Maral Ouzounian

Impact of Preoperative Angiotensin-Converting Enzyme Inhibitor Use on Clinical Outcomes After Cardiac Surgery

BACKGROUND Controversy exists about whether preoperative angiotensin-converting enzyme inhibitor (ACEi) therapy is associated with adverse outcomes after coronary artery bypass grafting (CABG). METHODS We analyzed the outcomes of consecutive patients who underwent isolated CABG between 1998 and 2007 at a single institution. We used multivariable models to examine the association between preoperative ACEi therapy and in-hospital and long-term outcomes. RESULTS Of the 5946 patients undergoing isolated CABG during the study period, 3,262 (54.9%) were treated with an ACEi preoperatively and 2,684 (45.1%) were not. Median follow-up was 3.8 years. Patients treated with an ACEi preoperatively were more likely to have diabetes, hypertension, an ejection fraction of less than 40%, and recent myocardial infarction (all p<0.0001). They were less likely to have pre-existing renal failure (p=0.004) or require an urgent or emergent CABG (p=0.03). Postoperative use of an inotrope (26% vs 20%, p<0.0001) or intra-aortic balloon pump (1.8% vs 1.1%, p=0.03) was more frequent in patients treated preoperatively with an ACEi; however, preoperative ACEi use was not an independent predictor of in-hospital mortality (odds ratio [OR], 1.1; p=0.76), prolonged length of stay in the intensive care unit (OR, 0.9; p=0.09), or new-onset renal failure (OR, 0.7; p=0.09). Furthermore, preoperative use of an ACEi had no independent association with long-term survival (p=0.54) or freedom from acute coronary syndrome (p=0.07). However, it was associated with an increased risk of readmission for heart failure over time (hazard ratio, 1.2; p=0.007). CONCLUSIONS We found no association between preoperative ACEi therapy and adverse in-hospital outcomes or long-term survival after CABG. Preoperative ACEi therapy appears to be safe in patients undergoing CABG.

Predict, prevent and personalize: Genomic and proteomic approaches to cardiovascular medicine

Genomic and proteomic approaches to cardiovascular medicine promise to revolutionize our understanding of disease initiation and progression. This improved appreciation of pathophysiology may be translated into avenues of clinical utility. Gene-based presymptomatic prediction of illness, finer diagnostic subclassifications and improved risk assessment tools will permit earlier and more targeted intervention. Pharmacogenetics will guide our therapeutic decisions and monitor response to therapy. Personalized medicine will require the integration of clinical information, stable and dynamic genomics, and molecular phenotyping. Bioinformatics will be crucial in translating these data into useful applications, leading to improved diagnosis, prediction, prognostication and treatment. The present paper reviews the potential contributions of genomic and proteomic approaches in developing a more personalized approach to cardiovascular medicine.

The cardiac surgery workforce: a survey of recent graduates of Canadian training programs.

BACKGROUND The number of applications to Canadian cardiac surgery programs has declined recently. Perception of a difficult job market for new graduates may contribute to this decline. The objective of this survey was to document the experience of recent graduates of Canadian cardiac surgery training programs. METHODS A 45-question, web-based survey was distributed to all graduates of Canadian cardiac surgery training programs who completed their training between 2002 and 2008. RESULTS Of the 62 estimated recent graduates, 50 completed the survey (81%). Mean age was 36 + or - 3 years and 90% were male. The mean number of years of training after medical school was 9.4 + or - 1.6 years; 78% completed a graduate degree; and 27% extended their training because of a lack of jobs. When asked about employment, 74% mostly or definitely got the job they wanted, although 34% considered themselves underemployed. Most respondents (98%) considered finding employment for a new graduate in cardiac surgery today difficult or extremely difficult, and 64% believed that there is currently an excess of cardiac surgeons in Canada. Only 54% of participants would strongly recommend cardiac surgery to potential trainees. CONCLUSIONS The majority of recent graduates from Canadian cardiac surgery training programs were successful in finding secure employment. A substantial proportion, however, extended their training because of a lack of jobs and reported feeling underemployed. Survey respondents agreed that a new graduate might have difficulty finding a job in cardiac surgery today. These concerns may contribute to the challenges of recruiting to the specialty.

