- Email: [email protected]
Canadian Cardiovascular Society (CCS) CCS155 Poster: Assessment of Interventional Outcomes Sunday, October 24, 2010
Abstracts
006
A SYSTEMATIC REVIEW OF THE POTENTIAL INTERACTION BETWEEN CLOPIDOGREL AND PROTON PUMP INHIBITORS J de Aquino Lima, J Brophy Montréal, Québec BACKGROUND: Conflicting evidence exists for a clinically significant drug interaction between clopidogrel and proton pump inhibitors (PPIs) and a systematic review may help resolve the present uncertainty. CONCLUSION: The observed association between clopidogrel and PPIs is found uniquely in studies judged to be of low quality with an increased risk of bias. High quality evidence supporting a clinically significant clopidogrel / PPI interaction is presently lacking.
007
CLINICAL UTILITY OF ADDING A GENETIC RISK SCORE OR FAMILY HISTORY OF CARDIOVASCULAR DISEASE TO CARDIOVASCULAR RISK PREDICTION MODELS – THE FRAMINGHAM OFFSPRING STUDY G Thanassoulis, G Peloso, M Pencina, S Hwang, CJ O’Donnell Framingham, Massachusetts BACKGROUND: Genome-wide association studies have uncovered several genetic markers associated with coronary artery disease. However, there is limited data to suggest that a genetic risk score (GRS) or a family history of cardiovascular disease (CVD) provides incremental information for coronary heart disease risk prediction over and above traditional risk factors. CONCLUSION: Although a genetic risk score is an independent predictor of incident cardiovascular events in Framingham Offspring, the addition of a genetic risk score did not significantly improve risk discrimination or reclassification. However, the addition of a family history of CVD to CVD risk prediction models is warranted. CIHR Fellowship, FRSQ Fellowship
008
NONLINEAR BEHAVIOUR OF AORTA AT CRITICAL FLOW CONDITIONS RELATED TO DISSECTION M Amabili, K Karagiozis, R Mongrain, MP Paidoussis, R Cartier Montréal, Québec BACKGROUND: One of the most catastrophic cardiovascular diseases is associated with dissection of the thoracic aorta when sudden rupture and tearing of the tunica intima layer occurs in a transverse direction. Recently, true-lumen collapse of the ascending aorta has been detected using computed tomography images. The large deformation of the ascending aorta during the collapse is considered to be responsible for the transverse dissection which propagates along a helicoidal path. In addition, the strong association between dissection and hypertension or aortic dilation has been clinically proven with more than 80% of the patients with aortic dissection suffering from high blood pressure. CONCLUSION: The results show that flow-induced buckling (or even collapse) of the aorta is possible under specific flow and pressure conditions. Under these critical conditions a highly subcritical nonlinear behaviour arises with multiple stable solutions (zero deformation shape, buckled aorta, or total collapse) coexisting for a wide range of blood flow velocities. Increasing the transmural pressure renders the system more stable with respect to the onset of buckling, and it induces a ballooning effect. It is here conjectured that the pressurization-depressurization of the aorta due to the systolic-diastolic cycle or a strenuous exercise regime which leads to a constant oscillation of the aorta, when coupled with cardiovascular disease or other pathological problems, might induce material deterioration and thus the appearance and growth of aneurysms or dissection.
28D
Canadian Cardiovascular Society (CCS) CCS155 Poster ASSESSMENT OF INTERVENTIONAL OUTCOMES Sunday, October 24, 2010 011
CAN QUEBEC’S HOSPITAL INPATIENT AND DAY SURGERY DATABASE (MED-ÉCHO) BE USED TO COUNT PERCUTANEOUS CORONARY INTERVENTIONS (PCI)? KA Brown, K David, LJ Lambert, P Bogaty Montréal, Québec BACKGROUND: An important variation in regional rates of PCI has been observed. In the absence of a PCI registry, comparisons of rates across Canada depend on clinical-administrative data. However, in Québec, submission of a hospital abstract is not required for patients receiving care in all outpatient settings, thus PCI may be under-reported. In collaboration with the Canadian Institute for Health Information (CIHI), AETMIS (Agence d’évaluation des technologies et modes d’intervention en santé) examined counts of PCI in two different data sources in Québec: 1) physician claims database, and 2) hospital inpatient and day surgery database (Fichier des hospitalisations MED-ÉCHO). CONCLUSION: In 2007/2008, almost 24% of PCIs documented in Québec’s physician claims data base were not reported to MED-ÉCHO by the performing PCI centre and 14% of PCIs were not reported by any hospital. Hospital reporting practices for PCI appeared to vary widely across Québec’s 15 PCI centres and in those non-tertiary centres that referred patients for PCI. In Québec, it may be more appropriate to use the physician claims database to count PCI rather than MED-ÉCHO. Interprovincial comparisons of rates of PCI that include Québec and interregional comparisons within Québec that use clinical-administrative data, may be hindered by a lack of uniformity in provincial reporting requirements and practices by hospitals.
