Acute coronary syndrome patients admitted to a cardiology vs non-cardiology service: variations in treatment & outcome.

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 diagnosed with ACS by their attending team. Patients admitted to non-cardiology and cardiology services were compared, using linked data from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry and the Strategic Clinical Network for Cardiovascular Health and Stroke. RESULTS: From January 1, 2007 to December 31, 2008, 2105 ACS patients were identified, with 1636 (77.7%) admitted to cardiology and 469 (22.3%) to non-cardiology services. Patients admitted to non-cardiology services were older, had more comorbidities, and rarely received cardiology consultation (5.1%). Cardiac catheterization was underutilized (5.1% vs 86.4% in cardiology patients (p < 0.0001)), as was evidence-based pharmacotherapy (p < 0.0001). Following adjustment for baseline comorbidities, 30-day through 4-year mortality was significantly higher on non-cardiology vs. cardiology services (49.1% vs. 11.0% respectively at 4-years, p < 0.0001). CONCLUSION: In a large ACS population in the Calgary Health Region, 25% were admitted to non-cardiology services. These patients had worse outcomes, despite adjustment for baseline risk factor differences. Although many patients were appropriately admitted to non-cardiology services, the low use of investigations and secondary prevention medications may contribute to poorer patient outcome. Further research is required to identify process of care strategies to improve outcomes and lessen the burden of illness for patients and the health care system.

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.

BACKGROUND: Little 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. METHODS: Hospital 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. RESULTS: Following 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. CONCLUSIONS: Chinese 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.

A Case of Electrical Right-Ventricular Infarction in the Absence of Clinical Right-Ventricular Failure.

In the setting of acute coronary syndrome, right-ventricular (RV) infarction, which has significant clinical implications, can occur in conjunction with inferior left-ventricular (LV) infarction. In rare cases, RV infarction is isolated. We describe a case of isolated RV infarction identified based on previously described electrocardiogram findings in the absence of hemodynamic or imaging evidence of RV dysfunction. This case highlights the fact that RV transmural ischemia can exist in the absence of the clinical syndrome associated with RV infarction, which we hypothesize is related to the proportion of RV myocardium involved in the infarct, or conversely, the amount of myocardium protected through various mechanisms.

Dans le cadre du syndrome coronarien aigu, l'infarctus du ventricule droit, qui a des répercussions cliniques importantes, peut survenir conjointement avec un infarctus inférieur du ventricule gauche. Dans de rares cas, l'infarctus du ventricule droit est isolé. Nous décrivons un cas d'infarctus du ventricule droit isolé décelé à l'aide des résultats précédemment décrits d'un électrocardiogramme faute de résultats hémodynamiques ou d'imagerie indiquant une dysfonction ventriculaire droite. Ce cas souligne le fait qu'une ischémie transmurale du ventricule droit peut survenir même sans syndrome clinique associé à l'infarctus du ventricule droit, ce qui s'explique, selon notre hypothèse, par la proportion de myocarde ventriculaire droit touché par l'infarctus ou, à l'inverse, la quantité de myocarde protégé par divers mécanismes.

Causes of Cardiovascular Hospitalization and Death in Patients With Transthyretin Amyloid Cardiomyopathy (from the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial [ATTR-ACT]).

In the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT), tafamidis significantly reduced mortality and cardiovascular (CV)-related hospitalizations compared with placebo in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). This analysis aimed to assess the causes of CV-related death and hospitalization in ATTR-ACT to provide further insight into the progression of ATTR-CM and efficacy of tafamidis. ATTR-ACT was an international, double-blind, placebo-controlled, and randomized study. Patients with hereditary or wild-type ATTR-CM were randomized to tafamidis (n = 264) or placebo (n = 177) for 30 months. The independent Endpoint Adjudication Committee determined whether certain investigator-reported events met the definition of disease-related efficacy endpoints using predefined criteria. Cause-specific reasons for CV-related deaths (heart failure [HF], arrhythmia, myocardial infarction, sudden death, stroke, and other CV causes) and hospitalizations (HF, arrhythmia, myocardial infarction, transient ischemic attack/stroke, and other CV causes) were assessed. Total CV-related deaths was 53 (20.1%) with tafamidis and 50 (28.2%) with placebo, with HF (15.5% tafamidis, 22.6% placebo), followed by sudden death (2.7% tafamidis, 5.1% placebo), the most common causes. The number of patients with a CV-related hospitalization was 138 (52.3%) with tafamidis and 107 (60.5%) with placebo; with HF the most common cause (43.2% tafamidis, 50.3% placebo). All predefined causes of CV-related death or hospitalization were less frequent with tafamidis than placebo. In conclusion, these data provide further insight into CV disease progression in patients with ATTR-CM, with HF the most common adjudicated cause of CV-related hospitalization or death in ATTR-ACT. Clinical trial registration ClinicalTrials.gov: NCT01994889.

