Publications (8)94.41 Total impact
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Article: Reduction in mortality as a result of direct transport from the field to a receiving center for primary percutaneous coronary intervention.
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ABSTRACT: This study sought to determine whether mortality complicating ST-segment elevation myocardial infarction (STEMI) was impacted by the design of transport systems. It is recommended that regions develop systems to facilitate rapid transfer of STEMI patients to centers equipped to perform primary percutaneous coronary intervention (PCI), yet the impact on mortality from the design of such systems remains unknown. Within the framework of a citywide system where all STEMI patients are referred for primary PCI, we compared patients referred directly from the field to a PCI center to patients transported beforehand from the field to a non-PCI-capable hospital. The primary outcome was all-cause mortality at 180 days. A total of 1,389 consecutive patients with STEMI were assessed by the emergency medical services (EMS) and referred for primary PCI: 822 (59.2%) were referred directly from the field to a PCI center, and 567 (40.8%) were transported to a non-PCI-capable hospital first. Death at 180 days occurred in 5.0% of patients transferred directly from the field, and in 11.5% of patients transported from the field to a non-PCI-capable hospital (p < 0.0001. After adjusting for baseline characteristics in a multivariable logistic regression model, mortality remained lower among patients referred directly from the field to the PCI center (odds ratio: 0.52, 95% confidence interval: 0.31 to 0.88, p = 0.01). Similar results were obtained by using propensity score methods for adjustment. A STEMI system allowing EMS to transport patients directly to a primary PCI center was associated with a significant reduction in mortality. Our results support the concept of STEMI systems that include pre-hospital referral by EMS.Journal of the American College of Cardiology 10/2012; 60(14):1223-30. · 14.16 Impact Factor -
Article: The impact of therapeutic hypothermia as adjunctive therapy in a regional primary PCI program.
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ABSTRACT: BACKGROUND: Therapeutic hypothermia (TH) is associated with improved neurologic outcomes in comatose survivors of out-of-hospital cardiac arrest (OHCA). There are currently limited data on the outcomes of patients presenting with resuscitated OHCA in the setting of ST-segment elevation myocardial infarction (STEMI). We conducted a retrospective study to determine the outcomes of patients treated with TH for OHCA in a large regionalized STEMI program. METHODS: Patients referred for primary PCI and TH between July 2004 and April 2011 were identified from the University of Ottawa Heart Institute STEMI database. The primary endpoint was survival to hospital discharge with sufficient neurologic recovery to enable discharge home. RESULTS: Among 2467 consecutive patients referred for primary PCI, we identified 50 patients treated with TH following OHCA. Forty-nine underwent PCI, of which 47 (96%) received a stent. Median door-to-balloon time was 113min (IQR 91-151). Patients with good neurologic recovery were younger, mean 51±9 years versus 64±12, p<0.001, and had higher baseline creatinine clearance, 70±19mL/min/1.73m(2) versus 53±23mL/min/1.73m(2), p=0.007. The primary endpoint of survival with sufficient neurologic recovery to enable discharge home was reached in 30 patients (60%). Four survivors required levels of assistance that precluded discharge home. CONCLUSIONS: Therapeutic hypothermia in conjunction with primary PCI is associated with a favorable neurologic outcome in the majority of STEMI patients surviving OHCA. Our results suggest that TH is an important adjunctive therapy for STEMI patients suffering OHCA.Resuscitation 08/2012; · 3.60 Impact Factor -
Article: Transradial versus transfemoral artery approach for coronary angiography and percutaneous coronary intervention in the extremely obese.
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ABSTRACT: This study sought to evaluate the safety and efficacy of transradial versus transfemoral access for coronary angiography and percutaneous coronary intervention in patients with a body mass index ≥ 40 kg/m(2). Coronary angiography is most commonly performed via femoral artery access; however, the optimal approach in extremely obese (EO) patients remains unclear. Between January 2007 and August 2010, a cohort of consecutive EO patients who underwent coronary angiography was identified in our center's registry of angiography and percutaneous coronary intervention procedures. Of 21,103 procedures, 564 (2.7%) were performed in unique EO patients: 203 (36%) via the transradial approach; and 361 (64%) via the transfemoral approach. The primary outcome, a combined endpoint of major bleeding, access site complications, and nonaccess site complications, occurred in 7.5% of the transfemoral group and 2.0% of the transradial group (odds ratio [OR]: 0.30, 95% confidence interval [CI]: 0.10 to 0.88, p = 0.029), an endpoint driven by reductions in major bleeding (3.3% vs. 0.0%, OR: 0.12, 95% CI: 0 to 0.71, p = 0.015), as well as access site injuries (4.7% vs. 0.0%, OR: 0.08, 95% CI: 0 to 0.48, p = 0.002). There were no differences in nonaccess site complications (1.7% vs. 2.0%, OR: 1.50, 95% CI: 0.41 to 5.55), but transradial access procedures were associated with an increase in procedure time and patient radiation dose (p < 0.05). Transfemoral access for coronary angiography and percutaneous coronary intervention was associated with more bleeding and access site complications when compared with a transradial approach. Important reductions in procedural associated morbidity may be possible with a transradial approach in EO patients.08/2012; 5(8):819-26. · 1.07 Impact Factor -
Article: Rescue percutaneous coronary interventions for failed fibrinolytic therapy in ST-segment elevation myocardial infarction: a population-based study.