012
REVASCULARIZATION OUTCOMES ON THE JOINT CARDIOLOGY-CARDIOTHORACIC MULTIDISCIPLINARY TEAM MEETING W Choo, R Amersey London, United Kingdom WITHDRAWN
013
A HOLISTIC ASSESSMENT OF PATIENTS’ CORONARY REVASCULARIZATION RISK WITH THE BRITISH COLUMBIA PCI SCORE IS SUPERIOR TO RISK ASSESSED FROM THE ANGIOGRAM ALONE SP Hoole, MD Seddon, RS Poulter, JN Hamburger Vancouver, British Columbia BACKGROUND: Selecting the optimal revascularization strategy for patients with coronary artery disease is guided by coronary anatomy alone or by also assessing clinical data using the British Columbia (BC) PCI score (www.canadascore.org) and the logistic EuroSCORE (www.euroscore.org). Patients with coronary anatomy SYNTAX scores <22 possibly fair better with PCI whereas those with a score >33 do better with surgery. Either revascularization strategy is appropriate when the score is 22-33. We hypothesized that assessing clinical and anatomical factors by using the BC PCI score and logistic EuroSCORE improve patient risk stratification and selection of the optimal revascularization strategy. CONCLUSION: There is a stronger correlation between the BC PCI score and log EuroSCORE (R=0.80), than the correlations with a score that assesses anatomy alone (R=0.44 and R=0.54 respectively). Selecting a revascularization strategy based on an anatomical assessment alone, selects a suboptimal revascularization strategy in significant proportion of patients (n=13, 12%). There is added value in comparing the validated BC PCI
Can J Cardiol Vol 26 Suppl D October 2010
Abstracts score and log EuroSCORE to predict 30-day mortality. When predicted surgical risk was high, the predicted mortality risk for PCI was often higher, suggesting that surgical turndowns should not necessarily default to a PCI treatment strategy. Comparison of PCI and surgical predicted risk helps guide the optimal revascularization strategy, particularly in cases where the anatomical score suggests equipoise between surgical and percutaneous approaches.
014
IMPACT OF THE SYNTAX SCORE ON THE REFERRAL TO CORONARY ARTERY BYPASS GRAFT SURGERY BEFORE AND AFTER SYNTAX TRIAL PUBLICATION G Abou Nader, LM Stevens, F Gobeil, A Kokis, N Noiseux, JB Masson, S Mansour Montréal, Québec BACKGROUND: The Syntax score (SXscore) has been developed as a combination of several validated angiographic classifications aiming to characterize the coronary lesions with respect to their functional impact, location, and complexity. Its prognostic value has recently been highlighted in patients with left main (LM) and/or multivessel (MV) coronary artery disease. The aim of this study was to evaluate the impact of the SYNTAX trial publication on the referral of this population of patients to coronary artery bypass graft surgery (CABG) in a high volume tertiary center. CONCLUSION: The majority of patients referred for CABG based on physician decision before and after the SYNTAX trial publication had an intermediate and high SXscore. However, relying on the SXscore in the elderly population could prevent referral and avoid CABG for patients with low SXscore but elevated surgical risk.
015
RELIABILITY OF THE ASSESSMENT OF PATIENT COMORBIDITIES USING QUEBEC’S MEDICOADMINISTRATIVE DATA LJ Lambert, C Blais, D Hamel, KA Brown, M Giguère, C Beauchamp, C Carroll, S Rinfret, R Cartier, P Bogaty Montréal, Québec BACKGROUND: Surveillance of chronic diseases and the evaluation of outcomes following cardiovascular interventions are essential components of a modern healthcare system. In Québec, the INSPQ (Institut national de santé publique du Québec), a government-funded but independent body, monitors the occurrence of health problems like acute myocardial infarction (AMI) while AETMIS (Agence d’évaluation des technologies et des modes d’intervention en santé) is mandated to evaluate healthcare interventions. In the absence of clinical registries, both organizations depend on analyses of medico-administrative data. Thus, it has become essential to ascertain the reliability of Québec’s hospital database (MEDÉCHO). CONCLUSION: Documentation of comorbidities in Québec’s hospital discharge database had considerable agreement with the medical chart of patients admitted to hospital for AMI or a revascularization procedure. A multivariate risk adjustment model for 1-year mortality derived from MEDÉCHO had the same discrimination as a model derived from the medical chart. While ascertainment of comorbidities using medico-administrative data has limitations, it has the advantage of readily available data from previous admissions and all hospitals involved in the patient’s care. Importantly, these results suggest that Québec’s medico-administrative data has sufficient reliability to be used for surveillance of cardiac disease and evaluation of associated healthcare outcomes. Public Health Agency of Canada
Can J Cardiol Vol 26 Suppl D October 2010
016
TRAINEE AND PROGRAM DIRECTOR SURVEY OF INTERVENTIONAL CARDIOLOGY FELLOWSHIP PROGRAMS IN CANADA P Dehghani, W Sharieff, DA Wood, AN Cheema Toronto, Ontario Formal fellowship training in Interventional Cardiology (IC) has been offered at Canadian institutions for more than two decades. However, entry criteria and training requirements are developed and implemented by individual programs without a formal process to ensure uniformity of training at a national level. This paucity in national standards for training and competency mainly stems from lack of accreditation and subspecialty status designation for IC by the Royal College of Physicians and Surgeons of Canada. The objective of this survey was to determine the structure of IC training programs across Canada and characterize training environment of various institutions. This study demonstrates a comparable PCI fellowship experience across Canada with adequate clinical and didactic exposure in IC. However, disagreement between the trainees and the program directors for administrative components of the fellowship program suggest an important role for a national body to optimize program administration.