Effect of low-carbohydrate diets on cardiometabolic risk, insulin resistance, and metabolic syndrome.

PURPOSE OF REVIEW: An obesity epidemic has resulted in increasing prevalence of insulin resistance, hyperinsulinemia, metabolic syndrome (MetS), and cardiovascular disease (CVD). The Diet-Heart Hypothesis posited that dietary fat is the culprit. Yet dietary fat reduction has contributed to the problem, not resolved it. The role of hyperinsulinemia, the genesis of its atherogenic dyslipidemia and systemic inflammation in CVD and its reversal is reviewed. RECENT FINDINGS: Overnutrition leads to weight gain and carbohydrate intolerance creating a vicious cycle of insulin resistance/hyperinsulinemia inhibiting fat utilization and encouraging fat storage leading to an atherogenic dyslipidemia characterized by hypertriglyceridemia, low HDL, and small dense LDL. The carbohydrate-insulin model better accounts for the pathogenesis of obesity, MetS, and ultimately type 2 diabetes (T2DM) and CVD. Ketogenic Diets reduce visceral obesity, increase insulin sensitivity, reverse the atherogenic dyslipidemia and the inflammatory biomarkers of overnutrition. Recent trials show very high adherence to ketogenic diet for up to 2 years in individuals with T2DM, reversing their metabolic, inflammatory and dysglycemic biomarkers as well as the 10-year estimated atherosclerotic risk. Diabetes reversal occurred in over 50% and complete remission in nearly 8%. SUMMARY: Therapeutic carbohydrate-restricted can prevent or reverse the components of MetS and T2DM.

Low carbohydrate diet: are concerns with saturated fat, lipids, and cardiovascular disease risk justified?

PURPOSE OF REVIEW: There is an extensive literature on the efficacy of the low carbohydrate diet (LCD) for weight loss, and in the improvement of markers of the insulin-resistant phenotype, including a reduction in inflammation, atherogenic dyslipidemia, hypertension, and hyperglycemia. However, critics have expressed concerns that the LCD promotes unrestricted consumption of saturated fat, which may increase low-density lipoprotein (LDL-C) levels. In theory, the diet-induced increase in LDL-C increases the risk of cardiovascular disease (CVD). The present review provides an assessment of concerns with the LCD, which have focused almost entirely on LDL-C, a poor marker of CVD risk. We discuss how critics of the LCD have ignored the literature demonstrating that the LCD improves the most reliable CVD risk factors. RECENT FINDINGS: Multiple longitudinal clinical trials in recent years have extended the duration of observations on the safety and effectiveness of the LCD to 2-3 years, and in one study on epileptics, for 10 years. SUMMARY: The present review integrates a historical perspective on the LCD with a critical assessment of the persistent concerns that consumption of saturated fat, in the context of an LCD, will increase risk for CVD.

Relative and cumulative effects of lipid and blood pressure control in the Stroke Prevention by Aggressive Reduction in Cholesterol Levels trial.

