Purpose: A descriptive study to fill a knowledge gap regarding Chagas disease cardiomyopathy prevalence in Guyana by testing for antibodies to Trypanosoma cruzi in patients throughout the country who are identified as having cardiac abnormalities on screening Echocardiogram(ECG) and echocardiography. This has public health significance as the chronic disease phase carries a high mortality rate due to its progression to dilated cardiomyopathy in 20-30% of cases. Methods & Materials: Health workers at Regional Health Centers recruit and screen patients that present with unexplained syncope, palpitations or overt/suspected heart failure. This is occurring throughout all 10 regions of Guyana. Consenting patients undergo screening with 12 lead ECG and Echocardiography. Patients with abnormal findings including: (1) AV conduction abnormality on ECG, (2) RBBB on ECG, or (3) echocardiographic evidence of left ventricular dysfunction, has blood drawn and the Standard Diagnostics Rapid Test for T. Cruzi (sensitivity 99.3%; specificity 100%) performed to determine if seropositive for antibodies to T. Cruzi. We anticipate screening 1200 patients, 300 at the Georgetown Public Hospital Corporation, and 100 patients per region in the outlying 9 regions. Data collection began in July 2016. Patients with a positive Test and their local physician are provided with test results, as well as education regarding Chagas positivity and management of cardiac disease as indicated by their individual results. All Chagas seropositive patients will also receive a referral to Vector Control Services, Ministry of Public Health of Guyana. Results: Expected: The seroprevalence of T. cruzi in patients with cardiac abnormalities will be similar to that of other countries in the Guyana Shield where it is endemic. Chagas associated cardiac disease prevalence may represent a higher preventable burden of morbidity and mortality than previously identified. Conclusion: Considering the prevalence (.5%-6.7%) and significant public health burden of Chagas disease in countries surrounding Guyana and the status of Chagas Disease as a neglected tropical disease, knowledge about its prevalence in the country is critical for public health planning and vector control. With knowledge about the rates of Chagas infection, resources could be allocated to improved prevention and earlier treatment leading to decreased morbidity and mortality.

Conference on cardiac transplantation in 2003 (1).The present Executive Summary provides an update on the previous document, with a focus on new evidence and significant changes in our understanding of relevant issues and management of cardiac transplantation.The standard guidelines used in these recommendations are shown in Table 1.

AIM:To determine the impact of previous coronary artery revascularization by percutaneous transluminal coronary angioplasty and/or stenting (PCI) on outcome after subsequent coronary artery bypass grafting (CABG).METHODS AND RESULTS:The ischaemia management with Accupril post-bypass Graft via Inhibition of the coNverting Enzyme (IMAGINE) trial, conducted between November 1999 and September 2004, tested whether early initiation of an angiotensin-converting enzyme inhibitor post-CABG, in stable patients with LVEF >or=40%, would reduce cardiovascular events. Of the 2489 patients included in the IMAGINE trial, undergoing their first operation, 430 had a history of PCI prior to surgery (PCI group), and 2059 were referred to surgery without previous PCI (non-PCI group). There was a significant increase in the primary IMAGINE endpoint in the PCI group, HR = 1.53 [1.17-1.98], P = 0.0016. Coronary revascularization, HR = 1.80 [1.13-2.87], P = 0.014, unstable angina requiring hospitalization, HR = 2.43 [1.52-3.89], P = 0.0002, were the two individual components that significantly increased in the PCI group, even when adjusted for baseline characteristics (age, sex, history of myocardial infarction or stroke, diabetes, treatment group, or off-pump surgery).CONCLUSION:Patients with left ventricular ejection fraction >or=40% having a history of PCI prior to surgery had a worse outcome post-CABG than those with no prior PCI. Further studies are needed to investigate whether these results apply for drug eluting stents.

BACKGROUND:Patients at high risk for intracranial hemorrhage (ICH) are generally excluded from thrombolytic trials. Because the frequency and predictors of ICH reported from these studies may not be widely applicable, we sought to examine this matter further in unselected patients with acute myocardial infarction in the community.METHODS:FASTRAK II is a prospective ongoing registry of acute coronary syndromes involving 111 Canadian hospitals. Trained medical personnel recorded admission, treatment, and discharge data on patients admitted with acute coronary syndromes.RESULTS:From January 1, 1998, to December 31, 2000, 12,739 patients received fibrinolytic therapy for acute myocardial infarction. Of these, 146 patients (1.15%) sustained strokes and 82 patients (0.65%) had an ICH. Advanced age, female sex, history of cerebrovascular event, and systolic hypertension on arrival (systolic blood pressure >160 mm Hg) were identified with a multivariate logistic regression model to be important independent risks factors for ICH. Patients receiving streptokinase had a lower risk of ICH. Among the patients at high risk for ICH, the ICH rates remained low, ranging from 0.7% to 1.8%.CONCLUSION:ICH is an infrequent event after fibrinolytic therapy in ST-elevation MI; this low rate supports broad penetration of this therapy. Simple clinical characteristics are useful in predicting the risk of ICH and allow a clinician to individualize the risk-benefit assessment of this therapy.