017
A CORONARY ARTERY BYPASS GRAFT SURGERY (CABG) EVALUATION PROJECT: BY, FOR, AND WITH CARDIAC SURGEONS LJ Lambert, S Poliquin, KA Brown, J Moutquin, M Carrier, Y Langlois, P Mathieu, N Dendukuri, JE Morin, JR Guertin, P Bogaty Montréal, Québec BACKGROUND: Our Tertiary Cardiology Evaluation Unit conducts evaluations and outcomes research within a paradigm where continuous improvement of quality of care is based on measurement of clinical process and associated outcomes followed by feedback. Within this model, the impact of feedback on change in practice is highly dependent on clinicians’ participation and their acceptance of the evaluation process. For our evaluation of the outcomes of CABG in Québec, we aimed to maximize cardiac surgeons’ acceptance of the project by inviting them to be members of the project’s Scientific and Steering Committees. CONCLUSION: The involvement of clinical experts in the development of an evaluation protocol and in the interpretation of preliminary observations and final results of data analyses may provide important advantages. The evaluation team benefits from in-depth clinical perspective. The clinicians benefit from a better understanding of the methods used to systematically measure the process of care and associated outcomes. This collaborative process led to agreement between the clinicians and the evaluation team that individual hospital results would remain confidential since use of medico-administrative data alone may result in an inappropriate adjustment of risk. It is hoped that clinician involvement in this evaluation will benefit patients as a result of improved clinical practice.
018
USEFULNESS OF THE EUROSCORE AND THE TEXAS SCORE TO PREDICT OUTCOMES IN OCTOGENARIANS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION J Déry, J Steele, H Tizón-Marcos, PL Bernard, C Boulanger-Gobeil, J Plaisance, É Larose, S Rinfret, G Barbeau, O Gleeton, CM Nguyen, G Proulx, B Noël, L Roy, R De Larochellière, J Rodés-Cabau, OF Bertrand Québec, Québec BACKGROUND: Octogenarians undergoing PCI are at a higher risk of complications compared to younger patients. Risk-prediction models may be helpful to guide clinicians in the treatment of these patients. We sought to determine the ability of three different risk scores (Euroscore standard, Euroscore logistic and Texas risk score) to predict long-term outcomes in octogenarians undergoing PCI.
29D
Abstracts CONCLUSION: In this study of octogenarians undergoing PCI, the Euroscore was superior to the Texas score to predict mortality and MACE at one year. Although the Euroscore shows some potential, its predictive ability remains limited. Further investigations are needed to develop adequate tools to predict outcomes in this high risk PCI population. Fondation de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec
019
DIFFERENCES IN ANGIOGRAPHIC PARAMETERS AND PREDICTORS OF FUNCTIONALLY SIGNIFICANT CORONARY STENOSIS ASSESSED BY FRACTIONAL FLOW RESERVE MD Seddon, S Hoole, R Poulter, D Wood, A Fung, A Starovoytov, GJ Mancini, J Saw Vancouver, British Columbia BACKGROUND: Angiographic assessment of intermediate-severity coronary stenosis, guided by percent diameter stenosis, is poor in determining functional significance. In contrast, fractional flow reserve (FFR) is a robust validated index of the physiological significance of coronary stenoses, and FFR-guided revascularization of ischemic lesions improved clinical outcomes in the FAME trial over angiographic guidance alone. However, FFR measurement is invasive, not universally available, and adds time and costs to angiography. Based on the parameters incorporated into FFR measurement and Poiseuille’s law of fluid dynamics, we sought to identify clinical and angiographic parameters that may help to better predict a lesion’s functional significance. CONCLUSION: In our retrospective analysis of 100 patients with FFR assessment for intermediate lesions, we found that lesions with FFR≤0.80 were longer, had smaller minimal luminal diameters, had greater myocardial jeopardy index for the myocardium subtended, and were more likely to be irregular, hazy, and involve multi-vessels. With multivariate analysis, several of these parameters remained independent predictors for FFR≤0.80. These results indicate that there are several useful angiographic parameters that could predict functional significance of intermediate lesions. A comprehensive assessment of these angiographic parameters is likely to more accurately predict a lesion’s functional significance than visual assessment of percent diameter stenosis alone.
