BACKGROUND:Although prior studies have demonstrated racial disparities regarding acute coronary syndrome (ACS) care within private or mixed healthcare systems, few researchers have explored such disparities within universal healthcare systems. We aimed to evaluate the quality and outcomes of in-hospital ACS management for White patients vs patients of colour, within a universal healthcare context.METHODS:We performed a post hoc analysis of the Acute Myocardial Infarction - Knowledge Translation to Optimize Adherence to Evidence-Based Therapy study, a cluster-randomized trial evaluating a knowledge-translation intervention at 24 hospitals in Quebec, Canada (years: 2009 and 2012). The primary endpoint was coronary catheterization. The secondary endpoints included in-hospital mortality, percutaneous and surgical coronary revascularization, major bleeding, total stroke, and discharge prescription of evidence-based medical therapy.RESULTS:Of 3444 included patients, 2738 were White, and 706 were people of colour. The mean age was 68.2 years (33.3% women) among White patients and 69.5 years (36.0% women) among patients of colour. Patients of colour were less likely to undergo in-hospital coronary catheterization than were White patients (74.5% vs 80.3%, P = 0.001). This difference was attenuated after adjusting for patient-level characteristics (odds ratio 0.89; 95% confidence interval 0.73-1.09), and it was eliminated after adjusting for hospital-level characteristics (odds ratio 1.04; 95% confidence interval 0.73-1.49).CONCLUSIONS:Racial disparity in coronary catheterization for ACS persists within a universal healthcare context. Patients' comorbidities and hospital-level factors may be partially responsible for this inequality. Future research on cardiovascular healthcare in patients with diverse racial/ethnic backgrounds in universal healthcare systems is needed to remediate racial inequality in ACS management.

Background: The incidence and predictors of contrast-induced nephropathy (CIN) in patients with normal glomerular filtration rate (GFR) are not well ascertained. We aim to determine the incidence and predictors for CIN after coronary catheterization (CATH) for acute coronary syndromes (ACS). Methods: We combined the datasets of two studies. The AMI-QUEBEC was an observational cohort of patients with ST-segment elevation myocardial infarctions in 2003. The AMI-OPTIMA was a study of patients hospitalized with ACS in 2009 and 2012. For this analysis, we retained only patients with GFR > 60 ml/min who underwent CATH. We defined “hyperfiltrators” as patients with GFR above the 95th percentile age and sex-adjusted value. CIN was defined as an increase in serum creatinine >0.5 mg/dL (44.2 μmols/L) or > 50% from baseline serum creatinine. Results: There were 3,188 patients with GFR > 60 ml/min : 39 hyperfiltrators and 3,149 without hyperfiltration. The mean age was similar between the two groups of patients (62 years); 21% and 27% females in hyperfiltrators and non-hyperfiltrators (p<0.0001). The prevalences of diabetes mellitus and hypertension were 36% and 64%, respectively in hyperfiltrators compared to 20% and 46%, respectively in non-hyperfiltrators. The mean baseline GFR and creatinine were 112 ml/min and 50 μmols/L, respectively in hyperfiltrators; 84.2 ml/min and 80 μmols/L in non-hyperfiltrators. There were 225 CIN following CATH; 7.1% of the whole cohort with 35.9% in the hyperfiltrators and 6.7% in non-hyperfiltrators. Hyperfiltration was independently associated with a 13-fold increase in the risk of CIN (Table 1). Each year of increase in age was associated with a 5% increase in the risk of CIN. Shock was also associated with an 11-fold increase in the risk of CIN. Conclusion: Hyperfiltrators may be at high risk of CIN following CATH in ACS. The risk of CIN associated with hyperfiltration should be evaluated in other populations.