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ABSTRACT: Fibrinolytic therapy remains the reperfusion strategy of choice for many regions treating patients presenting with ST-segment elevation myocardial infarction (STEMI). However, limited data exist regarding the pattern of use of rescue percutaneous coronary intervention (PCI) in patients with STEMI who failed fibrinolysis, factors associated with its use, and its impact on long-term outcomes. Observational analysis of a population-based cohort was done, which included 2,953 patients with STEMI hospitalized from 2004 to 2005 in Ontario, Canada. Failed fibrinolysis was defined as <50% ST-segment resolution on follow-up electrocardiogram at 60 to 90 minutes after fibrinolysis. The main outcome of measure was death or repeat hospitalization for acute coronary syndrome at 4 years. Among the 1,517 patients who received fibrinolytic therapy, 611 patients (40.3%) failed fibrinolysis. Of these, rescue PCI was performed in 212 patients (34.7%); conservative management, in 373 patients (61.1%); and repeat fibrinolysis, in 26 patients (4.3%). Initial presentation to a PCI hospital was the strongest predictor of rescue PCI use (odds ratio 3.7, 95% CI 2.2-6.0). At 4-year follow-up, the primary end point occurred in 24.5% of patients who received rescue PCI and 36.5% in patients with no rescue PCI (adjusted hazard ratio 0.69, 95% CI 0.49-0.96). This difference was attributable mainly to a significant reduction in death favoring rescue PCI patients (hazard ratio 0.60, 95% CI 0.38-0.94). Rescue PCI was associated with significantly lower risk of long-term adverse outcomes for patients with STEMI who failed fibrinolytic therapy. However, rescue PCI is substantially underused in clinical practice.American heart journal 04/2011; 161(4):764-770.e1. · 4.65 Impact Factor -
Article: The potential economic impact of restricted access to angiotensin-receptor blockers.
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ABSTRACT: The use of angiotensin-receptor blockers increased by more than 4000% in Canada from 1996 to 2006. The benefit of these medications over angiotensin-converting-enzyme (ACE) inhibitors has not been proven aside from a reduction in dry cough. We estimated the potential cost savings that might have been achieved had access to angiotensin-receptor blockers been restricted. We performed a cost-minimization analysis with a decision-tree model using a societal perspective over a one-year period. Sources of data for model parameters included IMS Health Canada data collected from one-third of all retail pharmacies for the cost and use of angiotensin-receptor blockers and ACE inhibitors in each province, as well as published studies for administrative costs and incidence of dry cough. We used Monte Carlo simulations with 10 000 iterations to test the impact of several model parameters (e.g., drug prices, administrative costs and the incidence of dry cough). All data are in 2006 Canadian dollars. A policy that would have restricted access to angiotensin-receptor blockers might have saved more than $77 million in Canada in 2006. The simulations yielded similar savings for the year (mean $58.3 million, 95% confidence interval $29.3 million to $90.8 million). Every simulation showed a cost savings. Had access to angiotensin-receptor blockers been restricted, the potential cost savings to the Canadian health care system might have been more than $77 million in 2006, likely without any adverse effect on cardiovascular health.Canadian Medical Association Journal 02/2011; 183(3):E180-6. · 8.22 Impact Factor -
Article: Primary percutaneous coronary angioplasty with and without eptifibatide in ST-segment elevation myocardial infarction: a safety and efficacy study of integrilin-facilitated versus primary percutaneous coronary intervention in ST-segment elevation myocardial infarction (ASSIST).
