Introduction: The impact of frailty on outcomes in a contemporary ST-segment-elevation myocardial infarction (STEMI) population is unclear. This study hypothesized that frail STEMI patients undergoing primary percutaneous coronary intervention (pPCI) have worse in-hospital and 1-year outcomes compared to non-frail STEMI patients. Methods: We retrospectively identified 600 STEMI patients who had received pPCI (2013 - 2016). A frailty index (FI) was determined using the health deficit accumulation model (Table 1). Frail patients were defined as those with a FI > 0.25. The composite outcome comprised in-hospital heart failure, cardiogenic shock, re-infarction, major bleeding, stroke and all-cause mortality. A multivariable model adjusting for age and sex was performed. Results: Among 600 STEMI patients receiving pPCI, 67 (11.2%) were classified as frail. Compared to non-frail patients, frail patients were older (mean 80.3 vs. 75.8 years, p < 0.001) and had a higher comorbidity burden. After adjustment, baseline frailty was independently associated with delayed reperfusion time, in-hospital all-cause mortality, and higher incidence of the composite outcome (Figure 1). Frailty was also associated with increased 1-year all-cause mortality and cardiovascular rehospitalization. Conclusions: Among STEMI patients receiving pPCI, 1 in 10 were frail. Frailty was associated with increased rate of the primary in-hospital composite adverse outcome, delayed reperfusion time and worse long-term outcomes. Efforts to routinely identify frail STEMI patients and to implement best practices to reduce the risk of adverse events in this vulnerable population are warranted.

With the onset of the COVID-19 pandemic, two heart function clinics (HFCs), both based at quaternary-care hospitals, began virtual visits. New protocols and workflows were developed quickly and amended as the pandemic progressed. We report an evaluation of this telemedicine model to determine its effectiveness in achieving target medical therapy, patient satisfaction and costs to patients.

BACKGROUND/PURPOSE "RESUME-HFC" – Exploring an alternative model of heart failure care for patients with substance use disorder and/or mental health needs. Heart failure (HF) care often requires multidisciplinary care, including intensive patient education, testing and follow-up. Literature shows that patients with substance use disorder (SUD) and/or mental health needs have difficulty adhering to the requirements of a regimented care model and recommends an individualized, flexible follow-up schedule. Our experience has shown that these patients often attended HFC haphazardly, if at all. We proposed an alternative model of heart failure care whereby these patients were seen by a HF specialist Nurse Practitioner (NP) who assessed the patient's ability to manage medications, appointments and learning needs on an individual basis, and tailored a care plan around these potential barriers. For patients that had had previous referrals but did not attend appointments, the NP would go to the emergency department or inpatient unit to meet patient and discuss the referral to our clinic, in hopes of approving attendance. Key elements in the care plan included utilizing community support workers to bring patients to appointments, connecting with community pharmacy for daily medication management, connecting with primary care provider/clinic to discuss plan and requesting outreach if indicated. We conducted a pilot study to explore the feasibility of providing this alternative model of outpatient care for patients with HF and SUD and/or mental health needs who are unlikely or unable to attend the HFC. We also sought to determine if outcomes are impacted by this alternative model. METHODS/RESULTS Using a pre-test/post-test design with patients as their historical controls we collected data on ED visits, hospitalizations, quality of life, ejection fraction and mortality for 1 year pre- and 1 year post-index visit. 23 of 26 patients completed the study (lost to follow-up = 1; death = 1 (unknown cause); moved = 1). There was a statistically significant reduction in total hospitalizations (2.8 vs 1.4, p = 0.017), length of stay (11.5 vs 0, p = 0.009), increase in quality of life (4.27 vs 6.73, p = 0.04 and a clinically significant increase in ejection fraction (33% vs 45%, p NS). CONCLUSION/IMPLICATIONS FOR PRACTICE This NP-led model of care that provided individually tailored, flexible management of HF in those with SUD and/or mental health needs can be feasible, if appropriately resourced. This model of care shows promise for HF management in this complex patient population. "RESUME-HFC" – Exploring an alternative model of heart failure care for patients with substance use disorder and/or mental health needs. Heart failure (HF) care often requires multidisciplinary care, including intensive patient education, testing and follow-up. Literature shows that patients with substance use disorder (SUD) and/or mental health needs have difficulty adhering to the requirements of a regimented care model and recommends an individualized, flexible follow-up schedule. Our experience has shown that these patients often attended HFC haphazardly, if at all. We proposed an alternative model of heart failure care whereby these patients were seen by a HF specialist Nurse Practitioner (NP) who assessed the patient's ability to manage medications, appointments and learning needs on an individual basis, and tailored a care plan around these potential barriers. For patients that had had previous referrals but did not attend appointments, the NP would go to the emergency department or inpatient unit to meet patient and discuss the referral to our clinic, in hopes of approving attendance. Key elements in the care plan included utilizing community support workers to bring patients to appointments, connecting with community pharmacy for daily medication management, connecting with primary care provider/clinic to discuss plan and requesting outreach if indicated. We conducted a pilot study to explore the feasibility of providing this alternative model of outpatient care for patients with HF and SUD and/or mental health needs who are unlikely or unable to attend the HFC. We also sought to determine if outcomes are impacted by this alternative model. Using a pre-test/post-test design with patients as their historical controls we collected data on ED visits, hospitalizations, quality of life, ejection fraction and mortality for 1 year pre- and 1 year post-index visit. 23 of 26 patients completed the study (lost to follow-up = 1; death = 1 (unknown cause); moved = 1). There was a statistically significant reduction in total hospitalizations (2.8 vs 1.4, p = 0.017), length of stay (11.5 vs 0, p = 0.009), increase in quality of life (4.27 vs 6.73, p = 0.04 and a clinically significant increase in ejection fraction (33% vs 45%, p NS). This NP-led model of care that provided individually tailored, flexible management of HF in those with SUD and/or mental health needs can be feasible, if appropriately resourced. This model of care shows promise for HF management in this complex patient population.