020
CANADIAN PROSPECTIVE OBSERVATIONAL STUDY ON THE USE OF LMWH IN THE SETTING OF PERCUTANEOUS CORONARY INTERVENTION: THE CANADIAN ANTICOAGULANT PCI REGISTRY (CAPCIR) R Welsh, A Fung, N Fam, RH Zimmermann, AJ DellaSiega, J Déry, E Schampaert, N Komari, S Welsh, B Rose Edmonton, Alberta Low molecular weight heparin (LMWH) is frequently utilized in ACS patients awaiting cardiac catheterization. Management of anticoagulation at the time of percutaneous coronary intervention (PCI) varies widely in patients treated with LMWH. Enoxaparin has been shown to have enhanced safety and sustained efficacy in patient undergoing elective PCI compared to unfractionated heparin. Since there is no consensus on the best transition strategy and limited real word data on the utilization of LMWH in the cardiac catheterization laboratory, a multicenter prospective observational study was conducted in this population across Canada. The Canadian Anticoagulant PCI Registry will provide key data on anticoagulation management of patients treated with LMWH during PCI in Canada as well as patient characteristics that influence management and outcomes. The overall goal is to optimize anticoagulation management and improve PCI-related outcomes in the Canadian PCI setting. sanofi aventis
30D
Canadian Cardiovascular Society (CCS) CCS160 Poster ACUTE CORONARY SYNDROMES: ASSESSMENT, STRATIFICATION AND MANAGEMENT Sunday, October 24, 2010 023
VERY EARLY INVASIVE VERSUS LESS EARLY INVASIVE STRATEGIES FOR NON-ST-ELEVATION ACUTE CORONARY SYNDROMES: A META-ANALYSIS OF RANDOMIZED TRIALS AO Abualsaud Montréal, Québec BACKGROUND: Guidelines recommend routine angiography within 48 hours (early invasive strategy) in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, optimal timing of angiography after NSTE-ACS is unknown and the theoretical benefits of very early percutaneous coronary intervention within the first few hours have yet to be proven. CONCLUSION: In NSTE-ACS, routine use of a very early invasive strategy does not reduce mortality or cardiac events and is associated with a similar risk of major bleeding as compared with a less early invasive strategy. The role of very early angiography and percutaneous coronary intervention in the subgroup of patients at the highest risk remains unclear and warrants further study.
024
RELATIVE EFFICACY OF ATORVASTATIN AND ROSUVASTATIN IN ACHIEVING TARGET LIPID LEVELS AND IMPACT ON LONG-TERM CLINICAL OUTCOMES FOLLOWING ST-ELEVATION MYOCARDIAL INFARCTION G Ong, J Déry, U Déry, P Lachance, É Larose, S Rinfret, J Rodés-Cabau, G Barbeau, O Gleeton, L Roy, B Noël, CM Nguyen, G Proulx, R De Larochellière, J Després, OF Bertrand Québec, Québec BACKGROUND: Aggressive lipid lowering therapy to achieve a LDL-C <2.0 mmol/l and a total cholesterol (TC)/HDL-C ratio<4.0 have been proposed as therapeutic targets to further reduce cardiovascular events in patients with coronary artery disease. Whether these goals are better achieved when patients are discharged with rosuvastatin rather than atorvastatin, and whether the choice of one agent over the other has an impact on clinical outcomes after ST-elevation myocardial infarction (STEMI) remain to be demonstrated. CONCLUSION: In the present study, patients treated with rosuvastatin and atorvastatin achieved current therapeutic lipid targets in similar proportion and experienced comparable rates of recurrent ischemic events. Nonetheless, a significant number of patients who suffered a STEMI did not achieve currently recommended target lipid levels. Factors other than the choice of statin seem to be responsible for this care gap. A more aggressive approach to lipid management, including the use of higher statin doses, should be encouraged together with appropriate management of all other risk factors in order to improve long-term outcomes in STEMI patients. AstraZeneca
025
LESSONS FROM CANRACE REGISTRY: CARE GAPS IN ACS IN CANADA: MEDICATION ADHERENCE AT HOSPITAL DISCHARGE AND AT SIX MONTHS JM Kornder, JP DeYoung, RC Welsh, S Goodman, RT Yan, GC Wong, FA Spencer, F Grondin, AT Yan Surrey, British Columbia BACKGROUND: Practice guidelines recommend evidence-based secondary prevention therapies in the management of acute coronary syndromes (ACS). However, there are limited contemporary data on the
Can J Cardiol Vol 26 Suppl D October 2010
006
A SYSTEMATIC REVIEW OF THE POTENTIAL INTERACTION BETWEEN CLOPIDOGREL AND PROTON PUMP INHIBITORS J de Aquino Lima, J Brophy Montréal, Québec BACKGROUND: Conflicting evidence exists for a clinically significant drug interaction between clopidogrel and proton pump inhibitors (PPIs) and a systematic review may help resolve the present uncertainty. CONCLUSION: The observed association between clopidogrel and PPIs is found uniquely in studies judged to be of low quality with an increased risk of bias. High quality evidence supporting a clinically significant clopidogrel / PPI interaction is presently lacking.