Introduction: It remains unclear whether cardiac rehabilitation (CR) can enhance adherence to cardiovascular (CV) medications. We aim to determine the impact of CR on 6-month adherence to CV pharmacotherapy. Methods: We conducted a prospective observational cohort study of patients hospitalized for acute coronary syndromes (ACS) in Quebec, Canada, during 2016-2018. The primary endpoint was 6-month adherence to all of these drugs (dual anti-platelets, beta-blockers, hypocholesterolemiants, angiotensin pathway inhibitors). The secondary endpoints were adherence to each individual class of CV medication. Adherence was determined by measuring the proportion of days covered (PDC) (evaluated by pharmacies refills). PDC was measured both as continuous and categorical variables. Suboptimal adherence was defined as PDC< 80%. We used inverse probability weighting to adjust for various factors which may have influenced the referral for CR and confounded the impact of CR on 6-month adherence (age, sex, coronary angioplasty, marital status, education, and occupation). All patients signed informed consent. Results: We enrolled 318 patients. Their mean age was 66±12 years; 30% were females. Of these patients, 152 undertook CR and 166 received standard follow-up. The mean age was 68 and 64 years, respectively. The proportions of females were similar in both groups. Overall PDC were 96%±13% vs 93%±17%; 7.2% and 11.2% patients had 6-month suboptimal adherence, respectively in patients who had CR vs patients without CR. After inverse weighting adjustment, CR was independently associated with improved adherence only with hypocholesterolemiants (Table 1). Conclusion: CR was not associated with improved 6-month overall adherence. However, patients who undertook CR were more adherent to hypocholesterolemiants than patients who did not undergo CR. CR programs should reinforce further to patients the importance of adherence to all ACS medications.

Importance:Electronic cigarettes (e-cigarettes) for smoking cessation remain controversial.Objective:To evaluate e-cigarettes with individual counseling for smoking cessation.Design, Setting, and Participants:A randomized clinical trial enrolled adults motivated to quit smoking from November 2016 to September 2019 at 17 Canadian sites (801 individuals screened; 274 ineligible and 151 declined). Manufacturing delays resulted in early termination (376/486 participants, 77% of target). Outcomes through 24 weeks (March 2020) are reported.Interventions:Randomization to nicotine e-cigarettes (n = 128), nonnicotine e-cigarettes (n = 127), or no e-cigarettes (n = 121) for 12 weeks. All groups received individual counseling.Main Outcomes and Measures:The primary end point was point prevalence abstinence (7-day recall, biochemically validated using expired carbon monoxide) at 12 weeks, changed from 52 weeks following early termination. Participants missing data were assumed to be smoking. The 7 secondary end points, examined at multiple follow-ups, were point prevalence abstinence at other follow-ups, continuous abstinence, daily cigarette consumption change, serious adverse events, adverse events, dropouts due to adverse effects, and treatment adherence.Results:Among 376 randomized participants (mean age, 52 years; 178 women [47%]), 299 (80%) and 278 (74%) self-reported smoking status at 12 and 24 weeks, respectively. Point prevalence abstinence was significantly greater for nicotine e-cigarettes plus counseling vs counseling alone at 12 weeks (21.9% vs 9.1%; risk difference [RD], 12.8 [95% CI, 4.0 to 21.6]) but not 24 weeks (17.2% vs 9.9%; RD, 7.3 [95% CI, -1.2 to 15.7]). Point prevalence abstinence for nonnicotine e-cigarettes plus counseling was not significantly different from counseling alone at 12 weeks (17.3% vs 9.1%; RD, 8.2 [95% CI, -0.1 to 16.6]), but was significantly greater at 24 weeks (20.5% vs 9.9%; RD, 10.6 [95% CI, 1.8 to 19.4]). Adverse events were common (nicotine e-cigarette with counseling: 120 [94%]; nonnicotine e-cigarette with counseling: 118 [93%]; counseling only: 88 [73%]), with the most common being cough (64%) and dry mouth (53%).Conclusions and Relevance:Among adults motivated to quit smoking, nicotine e-cigarettes plus counseling vs counseling alone significantly increased point prevalence abstinence at 12 weeks. However, the difference was no longer significant at 24 weeks, and trial interpretation is limited by early termination and inconsistent findings for nicotine and nonnicotine e-cigarettes, suggesting further research is needed.Trial Registration:ClinicalTrials.gov Identifier: NCT02417467.

Evidence-based cardiovasular (CV) pharmacotherapy is associated with reduced risk of adverse CV outcomes after an acute coronary syndrome (ACS). Nevertheless, adherence to CV pharmacotherapy following ACS is often suboptimal. CV rehabilitation (CR) improves well-being. However, it remains uncertain whether CR can enhance adherence to CV medications. Therefore, we aim to determine the impact of CR on 6-month adherence to CV pharmacotherapy in secondary prevention of patients ACS.

