syndromes (NSTEACS), early invasive management improves survival. However, since treatment strategies are urgent, not emergent, decisions to postpone invasive management due to weekend admission could affect outcome. Methods: Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), a population-based registry capturing all cardiac admissions in southern Alberta, we compared time to cardiac catheterization, modality of revascularization, and crude and risk-adjusted mortality for NSTEACS patients presenting on weekends vs. weekdays. From 1 April 2005 to 31 October 2010, 11,981 patients were admitted to care facilities in southern Alberta (32.1% on weekends and 67.9% on weekdays). Results: Baseline characteristics were similar. Mean time to cardiac catheterization was 67.2 h in the weekend group, compared to 62.4 h in the weekday group (p=0.03), with 34.7% of weekend and 45.1% of weekday patients receiving catheterization within 24 h of admission (p<0.0001), and 49.1 and 59.9%, respectively, within 48 h (p=0.002). Mortality at 30 days was 2.2% in the weekend group compared to 2.0% in the weekday group (p=0.58). The crude hazard ratio (HR) for 30-day mortality in the weekend group was 1.08 (95% CI 0.83–1.40). After adjusting for baseline risk factors, the HR for mortality remained non-significant (HR 1.06, 95% CI 0.82–1.38). Mortality at 1 year was also similar. Conclusions: In a large unselected population of NSTEACS patients, weekend admission was associated with modest delays (4.8 h) in time to catheterization, but not with increased 30-day or 1-year mortality.

Revascularization Strategies for Coronary Disease: Art or Science?

As clinicians, we continue to struggle with therapeutic decisions for patients with coronary artery disease (CAD). In a stable environment, the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) study suggests optimal medical management might be the best approach to managing CAD. In diabetic patients, the Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes (BARI 2D) study suggests medical management is as efficacious as prompt revascularization. Yet, the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial, comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) surgery for multivessel CAD, found CABG to be the standard of care for multivessel coronary revascularization. Despite the overall trial results clearly favouring CABG, interventionalists latched onto a subgroup analysis suggesting patients with lower SYNTAX scores did equally well with PCI. Nevertheless, the 5-year follow-up of the SYNTAX trial results found patients with a low SYNTAX score (less complicated disease) performed just as well with CABG. In this issue of the Canadian Journal of Cardiology, Schwalm et al. evaluated the effect of coronary anatomy and SYNTAX score on the variation of revascularization strategies used for patients with multivessel CAD. Approximately 1800 angiograms from 17 cardiac centres in Ontario were evaluated. Approximately 50% of these patients had acute coronary syndromes. Approximately one-third of patients had multivessel CAD. Four blinded cardiologists reviewed all angiographic films and reported coronary anatomy without any clinical knowledge of the patient’s clinical status and/or comorbidities. When comparing the coronary anatomy reported by the blinded clinicians with abstracted chart data,

How do hospital administrators perceive cardiac rehabilitation in a publicly-funded health care system?

BackgroundPatient and provider-related factors affecting access to cardiac rehabilitation (CR) have been extensively studied, but health-system administration factors have not. The objectives of this study were to investigate hospital administrators’ (HA) awareness and knowledge of cardiac rehabilitation (CR), perceptions regarding resources for and benefit of CR, and attitudes toward and implementation of inpatient transition planning for outpatient CR.MethodsA cross-sectional and observational design was used. A survey was administered to 679 HAs through Canadian and Ontario databases. A descriptive examination was performed, and differences in HAs’ perceptions by role, institution type and presence of within-institution CR were compared using t-tests.Results195 (28.7%) Canadian HAs completed the survey. Respondents reported good knowledge of what CR entails (mean=3.42±1.15/5). Awareness of the closest site was lower among HAs working in community versus academic institutions (3.88±1.24 vs. 4.34±0.90/5 respectively; p=.01). HAs in non-executive roles (4.77±0.46/5) perceived greater CR importance for patients’ care than executives (4.52±0.57; p=.001). HAs perceived CR programs should be situated in both hospitals and community settings (n=134, 71.7%).ConclusionsHAs value CR as part of patients’ care, and are supportive of greater CR provision. Those working in community settings and executives may not be as aware of, or less-likely to value, CR services. CR leaders from academic institutions might consider liaising with community hospitals to raise awareness of CR benefits, and advocate for it with the executives in their home institutions.

The Canadian Cardiovascular Society thanks Pulsus Group

In this final issue of The Canadian Journal of Cardiology to be published by Pulsus Group, we wish to thank Robert B Kalina and his staff for their commitment to and passion for the Journal during our partnership of more than 20 years. Pulsus Group has published the Journal for more than 26 years and it was with sincere gratitude that we showed our appreciation for Pulsus at the Canadian Cardiovascular Congress 2010 Awards Ceremony. Robert B Kalina, as owner of Pulsus Group and founder of The Canadian Journal of Cardiology, accepted recognition for his organization’s significant contribution to cardiovascular research and knowledge dissemination in Canada. The Canadian Cardiovascular Society (CCS) is pleased to assume ownership of The Canadian Journal of Cardiology from Pulsus Group. We look forward to the continued growth and impact of The Canadian Journal of Cardiology. In January 2011, the CCS will work with Elsevier to take the journal to the international stage. This is the next step for the CCS-owned journal, and will provide a global platform for excellent Canadian-generated and international research and knowledge, under the editorial leadership of Dr Stanley Nattel, based at the Montreal Heart Institute, Montreal, Quebec.