Primary Panel: Heather Ross (Co-Chair), Paul Hendry (Co-Chair), Anne Dipchand, Nadia Giannetti, Greg Hirsch, Debra Isaac, Narendra Singh, Lori West, Michel White Secondary Panel: Andrew Ignaszewski, Anton Maria Chung, Lynn Straatman, Dennis Modry, Wayne Tymchak, Jeffrey Burton, Wayne Warnica, Jose Eduardo Azevedo, William Kostuk, Alan Menkis, Peter Pflugfelder, Mackenzie Quantz, Ross Davies, Henry Haddad, Roy Masters, Robert Cusimano, Diego Delgado, Chris Feindel, Vivek Rao, Marcelo Cantarovich, Renzo Cecere, Michel Carrier, Michel Pellerin, Daniel Doyle, Marie-Hélène LeBlanc, Jonathan Howlett

BACKGROUND:Although quality indicators for the care of acute myocardial infarction (AMI) patients have been described for other countries, there are none specifically designed for the Canadian health care system. The authors' goal was to develop a set of Canadian quality indicators for AMI care.METHODS:A literature review identified existing quality indicators for AMI care. A list of potential indicators was assessed by a nine-member panel of clinicians from a variety of disciplines using a modified-Delphi panel process. After an initial round of rating the potential indicators, a series of indicators was identified for a second round of discussion at a national meeting. Further refinement of indicators occurred following a teleconference and review by external reviewers.RESULTS:To identify an AMI cohort, case definition criteria were developed, using a hospital discharge diagnosis for AMI of International Classification of Diseases-Ninth revision (ICD-9) code 410.x. Thirty-seven indicators for AMI care were established. Pharmacological process of care indicators included administration of acetylsalicylic acid, beta-blockers, angiotensin-converting enzyme inhibitors, thrombolytics and statins. Mortality and readmissions for AMI, unstable angina and congestive heart failure were recommended as outcome indicators. Nonpharmacological indicators included median length of stay in the emergency department, and median waiting times for cardiac catheterization, percutaneous coronary intervention and/or coronary artery bypass graft surgery.INTERPRETATION:A set of Canadian quality indicators for the care of AMI patients has been established. It is anticipated that these indicators will be useful to clinicians and researchers who want to measure and improve the quality of AMI patient care in Canada.

Objective: The primary objective of this study was to determine the effect of implementing a critical path on use of proven efficacious therapies and outcomes in patients admitted to a hospital with acute myocardial infarction (AMI). The secondary objectives were to evaluate the use of unproven medications and to develop an understanding of the factors associated with adverse in-hospital outcomes in these patients.Study Design: A nonrandomized before-after study design was used to evaluate the efficacy of a critical path instrument in patients admitted to hospital with AMI.Patients and Methods: Consecutive patients admitted with AMI in nine participating hospitals were enrolled in the study. The critical path instrument consisted of a locally developed, preprinted physician order form. Practice patterns were determined before (n=2305) and after (n=2349) implementation of the critical path by primary chart review. Multivariate analysis of risk factors for mortality was performed on a combined database of 6088 AMI patients.Results: The use of acetylsalicylic acid (ASA), nitrates, and beta blockers increased significantly by 3%, 2%, and 9%, respectively, after implementation of the critical path. Use of thrombolytics remained stable at 41 %, and calcium channel blocker use decreased significantly by 8%. In-hospital mortality decreased by 1%. There was less use of ASA, nitrates, beta blockers, and thrombolytic therapy in women and the elderly. Multivariate analysis showed that advanced age was associated with increased mortality risk, whereas ASA, beta blockers, nitrates, and calcium channel blockers were associated with reduced mortality risk.Conclusion: Implementation of a critical path resulted in increased use of proven efficacious therapies, reduced use of noneffective therapy, and a trend toward reduced mortality.

BACKGROUND:The objectives were to investigate the factors influencing signal-averaged ECGs (SAECGs) recorded in patients after myocardial infarction (MI) and to develop criteria for predicting arrhythmic events (AEs) that account for these factors. METHODS AND RESULTS:SAECGs were recorded 5 to 15 days after MI in 2461 patients without bundle-branch block. The duration (QRSd), terminal potential (VRMS), and terminal duration (LAS) of the filtered QRS were measured. During follow-up (17 +/- 8 months), AEs (arrhythmic death; ventricular tachycardia, VT; ventricular fibrillation, VF) occurred in 80 patients (3.3%). Receiver operating characteristic curves showed that QRSd discriminated patients with all types of AEs, but VRMS and LAS discriminated only VT patients; QRSd minus LAS also discriminated AE patients. Sex, age, and MI location significantly affected the SAECG; survivors without VT or VF were divided into subgroups (2 sex x 4 age x 2 MI), and QRSd values exceeding the 70th percentile in each subgroup predicted AEs with a sensitivity of 65.4%. An unadjusted QRSd criterion showed the same overall sensitivity and specificity but with less uniform values for each subgroup. A Cox model was constructed by use of multiple prognostic indicators, and in rank order, QRSd, previous MI, and Killip class were predictive of AEs. CONCLUSIONS:SAECG adjustments for sex, age, and MI location did not improve sensitivity and specificity but produced a more uniform predictive performance. The proposed criteria are based only on QRSd, because late potentials (VRMS and LAS) did not discriminate patients with sudden death. Duration of high-level activity during QRS (QRSd-LAS) can predict AEs, suggesting that the arrhythmogenic substate involves a large mass of myocardium.