Living too far from advanced cardiac care decreases your odds of survival

January 31, 2018, Elsevier
Incidence of A) patients admitted to hospital with ACS complicated by cardiogenic shock relative to the population of that district health authority (DHA) and B) patients transferred to the QEII-HSC relative to cases presenting in that DHA. Credit: Canadian Journal of Cardiology

A new study published in the Canadian Journal of Cardiology determined that patients with acute cardiac syndrome (ACS) and cardiogenic shock (CS), who live far from the only cardiac catheterization facility in Nova Scotia, Canada, have a survival rate about half that of patients with more direct access.

ACS includes various forms of ("heart attacks") and is a major medical emergency. CS is one of the most serious complications and leading causes of mortality among hospitalized with ACS. Both conditions require immediate treatment and invasive cardiac care. The optimal management of patients with ACS usually requires access to invasive coronary diagnostic and intervention such as percutaneous coronary interventions (PCI) to open up blocked arteries. The only institution capable of providing invasive for PCI and surgery in Nova Scotia is the Queen Elizabeth II Health Sciences Centre (QEII-HSC) in Halifax. This study evaluated whether the distances involved in getting patients to QEII-HSC affect survival rates.

'While PCI is often considered the preferred mode of reperfusion if performed by an experienced team in a timely fashion, it may not always be possible," explained lead investigator Jean-François Légaré, MD, FRCSC, Head of Cardiac Surgery at the New Brunswick Heart Centre, Saint John, NB, Canada. "This is particularly true in Nova Scotia where a large proportion of the population lives in rural communities that are several hours from the single cardiac catheterization laboratory located centrally in Halifax. Furthermore, this is compounded by logistic challenges in arranging ambulance services (air versus ground), lack of onsite physician coverage, and limited resources."

Using data from the clinical database of Cardiovascular Health Nova Scotia, 418 consecutive patients diagnosed with ACS and CS and admitted to hospital in 2009-2013 were included. Of these, 309 (73.9 percent) were close to or directly admitted to QEII-HSC and were classified as having direct access to invasive care. Of the 109 patients in other parts of the province, 64.2 percent were transferred to QEII-HSC. The mortality rate among the 309 patients with direct access to invasive care was significantly lower than the 109 patients who did not have access (41.7 percent vs. 83.5 percent, p <0.0001). Unadjusted mortality was lowest among patients undergoing primary percutaneous coronary intervention (33.1 percent). After adjustment for clinical differences, direct access to cardiac catheterization remained an independent predictor of survival.

When comparing patients presenting with ACS + CS relative to the population in each of the nine separate District Health Authorities (DHA) in Nova Scotia, investigators identified regions with a greater than four-fold difference from the highest to lowest incidence, with the DHAs at the geographic extremes from Halifax having the highest incidence (see maps in Figure). They also determined that the percentage of cases resulting in transfer to QEII-HSC from each DHA ranged from about 47 percent (DHA 2) to about 87 percent (DHA 9, including QEII-HSC). This almost two-fold difference in transfer rates was congruent with the areas of highest incidence.

The investigators note that during the five-year study period, the incidence of ACS complicated by CS was 2.9 percent, which is lower than the 6.3 percent previously found in Nova Scotia, and which follows a global trend of decreasing incidence of CS. They also found that the overall mortality rate for ACS + CS patients decreased to 52.6 percent versus the previously reported 60.1 percent. Nevertheless, the marked disparities across the Province point to areas for improvement.

According to Dr. Légaré, "Our study suggests that patients living furthest from the only cardiac catheterization center in the Province have the highest rates of ACS + CS and lowest access to invasive care. Given that access to invasive care appears to provide the best chance of survival, continued public health efforts to increase access and gaining a better understanding of barriers to care are needed."

Explore further: AHA: Cardiac troponin I IDs low risk of MI, cardiac death

More information: "Where you live in Nova Scotia can significantly impact your access to life saving cardiac care: Access to invasive care influences survival," Canadian Journal of Cardiology, DOI: 10.1016/j.cjca.2017.11.021

Related Stories

AHA: Cardiac troponin I IDs low risk of MI, cardiac death

November 13, 2017
(HealthDay)—High-sensitivity cardiac troponin I concentration can identify individuals at low risk of myocardial infarction or cardiac death within 30 days among patients with suspected acute coronary syndrome, according ...

Cardiac arrest patients do better if taken immediately to a specialist heart center

March 28, 2017
People who suffer cardiac arrest outside of hospital have a better chance of survival if they are taken immediately to a specialist heart centre rather than to the nearest general hospital, according to research published ...

Are patients in rural areas being deprived of potentially lifesaving therapy?

January 25, 2017
The implantable cardioverter defibrillator (ICD), a primary prevention device therapy, can help save the lives of patients suffering from heart failure or following a heart attack. Specialized heart function clinics often ...

Percutaneous coronary intervention is a well-justified option in severe coronary artery disease

December 12, 2017
The treatment of left main coronary artery disease by percutaneous coronary intervention is associated with a smaller risk of severe cardiovascular events than coronary artery bypass grafting in the weeks following surgery. ...

Highest safety rating awarded to cardiac catheterization laboratory

November 24, 2015
The Cardiac Catheterization Laboratory of Mount Sinai Heart at The Mount Sinai Hospital has once again received the highest "two-star" safety rating from the New York State Department of Health for its percutaneous coronary ...

Recommended for you

Surgery involving ultrasound energy found to treat high blood pressure

May 23, 2018
An operation that targets the nerves connected to the kidney has been found to significantly reduce blood pressure in patients with hypertension, according to the results of a clinical trial led in the UK by Queen Mary University ...

To have or not to have... your left atrial appendage closed

May 22, 2018
Each year in the U.S., more than 300,000 people have heart surgery. To reduce risk of stroke for their patients, surgeons often will close the left atrial appendage, which is a small sac in the left side of the heart where ...

Natural antioxidant bilirubin may improve cardiovascular health

May 18, 2018
Bilirubin, a yellow-orange pigment, is formed after the breakdown of red blood cells and is eliminated by the liver. It's not only a sign of a bruise, it may provide cardiovascular benefits, according to a large-scale epidemiology ...

New algorithm more accurately predicts life expectancy after heart failure

May 17, 2018
A new algorithm developed by UCLA researchers more accurately predicts which people will survive heart failure, and for how long, whether or not they receive a heart transplant. The algorithm would allow doctors to make more ...

New genes found that determine how the heart responds to exercise

May 17, 2018
A new study by researchers at Queen Mary University of London and University College London (UCL) has discovered 30 new gene locations that determine how the heart responds to and recovers from exercise.

Novel therapy inhibits complement to preserve neurons and reduce inflammation after stroke

May 16, 2018
A team of investigators at the Medical University of South Carolina (MUSC) has developed a novel therapy for ischemic (clot-caused) stroke and has shown in a preclinical model that it locally inhibits complement at and around ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.