Michelle Graham

• BSc, MD
• Professor at University of Alberta

Aims Treatment of patients with cancer presenting with ST-elevation myocardial infarction (STEMI) is complex given the increased risk of both thrombotic and major bleeding complications. Methods and results A nationally linked cohort of STEMI patients between January 2005 and March 2019 was obtained from the UK Myocardial Infarction National Audit...

A 42-year-old man experienced recurrent coronary artery spasm (CAS) secondary to eosinophilic asthma despite being on multiple medications. He underwent a successful unilateral stellate ganglion block followed by bilateral thoracoscopic sympathectomy, with no subsequent recurrence of CAS. These invasive therapies offer a potential treatment option...

Patients with chest pain and symptoms of acute coronary syndromes (ACS) account for over 600,000 emergency department (ED) visits annually in Canada. Over 80% of these patients do not have ACS, and most are discharged from the ED after a thorough evaluation. However, a large proportion of these patients are referred for outpatient objective cardiac...

Background Hospital‐ and physician‐level variation for selection of percutaneous coronary intervention versus coronary artery bypass grafting (CABG) for patients with coronary artery disease has been associated with outcome differences. However, most studies excluded patients treated medically. Methods and Results From 2010 to 2019, adults with 3‐...

Background Coronary artery disease (CAD) confers increased risks of premature mortality, non-fatal morbidity, and significant impairment in functional status and health-related quality of life. Routine administration of electronic patient-reported outcome measures (PROMs) and its real time delivery to care providers is known to have the potential t...

Objective The objective of this scoping review is to understand the current body of knowledge regarding deprescribing in adults aged 60 and over in acute care settings, including the deprescribing activities that are being undertaken, and the feasibility, challenges, and outcomes of the practice. Introduction Polypharmacy is prevalent amongst olde...

Purpose Patients with coronary artery disease (CAD) experience significant angina symptoms and lifestyle changes. Revascularization procedures can result in better patient-reported outcomes (PROs) than optimal medical therapy (OMT) alone. This study evaluates the impact of response shift (RS) on changes in PROs of patients with CAD across treatment...

Background Balancing the effects of dual antiplatelet therapy (DAPT) in the era of potent purinergic receptor type Y, subtype 12 (P2Y12) inhibitors remains a challenge in the management of acute coronary syndrome (ACS). Methods We conducted a systematic review and meta-analysis following a 2-stage process consisting of searching for systematic rev...

It is uncertain whether sex is an independent risk factor for poor outcomes after non-cardiac surgery. We examined sex differences in short- and long-term mortality and morbidity in patients undergoing non-cardiac surgery in Alberta, Canada. Using linked administrative databases, we identified patients undergoing one of 45 different non-cardiac sur...

Purpose of program: Different models exist to guide successful implementation of electronic health tools into clinical practice. The Contrast Reducing Injury Sustained by Kidneys (Contrast RISK) initiative introduced an electronic decision support tool with physician audit and feedback into all of the cardiac catheterization facilities in Alberta,...

Myocardial infarction (MI) remains a leading cause of morbidity and mortality. In atherothrombotic MI (ST-elevation MI and type 1 non-ST-elevation MI), coronary artery occlusion leads to ischemia. Subsequent cardiomyocyte necrosis evolves over time as a wavefront within the territory at risk. The spectrum of ischemia and reperfusion injury is wide:...

BACKGROUND Sex-based outcome differences for women with ST-segment–elevation myocardial infarction (STEMI) have not been adequately addressed, and the role played by differences in prescription of potent P2Y 12 inhibitors (P-P2Y 12 ) is not well defined. This study explores the hypothesis that disparities in P-P2Y 12 (prasugrel or ticagrelor) use m...

Objective: to determine the prognostic relevance, clinical characteristics, and 30-day outcomes associated with myocardial injury after noncardiac surgery (MINS) in major general surgery patients. Background: MINS has been independently associated with 30-day mortality after noncardiac surgery. The characteristics and prognostic importance of MI...

