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Background: Adherence to guidelines is associated with better patient outcomes. Although studies show suboptimal adherence to cardiovascular prevention guidelines among general practitioners, adherence among specialist physicians is understudied. The aim of this analysis was to identify practice gaps among cardiologists in a tertiary academic centre., Methods: We retrospectively audited cardiology outpatient clinic notes taken at the Cardiology Clinic at the Centre hospitalier de l'Université de Montréal (CHUM), from the period January 1, 2019 to February 28, 2019. Data were abstracted from hospital medical records. The primary outcome of interest was the rate of adherence to cardiovascular prevention guidelines. We compared the chart-documented practice at our centre to the Canadian hypertension, lipid, diabetes, antiplatelet, and heart failure guidelines in effect at the time of the audit. We also collected information regarding discussions of smoking, alcohol consumption, physical activity, and diet., Results: A total of 2503 patients were included, with a mean age of 65.6 ± 14.5 years. Dyslipidemia occurred in 63% of patients, hypertension in 55%, and coronary artery disease in 41%. Optimal low-density lipoprotein control was documented as having been achieved in just 39% of cases. Blood pressure control was adequate for 65% of patients, and glycemic control was achieved in 47% of patients with diabetes. Heart failure treatment was optimal in 34% of patients. Nearly all patients with coronary artery disease (95%) had appropriate antithrombotic therapy. The incidence of discussion of nonpharmacologic interventions varied, ranging from 91% (smoking) to 16% (diet)., Conclusions: Primary and secondary prevention of cardiovascular events was found to be suboptimal in an academic tertiary-care outpatient cardiology clinic and may be representative of similar shortcomings nationwide. Strategies to ensure guideline adherence are needed., (© 2023 The Authors.)

Background: Prehospital electrocardiographic ST-elevation myocardial infarction (STEMI) diagnosis and prehospital cardiac catheterization laboratory activation have been shown to significantly reduce average treatment delay, and further standardization of such systems may help reduce sex-related treatment and outcome gaps. However, what types of prehospital STEMI activation systems are in place across Canada, and to what extent sex-based STEMI treatment disparities are tracked, is unknown., Methods: We conducted a national survey of catheterization laboratory directors between October 11 and December 25, 2021. Seventeen catheterization laboratory directors representing 6 community and 11 academic centres completed the survey (40% response rate)., Results: : All responding centres use a prehospital STEMI diagnosis and cardiac catheterization laboratory activation system, and the majority (59%) rely on real-time physician oversight. Slightly less than half (47%) of percutaneous coronary intervention centres reported prospectively tracking sex-related differences in STEMI care, and only one respondent believed that a significant systemic sex-related bias was present in their prehospital STEMI referral system. Patient factors (symptom description or time to presentation; 23.5%) and limitations of electrocardiogram diagnosis of STEMI in women (23.5%) were cited most frequently as contributing to sex-related bias in STEMI referral systems. In contrast, implicit bias in the referral algorithm, prehospital provider bias, and physician bias were not considered important contributing factors., Conclusions: Although all responding centres employ prehospital activation systems, less than half tracked sex-related differences, and most respondents believed that no sex-related bias existed in their prehospital STEMI system., (© 2022 The Authors.)

Background: The management of atrial fibrillation and/or flutter (AF) patients requiring percutaneous coronary intervention (PCI) has evolved significantly. The Canadian Cardiovascular Society AF guidelines, last updated in 2020, seek to aid physicians in balancing both bleeding and thrombotic risks., Methods: A tertiary academic centre registry of patients with AF who had PCI was examined for the antithrombotic therapy at discharge in 4 time periods (cohort 2010-2011; cohort 2014-2015; cohort 2017; cohort 2019). Discharge prescription patterns were compared among the cohorts, using the χ 2 test. In addition, antithrombotic management in cohorts 2017 and 2019 were compared to guideline-expected therapy, using the χ 2 test., Results: A total of 576 AF patients undergoing PCI were included. Clinical and procedural characteristics were similar among cohorts, except for an increase in drug-eluting stent use in the most recent cohort (94% vs 99%; P  = 0.04). The rate of oral anticoagulation increased over time (75% vs 89%; P < 0.01), driven primarily by an increase in direct oral anticoagulants prescription (63% vs 84%; P < 0.01). In contrast to previous cohorts, there was no significant difference between the observed and the guideline-expected anticoagulation rate in cohort 2019 (89% vs 94%; P  = 0.23)., Conclusions: A combination of expert guidance and educational initiatives in the past decade contributed to dramatic changes in the management of patients with AF undergoing PCI., (© 2021 The Authors.)

