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Canadian Journal of Cardiology

WHERE YOU LIVE IN NOVA SCOTIA CAN SIGNIFICANTLY IMPACT YOUR ACCESS TO LIFE SAVING CARDIAC CARE

      Background

      Invasive cardiac care is the preferred method of treatment for patients with acute coronary syndromes (ACS) complicated by cardiogenic shock (CS). In Nova Scotia, invasive cardiac care is only available in Halifax at the QEII Health Sciences Centre (HSC), but efforts to improve access are ongoing. This study was designed to evaluate outcomes of patients suffering from ACS + CS in the entire Province of Nova Scotia and examine their access to cardiac catheterization.

      Methods

      All consecutive patients diagnosed with ACS + CS in 2009-2013 in Nova Scotia were included in the present study. Data were obtained from the clinical database of Cardiovascular Health Nova Scotia. Access was defined as admission or transfer to Halifax as the sole cardiac catheterization centre.

      Results

      From a total of 14 205 patients admitted to hospital for ACS during the study period, 418 patients with ACS + CS were identified. Access to invasive care was limited to 309 (74%) of these patients. For those who presented elsewhere in the province, 64% were transferred to the QEII-HSC in order to have access. The overall mortality rate was 53%. The mortality rate among the 309 patients with access to invasive care was significantly lower than the 109 patients who did not have access (42% vs. 84%, p < 0.0001). Unadjusted mortality was lowest among patients undergoing primary percutaneous coronary intervention (PPCI; 33%). After adjustment for clinical differences, access to cardiac catheterization remained an independent predictor of survival with an odds ratio of 0.20 (0.11-0.36). Heat map analysis of the Province revealed that not only was the incidence of ACS + CS highest in regions furthest from Halifax but that likelihood of transfer (access) was also the lowest (Figure 1).

      Conclusion

      During our study period, the incidence of ACS + CS was 4.5 patients per 10 000 population and carried a 53% mortality. Our findings demonstrate that access to cardiac catheterization was an independent predictor for survival. Furthermore, patients who lived the furthest from Halifax were least likely to be transferred suggesting that geography alone may still remain an important barrier to life saving care. While regional PPCI facilities are unlikely to become available, a rapid transfer program for ACS + CS to the sole interventional facility should be a health system priority.
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      Medical Research Foundation Leo Alexander Endowment