LV dysfunction is common after STEMI, and is associated with worse outcomes. The EPHESUS trial demonstrated that use of a mineralocorticoid receptor antagonist (MRA) compared with placebo reduced mortality when started within 3-14 days (particularly when started within 7 days) after hospitalization for acute MI with LV dysfunction and either clinical HF or diabetes. Current guidelines therefore recommend their use in this setting. Among patients included in the Vancouver Coastal Health Authority (VCHA) STEMI database, we previously showed that only 22% of STEMI patients with LV dysfunction eligible for an MRA were prescribed one at discharge. Clinicians caring for these patients during the index admission may favour delaying MRA initiation until after titration of other LV-enhancing therapies, such as ACE inhibitors and beta-blockers. The primary objective of this follow-up study was to determine the proportion of MRA-eligible STEMI patients prescribed an MRA in the subsequent 3 months after discharge. The secondary objective was to identify patient characteristics associated with post-discharge MRA prescription among MRA-eligible patients.

Major bleeding is an independent predictor of mortality, reinfarction, and stroke among ST-elevation myocardial infarction (STEMI) patients receiving primary percutaneous coronary intervention (pPCI). Limited data exists on the association of major bleeding post-PCI and other significant in-hospital outcomes. Furthermore, bleeding avoidance strategies (BAS) such as radial access and bivalirudin are associated with reductions in major bleeding but the impact on the reduction of other in-hospital adverse events has not been reported. We identified 1494 STEMI patients who underwent primary pPCI within the Vancouver Coastal Health Authority (2012-2018) of whom 121 (8.1%) had major bleeding. Access site bleeding occurred in 2.0% whereas non-access site bleeding occurred in 6.1%. Between-group differences in (unadjusted) in-hospital clinical outcomes including cardiac arrest, reinfarction, stroke, cardiogenic shock, heart failure, and mortality were assessed. Spearman correlation and multivariate logistic regression were used to evaluate the relationship of major bleeding with in-hospital outcomes. Compared with no major bleeding, patients experiencing major bleeding were more likely to be female, older, have atrial fibrillation, chronic kidney disease, anemia, heart failure, prehospital cardiac arrest or cardiogenic shock at baseline. Major bleeding was associated with higher rates of in-hospital death (20.7% vs. 4.4%; P < 0.001), stroke or intracranial hemorrhage (10.8% vs 1.1%; P < 0.001), cardiogenic shock (38.3 vs 6.3%; P < 0.001), heart failure (40.8% vs. 12.0%; P < 0.001), or cardiac arrest post-PCI (20.0 vs 3.5%; P < 0.001). Major bleeding was also associated with a significantly longer hospital stay (median 7.8. vs 3.0 days; P < 0.001). Major bleeding was independently associated with death (OR 3.15; 95% CI 1.59-6.25), cardiogenic shock (OR 8.10; 95% CI 4.46-14.72), heart failure (OR 3.43; 95% CI 2.09-5.63), and in-hospital cardiac arrest post-PCI (OR 4.19; 95% CI 2.21-7.94). The use of any BAS (radial access, bivalirudin, vascular closure device) was associated with a reduction in major bleeding (OR 0.49; 95% CI 0.32-0.74) and mortality (OR 0.20; 95% CI 0.13 to 0.32) but after adjustment did not reduce major bleeding (OR 0.68; 