BACKGROUND AND PURPOSE: The relative contributions of on-treatment low- and high-density lipoprotein cholesterol (LDL-C, HDL-C), triglycerides, and blood pressure (BP) control on the risk of recurrent stroke or major cardiovascular events in patients with stroke is not well defined. METHODS: We randomized 4731 patients with recent stroke or transient ischemic attack and no known coronary heart disease to atorvastatin 80 mg per day or placebo. RESULTS: After 4.9 years, at each level of LDL-C reduction, subjects with HDL-C value above the median or systolic BP below the median had greater reductions in stroke and major cardiovascular events and those with a reduction in triglycerides above the median or diastolic BP below the median showed similar trends. There were no statistical interactions between on-treatment LDL-C, HDL-C, triglycerides, and BP values. In a further exploratory analysis, optimal control was defined as LDL-C <70 mg per deciliter, HDL-C >50 mg per deciliter, triglycerides <150 mg per deciliter, and SBP/DBP <120/80 mm Hg. The risk of stroke decreased with as the level of control increased (hazard ratio [95% confidence interval] 0.98 [0.76 to 1.27], 0.78 [0.61 to 0.99], 0.62 [0.46 to 0.84], and 0.35 [0.13 to 0.96]) for those achieving optimal control of 1, 2, 3, or 4 factors as compared to none, respectively. Results were similar for major cardiovascular events. CONCLUSIONS: We found a cumulative effect of achieving optimal levels of LDL-C, HDL-C, triglycerides, and BP on the risk of recurrent stroke and major cardiovascular events. The protective effect of having a higher HDL-C was maintained at low levels of LDL-C.

Quality of Cardiac Care in Canada: Recommendations for Building a Sustainable Future.

Cardiovascular (CV) disease continues to present a significant disease and economic burden in Canada. To improve the quality of care and ensure sustainability of services, a national quality improvement initiative is required. The purpose of this analysis was to review the evidence for public reporting (PR) and external benchmarking (EB) to improve patient outcomes, and to recommend a strategy to improve CV care in Canada. To incorporate recent literature, the Canadian Cardiovascular Society (CCS) commissioned the Institute of Health Economics to provide a rapid update on the literature of PR and EB. The review showed that EB is more likely to promote positive effects, such as improved mortality, morbidity, and evidence-based clinical practice, and to limit negative effects, such as access restrictions or unintended provider behaviour associated with some forms of "top-down" PR. On the basis of these findings, this we recommend the following: (1) secure funding for the provincial collection of CV quality indicators and the creation of annual National CV Quality Reports; (2) enhance the culture of using CV quality indicator data for continuous quality improvement and opportunities for national or regional EB and sharing best practices; and (3) implement ongoing evaluation and revision of CCS clinical practice guidelines incorporating key quality indicators. This is already under way to a limited extent by the CCS with its Quality Project, but intentional, sustained support needs to be secured to enhance this ongoing effort and improve the quality of CV care for all Canadians.

The Effect of Nurse Practitioner-Led Intervention in Diabetes Care for Patients Admitted to Cardiology Services.

OBJECTIVE: To determine the benefits of diabetes nurse practitioner (DNP) intervention on glycemic control, quality of life and diabetes treatment satisfaction in patients with type 2 diabetes (T2DM) admitted to cardiology inpatient services at a tertiary centre. PATIENTS AND METHODS: Patients admitted to the cardiology service with T2DM who had suboptimal control (HbA1c >6.5%) were approached for the study. Diabetes care was optimized by the DNP through medication review, patient education and discharge care planning. Glycemic control was evaluated with 3-month post-intervention HbA1c. Secondary outcomes of lipid profiles, quality of life and treatment satisfaction were evaluated at baseline and at 3 months with fasting lipids, Audit of Diabetes-Dependent Quality of Life questionnaires (ADDQoL) and Diabetes Treatment Satisfaction Questionnaires (DTSQ) respectively. RESULTS: With almost 49% of patients admitted to the Mazankowski Alberta Heart Institute having HbA1c <6.5%, only 23 patients completed the study over a 12-month period. We found a significant decrease in HbA1c values at 3 months post-intervention from 8.0% (SD=1. 2) to 6.9% (SD=0.7), p=0.002. LDL showed a significant decrease at 3 months from 1.7 mmol/L (SD=0.7) to 1.1 mmol /L (SD=0.6), p=0.011. Overall median ADDQoL impact scores improved at follow up, from -1.4 to -0.4, p = 0.0003. Overall no significant changes in DTSQ scores were seen. CONCLUSIONS: Short-term DNP intervention in T2DM patients admitted to the inpatient cardiology service was associated with benefits in areas of glycemic control and various domains of QoL. Our study provides support for the involvement of DNP in the care of cardiology inpatients at tertiary centres.

Improved prediction of early-onset coronary artery disease using APOE epsilon4, BChE-K, PPARgamma2 Pro12 and ENOS T-786C in a polygenic model.

