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Benjamin Hibbert,
Andrea Macdougall,
Melissa Blondeau,
Edward R O'Brien,
Derek Y F So,
Marino Labinaz, Alexander Dick,
Christopher Glover,
Michael Froeschl,
Jean-Francois Marquis,
George A Wells,
Michel R Le May
Circulation Cardiovascular Interventions 04/2013; 6(2):e27. · 6.06 Impact Factor
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Benjamin Hibbert,
Andrea Macdougall,
Marino Labinaz,
Edward R O'Brien,
Derek Y F So, Alexander Dick,
Christopher Glover,
Michael Froeschl,
Jean-Francois Marquis,
George A Wells,
Melissa Blondeau,
Michel R Le May
[show abstract]
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ABSTRACT: BACKGROUND: DATA FROM RANDOMIZED TRIALS HAS DEMONSTRATED THE SUPERIORITY OF BIVALIRUDIN TO GLYCOPROTEIN IIB/IIIA INHIBITORS PLUS HEPARIN IN PATIENTS UNDERGOING PRIMARY PERCUTANEOUS CORONARY INTERVENTION. REAL-WORLD PERFORMANCE OF BIVALIRUDIN IN PRIMARY PERCUTANEOUS CORONARY INTERVENTION AND THE BENEFIT OF BIVALIRUDIN OVER HEPARIN REMAIN UNKNOWN IN AN ERA OF ROUTINE DUAL ANTIPLATELET THERAPY.METHODS AND RESULTS: FROM JULY 2004 TO DECEMBER 2010, 2317 CONSECUTIVE PATIENTS WERE INDEXED IN THE UNIVERSITY OF OTTAWA HEART INSTITUTE ST-ELEVATION MYOCARDIAL INFARCTION REGISTRY. DURING THIS PERIOD 748 PATIENTS RECEIVED BIVALIRUDIN, 699 PATIENTS RECEIVED GLYCOPROTEIN IIB/IIIA INHIBITORS, AND 676 PATIENTS RECEIVED UNFRACTIONATED HEPARIN ALONE. THE PRIMARY OUTCOME WAS THE RATE OF NONCORONARY ARTERY BYPASS GRAFT RELATED THROMBOLYSIS IN MYOCARDIAL INFARCTION MAJOR BLEEDING. BIVALIRUDIN SIGNIFICANTLY REDUCED THE PRIMARY OUTCOME COMPARED WITH HEPARIN PLUS GLYCOPROTEIN IIB/IIIA INHIBITORS (2.7% VERSUS 7.3%, ADJUSTED OR 2.96, 95% CI: 1.615.45, P0.001) AND THE COMPOSITE END POINT OF DEATH, STROKE, REINFARCTION AND MAJOR BLEED (OR 1.66, 95% CI: 1.122.45, P=0.01). COMPARED WITH HEPARIN ALONE, A REDUCTION IN MAJOR BLEEDS (OR 1.21, 95% CI: 0.602.44, P=0.59) OR THE COMPOSITE END POINT (1.05, 95% CI: 0.681.63, P=0.83) WITH BIVALIRUDIN COULD NOT BE DEMONSTRATED. NOTABLY, MAJOR BLEEDING WAS ASSOCIATED WITH A 5-FOLD INCREASE IN THE RISK OF MORTALITY BOTH IN-HOSPITAL (3.5% VERSUS 20.6%) AND OUT TO 180 DAYS (5.6% VERSUS 25.8%).CONCLUSIONS: Bivalirudin use compared with glycoprotein IIb/IIIa inhibitors plus heparin as an antithrombotic strategy in primary percutaneous coronary intervention results in less major bleeding in contemporary practice. A benefit of bivalirudin over heparin could not be established with this registry and requires additional investigations to either confirm or refute.
Circulation Cardiovascular Interventions 11/2012; · 6.06 Impact Factor
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Michel R Le May,
George A Wells,
Derek Y So,
Chris A Glover,
Michael Froeschl,
Justin Maloney,
Richard Dionne,
Jean-François Marquis,
Edward R O'Brien, Alexander Dick,
Heather L Sherrard,
John Trickett,
Pierre Poirier,
Melissa Blondeau,
Jordan Bernick,
Marino Labinaz
[show abstract]
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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
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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
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Benjamin Hibbert,
Trevor Simard,
Kumanan R Wilson,
Steven Hawken,
George A Wells,
F Daniel Ramirez,
Michel R Le May,
Derek Y So,
Chris A Glover,
Michael Froeschl,
Jean-Francois Marquis,
Marino Labinaz, Alexander Dick,
Edward R O'Brien
[show abstract]
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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
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Jason D Roberts,
George A Wells,
Michel R Le May,
Marino Labinaz,
Chris Glover,
Michael Froeschl, Alexander Dick,
Jean-Francois Marquis,
Edward O'Brien,
Sandro Goncalves,
Irena Druce,
Alexandre Stewart,
Michael H Gollob,
Derek Y F So
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ABSTRACT: Prospective assessment of pharmacogenetic strategies has been limited by an inability to undertake bedside genetic testing. The CYP2C19*2 allele is a common genetic variant associated with increased rates of major adverse events in individuals given clopidogrel after percutaneous coronary intervention (PCI). We used a novel point-of-care genetic test to identify carriers of the CYP2C19*2 allele and aimed to assess a pharmacogenetic approach to dual antiplatelet treatment after PCI.
Between Aug 26, 2010, and July 7, 2011, 200 patients were enrolled into our prospective, randomised, proof-of-concept study. Patients undergoing PCI for acute coronary syndrome or stable angina were randomly assigned to rapid point-of-care genotyping or to standard treatment. Individuals in the rapid genotyping group were screened for the CYP2C19*2 allele. Carriers were given 10 mg prasugrel daily, and non-carriers and patients in the standard treatment group were given 75 mg clopidogrel daily. The primary endpoint was the proportion of CYP2C19*2 carriers with high on-treatment platelet reactivity (P2Y12 reactivity unit [PRU] value of more than 234) after 1 week of dual antiplatelet treatment, which is a marker associated with increased adverse cardiovascular events. Interventional cardiologists and data analysts were masked to genetic status and treatment. Patients were not masked to treatment allocation. All analyses were by intention to treat. This study is registered with ClinicalTrials.gov, NCT01184300.
After randomisation, 187 patients completed follow-up (91 rapid genotyping group, 96 standard treatment). 23 individuals in each group carried at least one CYP2C19*2 allele. None of the 23 carriers in the rapid genotyping group had a PRU value of more than 234 at day 7, compared with seven (30%) given standard treatment (p=0·0092). The point-of-care genetic test had a sensitivity of 100% (95% CI 92·3-100) and a specificity of 99·3% (96·3-100).
Point-of-care genetic testing after PCI can be done effectively at the bedside and treatment of identified CYP2C19*2 carriers with prasugrel can reduce high on-treatment platelet reactivity.
Spartan Biosciences.
The Lancet 03/2012; 379(9827):1705-11. · 38.28 Impact Factor