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ABSTRACT: Primary percutaneous coronary intervention, if performed promptly, is the preferred strategy to restore flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction. We sought to determine whether eptifibatide, a platelet glycoprotein IIb/IIIa inhibitor, given before catheterization would improve clinical outcomes in patients referred for primary percutaneous coronary intervention. We randomly assigned a total of 400 patients with ST-segment elevation myocardial infarction referred for primary percutaneous coronary intervention to treatment initiated before cardiac catheterization, with either heparin plus eptifibatide (201 patients) or heparin alone (199 patients), in addition to oral aspirin (160 mg) and high-dose clopidogrel (600 mg). The primary end point was a composite of death from any cause, recurrent myocardial infarction, or recurrent severe ischemia during the first 30 days after randomization. At 30 days, the primary end point was reached by 13 patients (6.47%) assigned to heparin plus eptifibatide and by 11 patients (5.53%) assigned to heparin alone (relative risk, 1.18; 95% CI, 0.52 to 2.70; P=0.69). The rates of major or minor bleeding were higher in patients assigned to heparin plus eptifibatide than that in patients assigned to heparin alone (22.4% versus 14.6%; relative risk, 1.69; 95% CI, 1.01 to 2.83; P=0.04). In patients pretreated with high-dose clopidogrel who were referred for primary PCI, treatment with heparin plus eptifibatide, when compared with heparin alone, did not improve clinical outcomes and was associated with more bleeding complications.Circulation Cardiovascular Interventions 08/2009; 2(4):330-8. · 6.06 Impact Factor -
Article: A survey of primary percutaneous coronary intervention for patients with ST segment elevation myocardial infarction in Canadian hospitals.
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ABSTRACT: Historically, access to primary percutaneous coronary intervention (PCI) for the treatment of patients with ST segment elevation myocardial infarction (STEMI) has been limited in Canada. Recent studies have identified innovative strategies to improve timely access and reduce reperfusion time. Accordingly, the contemporary use of primary PCI treatment in Canada was ascertained. A cross-sectional survey of all 38 Canadian hospitals that were capable of performing PCI procedures was conducted from June 2007 to November 2007. The survey focused on the practice of primary PCI for patients with STEMI and whether the hospitals had implemented internal strategies to reduce 'door-to-balloon' times. Analyses were performed at the level of geographical regions. Overall, 71% of PCI hospitals (27 of 38) provided around-the-clock primary PCI for patients with STEMI, but the proportion of PCI hospitals offering this service varied widely, from 33% to 100% across regions. All Canadian PCI hospitals provided around-the-clock rescue PCI treatment to STEMI patients who had failed fibrinolytic therapy. In terms of strategies that are associated with reduced reperfusion time, it was observed that only 42% of PCI hospitals (16 of 38) provided feedback on door-to-balloon time to the emergency department and to the cardiac catheterization laboratories within one week of the primary PCI procedure. Overall, 24% of the hospitals had not adopted any of the four identified strategies to improve door-to-balloon time. Although the majority of Canadian hospitals with PCI capability provide around-the-clock primary PCI for patients with STEMI, significant variations in this practice exist across the country. Canadian PCI hospitals have not consistently adopted strategies that are associated with improved door-to-balloon time.The Canadian journal of cardiology 12/2008; 24(11):839-43. · 3.36 Impact Factor -
Article: A citywide protocol for primary PCI in ST-segment elevation myocardial infarction.
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ABSTRACT: If primary percutaneous coronary intervention (PCI) is performed promptly, the procedure is superior to fibrinolysis in restoring flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction. The benchmark for a timely PCI intervention has become a door-to-balloon time of less than 90 minutes. Whether regional strategies can be developed to achieve this goal is uncertain. We developed an integrated-metropolitan-area approach in which all patients with ST-segment elevation myocardial infarction were referred to a specialized center for primary PCI. We sought to determine whether there was a difference in door-to-balloon times between patients who were referred directly from the field by paramedics trained in the interpretation of electrocardiograms and patients who were referred by emergency department physicians. Between May 1, 2005, and April 30, 2006, a total of 344 consecutive patients with ST-segment elevation myocardial infarction were referred for primary PCI: 135 directly from the field and 209 from emergency departments. Primary PCI was performed in 93.6% of patients. The median door-to-balloon time was shorter in patients referred from the field (69 minutes; interquartile range, 43 to 87) than in patients needing interhospital transfer (123 minutes; interquartile range, 101 to 153; P<0.001). Door-to-balloon times of less than 90 minutes were achieved in 79.7% of patients who were transferred from the field and in 11.9% of those transferred from emergency departments (P<0.001). Guideline door-to-balloon-times were more often achieved when trained paramedics independently triaged and transported patients directly to a designated primary PCI center than when patients were referred from emergency departments.New England Journal of Medicine 01/2008; 358(3):231-40. · 53.30 Impact Factor
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2008–2009
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University of Ottawa
Ottawa, Ontario, Canada
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