OBJECTIVES: Coronary artery disease (CAD) is often polygenic due to multiple mutations that contribute small effects to susceptibility. Since most prior studies only evaluated the contribution of single candidate genes, we therefore looked at a combination of genes in predicting early-onset CAD [apolipoprotein E (APOE) epsilon4, butyrylcholinesterase (BChE) K, peroxisome proliferator-activated receptor gamma2 (PPARgamma2) Pro12Ala and endothelial nitric oxide synthase (ENOS) T-786C]. DESIGN AND METHODS: We examined the frequencies, individually and in combination, of all four alleles among patients with early-onset CAD (n = 150; <50 years), late-onset CAD (n = 150; >65 years) and healthy controls (n = 150, age range 47-93 years). Differences in the proportion of subjects in each group with the given gene combination were assessed and likelihood ratios (LR) were calculated using logistic regression to combine the results of multiple genes. RESULTS: Early-onset CAD patients had increased, but non-significant, frequencies of PPARgamma2 Pro12/Pro12 (P = 0.39) and ENOS T-786C (P = 0.72), while BChE-K was only significantly higher in early-onset CAD patients compared to controls (P = 0.03). There were significantly more APOE epsilon4 alleles alone (P = 0.02) or in combination with BChE-K (P = 0.02) among early-onset CAD patients compared to late-onset CAD ones or controls. When combined, there was a higher prevalence of all four alleles in early-onset CAD (early-onset CAD patients: 10.7%, late-onset CAD patients: 3.3% and controls: 2.7%, P = 0.01). LR for early-onset CAD for a single allele was relatively small (1.08 for PPARgamma2 to 1.70 for APOE epsilon4). This increased to 2.78 (1.44-5.37) when combining all four alleles, therefore increasing the pre-test probability of CAD from 5% to a post-test probability of 12.7%. CONCLUSIONS: While any single mutation causes only a mildly increased LR (none > 1.7), in combination, the likelihood of early-onset CAD increased to 2.78 with four mutations. The genetics of early-onset CAD appear to be multifactorial, requiring polygenic models to elucidate risk.

Treating the right patient at the right time: Access to cardiac catheterization, percutaneous coronary intervention and cardiac surgery.

The Canadian Cardiovascular Society Access to Care Working Group was formed with a mandate to use the best science and information available to establish reasonable triage categories and safe wait times for common cardiovascular services and procedures through a series of commentaries. The present commentary discusses the rationale for access benchmarks for cardiac catheterization and revascularization procedures for patients with stable angina, and access benchmarks for cardiac catheterization and surgery for patients with valvular heart disease. Literature on standards of care, wait times and wait list management was reviewed. A survey of cardiac centres in Canada was performed to develop an inventory of current practices in identifying and triaging patients. The Working Group recommends the following medically acceptable wait times for access to cardiac catheterization: 14 days for symptomatic aortic stenosis and six weeks for patients with stable angina and other valvular disease. For percutaneous coronary intervention in stable patients with high-risk anatomy, immediate revascularization or a wait time of 14 days is recommended; six weeks is recommended for all other patients. The target for bypass surgery in those with high-risk anatomy or valve surgery in patients with symptomatic aortic stenosis is 14 days; for all others, the target is six weeks. All stakeholders must affirm the appropriateness of these standards and work continuously to achieve them. There is an ongoing need to continually reassess current risk stratification methods to limit adverse events in patients on waiting lists and assist clinicians in triaging patients for invasive therapies.

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.

Universal access -- but when? Treating the right patient at the right time: access to electrophysiology services in Canada.

The Canadian Cardiovascular Society Access to Care Working Group has published a series of commentaries on access to cardiovascular care in Canada. The present article reviews the evidence for timely access to electrophysiology services. Using the best available evidence along with expert consensus by the Canadian Heart Rhythm Society, the panel proposed a series of benchmarks for access to the full scope of electrophysiology services, from initial consultation through to operative procedures. The proposed benchmarks are presented herein.

Strategic Clinical Networks: Alberta's Response to Triple Aim.