Giving and getting more: The Canadian Cardiovascular Society wants you!

As a Maritimer assuming the helm of the Canadian Cardiovascular Society (CCS), I cannot help but be humbled by the calibre of this organization and its growth, particularly over the past few years. We are now 1900 members strong with more than 1000 regular members and 500 trainees. As a professional society, we are blessed with a very dedicated and professional staff – now 15 full-time employees in size, and led by our very effective and ever-enthusiastic CEO of seven years, Ms Anne Ferguson. Dr Blair J O’Neill Our CCS team provides continuity for both our own organization and our charitable sister society, the CCS Academy. They tirelessly support our Executive Committee and Council, as well as the volunteer committees and working groups that serve our members so well. For this reason, I would like to begin my term with a round of thanks to the team that has prepared me so well and will ably assist me during the journey ahead. Outgoing President Charles Kerr and Past-President Lyall Higginson have truly been visionary leaders and dedicated champions for our society. They have mentored me well for the job ahead and I cannot thank them enough. I am fortunate to have an excellent executive team to help steward our society, all of whom have served the CCS in many capacities over the years, know the organization well and are committed to strengthening it for our membership. I look forward to working with the following individuals: Mario Talajic as our incoming Vice-President; Ross Davies as Secretary; Milan Gupta as Treasurer; and Chris Simpson as Member-at-Large. It is truly an honour and a privilege to be working with such an impressive team. I was recently asked to fast-forward two years into the future – to the end of my tenure as President of the CCS – and predict what sort of legacy I might leave behind. It is, of course, presumptuous to think I alone, or any one of us for that matter, will leave behind anything resembling a legacy. But the question got me thinking anyway, mostly about my aspirations for the CCS at this very early juncture. The first thing that strikes me is the tremendous opportunity we all have to serve as volunteers and members of the CCS. I used to think of volunteering as giving back – to my profession, to my community and to those less fortunate. But my thinking has changed over the years, and I now see volunteering as an exercise in getting: drawing on the energy, enthusiasm, wisdom and sheer determination of colleagues across Canada. I encourage all of you – whether practitioners, researchers, administrators or trainees – to join the CCS and get involved. You’ll quickly discover that giving is measured by how much you get along the way. Of course, the most valuable reward of all will be the network of friends in this great country of ours! Our impressive knowledge translation (KT) track record is, perhaps, the best give-and-get example I can think of. As CCS members and staff work tirelessly to raise the profile, calibre and strength of our growing array of KT programs and resources (the ‘give’), those involved find they are rewarded by the universally positive feedback these programs receive (the ‘get’). As a society, it seems the more we give, the more we emerge as the strong and credible voice for all matters related to cardiology; as a body of leading practitioners, researchers and trainees; as a leading advocate for access to quality and timely care; and as a leader and teacher for so many aspects of cardiovascular disease, treatment and policy initiatives. One of my top priorities over the next two years is to do a much better job creating (aka giving!) evidence-based tools and resources that are designed specifically for the learning styles and needs of our emerging professionals. It is no secret that a technological generation gap threatens to divide our profession, with opportunities for traditional learners (classroom, conference and in-person delivery methods) often trumping the needs of new-age learners (asynchronous e-learning, social media and spontaneous networking). It is time for all of us at the CCS to start bridging this gap by offering a greater selection of new learning methodologies. Along the way, perhaps this will entice some of our old e-dogs (aka me!) to learn a few new e-tricks. Looking ahead, I also foresee numerous opportunities to expand on the tremendous draw of the Canadian Cardiovascular Congress. As we continue to strengthen the depth and breadth of offerings each year, sadly, many colleagues who would like to participate are back home providing timely access to care. For this reason, I believe we need to increase our capacity through webinars and broadcasts, post-Congress activities and other KT programs to expand our reach and, ultimately, improve the care of our patients. We must continue to increase cross-specialty research, collaboration and KT program development, particularly in areas such as diabetes care, by partnering with colleagues in related fields of endocrinology, internal medicine and obesity. These are just a few of my thoughts as I look ahead to what will most certainly be two exciting years as your president. I want to hear from you and other insightful colleagues within our society. How do you think we can offer the most value to members? How do we further advance the CCS as the national voice and umbrella organization, not only for cardiovascular physicians and scientists, but even more so for the patients who entrust their care to us? Most importantly, I would like to invite all of you to think about what you can give to the CCS as your own personal legacy. I can assure you that you will get back far more than you give. Your first step could be responding to the calls for nominations, or simply telling me what you think. E-mail me at ac.scc@tnediserp. I’d love to hear from you!