95% CI 0.43-1.07) or mortality (OR 0.63; 95% CI 0.33-1.20). In a contemporary STEMI cohort receiving pPCI, major bleeding was predominately caused by non-access site bleeding and was independently associated with in-hospital mortality, cardiogenic shock, heart failure, and cardiac arrest post-PCI. After adjustment, BAS were not associated with a reduction in major bleeding nor in-hospital mortality, likely due to low rates of access-site bleeding. Additional study of strategies to reduce the incidence or impact of non-access site bleeding appears warranted.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

LV dysfunction (defined as LVEF ≤40%) is present in approximately 25% of patients post-MI and is associated with increased mortality. The EPHESUS trial demonstrated that, compared to placebo, mineralocorticoid receptor antagonist (MRA) therapy reduced mortality when started within 3-14 days (particularly when started within 7 days) after hospital admission for acute MI in patients with LV dysfunction and either clinical HF or diabetes, leading guidelines to recommend their use in these patients. However, there is substantial practice variability and under-use of MRA therapy, with data from the United States suggesting that only 14% of MRA-eligible MI patients are prescribed these agents at discharge. We analyzed a large, population-based Canadian STEMI database to evaluate rates of MRA prescription at discharge among MRA-eligible STEMI patients, and to identify clinical predictors of MRA prescription. Using data from the prospective, population-based Vancouver Coastal Health Authority (VCHA) STEMI database, we identified adults admitted for STEMI and discharged from hospital alive between June 26, 2007 and March 31, 2018 who were revascularized using primary PCI or fibrinolysis. We excluded patients with out-of-hospital cardiac arrest or missing data on LVEF, diabetes or discharge prescriptions. The primary outcome was the proportion of MRA-eligible STEMI patients (LVEF ≤40% plus: clinical HF on presentation or in hospital, or diabetes) who were prescribed an MRA at discharge. A pre-specified list of candidate predictors of MRA prescription at discharge was evaluated in multivariable logistic regression: Age, sex, anterior MI, hospital length-of-stay, LVEF, presentation to a PCI-capable hospital, ACE inhibitor/ARB within 24 hours of presentation. P-values < 0.05 were considered statistically significant. Of 2691 STEMI patients, 318 (11.8%) had LVEF ≤40% and were MRA-eligible. Among MRA-eligible STEMI patients, median age was 67.4 years, 21.4% were female, and 21.7% presented with an anterior MI. Further, mean LVEF was 32.6% (standard deviation ±6.6%), 47.8% had diabetes, and 68.9% had clinical HF (18.6% on presentation, 65.1% in hospital). Of MRA-eligible patients, 70 (22%) were prescribed an MRA at discharge. In the pre-specified multivariable analysis, only LVEF was significantly associated with MRA prescription at discharge (Table). In contemporary practice, MRAs are not prescribed at discharge in most eligible STEMI patients, despite high-quality evidence demonstrating that early use reduces mortality. Furthermore, aside from lower LVEF, MRA prescription was not associated with any clinical predictors, suggesting unexplained variability in clinical practice. Quality and process improvement strategies should be implemented to target this gap in STEMI care.