007
CLINICAL UTILITY OF ADDING A GENETIC RISK SCORE OR FAMILY HISTORY OF CARDIOVASCULAR DISEASE TO CARDIOVASCULAR RISK PREDICTION MODELS – THE FRAMINGHAM OFFSPRING STUDY G Thanassoulis, G Peloso, M Pencina, S Hwang, CJ O’Donnell Framingham, Massachusetts BACKGROUND: Genome-wide association studies have uncovered several genetic markers associated with coronary artery disease. However, there is limited data to suggest that a genetic risk score (GRS) or a family history of cardiovascular disease (CVD) provides incremental information for coronary heart disease risk prediction over and above traditional risk factors. CONCLUSION: Although a genetic risk score is an independent predictor of incident cardiovascular events in Framingham Offspring, the addition of a genetic risk score did not significantly improve risk discrimination or reclassification. However, the addition of a family history of CVD to CVD risk prediction models is warranted. CIHR Fellowship, FRSQ Fellowship
008
NONLINEAR BEHAVIOUR OF AORTA AT CRITICAL FLOW CONDITIONS RELATED TO DISSECTION M Amabili, K Karagiozis, R Mongrain, MP Paidoussis, R Cartier Montréal, Québec BACKGROUND: One of the most catastrophic cardiovascular diseases is associated with dissection of the thoracic aorta when sudden rupture and tearing of the tunica intima layer occurs in a transverse direction. Recently, true-lumen collapse of the ascending aorta has been detected using computed tomography images. The large deformation of the ascending aorta during the collapse is considered to be responsible for the transverse dissection which propagates along a helicoidal path. In addition, the strong association between dissection and hypertension or aortic dilation has been clinically proven with more than 80% of the patients with aortic dissection suffering from high blood pressure. CONCLUSION: The results show that flow-induced buckling (or even collapse) of the aorta is possible under specific flow and pressure conditions. Under these critical conditions a highly subcritical nonlinear behaviour arises with multiple stable solutions (zero deformation shape, buckled aorta, or total collapse) coexisting for a wide range of blood flow velocities. Increasing the transmural pressure renders the system more stable with respect to the onset of buckling, and it induces a ballooning effect. It is here conjectured that the pressurization-depressurization of the aorta due to the systolic-diastolic cycle or a strenuous exercise regime which leads to a constant oscillation of the aorta, when coupled with cardiovascular disease or other pathological problems, might induce material deterioration and thus the appearance and growth of aneurysms or dissection.
28D
Canadian Cardiovascular Society (CCS) CCS155 Poster ASSESSMENT OF INTERVENTIONAL OUTCOMES Sunday, October 24, 2010 011
CAN QUEBEC’S HOSPITAL INPATIENT AND DAY SURGERY DATABASE (MED-ÉCHO) BE USED TO COUNT PERCUTANEOUS CORONARY INTERVENTIONS (PCI)? KA Brown, K David, LJ Lambert, P Bogaty Montréal, Québec BACKGROUND: An important variation in regional rates of PCI has been observed. In the absence of a PCI registry, comparisons of rates across Canada depend on clinical-administrative data. However, in Québec, submission of a hospital abstract is not required for patients receiving care in all outpatient settings, thus PCI may be under-reported. In collaboration with the Canadian Institute for Health Information (CIHI), AETMIS (Agence d’évaluation des technologies et modes d’intervention en santé) examined counts of PCI in two different data sources in Québec: 1) physician claims database, and 2) hospital inpatient and day surgery database (Fichier des hospitalisations MED-ÉCHO). CONCLUSION: In 2007/2008, almost 24% of PCIs documented in Québec’s physician claims data base were not reported to MED-ÉCHO by the performing PCI centre and 14% of PCIs were not reported by any hospital. Hospital reporting practices for PCI appeared to vary widely across Québec’s 15 PCI centres and in those non-tertiary centres that referred patients for PCI. In Québec, it may be more appropriate to use the physician claims database to count PCI rather than MED-ÉCHO. Interprovincial comparisons of rates of PCI that include Québec and interregional comparisons within Québec that use clinical-administrative data, may be hindered by a lack of uniformity in provincial reporting requirements and practices by hospitals.