Atrial fibrillation (AF) is a common disease with high burden of emergency room (ER) visits. The impact of integrated nursing-led care and knowledge translation (KT) remains unclear in the management of AF. We aim to evaluate whether a one-year program of nursing-led KT and integrated cardiovascular (CV) care would reduce ER visits for CV-related conditions in patients with AF. We completed a prospective pre and post cohort study of KT (the INTEGRATE-FACILITER program) at 13 Québec hospitals, during 2013-2014. This program consisted of a comprehensive, individualized, nursing-led care of patients with AF. Each patient received a one-hour individualized KT with emphasis on pharmacotherapy and prevention of AF-related complications. The patients were subsequently followed for one year by dedicated nurses. The dedicated nurses coordinated the CV care of these patients (supervised by a cardiologist or team of cardiologists). The patients were then contacted by phone at 1, 3 and 6-months and were invited to contact first the INTEGRATE-FACILITER team for any CV concern, rather than direct presentation to the ER. For the purpose of this abstract, we retained only patients with at least one year duration of AF (chronic or paroxysmal) prior to enrolment in the program. For each patient, we compared the occurrence of CV-related ER visits during the year prior to and during the year enrolled in the KT program. Of the 2,010 patients in the INTEGRATE-FACILITER program, there were 1,429 patients with at least 1-year of AF prior to enrolment. These patients had a mean age of 69 ± 10.8 years, 41% were females, 20% had diabetes mellitus, 64% were hypertensive and 12% had heart failure. Prior to KT, 32.5 % of the patients had at least one CV-related ER visit whereby only 9.1% of these patients had a CV-related ER visit during the KT year (relative reduction of 72.0%; p < 0.0001). Moreover, 36.0% of patients required an all-cause ER visit prior to KT compared to 13.4 % (relative reduction of 62.8%; p < 0.0001) during the year of KT. One-year multi-disciplinary nursing-led KT and integrated AF care was associated with substantial reductions in CV-related ER visits and all-cause ER visits. Our results may justify future investment in similar models of AF care. Longer follow-up is also needed to ensure that the benefits of integrated AF care and KT persist after cessation of KT and integrated AF care.

Background Adherence to statins is often sub-optimal and declines over time. Direct costs incurred by patients are often cited as responsible for inadequate statin adherence. To determine whether patients with ST-segment elevation myocardial infarction (STEMI) who benefit from low or no-cost drug dispensation have optimal long-term adherence to statins, we aimed to evaluate 10-year adherence to statin in a cohort of STEMI survivors. Methods The AMI-QUEBEC Study follows a cohort of STEMI patients hospitalized at 17 hospitals in Quebec, Canada during the year 2003. We obtained 10-year data on lipid lowering therapy (LLT) consumption in STEMI survivors with drug coverage by the Quebec Provincial Health Board (i.e., Regie de l'Assurance Maladie du Quebec - RAMQ). Optimal adherence was defined as the proportion of days covered (PDC) of >= 80%. We used multivariate logistic regression to determine factors independently associated with optimal adherence to statins. Results Complete 10-year data on statin dispensation was available for 524 patients. Optimal adherence remained stable over time at 80% and more during the 10-year follow-up period. During the last 5 years, despite being STEMI patients at very high-risk and therefore requiring some LLT therapy, 12% of patients did not use any LLT. Patients between the age of 60 and 80 years had the most optimal PDC. Older age (up to 80 years), living in less socially deprived areas, concomitant use of angiotensin-converting-enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), and admission to percutaneous coronary interventions (PCI)-hospitals were associated with improved statin adherence. Conclusion Future studies are needed to explore the potential factors associated with concomitant use of ACEI/ ARB, and admission to PCI-hospitals that may have optimized statin adherence. As for socially deprived patients (single, widow, single-parent family member, and those who lived alone), they may benefit from more support and encouragement to enhance their long-term statin adherence.

The characteristics and predictors of long-term recurrent ischemic cardiovascular events (RICEs) after myocardial infarction with ST-segment elevation (STEMI) have not yet been clarified. We aimed to characterize the 10-year incidence, types, and predictors of RICE. We obtained 10-year follow-up of STEMI survivors at 17 Quebec hospitals in Canada (the AMI-QUEBEC Study) in 2003. There were 858 patients; mean age was 60 years and 73% were male. The majority of patients receive reperfusion therapy; 53.3% and 39.2% of patients received primary percutaneous coronary intervention (PCI) and fibrinolytic therapy, respectively. Seventy-five percent of patients underwent in-hospital PCI (elective, rescue, and primary). At 10 years, 42% of patients suffered a RICE, with most RICEs (88%) caused by recurrent cardiac ischemia. The risk of RICE was the highest during the first year (23.5 per patient-year). At 10 years, the all-cause mortality was 19.3%, with 1/3 of deaths being RICE-related. Previous cardiovascular event, heart failure during the index STEMI hospitalization, discharge prescription of calcium blocker increased the risk of RICE by almost twofold. Each point increase in TIMI (Thrombolysis In Myocardial Infarction) score augmented the risk of RICE by 6%, whereas discharge prescription of dual antiplatelets reduced the risk of RICE by 23%. Our findings suggested that survivors of STEMI remain at high long-term risk of RICE despite high rate of reperfusion therapy and in-hospital PCI. Patients with previous cardiovascular event, in-hospital heart failure, and high TIMI score were particularly susceptible to RICE. Future studies are needed to confirm the impacts of calcium blocker and dual antiplatelets on long-term risk of RICE.