The Vancouver Coastal Health Authority (VCHA) STEMI Program was created to integrate all aspects of STEMI care in a large geographically complex urban centre, including optimization of in-field diagnosis, interhospital patient transportation and delivery of reperfusion therapy. The program evolved over 3 implementation phases: (Phase 1 [P1]: 2007 - regionalization of STEMI orders; Phase 2 [P2]: 2008 - implementation of prehospital ECGs; Phase 3 [P3]: 2011 – optimization of interfacility transfers from urban community hospitals to increase primary PCI (PPCI) availability. We report on the impact of our program on reperfusion times and clinical outcomes for all STEMI patients treated over 11 years. We analyzed 3794 STEMI patients treated with either PPCI, fibrinolysis or no reperfusion (NR) between June 2007 and March 2018. 63% of patients were treated in PCI-capable centres (PCI-C). Implementation of interfacility transfer (T-PPCI) in P3 resulted in an increased proportion of PPCI-treated patients compared to P1/2, with a corresponding decrease in the proportion of patients treated with either fibrinolysis or NR (Figure 1a). Regional median first medical contact to device time (FMC-DT) for PPCI treated patients was 103min (95min and 126min for patients presenting to PCI-Cs and non-PCI-Cs, respectively). A greater proportion of patients met guideline-recommended reperfusion times for PPCI in P3 compared to P1/2 (45.9% vs 40.5%, p=0.009) (Figure 1b). Overall 11-year regional mortality was 9.2%; overall reperfusion-specific mortality was 5.7%, 3.6% and 31.3% amongst patients treated with PPCI, fibrinolysis and NR respectively. After implementation of T-PPCI in P3 there was no change in mortality amongst patients treated with PPCI (P3 5.7% vs P1/2, 5.8%, p=0.91) nor fibrinolysis (P3 3.0% vs P1/2 4.2%, p=0.63), possibly because of increasing co-morbidities in STEMI patients over time. There was a significant mortality increase amongst patients receiving NR (41.7% vs 22.2%, p=0.0003). A greater proportion of patients receiving NR were treated at PCI-Cs in P3 compared to P21/2 (67% vs 45.6%, p=0.0002). A regional approach to STEMI care resulted in a greater proportion of patients treated with PPCI, with a higher proportion meeting guideline recommended FMC-DT following the implementation of T-PPCI. T-PPCI did not result in a reduction in overall regional mortality nor mortality amongst PPCI-treated patients. Although the proportion of patients receiving NR decreased over time, they had a significant increase in mortality, with a higher proportion of them being treated at PCI-Cs. STEMI patients receiving NR remain an important subgroup of patients impacting regional STEMI clinical outcomes.