012
REVASCULARIZATION OUTCOMES ON THE JOINT CARDIOLOGY-CARDIOTHORACIC MULTIDISCIPLINARY TEAM MEETING W Choo, R Amersey London, United Kingdom WITHDRAWN
013
A HOLISTIC ASSESSMENT OF PATIENTS’ CORONARY REVASCULARIZATION RISK WITH THE BRITISH COLUMBIA PCI SCORE IS SUPERIOR TO RISK ASSESSED FROM THE ANGIOGRAM ALONE SP Hoole, MD Seddon, RS Poulter, JN Hamburger Vancouver, British Columbia BACKGROUND: Selecting the optimal revascularization strategy for patients with coronary artery disease is guided by coronary anatomy alone or by also assessing clinical data using the British Columbia (BC) PCI score (www.canadascore.org) and the logistic EuroSCORE (www.euroscore.org). Patients with coronary anatomy SYNTAX scores <22 possibly fair better with PCI whereas those with a score >33 do better with surgery. Either revascularization strategy is appropriate when the score is 22-33. We hypothesized that assessing clinical and anatomical factors by using the BC PCI score and logistic EuroSCORE improve patient risk stratification and selection of the optimal revascularization strategy. CONCLUSION: There is a stronger correlation between the BC PCI score and log EuroSCORE (R=0.80), than the correlations with a score that assesses anatomy alone (R=0.44 and R=0.54 respectively). Selecting a revascularization strategy based on an anatomical assessment alone, selects a suboptimal revascularization strategy in significant proportion of patients (n=13, 12%). There is added value in comparing the validated BC PCI
Can J Cardiol Vol 26 Suppl D October 2010
Abstracts score and log EuroSCORE to predict 30-day mortality. When predicted surgical risk was high, the predicted mortality risk for PCI was often higher, suggesting that surgical turndowns should not necessarily default to a PCI treatment strategy. Comparison of PCI and surgical predicted risk helps guide the optimal revascularization strategy, particularly in cases where the anatomical score suggests equipoise between surgical and percutaneous approaches.
014
IMPACT OF THE SYNTAX SCORE ON THE REFERRAL TO CORONARY ARTERY BYPASS GRAFT SURGERY BEFORE AND AFTER SYNTAX TRIAL PUBLICATION G Abou Nader, LM Stevens, F Gobeil, A Kokis, N Noiseux, JB Masson, S Mansour Montréal, Québec BACKGROUND: The Syntax score (SXscore) has been developed as a combination of several validated angiographic classifications aiming to characterize the coronary lesions with respect to their functional impact, location, and complexity. Its prognostic value has recently been highlighted in patients with left main (LM) and/or multivessel (MV) coronary artery disease. The aim of this study was to evaluate the impact of the SYNTAX trial publication on the referral of this population of patients to coronary artery bypass graft surgery (CABG) in a high volume tertiary center. CONCLUSION: The majority of patients referred for CABG based on physician decision before and after the SYNTAX trial publication had an intermediate and high SXscore. However, relying on the SXscore in the elderly population could prevent referral and avoid CABG for patients with low SXscore but elevated surgical risk.
015
RELIABILITY OF THE ASSESSMENT OF PATIENT COMORBIDITIES USING QUEBEC’S MEDICOADMINISTRATIVE DATA LJ Lambert, C Blais, D Hamel, KA Brown, M Giguère, C Beauchamp, C Carroll, S Rinfret, R Cartier, P Bogaty Montréal, Québec BACKGROUND: Surveillance of chronic diseases and the evaluation of outcomes following cardiovascular interventions are essential components of a modern healthcare system. In Québec, the INSPQ (Institut national de santé publique du Québec), a government-funded but independent body, monitors the occurrence of health problems like acute myocardial infarction (AMI) while AETMIS (Agence d’évaluation des technologies et des modes d’intervention en santé) is mandated to evaluate healthcare interventions. In the absence of clinical registries, both organizations depend on analyses of medico-administrative data. Thus, it has become essential to ascertain the reliability of Québec’s hospital database (MEDÉCHO). CONCLUSION: Documentation of comorbidities in Québec’s hospital discharge database had considerable agreement with the medical chart of patients admitted to hospital for AMI or a revascularization procedure. A multivariate risk adjustment model for 1-year mortality derived from MEDÉCHO had the same discrimination as a model derived from the medical chart. While ascertainment of comorbidities using medico-administrative data has limitations, it has the advantage of readily available data from previous admissions and all hospitals involved in the patient’s care. Importantly, these results suggest that Québec’s medico-administrative data has sufficient reliability to be used for surveillance of cardiac disease and evaluation of associated healthcare outcomes. Public Health Agency of Canada
Can J Cardiol Vol 26 Suppl D October 2010
016
TRAINEE AND PROGRAM DIRECTOR SURVEY OF INTERVENTIONAL CARDIOLOGY FELLOWSHIP PROGRAMS IN CANADA P Dehghani, W Sharieff, DA Wood, AN Cheema Toronto, Ontario Formal fellowship training in Interventional Cardiology (IC) has been offered at Canadian institutions for more than two decades. However, entry criteria and training requirements are developed and implemented by individual programs without a formal process to ensure uniformity of training at a national level. This paucity in national standards for training and competency mainly stems from lack of accreditation and subspecialty status designation for IC by the Royal College of Physicians and Surgeons of Canada. The objective of this survey was to determine the structure of IC training programs across Canada and characterize training environment of various institutions. This study demonstrates a comparable PCI fellowship experience across Canada with adequate clinical and didactic exposure in IC. However, disagreement between the trainees and the program directors for administrative components of the fellowship program suggest an important role for a national body to optimize program administration.