Background and Aims: Patients with heart failure (HF) with reduced ejection fraction (HFrEF) are at high risk for cardiovascular events following non-cardiac surgery. The perioperative period represents many challenges to maintain guideline directed medical therapy (GDMT). We examined GDMT use in HFrEF patients following non-cardiac surgery, and th...

Background: Type 2 myocardial infarction (T2MI) occurs when myocardial oxygen demand exceeds myocardial oxygen supply. T2MIs occur more frequently and have worse outcomes compared to Type 1 myocardial infarction caused by an acute plaque rupture. No clinical trial evidence is available to guide pharmacological therapies in this high-risk populatio...

Background Patients with chronic kidney disease (CKD) can experience acute coronary syndromes (ACS) with high morbidity and mortality. Early invasive management of ACS is recommended for most high‐risk patients; however, choosing between an early invasive versus conservative management approach may be influenced by the unique risk of kidney failure...

Background Acute kidney replacement therapy (KRT) is delivered to acutely ill patients to support organ function and life in the Intensive Care Unit (ICU). Implementing standardized acute KRT pathways can ensure its safe and effective management. At present, there is no standardized approach to the management of acute KRT in Alberta ICUs. Methods...

Background For younger women with acute myocardial infarction (AMI), little is known regarding their contemporary care pathways and clinical outcomes. Methods We studied AMI patients aged 18-55 years, hospitalized from April 1, 2009, to March 31, 2019, in Ontario, Canada. We compared trends in comorbidities, angiographic findings, and revascularis...

Importance: Contrast-associated acute kidney injury (AKI) is a common complication of coronary angiography and percutaneous coronary intervention (PCI) that has been associated with high costs and adverse long-term outcomes. Objective: To determine whether a multifaceted intervention is effective for the prevention of AKI after coronary angiogra...

This cohort study examines the association of Hospital Frailty Risk Score classification, demographic characteristics, and type of surgery with risk of mortality among patients undergoing noncardiac surgery.

There is a complex interaction between cardiac and renal function. They are intricately tied together and there are a range of disorders in both the heart and kidneys which can alter the function of the other. The pathophysiology is complex, and these conditions are termed cardiorenal syndromes. They can be acute and or chronic in nature and result...

Aims: Post-acute coronary syndrome (ACS) P2Y12 inhibitor non-adherence is common and associated with greater risk of major adverse cardiovascular events (MACEs). Non-adherence can follow different trajectories from an inability to initiate, implement, or continue therapy for the intended duration. We aimed to evaluate P2Y12 inhibitor adherence tra...

Background Assisted reproductive technology (ART) has emerged as a common treatment option for infertility, a problem that affects an estimated 48 million couples worldwide. Advancing maternal age with increasing prepregnancy cardiovascular risk factors, such as chronic hypertension, obesity, and diabetes, has raised concerns about pregnancy compli...

Frailty is an established risk factor for adverse outcomes following non-cardiac surgery. The Hospital Frailty Risk Score (HFRS) is a recently described frailty assessment tool that harnesses administrative data and is composed of 109 International Classification of Disease variables. We aimed to examine the incremental prognostic utility of the HF...

Background: Beta-blockers (BB) are cornerstones of medical therapy for acute coronary syndromes (ACS). However, benefits of long-term treatment with preserved left ventricular ejection fraction (LVEF) are not well established. We examined whether long-term BB prescription is associated with risks of recurrent ischemic events or all-cause mortality...

The pursuit of more efficient patient-friendly health systems and reductions in tertiary health services use has seen enormous growth in the application and study of remote patient monitoring systems for cardiovascular patient care. While there are many consumer-grade products available to monitor patient wellness, the regulation of these technolog...

Background Contrast-associated acute kidney injury (CA-AKI) is a potentially preventable complication of coronary angiography and intervention. Relatively little research has been done to demonstrate how knowledge on CA-AKI prevention can be translated into clinical practice. Methods We developed, implemented, and surveyed end-users about the usab...