From 2007 to 2016, the Vancouver Coastal Health Authority implemented several care processes resulting in reduced reperfusion times for patients with ST-elevation myocardial infarction (STEMI). However, these reductions were not accompanied by a parallel improvement in clinical outcomes, including mortality, similar to what has been described in other North American case series. We hypothesized that this may at least be partially attributable to an increased co-morbidity burden in the population. To describe the burden of patient co-morbidities in the VCH STEMI database from 2007-2016, and determine their association with adverse in-hospital outcomes. We conducted a retrospective review of 1931 patients receiving primary percutaneous coronary intervention (pPCI) for acute STEMI between June 2007 and March 2016 across three phases (June 2007-May 2008: regionalization with standardized protocols; May 2008-May 2011: addition of pre-hospital ECGs and in-field re-direction to PCI-capable centres; May 2011-March 2016: addition of a single-call transfer protocol for non-PCI capable centres). We analyzed the specific co-morbidity frequency over the three phases of refinement of the regional model, as well as the association of individual co-morbidities with adverse in-hospital outcomes. Compared to Phase 1 (n=114), patients in Phase 3 (n=1203) were more likely to be hypertensive: (phase 1 [43.0%], phase 3 [55.1%], p=0.02), diabetic: (phase 1 [9.3%], phase 3 [21.5%], p=0.029), with a trend towards an increase in cerebrovascular disease (Figure). There was a trend towards an increased number of co-morbidities between Phases 1 (mean 2.2) and 3 (mean 2.4, p=0.2). In-hospital mortality was significantly increased with age over 65 (9.8 vs 2.9%, p<0.001), female sex (8.3 vs. 7.3%, p=0.047), hypertension (7.9 vs. 3.9%, p<0.001), diabetes (8.8 vs. 5.3%, p=0.011), previous heart failure (25.5 vs. 5.4%, p<0.001), and prior TIA/CVA (14.7 vs. 5.3%, p<0.001). In general, the greater the baseline co-morbidity burden, the more likely patients were to develop CHF, cardiogenic shock, a rise in creatinine, a reduction in ejection fraction, and to have increased in-hospital mortality. Among patients in our regional STEMI network who received pPCI, there was a trend toward increased co-morbidity burden over time, which was associated with worse in-hospital outcomes. The increased rate of co-morbidity burden among STEMI patients over time may partially explain the lack of improvement in clinical outcomes despite improved reperfusion times in regional models of STEMI care.

RESULTS:The sample included 59 SSD, 49 delirium and 114 patients with absence of SSD/delirium.In comparison to patients with absence of SSD/delirium, those with SSD were older, had more comorbidities, frequently presented fluid overload, longer length of stay and higher mortality rates than non-SSD or delirium patients.SSD and delirium share similar risk factors and complications.CONCLUSION AND IMPLICATIONS FOR PRACTICE: SSD patients exhibit worsened outcomes.SSD in cardiovascular care is still misunderstood and merits further work.As SSD identification can be challenging, this study underlines the need to develop interventions aimed at identifying and managing SSD among cardiac surgery patients.

Spontaneous coronary artery dissection (SCAD) is a form of acute coronary syndrome (ACS) most commonly experienced by younger women. It occurs when there is a blockage of a coronary artery due to dissection or hematoma. The literature reveals that women may experience ACS differently than men; most lifestyle management strategies recommended by health professionals are based on men's needs. Women identify a need for support with their social and emotional health after ACS, including help with anxiety and depression, close relationships and their role in the family unit, and communication with their primary health care providers. Current cardiac rehabilitation programs are not fully meeting the needs of women with ACS. There remains a gap in our understanding of the experiences of younger women with SCAD and the impact of this disease process on their health. This qualitative research aims to learn more about younger women's experience with lifestyle management after SCAD and to inform cardiovascular nursing practice and multidisciplinary care and interventions. We will conduct semi-structured interviews with women under 55 years old who have experienced SCAD in the past three to 18 months, and are recruited through a specialized cardiac clinic. We will discuss how interpretive description, a methodology that is appropriate for the knowledge needs of applied disciplines, has been used to guide the analysis and to present the preliminary findings. The new knowledge gained from the study will be used for nursing to meet the needs of this unique population. We will also provide some recommendations for nurses to consider in the care of women who experience SCAD.