017
A CORONARY ARTERY BYPASS GRAFT SURGERY (CABG) EVALUATION PROJECT: BY, FOR, AND WITH CARDIAC SURGEONS LJ Lambert, S Poliquin, KA Brown, J Moutquin, M Carrier, Y Langlois, P Mathieu, N Dendukuri, JE Morin, JR Guertin, P Bogaty Montréal, Québec BACKGROUND: Our Tertiary Cardiology Evaluation Unit conducts evaluations and outcomes research within a paradigm where continuous improvement of quality of care is based on measurement of clinical process and associated outcomes followed by feedback. Within this model, the impact of feedback on change in practice is highly dependent on clinicians’ participation and their acceptance of the evaluation process. For our evaluation of the outcomes of CABG in Québec, we aimed to maximize cardiac surgeons’ acceptance of the project by inviting them to be members of the project’s Scientific and Steering Committees. CONCLUSION: The involvement of clinical experts in the development of an evaluation protocol and in the interpretation of preliminary observations and final results of data analyses may provide important advantages. The evaluation team benefits from in-depth clinical perspective. The clinicians benefit from a better understanding of the methods used to systematically measure the process of care and associated outcomes. This collaborative process led to agreement between the clinicians and the evaluation team that individual hospital results would remain confidential since use of medico-administrative data alone may result in an inappropriate adjustment of risk. It is hoped that clinician involvement in this evaluation will benefit patients as a result of improved clinical practice.
018
USEFULNESS OF THE EUROSCORE AND THE TEXAS SCORE TO PREDICT OUTCOMES IN OCTOGENARIANS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION J Déry, J Steele, H Tizón-Marcos, PL Bernard, C Boulanger-Gobeil, J Plaisance, É Larose, S Rinfret, G Barbeau, O Gleeton, CM Nguyen, G Proulx, B Noël, L Roy, R De Larochellière, J Rodés-Cabau, OF Bertrand Québec, Québec BACKGROUND: Octogenarians undergoing PCI are at a higher risk of complications compared to younger patients. Risk-prediction models may be helpful to guide clinicians in the treatment of these patients. We sought to determine the ability of three different risk scores (Euroscore standard, Euroscore logistic and Texas risk score) to predict long-term outcomes in octogenarians undergoing PCI.
29D
Abstracts CONCLUSION: In this study of octogenarians undergoing PCI, the Euroscore was superior to the Texas score to predict mortality and MACE at one year. Although the Euroscore shows some potential, its predictive ability remains limited. Further investigations are needed to develop adequate tools to predict outcomes in this high risk PCI population. Fondation de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec
019
DIFFERENCES IN ANGIOGRAPHIC PARAMETERS AND PREDICTORS OF FUNCTIONALLY SIGNIFICANT CORONARY STENOSIS ASSESSED BY FRACTIONAL FLOW RESERVE MD Seddon, S Hoole, R Poulter, D Wood, A Fung, A Starovoytov, GJ Mancini, J Saw Vancouver, British Columbia BACKGROUND: Angiographic assessment of intermediate-severity coronary stenosis, guided by percent diameter stenosis, is poor in determining functional significance. In contrast, fractional flow reserve (FFR) is a robust validated index of the physiological significance of coronary stenoses, and FFR-guided revascularization of ischemic lesions improved clinical outcomes in the FAME trial over angiographic guidance alone. However, FFR measurement is invasive, not universally available, and adds time and costs to angiography. Based on the parameters incorporated into FFR measurement and Poiseuille’s law of fluid dynamics, we sought to identify clinical and angiographic parameters that may help to better predict a lesion’s functional significance. CONCLUSION: In our retrospective analysis of 100 patients with FFR assessment for intermediate lesions, we found that lesions with FFR≤0.80 were longer, had smaller minimal luminal diameters, had greater myocardial jeopardy index for the myocardium subtended, and were more likely to be irregular, hazy, and involve multi-vessels. With multivariate analysis, several of these parameters remained independent predictors for FFR≤0.80. These results indicate that there are several useful angiographic parameters that could predict functional significance of intermediate lesions. A comprehensive assessment of these angiographic parameters is likely to more accurately predict a lesion’s functional significance than visual assessment of percent diameter stenosis alone.