Objective To determine if virtual care with remote automated monitoring (RAM) technology versus standard care increases days alive at home among adults discharged after non-elective surgery during the covid-19 pandemic. Design Multicentre randomised controlled trial. Setting 8 acute care hospitals in Canada. Participants 905 adults (≥40 years) w...

Background Limited data exists regarding the use of implantable cardioverter-defibrillators (ICDs) in diverse populations. This study explores cardiovascular (CV) outcomes and mortality from ICD randomized controlled trials (RCTs) by sex, race and age. Methods Five electronic databases (PubMed, Emcare, Embase, Medline and CINAHL) were searched fro...

Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve upon current models of care delivery and integration within the health care system. Perioperative models of care are structured or conceptual arrangements for surgical patients before, during and after their surgery. Models of care such as the Perioper...

Background: After nonelective (i.e., semiurgent, urgent and emergent) surgeries, patients discharged from hospitals are at risk of readmissions, emergency department visits or death. During the coronavirus disease 2019 (COVID-19) pandemic, we are undertaking the Post Discharge after Surgery Virtual Care with Remote Automated Monitoring Technology...

Introduction Cardiac rehabilitation (CR) is a proven therapy for reducing cardiovascular death and hospitalization. Whether CR participation is associated with improved outcomes in people with CKD is unknown. Methods We obtained data on all adult patients in Calgary, Alberta, Canada with angiographically proven coronary artery disease from 1996-20...

Background The Seattle Angina Questionnaire (SAQ) is a widely-used patient-reported outcomes measure in patients with heart disease. This study assesses the validity and reliability of the SAQ in a Canadian cohort of individuals with stable angina. Methods and results Data are from the Alberta Provincial Project for Outcome Assessment in Coronary...

Background Acute kidney injury (AKI) after cardiac catheterization procedures is associated with poor health outcomes. We sought to characterize the experiences of patients after receiving standardized information on their risk of AKI accompanied by instructions for follow-up care after cardiac catheterization. Methods We implemented an initiative...

Background: In studies showing associations between ambient air pollution and myocardial infarction (MI), data have been lacking on the inherent spatial variability of air pollution. The aim of this study was to determine whether the long-term spatial distribution of air pollution influences short-term temporal associations between air pollution a...

BACKGROUND Background: Continuous hemodynamic monitoring is the standard of care for patients intraoperatively, but vital signs monitoring is performed only periodically on post-surgical wards, and patients are routinely discharged home with no surveillance. Wearable continuous monitoring biosensor technologies have the potential to transform posto...

Background: Continuous hemodynamic monitoring is the standard of care for patients intraoperatively, but vital signs monitoring is performed only periodically on post-surgical wards, and patients are routinely discharged home with no surveillance. Wearable continuous monitoring biosensor technologies have the potential to transform postoperative c...

Background: Patients with chronic kidney disease (CKD) and heart disease face challenging treatment decisions. We sought to explore the perceptions of patients and physicians about shared decision-making for coronary procedures for people with CKD, as well as opinions about strategies and tools to improve these decisions. Methods: We partnered w...

Background Atrial fibrillation or flutter (AFF) are common arrhythmias diagnosed in the emergency department (ED) and prompt follow-up with specialists may yield better outcomes. This study examines time to first specialist outpatient visit following ED discharge for AFF. Methods Alberta residents aged ≥35 years with ED presentations for AFF endin...

Rationale & Objective Use of brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) for cardiovascular (CV) risk assessment in patients with end-stage kidney disease (ESKD) remains unclear. We examined the associations between different threshold elevations of these peptide levels and clinical outcomes in patients with ESKD. Study Desi...

What we already know about this topic: The Perioperative Ischemic Evaluation-2 study (POISE-2) authors previously reported that neither aspirin nor clonidine reduced a 30-day composite of nonfatal myocardial infarction or death. Aspirin caused perioperative bleeding, and clonidine provoked hypotension and bradycardia.In a subgroup analysis of pati...