Despite advances in reperfusion therapy, females with ST-elevation myocardial infarction (STEMI) treated with primary PCI (pPCI) continue to experience worse in-hospital outcomes compared to males. Our regional care delivery model increased access to pPCI and reduced overall median reperfusion times. We aimed to describe differences in clinical characteristics, as well as temporal trends in reperfusion times and in-hospital outcomes between females and males with STEMI receiving pPCI within our regional model of care. 1840 patients (406 females, 22.1%; 1434 males, 77.9%) presented with an acute STEMI between June 2007 and March 2016. The population was divided into an early cohort (2007-June 2011) when a mixed regional reperfusion model was utilized (fibrinolysis, pPCI), and a late cohort (June 2011-2016) when region-wide pPCI was utilized. Patients were analyzed accordingly within the early cohort (N = 724 patients) or the late cohort (N = 1116 patients). The primary endpoints evaluated were in-hospital mortality as well as reperfusion times. Comparisons between sexes were then made for a) the entire cohort, b) within the early cohort, c) within the late cohort and d) between the early and late cohort for all patients. We performed a logistic regression to compare the mortality rate between males and females and between early and late cohort. At presentation, females tended to be older, presented with more cardiovascular risk factors and were more often in cardiogenic shock (Table). Compared to males, females in both cohorts experienced significant delays in first medical contact (FMC) to presentation to the emergency room (ED) (26 vs. 20.5 mins, p < 0.001). Significant delays were also noted for females in FMC to device time in the late cohort (112 vs. 101 mins, p < 0.001) but not the early cohort (101 vs 100 mins, p = 0.291) (Figure). In a multivariable analysis comparing in-hospital mortality for females versus males, there was a trend toward increased in-hospital mortality in both the early cohort (OR 1.80 (0.52 – 6.17), p = 0.352) and the late cohort (OR 1.18 (0.55 – 2.54), p = 0.671). Among those patients treated with pPCI in our contemporary STEMI program, we found that females experienced significantly longer reperfusion times compared to males. During the course of implementation of regional access to pPCI, we unexpectedly noted longer reperfusion times among females. These results highlight the disparity of STEMI care between females and males, and present future opportunities for improvement.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Investigators have identified important racial-identity/ethnicity-based differences in some aspects of acute coronary syndrome (ACS) care (time to presentation, symptoms, receipt of coronary angiography/revascularization). Patient-based differences (e.g. pathophysiology, treatment-seeking behaviour) account only partly for the differences in subsequent outcomes. Understanding the factors that contribute to these differences is important, given the significant ethnic diversity in Canada. It is unknown if there are racial-identity/ethnicity-based variations in the initial emergency department (ED) triage and care of patients with suspected ACS in Canadian hospitals. We prospectively enrolled ED patients with suspected ACS from 3 acute care hospital sites (1 university affiliated/tertiary-care, 2 community). Trained research assistants administered a standardized interview to gather data on symptoms, treatment-seeking patterns, and self-reported racial/ethnic identity. Clinical parameters were obtained through chart review. The primary outcome was door-to-electrocardiogram (D2ECG) time, adjusted for relevant clinical and sociodemographic variables. Self-reported racial identity was categorized as "White", "South Asian" (SA), "Asian" or "neither White, Asian or SA/Unknown", though our initial analysis compared White participants to the group comprised of all those who identified differently. ECG times were log-transformed; 2 linear regression models were fit, controlling for important demographic, system and clinical factors. Of 448 participants, 209 (47%) reported White identity; 115 (26%) SA; 57 (13%) Asian, and 67 (15%) were neither White, Asian or SA, or unknown. Asian respondents were younger, more likely to report initial discomfort as "low" and be accompanied by family; respondents identifying as neither White, Asian or SA were more likely to report initial discomfort as "high". There was no statistically significant difference in D2ECG time between White participants and those who identified differently, but there were statistically significant differences by site, age and sex. Exploring more specific racial identities revealed similar findings: no significant differences between the White, SA, Asian and "neither White, Asian or SA" groups, while site, age and sex (older participants and women endured longer D2ECG times) remained statistically significantly different in the adjusted models (see Figure). Although racial/ethnicity-based differences in other aspects of ACS care have been previously identified, no such differences have been found in the current study of early emergency department care in a Canadian urban setting. However, women and elderly patients experience longer D2ECG times. While it is encouraging to see equity in the care provided among racial identity groups, improvements in the care of women and elderly ACS patients are necessary.