The Canadian Society of Cardiac Surgeons Perspective on the Cardiac Surgery Workforce in Canada

As the professional society representing cardiac surgeons in Canada, the Canadian Society of Cardiac Surgeons (CSCS) recognizes the importance of maintaining a stable cardiac surgical workforce. The current reactive approach to health human resource management in cardiac surgery is inadequate and may result in significant misalignment of cardiac surgeon supply and demand. The availability of forecasting models and high quality, consistent data on productivity, workload, utilization, and demand is a prerequisite for our professions capacity to predict and plan for changes in health human resources. The CSCS recognizes that improved workforce management is a key component to providing optimal cardiac surgical care for Canadians in the future and has developed the recommendations in this document as a call to action to interested stakeholders and policymakers to bring substantial improvements to health human resource management in cardiac surgery.

Determinants of Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting: An Interprovincial Comparison

BACKGROUND Marked variation exists concerning the utilization of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). The objective of this study was to examine differences in predictors of mode of revascularization across 3 provincial jurisdictions. METHODS All patients who underwent PCI and isolated CABG in British Columbia, Alberta, and Nova Scotia between 1996 and 2007 were considered. Age- and sex-standardized rates of PCI and CABG per 100,000 population and PCI to CABG ratios were calculated by year and province. Logistic regression models were constructed to identify independent predictors of mode of revascularization in each province. RESULTS A total of 32,190 and 69,409 patients underwent CABG and PCI, respectively, during the study period. Significant increases in the age- and sex-adjusted PCI to CABG ratios were observed in all 3 provinces, but these ratios differed between provinces. Across all 3 jurisdictions, female sex and diagnosis of acute coronary syndrome favoured increased PCI vs CABG, and increased age, left main, or 3-vessel disease occurring before myocardial infarction, and diabetes favoured lower PCI vs CABG. After adjusting for clinical and angiographic factors, there remained a significant variation in choice of PCI vs CABG between the 3 provinces over time. CONCLUSIONS Significant interprovincial variability in PCI to CABG ratios was observed. Though certain patient-related factors predictive of either PCI or CABG were identified, factors beyond clinical presentation played a role in the choice of revascularization approach.

The impact of sequential grafting on clinical outcomes following coronary artery bypass grafting

OBJECTIVES Sequential anastomoses in coronary artery bypass grafting (CABG) offer theoretical advantages including increased graft flow and more complete revascularisation. However, published studies concerning the safety and efficacy of this technique are not definitive. The objective of this study was to assess the effect of sequential anastomoses on outcomes following CABG. METHODS Perioperative data were prospectively collected on all patients with triple-vessel disease who underwent first-time, isolated, on-pump CABG between 1995 and 2005 at a single centre. Patients with a left internal mammary artery graft to the anterior wall and saphenous vein grafts to the lateral and posterior walls were included. RESULTS Compared to patients without sequential anastomoses (n=1108), patients with sequential anastomoses (n=1246) were more likely to have an ejection fraction (EF)<40% (14.9% vs 10.8%, p=0.004), a recent myocardial infarction (19.3% vs 14.3%, p=0.001) and an urgent/emergent operative status (19.6% vs 14.4%, p=0.0008). Median follow-up was 78 months. After adjusting for clinical covariates, sequential grafting was not an independent predictor of in-hospital adverse events (odds ratio (OR) 1.15, 95% confidence interval (CI) 0.88-1.50, p=0.31) or long-term mortality and/or readmission to hospital (hazard ratio (HR) 0.98, 95% CI 0.86-1.12, p=0.74). Sequential grafting was an independent predictor of receiving greater than three distal anastomoses (OR 9.26, 95% CI; 6.27-13.67, p<0.0001). CONCLUSIONS Patients undergoing sequential grafting presented with greater acuity and worse systolic function. After adjusting for baseline differences, sequential grafting was not found to be an independent predictor of adverse events. These results support the safety of sequential anastomoses in patients undergoing CABG.