Importance Guidelines currently recommend ticagrelor over clopidogrel for patients with acute coronary syndrome (ACS) based on randomized clinical trial data in which ticagrelor reduced major adverse coronary events (MACE) vs clopidogrel but increased bleeding and dyspnea. Objective To compare the risk of MACE with ticagrelor vs clopidogrel in pat...

Background: Identifying patients at increased risk of contrast-associated acute kidney injury (CA-AKI) can help target risk mitigation strategies toward these individuals during percutaneous coronary intervention. Illuminating which risk models best stratify risk is an important foundation for such quality improvement efforts. Methods and results...

Background: Contrast-induced acute kidney injury (CI-AKI) is a common and serious complication of invasive cardiac procedures. Quality improvement programs have been associated with a lower incidence of CI-AKI over time, but there is a lack of high-quality evidence on clinical decision support for prevention of CI-AKI and its impact on processes o...

Purpose: The APPROACH cardiovascular surgical intensive care unit (CVICU) readmission score has excellent discrimination and calibration for CVICU readmission after discharge to a surgical ward; however, it has not been prospectively validated. Material and methods: In a prospective consecutive cohort of 805 patients ≥18 years admitted to the CV...

It is unclear how best to predict peri‐operative cardiovascular risk in patients with atrial fibrillation undergoing non‐cardiac surgery. This study examined the accuracy of the revised cardiac risk index and three atrial fibrillation thrombo‐embolic risk models for predicting 30‐day cardiovascular events after non‐cardiac surgery in patients with...

Purpose Perceived social support is known to be an important predictor of health outcomes in patients with acute coronary syndrome (ACS). This study investigates patterns of longitudinal trajectories of patient-reported perceived social support in individuals with ACS. Methods Data are from 3013 patients from the Alberta Provincial Project for Out...

Chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD) are leading causes of morbidity and mortality. There are conflicting results regarding the association between COPD and CAD. We sought to measure the association between COPD and angiographically diagnosed CAD in a population-based cohort. We performed a retrospective an...

Background: Comorbidity indexes derived from administrative databases are essential tools of research in global health. We sought to develop and validate a novel cardiac-specific comorbidity index, and to compare its accuracy with the generic Charlson-Deyo and Elixhauser comorbidity indexes. Methods: We derived the cardiac-specific comorbidity i...

Objectives The objective of this study was to determine the frequency of and reasons for six months unplanned readmission to hospital post Percutaneous Coronary Intervention (PCI). Background PCI has become an important and effective way of treating heart disease; however the occurrence of hospital readmission post PCI is not well documented. Met...

Background: Few studies have explored the influence of short-term exposure to atmospheric pressure changes on the abrupt onset of ST-elevation myocardial infarction (STEMI). We sought to evaluate the association between acute atmospheric pressure changes and the occurrence of STEMI. Methods: We studied STEMI patients from the Alberta Provincial...

Background Postoperative clinical outcomes associated with the preoperative continuation or discontinuation of angiotensin‐converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) before cardiac surgery remain unclear. Methods and Results In a single‐center, open‐label, randomized, registry‐based clinical trial, patients underg...

Table S1. Physiological, Clinical, and Health Resource Utilization Outcomes by Study Treatment Received Table S2. Physiological, Clinical, and Health Resource Utilization Outcomes by Treatment Received Stratified by the Half‐Life (ie, short [≤12 h] or long [>12 h]) of Angiotensin‐Converting Enzyme Inhibitors or Angiotensin Receptor Blockers Table...

CLINICIAN’S CAPSULE What is known about the topic? Sex-specific, high-sensitivity cardiac troponin T (hs-cTnT) cut-offs increase the specificity of a myocardial infarction (MI) diagnosis. What did this study ask? Do sex-specific, hs-cTnT rule-out cut-offs enable ruling out MI in more patients while maintaining sensitivity? What did this study find?...