Fibrinolytic therapy is a viable option for patients with ST-elevation myocardial infarction (STEMI) who present to a non-PCI capable hospital (NPCICH) and cannot be transferred for primary PCI (PPCI) in a timely fashion. Comparisons of outcomes between patients receiving fibrinolysis and those transferred for PPCI could yield data of value in choosing the best option for patients presenting to NPCICHs. We retrospectively analyzed STEMI patients >18 years of age who presented to a NPCICH within the Vancouver Coastal Health Authority between 2007-2014 and who received either on-site reperfusion or were transferred for PPCI. Timely fibrinolysis was defined as first medical contact (FMC) to needle time < 30 min; timely PPCI was defined as FMC to balloon time < 120 min. We compared the composite of in-hospital mortality, heart failure, cardiogenic shock or major bleeding for patients in the following groups: timely vs delayed fibrinolysis, timely vs delayed PPCI and timely fibrinolysis vs delayed PPCI, using logistic regression analysis to adjust for clinically important baseline variables. We excluded patients who presented with cardiogenic shock (n=24), pre-hospital cardiac arrest (n=9) and who received no reperfusion therapy. We identified 699 eligible patients (198 on-site fibrinolysis, 501 PPCI). Timely reperfusion was achieved in 20% of fibrinolysis patients and 42% of patients transferred for PPCI. There were no significant differences in patient characteristics between patients receiving timely vs delayed reperfusion irrespective of the reperfusion strategy, apart from older age in those receiving delayed PPCI (mean 62.3yrs vs 66.4, P < 0.001). The primary outcome was less frequent with both timely vs delayed fibrinolysis (15.4% vs 21.8%, P=0.375) and timely vs delayed PPCI (9.2% vs 19.6%, P=0.002). (Table 1). In an adjusted logistic regression analysis, delayed reperfusion with fibrinolysis was associated with an increased risk of the composite end point compared to timely reperfusion with both fibrinolysis (OR 1.79 95% CI 1.07- 3.00) and PPCI (OR 1.80, 95% CI 1.12-2.89), respectively. Although the primary endpoint was numerically lower amongst patients with timely fibrinolysis compared to delayed PPCI, this association lost significance after an adjusted analysis (OR 0.98, 95% C.I. 0.34-2.77). A significant proportion of STEMI patients who present to NPCICHs do not receive timely fibrinolysis or PPCI. Delayed reperfusion is associated with worse outcomes irrespective of reperfusion strategy, although the primary outcome was the lowest with timely PPCI. Additional interventions are warranted to improve the timeliness of both pharmacological and mechanical reperfusion for NPCICHs.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

To describe the results of a left ventricular assist device (LVAD) survey conducted through the patient website “mylvad.com”. An online questionnaire consisting of 6 multiple choice questions and 4 open ended questions which asked respondents to describe dressing practices and experiences, was offered to all patients and caregivers who were registered with mylvad.com, a website funded by unrestricted educational grants from industry, that was created by LVAD professionals. The questionnaire was preceded by a statement outlining that de-identified responses might be used for future publication. We received 187 responses (110 LVAD patients and 77 caregivers) from across North America between August 20th and 24th, 2015. Implanted devices were: HeartMate II (n=146, 78%), HeartWare HVAD (n=26, 14%) or others (n=15, 8%). One hundred and forty four (77%) patients had lived with the LVAD for more than 1 year. Half of the respondents (n=93) changed their dressing 2-3 times per week, and a further 47 (25%) changed it weekly. Most patients and caregivers found the dressing change procedure easy to learn (n=143, 76%) and perform (n=149, 80%). Of the 32 patients who reported experiencing skin irritation, 23 (71%) reported modifying their dressing protocol vs. 53/155 (30%) patients who had no irritation (p = 0.000). Cost was mentioned as an issue when breaches in dressing change protocol occurred in 13 (7%) cases. Some common themes emerged in the comments received from both patients and caregivers. 1. Concerns about fatigue “after 5 years, it wears on you - help!”. 2. Creativity “We have created a little procedure to follow which seems to work...”. 3. Difficulties with showering “shower protectors are pretty much worthless”. Although there is some variation in dressing techniques taught by implanting centers, actual practice by patients and families in the outpatient setting varies considerably. These variations are due to skin irritation, convenience and cost. Comments received from patients clearly indicated that dressing procedures need to be individualized and better solutions to minimize skin irritation and enable stress-free bathing for LVAD patients need to be found.