The politicization of the wait times issue – and how to rise above it

Wait times for essential medical services remain a top concern for Canadians across the country. In every province and territory, some patients wait too long, causing anxiety, economic hardship, needless pain and suffering, and perhaps even unnecessary deaths. Provincial and federal governments of every political stripe have acknowledged the problem. Doctors, other health care professionals, hospital administrators, policy experts, Ministry of Health officials and politicians have all joined in the chorus. There is unusual unanimity when it comes to the definition of the problem and in the conviction that we must do better. So, what have we accomplished? Well, plenty. Many medical professional groups, under the umbrella of the Canadian Medical Association Wait Time Alliance (WTA), have invested considerable time, expertise and resources in the development of medically acceptable wait time benchmarks. Benchmarks are now established and published for cardiac care, cancer, diagnostic imaging, joint replacement, sight restoration, emergency medicine, psychiatry, plastic surgery, gastroenterology and anesthesiology. We have also had the Romanow and Kirby reports. We’ve had the “10-year plan to strengthen health care”. We’ve had the “Final report of the federal advisor on wait times”. We’ve had the former prime minister, Paul Martin, vow to “fix health care for a generation”. We’ve had the current government move toward the promise of “wait time guarantees”, including the 2007 announcement of an agreement between the federal government and the provinces and territories to commit to providing guarantees for one of the five so-called ‘priority areas’ (cancer, cardiac care, diagnostic imaging, joint replacement and sight restoration). We have had money poured into the effort – hundreds of millions of dollars. However, the ultimate goal remains elusive. Patients, providers and payers remain underwhelmed by the efforts and accomplishments to date. Complaints about wait times continue unabated among patients and family members. As we evaluate ourselves, we need to account for this ‘effort-results mismatch’ before we can continue to move forward. First, it is important to recognize that there are no villains here. Everyone wants to do the right thing. Although progress has been made, hard action and tangible results have been slow to materialize. The problem is simply this: the issue has become politicized. There are too many sound bites – too many early, easy and manufactured victories, an abundance of unrealistic expectations and, most importantly, no sense of collective responsibility or accountability. In the rush to see progress, we have all gravitated to the easy answers. We have claimed progress and success in areas where there never was a problem. We have undersold and set aside the most difficult tasks. And we have laid blame at others’ feet. The reality, of course, is that this issue is not something that can be fixed overnight. Furthermore, no one person or group has the ability or resources to address this adequately or comprehensively. The solution has to come as the result of a massive effort from all stakeholders in the context of a profound cultural shift toward collective responsibility and accountability. Everyone has to believe that this is important, and everyone has to be committed to making a change. It is patently ridiculous to blame failures on the government. Does anyone really believe that politicians in Ottawa, Regina, Fredericton, Victoria or Quebec City can fix this? It is not up to them. It is up to all of us –doctors, nurses, physiotherapists, pharmacists, occupational therapists, social workers, technologists, hospital managers, directors, administrators, bureaucrats, politicians and the public at large. This problem belongs to all of us, and the solution must come from all of us through an exercise in collective responsibility and accountability. We all have an important role to play. And we can only do it together. To move forward, we need to depoliticize the wait times issue. To do this, we need to realize some basic concepts: We need to accept and believe that ‘instant success’ is not possible. We need to believe that the current challenge is a process challenge. We need to fix the way we think about things and the way we do things. This will not result in instantaneous results, and that has to be okay. We need to develop a long-term plan and be willing to forego the ‘instant victories’. If we do not plan properly, we will never design the systems or train the health care professionals we need now and in the future. We need to reject the politics of component care. We need to stop thinking of wait times as a set of single numbers focused on a single surgical procedure. Wait time is fundamentally the continuum of the patient experience – from first symptom, to family doctor visit, to specialist consultation, to specialized testing, to surgery, procedure or treatment, to rehabilitation, to recovery. It is a patient journey through a cascade of diagnostic and therapeutic events that leads to a conclusion. Each component is as important as the others, and the sum total of these parts, with all their complex interactions and interdependencies, is the outcome of interest. Shortening a surgical wait time would be meaningless, for example, if, to accomplish it, a longer wait time to see the specialist in the first place were the consequence. We need to invert the political power relationship. The leadership on the wait times issue has to come from the grassroots – from patients and front-line providers, rather than from our elected officials. Political leadership can and will facilitate the institutional changes that are needed to move forward, but the heart and the ownership of the issue must rest with those who are closest to patients. This means that all of us, as providers and patient advocates, together with our patients, must seize the agenda. The health care system in Canada is a rich tapestry of intricately related components. We must embrace this inter-relatedness as a strength, not a liability. By conceptualizing the wait times problem as a patient care continuum issue that necessarily draws from multiple components and dimensions, we can begin to create a cloak of considerable durability. The competitive political (and ultimately destructive) view of the issue to date has only encouraged the creation of isolated solutions to small pieces of the puzzle – parallel threads that cannot withstand the test of time because they compete with, rather than complement, each other. Need clarification and motivation? It’s easy. All you need to do is to remember one thing: it’s not about doctors, nurses, hospitals, politicians, taxpayers, or money, or winners and losers. It’s about patients.