Introduction Coronary Artery Disease (CAD) patients are known to report higher healthcare resource use, such as inpatient [IP] and emergency department [ED] readmissions, than the general population. We investigate if the patient reported outcome measures (PROMs) improve the accuracy of readmissions risk prediction models in CAD. Objectives and Ap...

Delivering evidence-based, personalized care that engages patients requires profound changes in the structure, process and organization of care, along with revised incentives to support such changes. Healthcare providers must absorb and apply a vast, usually overwhelming, amount of scientific information in order to provide high-quality patient car...

Background: Health-related quality of life (HRQOL) assessment is an important health outcome for measuring the efficacy of treatments and interventions for coronary artery disease (CAD). HRQOL is known to improve over the first year after interventions for CAD, but there is limited knowledge of the changes in HRQOL beyond 1 year. We investigated h...

Background: Uncertainty remains about the effects of aspirin in patients with prior percutaneous coronary intervention (PCI) having noncardiac surgery. Objective: To evaluate benefits and harms of perioperative aspirin in patients with prior PCI. Design: Nonprespecified subgroup analysis of a multicenter factorial trial. Computerized Internet...

Background Available cardiac surgery risk scores have not been validated in octogenarians. Our objective was to compare the predictive ability of the Society of Thoracic Surgeons (STS) score, EuroSCORE I, and EuroSCORE II in elderly patients undergoing isolated coronary artery bypass grafting surgery (CABG). Methods All patients who underwent isol...

Data Supplement S1. Supplementary appendix.

Background: Coronary artery bypass grafting (CABG) with multiple distal target (MDT) grafts requires less graft material and reduces cardiopulmonary bypass time; however, there may be a higher incidence of graft failure. A real-world analysis reporting long-term outcomes associated with MDT grafts is lacking. Material and methods: In 6262 consec...

Background: The objective of this study was to quantify the sensitivity of very low concentrations of high-sensitivity cardiac troponin T (hsTnT) at ED arrival for acute myocardial infarction (AMI) in a large cohort of chest pain patients evaluated in real-world clinical practice. Methods: This retrospective study included consecutive ED patient...

Background Specialized cardiology services have contributed to reduced mortality in acute coronary syndromes (ACS). We sought to evaluate the outcomes of ACS patients admitted to non-cardiology services in Southern Alberta. Methods Retrospective chart review performed on all troponin-positive patients in the Calgary Health Region identified those...

Background: Symptoms of acute coronary syndrome account for a large proportion of emergency department (ED) visits and hospitalizations. High-sensitivity troponin can rapidly rule out or rule in acute myocardial infarction (AMI) within a short time of ED arrival. We sought to validate test characteristics and classification performance of 2-hour h...

Background: Identification of patients at risk of contrast-induced acute kidney injury (CI-AKI) is valuable for targeted prevention strategies accompanying cardiac catheterization. Methods: We searched MedLine and EMBASE for articles that developed or validated a clinical prediction model for CI-AKI or dialysis after angiography or percutaneous...

Purulent pericarditis is a rare, acutely life-threatening condition. Initial symptoms, signs and investigations can be non-specific. Echocardiography is invaluable for establishing the diagnosis and initial management. We present a case of a previously healthy patient with purulent pericarditis due to Streptococcus pneumoniae in the absence of a pr...

The Canadian Cardiovascular Society (CCS) Guidelines Committee and key Canadian opinion leaders believed there was a need for up-to-date guidelines for patients undergoing noncardiac surgery that used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system of evidence assessment. Strong recommendations included: 1) meas...

p> ABSTRACT Background: Current guidelines recommend triple antithrombotic therapy (TAT), defined as acetylsalicylic acid (ASA), clopidogrel, and warfarin, for patients with nonvalvular atrial fibrillation who have undergone percutaneous coronary intervention with stent implantation. The choice of anticoagulant/antiplatelet therapy in this popula...