Although many clinical and sociodemographic characteristics are known to be associated with patient-related treatment delay for symptoms of acute coronary syndrome (ACS), other aspects of treatment-seeking behaviour, such as the actions patients take in response to their symptoms, remain poorly understood. The association between ethnicity and patients seeking treatment is an area in which the research literature remains sparse. The aim of this cross-sectional study was to determine if there are ethnicity-based differences in the actions patients take when they experience symptoms of ACS.

Fluorogenic substrates incorporating the sequence Asp-Glu-Pro-Asp-Ser were able to quantify caspase-3 activity without notable caspase-7 and cathepsin B cross-reactivity.

In nursing, clinical report or "handover" is the process of transferring responsibility for patients' care between nurses. These reports are frequent and occur at various transition points including shift changes, off-unit treatments and diagnostic activities, and unit/hospital transfers. Historically, cardiac intensive care unit (CICU) nurses at our quaternary teaching hospital have completed report outside patients' rooms and patient/family input is minimal if any.

Heart failure (HF) is a debilitating syndrome affecting thousands of Canadians every year. It is one of the leading causes of death in Canada, and has been found to be the leading cause of readmission to hospital in the United States. A home visit by a cardiac nurse has previously been shown to reduce heart failure readmissions to hospital in the United Kingdom and Australia, yet little is known whether this intervention is effective in Canada. Purpose: We report whether there is a relationship between home visits by a cardiac nurse clinician and 30-day heart failure readmission rates in the adult population. Study design: A retrospective chart review with a sample of 300 patients who were hospitalized with a "most responsible diagnosis of heart failure." Between 2011 and 2013, 150 patients were referred to the home visit program and seen at home by the cardiac nurse clinician. An equivalent number in the comparison group received usual care, from 2009 to 2011. Intervention: A program overseeing the care of cardiac patients diagnosed with: myocardial infarction, unstable angina, heart failure, aortic valve replacement, coronary artery bypass grafting, mitral valve replacement. Prior to 2011, the intervention program did not treat patients who suffered from heart failure. Meleis' Transition Theory informed and guided the study, and Wagner's Chronic Care Model guided the intervention. The main outcome measure is 30-day hospital readmissions for heart failure. The findings will be presented, with discussion of the implications for post-discharge support and program planning for heart failure patients.

Torsades de Pointe (TdP) is a potentially catastrophic arrhythmia, and patients in acute and critical care units are at high risk for TdP. Authoritative associations strongly recommend QT interval monitoring in at-risk hospitalized patients, but the benefit of instituting routine QT monitoring remains unclear, since findings regarding QT prolongation preceding cardiac arrest (CA) are mixed. To determine the prevalence of prolonged QT prior to VT or VF CA among hospitalized patients, we conducted a retrospective chart review. We drew our sample from a CA database of all patients with CA at two hospitals (400-bed teaching; 200-bed community) between 2009 and 2013. Patients over 20 years old who were monitored at the time of their CA and experienced a ventricular tachycardia (VT) or ventricular fibrillation CA were included. 12-lead ECGs or rhythm strips recorded closest to the CA were identified, the Bazette’s corrected QT interval (QTc) calculated, and other relevant clinical variables collected. Preliminary analysis focused on 198 patients with VT, of which 97 were excluded because of missing data (n=41) or unevaluability due to poor quality, pacing or QRS>120 ms (n=56). Of the final sample, fifty-seven (56.4%) had prolonged QTc (overall mean 513.47 ms, minimum 365 ms, maximum 760 ms). These preliminary findings indicate that prolonged QTc frequently precedes CA, and that CA could potentially be averted with routine QT monitoring of the most acutely ill patients in hospitals. Nurses could play a key role in evidence-based, yet practical screening and intervention protocols in patients at risk for prolonged QT.