The 2016 Canadian Cardiovascular Society (CCS) Guidelines for the management of Dyslipidemia recommend to consider a target of <1.8mmol/L (70mg/dL) for subjects with an acute coronary syndrome (ACS) within the past 3 months. The AMI-OPTIMA study was a cluster randomized trial evaluating knowledge

BACKGROUND:Published data about nonagenarians with acute coronary syndrome (ACS) were mainly descriptive and limited by small sample sizes and unadjusted outcomes. We aim to describe the characteristics, management, and the impact of an invasive strategy on major adverse events in elderly patients hospitalized with ACS with focus on the nonagerians. METHODS AND RESULTS:We analyzed data collected as part of the AMI-OPTIMA study, a cluster-randomized study of knowledge translation intervention versus usual care on optimal discharge medications in patients admitted with ACS at 24 Canadian hospitals. To determine whether an invasive strategy improved outcomes in the elderly, we used inverse probability weighting to adjust for confounders between patients who underwent invasive versus conservative strategies. Of 4,569 consecutive patients: 2,395 (52%) were <70 years old, 1,031 (23%) were septuagenarians, 941 (21%) were octogenarians, and 202 (4.4%) were nonagenarians. An invasive strategy was associated with reduced in-hospital all-cause mortality in all age groups: 1.1% versus 3.8% in patients <70 years old (P < 0.001), 2.9% versus 7.4% in septuagenarians (P < 0.001), 5.1% versus 14.7% in octogenarians (P < 0.001), and 12.0% versus 25.1% in nonagenarians (P = 0.001). An invasive strategy was also associated with higher thrombolysis in myocardial infarction major bleeds in the nonagenarians (9.0% vs. 2.0%; P = 0.003). CONCLUSIONS:The reduction in in-hospital mortality associated with an invasive strategy in elderly and nonagenarians presented with ACS is generating hypothesis and merits further studies to confirm these benefits and to guide clinicians in the management of these high-risk patients.

BACKGROUND:Treatment times for primary percutaneous coronary intervention frequently exceed the recommended maximum delay. Automated "physicianless" systems of prehospital cardiac catheterization laboratory (CCL) activation show promise, but have been met with resistance over concerns regarding the potential for false positive and inappropriate activations (IAs).METHODS:From 2010 to 2015, first responders performed electrocardiograms (ECGs) in the field for all patients with a complaint of chest pain or dyspnea. An automated machine diagnosis of "acute myocardial infarction" resulted in immediate CCL activation and direct transfer without transmission or human reinterpretation of the ECG prior to patient arrival. Any activation resulting from a nondiagnostic ECG (no ST-elevation) was deemed an IA, whereas activations resulting from ECG's compatible with ST-elevation myocardial infarction but without angiographic evidence of a coronary event were deemed false positive. In 2012, the referral algorithm was modified to exclude supraventricular tachycardia and left bundle branch block.RESULTS:There were 155 activations in the early cohort (2010-2012; prior to algorithm modification) and 313 in the late cohort (2012-2015). Algorithm modification resulted in a 42% relative decrease in the rate of IAs (12% vs 7%; P < 0.01) without a significant effect on treatment delay.CONCLUSIONS:A combination of prehospital automated ST-elevation myocardial infarction diagnosis and "physicianless" CCL activation is safe and effective in improving treatment delay and these results are sustainable over time. The performance of the referral algorithm in terms of IA and false positive is at least on par with systems that ensure real-time human oversight.

Warfarin and novel oral anticoagulants (NOACS) may have different pharmacokinetic/pharmacodynamics depending on patient’s body weight. We sought to evaluate the impact of body weights on the safety and efficacy of anticoagulants (AC) in unselected patients. We conducted a prospective

“Physician-less” automated pre-hospital STEMI diagnosis and cardiac catheterization laboratory (CCL) activation has been shown to provide consistently short door-to-balloon (D2B) times and an acceptably low rate of inappropriate activations (IA). However, as human error accounts for up to 70% of IA with this system, real-time physician oversight might improve system performance further. Herein, we compare the performance of a “physician-less” pre-hospital CCL activation system in terms of the rates of IA and false positive (FP) activations to an otherwise identical system with real-time emergency physician oversight.