Verma and Bhatia make a compelling case for the Triple Aim to promote health system innovation and sustainability. We concur. Moreover, the authors offer a useful categorization of policies and actions to advance the Triple Aim under the "classic functions" of financing, stewardship and resource generation (Verma and Bhatia 2016). The argument is tendered that provincial governments should embrace the Triple Aim in the absence of federal government leadership, noting that, by international standards, we are at best mediocre and, more realistically, fighting for the bottom in comparative, annual cross-country surveys. Ignoring federal government participation in Medicare and resorting solely to provincial leadership seems to make sense for the purposes of this discourse; but, it makes no sense at all if we are attempting to achieve high performance in Canada's non-system (Canada Health Action: Building on the Legacy 1997; Commission on the Future of Health Care in Canada 2002; Lewis 2015). As for enlisting provincial governments, we heartily agree. A great deal can be accomplished by the Council of the Federation of Canadian Premiers. But, the entire basis for this philosophy and the reference paper itself assumes a top-down approach to policy and practice. That is what we are trying to change in Alberta and we next discuss. Bottom-up clinically led change, driven by measurement and evidence, has to meet with the top-down approach being presented and widely practiced. While true for each category of financing, stewardship and resource generation, in no place is this truer than what is described and included in "health system stewardship." This commentary draws from Verma and Bhatia (2016) and demonstrates how Alberta, through the use of Strategic Clinical Networks (SCNs), is responding to the Triple Aim. We offer three examples of provincially scaled innovations, each representing one or more arms of the Triple Aim.

Spindle cell sarcoma of the left atrium: an extremely rare and challenging tumour often masquerading as left atrial myxoma.

Spindle-cell sarcoma of the left atrium is an extremely rare diagnosis, with only 4 cases reported in the literature worldwide. We report on a 42-year-old man, who presented to the emergency department with dyspnea and decreased exercise tolerance. A computed tomography chest scan showed a large mass in the left atrium. Echocardiography demonstrated a significant gradient across the mitral valve. The patient had the mass excised in the operating room. He did well postoperatively. Eight months later, a repeat cardiac magnetic resonance imaging scan showed a recurrence. Right pneumonectomy was performed to ensure margins were clear. Although he has done well after surgery, his prognosis remains guarded.

An integrated approach for vascular health: a call to action.

Vascular diseases such as stroke, myocardial infarction, most causes of heart failure, dementia, peripheral arterial disease, certain kidney, and many lung and eye conditions are a result of disorders in the blood vessels (large and small) throughout the entire human body. Vascular diseases are the leading cause of preventable death and disability in Canada. Most vascular diseases share common risk factors (high blood pressure, diabetes, dyslipidemia, and obesity), which can be influenced by modifiable health behaviours such as unhealthy diet, smoking, lack of physical activity, and stress. Ninety percent of Canadians face an increased risk, which could be modified by managing these health behaviours and risk factors. Canada's aging population, combined with alarming trends in obesity, physical inactivity, high blood pressure, and diabetes are expected to further increase the social and economic effect of vascular diseases in the coming decades, unless there are major changes in health policy. Even more concerning is the increase in vascular risk factors among Canada's youth, and ethnically diverse populations. Vascular diseases affect not only the patient, but also place burdens on their spouses, families, friends, and communities. Tremendous potential exists to reduce the effects of vascular diseases through healthy public policy, supporting Canadians to make healthy lifestyle changes, and coordinating efforts across the continuum of care in a patient-focused manner. Vascular health requires partnerships for action across many sectors including government, health care practitioners, academia, not-for-profit organizations, and the private sector. The health sector alone cannot solve this problem.

Relation between butyrylcholinesterase K variant, paraoxonase 1 (PON1) Q and R and apolipoprotein E epsilon 4 genes in early-onset coronary artery disease.

OBJECTIVES: The common K variant of butyrylcholinesterase (BChE-K), an enzyme which metabolizes acetylcholine and organophosphates, has been associated with Alzheimer's disease, especially in the presence of the apolipoprotein E epsilon 4 allele (APOE-epsilon 4). Although APOE-epsilon 4 has been associated with the development of coronary artery disease (CAD), an association between the BChE-K variant and CAD has not been explored. Paraoxonase 1 (PON1), located within HDL, is an enzyme which also metabolizes organophosphates and may be antiatherogenic. The R192 variant of PON1 (PON1-R) has been associated with CAD. DESIGN AND METHODS: To determine whether BChE-K is also associated with premature CAD, we examined the frequency of BChE-K among patients with early-onset CAD (n = 150; < 50 yr) vs. late-onset CAD (n = 150; > 65 yr) by molecular analysis. We also examined the frequency of the PON1-R allele in both groups, and explored whether there was synergism between BChE-K and APOE-epsilon 4, BChE-K and PON1-R or PON1-R and APOE-epsilon 4. RESULTS: The frequency of the BChE-K allele tended to be greater among early-onset CAD patients compared to late-onset CAD patients (41.3% vs. 31.3%; p = 0.07), but without any significant difference between males and females. There was no difference in the prevalence of the PON1-R allele between those with early- or late-onset CAD (46.0% vs. 52.7%; p = 0.25). Twenty-two patients with early-onset CAD had both the BChE-K plus APOE-epsilon 4 alleles (14.7%) compared to 11 late-onset CAD patients (7.3%) (p = 0.04). There was no such association between BChE-K and PON1-R, nor PON1-R and APOE-epsilon 4. CONCLUSIONS: Our study suggests that there is a minor association between BChE-K and early-onset CAD, especially in the presence of the APOE-epsilon 4 allele.