Background Overt stroke after non-cardiac surgery has a substantial impact on the duration and quality of life. Covert stroke in the non-surgical setting is much more common than overt stroke and is associated with an increased risk of cognitive decline and dementia. Little is known about covert stroke after non-cardiac, non-carotid artery surgery....

Background: Acute kidney injury after cardiac surgery is associated with adverse in-hospital and long-term outcomes. Novel risk factors for acute kidney injury have been identified, but it is unknown whether their incorporation into risk models substantially improves prediction of postoperative acute kidney injury requiring renal replacement thera...

Coronary artery disease is the leading cause of morbidity and mortality even in the elderly population. Treatment opportunities in the elderly population are often underappreciated. Revascularization procedures (coronary artery bypass graft surgery and percutaneous coronary intervention) can be associated with important benefits in symptom control,...

Primary prevention of cardiovascular events in older adults is challenging because of a general paucity of evidence for safe and efficacious therapy. Furthermore, there is no validated cardiovascular risk assessment tool for older adults (≥75 years of age), yet most are intermediate-to high-risk. Assessment of cardiovascular risk should include a d...

The purpose of this study was to compare the outcomes of patients undergoing cardiac transplantation stratified by body mass index (BMI, kg/m(2)). The APPROACH registry captured 220 cardiac transplantations in Alberta, Canada from January 2004 to April 2013. All recipients were stratified by BMI into five groups (BMI: <20, 20-24.9, 25-29.9, 30-<34....

Objectives: Coronary artery bypass grafting (CABG) improves outcomes in patients with multivessel coronary artery disease. Bypass of angiographically significant lesions ≥70% is recommended, yet little is known about the incidence/outcomes with bypasses of 50-69% angiographically borderline lesions (ABLs) without fractional flow reserve testing. T...

Background: Clinical practice guidelines recommend admitting patients with stable non-ST-segment elevation acute coronary syndrome (NSTE ACS) to telemetry units, yet up to two-thirds of patients are admitted to higher-acuity critical care units (CCUs). The outcomes of patients with stable NSTE ACS initially admitted to a CCU vs a cardiology ward w...

Background: Clinical practice guidelines recommend admitting patients with stable non-ST segment elevation acute coronary syndrome (NSTE ACS) to telemetry units, yet up to two thirds of patients are admitted to critical care units (CCU). The outcomes of patients with stable NSTE ACS initially admitted to a CCU versus a cardiology ward with telemetr...

Family history (FHx) of premature coronary artery disease (CAD) is a risk factor for development of incident cardiovascular disease. However the association between FHx and outcomes in patients with established CAD is unclear. We followed 84,373 patients with angiographic CAD enrolled in the inclusive Alberta Provincial Project for Outcomes Assessm...

The optimal means of pre-operative risk stratification in patients with atrial fibrillation (AF) is uncertain. To examine the accuracy of AF thromboembolic risk models (the CHADS2 , CHA2 DS2 -VASc, and R2 CHADS2 scores) for predicting 30 day stroke and/or all-cause mortality after non-cardiac surgery in patients with preoperative AF, and to compare...

Objective: High-sensitivity troponin T (hs-TnT) assays detect myocardial injury sooner, possibly improving throughput times for emergency department (ED) assessment of suspected acute myocardial infarction (AMI). This study evaluates the influence of hs-TnT implementation on ED length of stay (LOS), consultations and admissions, as well as ED revi...

-It is unknown if the appropriate use of PCI has improved over time and whether trends in PCI appropriateness have been accompanied by changes in the use of PCI. -We applied Appropriate Use Criteria to determine the appropriateness of all 51,872 PCI performed in Washington State from 2010 through 2013. We evaluated the number of PCI performed from...

Background: It is unknown if the appropriate use of percutaneous coronary intervention (PCI) has improved over time and whether trends in PCI appropriateness have been accompanied by changes in the rate of PCI use. Methods: We applied 2012 Appropriate Use Criteria to determine the appropriateness of all 51,872 PCI performed in Washington State from...