020
CANADIAN PROSPECTIVE OBSERVATIONAL STUDY ON THE USE OF LMWH IN THE SETTING OF PERCUTANEOUS CORONARY INTERVENTION: THE CANADIAN ANTICOAGULANT PCI REGISTRY (CAPCIR) R Welsh, A Fung, N Fam, RH Zimmermann, AJ DellaSiega, J Déry, E Schampaert, N Komari, S Welsh, B Rose Edmonton, Alberta Low molecular weight heparin (LMWH) is frequently utilized in ACS patients awaiting cardiac catheterization. Management of anticoagulation at the time of percutaneous coronary intervention (PCI) varies widely in patients treated with LMWH. Enoxaparin has been shown to have enhanced safety and sustained efficacy in patient undergoing elective PCI compared to unfractionated heparin. Since there is no consensus on the best transition strategy and limited real word data on the utilization of LMWH in the cardiac catheterization laboratory, a multicenter prospective observational study was conducted in this population across Canada. The Canadian Anticoagulant PCI Registry will provide key data on anticoagulation management of patients treated with LMWH during PCI in Canada as well as patient characteristics that influence management and outcomes. The overall goal is to optimize anticoagulation management and improve PCI-related outcomes in the Canadian PCI setting. sanofi aventis
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Canadian Cardiovascular Society (CCS) CCS160 Poster ACUTE CORONARY SYNDROMES: ASSESSMENT, STRATIFICATION AND MANAGEMENT Sunday, October 24, 2010 023
VERY EARLY INVASIVE VERSUS LESS EARLY INVASIVE STRATEGIES FOR NON-ST-ELEVATION ACUTE CORONARY SYNDROMES: A META-ANALYSIS OF RANDOMIZED TRIALS AO Abualsaud Montréal, Québec BACKGROUND: Guidelines recommend routine angiography within 48 hours (early invasive strategy) in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, optimal timing of angiography after NSTE-ACS is unknown and the theoretical benefits of very early percutaneous coronary intervention within the first few hours have yet to be proven. CONCLUSION: In NSTE-ACS, routine use of a very early invasive strategy does not reduce mortality or cardiac events and is associated with a similar risk of major bleeding as compared with a less early invasive strategy. The role of very early angiography and percutaneous coronary intervention in the subgroup of patients at the highest risk remains unclear and warrants further study.
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RELATIVE EFFICACY OF ATORVASTATIN AND ROSUVASTATIN IN ACHIEVING TARGET LIPID LEVELS AND IMPACT ON LONG-TERM CLINICAL OUTCOMES FOLLOWING ST-ELEVATION MYOCARDIAL INFARCTION G Ong, J Déry, U Déry, P Lachance, É Larose, S Rinfret, J Rodés-Cabau, G Barbeau, O Gleeton, L Roy, B Noël, CM Nguyen, G Proulx, R De Larochellière, J Després, OF Bertrand Québec, Québec BACKGROUND: Aggressive lipid lowering therapy to achieve a LDL-C <2.0 mmol/l and a total cholesterol (TC)/HDL-C ratio<4.0 have been proposed as therapeutic targets to further reduce cardiovascular events in patients with coronary artery disease. Whether these goals are better achieved when patients are discharged with rosuvastatin rather than atorvastatin, and whether the choice of one agent over the other has an impact on clinical outcomes after ST-elevation myocardial infarction (STEMI) remain to be demonstrated. CONCLUSION: In the present study, patients treated with rosuvastatin and atorvastatin achieved current therapeutic lipid targets in similar proportion and experienced comparable rates of recurrent ischemic events. Nonetheless, a significant number of patients who suffered a STEMI did not achieve currently recommended target lipid levels. Factors other than the choice of statin seem to be responsible for this care gap. A more aggressive approach to lipid management, including the use of higher statin doses, should be encouraged together with appropriate management of all other risk factors in order to improve long-term outcomes in STEMI patients. AstraZeneca
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LESSONS FROM CANRACE REGISTRY: CARE GAPS IN ACS IN CANADA: MEDICATION ADHERENCE AT HOSPITAL DISCHARGE AND AT SIX MONTHS JM Kornder, JP DeYoung, RC Welsh, S Goodman, RT Yan, GC Wong, FA Spencer, F Grondin, AT Yan Surrey, British Columbia BACKGROUND: Practice guidelines recommend evidence-based secondary prevention therapies in the management of acute coronary syndromes (ACS). However, there are limited contemporary data on the
Can J Cardiol Vol 26 Suppl D October 2010