The 2004 ACC/AHA Guidelines: a perspective and adaptation for Canada by the Canadian Cardiovascular Society Working Group.

Major changes in acute ST elevation myocardial infarction (STEMI) management prompted a comprehensive rewriting of the American College of Cardiology/American Heart Association Guidelines. The Canadian Cardiovascular Society (CCS) participated in both the writing process and the external review. Subsequently, a Canadian Working Group (CWG), formed under the auspices of the CCS, developed a perspective and adaptation for Canada. Herein, accounting for specific realities of the Canadian cardiovascular health system, is a discussion of the implications for prehospital care and transport, optimal reperfusion therapy and an approach to decision making regarding reperfusion options and invasive therapy following fibrinolytic therapy. Major recent developments regarding indications for implantable cardioverter defibrillator(s) (ICDs) also prompted a review of indications for ICDs and the optimal timing of implantation given the potential for recovery of left ventricular function. At least a 40-day, preferably a 12-week, waiting period was judged to be optimal to evaluate left ventricular function post-STEMI. A recommended algorithm for the insertion of an ICD is provided. Implementation of the new STEMI guidelines has substantial implications for resources, organization and priorities of the Canadian health care system. While on the one hand, the necessary incremental funding to provide tertiary and quaternary care and to support revascularization and device implantation capability is desirable, it is equally or more important to develop enhanced prehospital care, including the capacity for early recognition, risk assessment, fibrinolytic therapy and/or triage to a tertiary care centre as part of an enlightened approach to improving cardiac care.

Statin therapy and the management of acute coronary syndromes.

The pathophysiology of acute coronary syndromes is related to erosion or rupture of vulnerable plaque leading to intracoronary thrombosis as a result of activation of the coagulation cascade and platelet aggregation. Potential benefit of hypolipidemic 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibition may be related to the pleiotropic effects such as endothelial function improvement, stabilization of the plaque in relation to reduced macrophage activity and smooth muscle cell proliferation, as well as other anti-inflammatory effects that have been demonstrated in animal models. With the publication of the Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) study, early initiation of statin therapy within 24 to 96 h has been recognized as an important addition to the therapeutic armamentarium in the management of patients with acute coronary syndromes.

Aligning health care policy with evidence-based medicine: the case for funding direct oral anticoagulants in atrial fibrillation.

Misalignment between evidence-informed clinical care guideline recommendations and reimbursement policy has created care gaps that lead to suboptimal outcomes for patients denied access to guideline-based therapies. The purpose of this article is to make the case for addressing this growing access barrier to optimal care. Stroke prevention in atrial fibrillation (AF) is discussed as an example. Stroke is an extremely costly disease, imposing a significant human, societal, and economic burden. Stroke in the setting of AF carries an 80% probability of death or disability. Although two-thirds of these strokes are preventable with appropriate anticoagulation, this has historically been underprescribed and poorly managed. National and international guidelines endorse the direct oral anticoagulants as first-line therapy for this indication. However, no Canadian province has provided these agents with an unrestricted listing. These decisions appear to be founded on silo-based cost assessment-the drug costs rather than the total system costs-and thus overlook several important cost-drivers in stroke. The discordance between best scientific evidence and public policy requires health care providers to use a potentially suboptimal therapy in contravention of guideline recommendations. It represents a significant obstacle for knowledge translation efforts that aim to increase the appropriate anticoagulation of Canadians with AF. As health care professionals, we have a responsibility to our patients to engage with policy-makers in addressing and resolving this barrier to optimal patient care.