Background: Women and the elderly with ST-elevation myocardial infarction (STEMI) experience longer treatment delays despite prehospital STEMI diagnosis and catheterization laboratory activation systems. It is not known what role specific STEMI referral systems might play in mediating this gap in care. We therefore examined sex- and age-based differences in STEMI treatment delay (TD) in different STEMI activation systems., Methods: This observational comparative effectiveness study comprised 3 retrospective STEMI cohorts: a traditional hospital-based activation cohort (Cohort 1), an automated "physician-blind" prehospital activation cohort (Cohort 2), and a prehospital activation with real-time physician oversight cohort (Cohort 3). Outcomes of interest included sex and age group (< or ≥ 75 years) differences in suboptimal (> 90 minutes) first medical contact-to-device time (FMC-to-device) within each cohort, as well as independent predictors of suboptimal FMC-to-device and in-hospital mortality across cohorts., Results: Five hundred-sixty STEMI activations were analyzed. In Cohort 1 (n = 179), women and those ≥ 75 were more likely to experience suboptimal FMC-to-device times (78.7% vs 36.4%, P  = 0.02 and 85.0% vs 58.3%, < 0.01, respectively). Similar findings were observed in Cohort 3 (n = 109) (53.5% vs 32.9%, 56.5% vs 33.3%, respectively; P  = 0.05, for both). In Cohort 2 (n = 272), however, there was no significant age-based difference (30.4% vs 21.7%, P  = 0.18), and the gap was numerically lower but still significant for women (32.1% vs 20.1%, P  = 0.04). When examining prehospital activation cohorts only, female sex ( P  = 0.03), off-hours presentation ( P < 0.01), and physician oversight ( P < 0.01) were independent predictors of longer FMC-to-device times. Age ≥ 75 ( P < 0.01), Killip class ( P < 0.01), and female sex ( P = 0.04) were independently associated with in-hospital mortality., Conclusions: Automated "physician-blind" STEMI activation was associated with a reduced TD gap in women and the elderly, suggesting possible systemic bias. Appropriately powered confirmatory studies are required, but incorporating automated diagnosis and catheterization laboratory activation may be a solution to treatment gaps in STEMI care., (© 2021 The Authors.)

Background: ST-elevation myocardial infarction diagnosis at first medical contact (FMC) and prehospital cardiac catheterization laboratory (CCL) activation are associated with reduced total ischemic time and therefore have become the dominant ST-elevation myocardial infarction referral method in primary percutaneous coronary intervention systems. We sought to determine whether physician oversight was associated with improved diagnostic performance in a prehospital CCL activation system and what effect the additional interpretation has on treatment delay., Methods: Between 2012 and 2015, all patients in 2 greater Montreal catchment areas with a chief symptom of chest paint or dyspnea had an in-the-field electrocardiogram (ECG). A machine diagnosis of "acute myocardial infarction" resulted either in automatic CCL (automated cohort without oversight) or transmission of the ECG to the receiving centre emergency physician for reinterpretation before CCL activation. System performance was assessed in terms of the proportion of false positive and inappropriate activations (IA), as well as the proportion of patients with FMC-to-device times ≤ 90 minutes., Results: Four hundred twenty-eight (428) activations were analyzed (311 automated; 117 with physician oversight). Physician oversight tended to decrease IAs (7% vs 3%; P  = 0.062), but was also associated with a smaller proportion of patients achieving target FMC-to-device (76% vs 60%; P < 0.001). There was no significant effect on the proportion of false positive activation., Conclusions: Real-time physician oversight might be associated with fewer IAs, but also appears to have a deleterious effect on FMC-to-device performance. Identifying predictors of IA could improve overall performance by selecting ECGs that merit physician oversight and streamlining others. Larger clinical studies are warranted., (© 2020 Canadian Cardiovascular Society. Published by Elsevier Inc.)

Background: Antithrombotic management following acute coronary syndromes (ACSs) has evolved significantly. However, given lingering uncertainty as to when an ACS may be considered stable, there is the possibility of practice divergence beyond the first year., Methods: An online adaptive survey describing patients with varying cardiac and extracardiac ischemic risk was developed in order to asses self-reported physician practice intentions pertaining to the antithrombotic management of ACS patients who lack a formal indication for therapeutic anticoagulation. Provincial "champions" (Prince Edward Island not represented) were identified to ensure dissemination of the survey within their jurisdictions via 3 coordinated e-mailings; the survey was made available in French and English from November 2018 through January 2019., Results: A total of 135 practitioners responded to the survey (response rate 15%). Surveys were fully completed in all cases. Nearly all respondents (97%) were cardiologists; 76% worked at an academic center, and 54% had been in practice ≥ 10 years. Most respondents (81%-90%, depending on the scenario) preferred ticagrelor-based dual antiplatelet therapy as the initial ACS treatment. However, beyond 12 months, management decisions differed significantly according to the balance of cardiac and extracardiac risk., Conclusions: This study provides a first look at how the introduction of rivaroxaban 2.5 mg might be integrated into the clinical management of ACS patients beyond the first year in Canada. Whether to pursue dual antiplatelet therapy or transition early to low-dose rivaroxaban plus acetylsalicylic acid will likely be driven by patient clinical characteristics and perceived cardiac vs extra-cardiac ischemic risk., (© 2020 Canadian Cardiovascular Society. Published by Elsevier Inc.)