Background: Nonagerians constitute a growing proportion of patients with acute coronary syndromes (ACS). Currently, little is known about their characteristics, prognosis and optimal management. We...

In 2012, we reported on a novel "physician-less" automated system of pre-hospital ST elevation myocardial infarction (STEMI) diagnosis and cardiac catheterization laboratory (CCL) activation. Our analysis at that time demonstrated consistently short door-to-balloon (D2B) times and an acceptable low rate of inappropriate activations (IA). Nevertheless, a number of targets for protocol improvement were identified and implemented. Herein, we report on the impact of these changes on the performance of the activation algorithm. Patient data were collected for all pre-hospital CCL activation from February 2010 to January 2015. ECG's were performed by first-responders in the field for all patients with a complaint of chest pain or dyspnea. An electrographic diagnosis of STEMI (Zoll Medical Corporation) resulted automatically in CCL activation and direct transfer without physician interpretation of the ECG. Inappropriate activation was defined as any activation resulting from a non-diagnostic ECG (No ST-elevation, judged independently by 2 cardiologist reviewers). Identified inappropriate activations were then analyzed for the reasons for erroneous CCL activation. Human error was defined as an improper application of the referral algorithm. Machine error was defined as an incorrect automated diagnosis of STEMI for a tracing of adequate quality. In March 2013, the protocol was amended to exclude tachycardia >140bpm from automatic CCL activation and an educational campaign was implemented for ambulance technicians in order to ensure proper application of the referral algorithm. Over the study period, we identified 489 pre-hospital CCL activations for STEMI (155 before protocol amendment). Full results will be presented at congress. The first 253 activations are presented here. Patient characteristics were similar both before and after protocol amendment. 225 patients (89%) presented ST-elevation on the ECG (ECG-appropriate; 213 confirmed STEMI and 12 ST-elevations without coronary occlusion). The remaining 28 activations (11%) were considered inappropriate. Of these, 19 occurred prior to protocol amendment and 9 occurred after. The IA rate therefore decreased from 12% to 9% (25% relative reduction) with our intervention. Pre-hospital "physician-less" automated STEMI diagnosis provided durable performance characteristics in terms of both false positive and inappropriate CCL activation. Moreover, simple interventions appear to result in further meaningful reductions in the rate of IA.

Primary percutaneous coronary intervention (pPCI) for ST elevation myocardial infarction (STEMI) is the revascularization method of choice provided that it can be achieved rapidly. Since 2010, we have adopted an automated system of pre-hospital CCL STEMI diagnosis at first medical contact and pre-hospital cardiac catheterization laboratory (CCL) activation without real-time physician oversight. This system was previously reported to significantly reduce door-to balloon (D2B) times at our center. Herein, we present our updated results at 5 years in order to report on the stability of the algorithm's performance over time. Pre-hospital ECG's were performed for all patients with a complaint of chest pain or shortness of breath. An electrographic diagnosis of STEMI (Zoll Medical Corporation) automatically resulted in CCL activation and direct transfer without prior physician interpretation of the ECG. Patient demographics, landmark time-points, treatments, and outcomes were abstracted for all consecutive pre-hospital CCL activations from February 2010 to January 2015. D2B was defined conventionally as the time from arrival at the hospital to first intracoronary device activation and contact-to-balloon (C2B) was defined as the time from first medical contact in the field to device activation. Over the study period, we identified 489 pre-hospital CCL activations for STEMI. In the first 253 activations analyzed, (full results will be presented at congress), 71% were male with a mean age of 65±14 years. 60% had high blood pressure, 58% dyslipidemia, 17% were known diabetics, and 21% had a history of known or suspected coronary disease. A total of 213 (84%) patients had a final diagnosis of STEMI. Of these, 207 (97%) underwent an attempt at PCI with a success rate of 97%. Median (IQR) D2B for this cohort was 46 minutes (35.75 - 56.0 min). The recommended D2B of <90 minutes was achieved in 99% of patients. Median (IQR) C2B was 75.5 minutes (67.0 - 87 min). The present series confirms that a high rate of target D2B times is achievable with a "physician-less" system of pre-hospital CCL activation. Furthermore, the present results demonstrate that such superior results appear sustained 5 years after protocol implementation.