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Applying the evidence: do patients with stroke, coronary artery disease, or both achieve similar treatment goals?

https://arctichealth.org/en/permalink/ahliterature152667
Source
Stroke. 2009 Apr;40(4):1417-24
Publication Type
Article
Date
Apr-2009
Author
Gustavo Saposnik
Shaun G Goodman
Lawrence A Leiter
Raymond T Yan
David H Fitchett
Neville H Bayer
Amparo Casanova
Anatoly Langer
Andrew T Yan
Author Affiliation
Division of Cardiology, Canadian Heart Research Centre and Terrence Donnelly Heart Centre, University of Toronto, Canada. saposnikg@smh.toronto.on.ca
Source
Stroke. 2009 Apr;40(4):1417-24
Date
Apr-2009
Language
English
Publication Type
Article
Keywords
Aged
Antihypertensive Agents - therapeutic use
Blood pressure
Canada - epidemiology
Coronary Artery Disease - drug therapy - epidemiology
Evidence-Based Medicine
Female
Fibrinolytic Agents - therapeutic use
Guideline Adherence
Humans
Hypolipidemic Agents - therapeutic use
Lipids - blood
Male
Middle Aged
Multivariate Analysis
Outpatients - statistics & numerical data
Prospective Studies
Registries
Risk factors
Sex Distribution
Stroke - drug therapy - epidemiology
Treatment Outcome
Abstract
The importance of early and aggressive initiation of secondary prevention strategies for patients with both coronary artery disease (CAD) and cerebrovascular disease (CVD) is emphasized by multiple guidelines. However, limited information is available on cardiovascular protection and stroke prevention in an outpatient setting from community-based populations. We sought to evaluate and compare differences in treatment patterns and the attainment of current guideline-recommended targets in unselected high-risk ambulatory patients with CAD, CVD, or both.
This multicenter, prospective, cohort study was conducted from December 2001 to December 2004 among ambulatory patients in a primary care setting. The prospective Vascular Protection and Guidelines-Oriented Approach to Lipid-Lowering Registries recruited 4933 outpatients with established CAD, CVD, or both. All patients had a complete fasting lipid profile measured within 6 months before enrollment. The primary outcome measure was the achievement of blood pressure (BP)
PubMed ID
19213947 View in PubMed
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The association between prior use of aspirin and/or warfarin and the in-hospital management and outcomes in patients presenting with acute coronary syndromes: insights from the Global Registry of Acute Coronary Events (GRACE).

https://arctichealth.org/en/permalink/ahliterature129401
Source
Can J Cardiol. 2012 Jan-Feb;28(1):48-53
Publication Type
Article
Author
Hani Amad
Andrew T Yan
Raymond T Yan
Thao Huynh
Joel M Gore
Gilles Montalescot
J Paul DeYoung
Richard Gallo
Barry Rose
P Gabriel Steg
Shaun G Goodman
Author Affiliation
Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Source
Can J Cardiol. 2012 Jan-Feb;28(1):48-53
Language
English
Publication Type
Article
Keywords
Acute Coronary Syndrome - diagnosis - drug therapy - mortality
Aged
Aged, 80 and over
Anticoagulants - therapeutic use
Aspirin - therapeutic use
Canada - epidemiology
Cause of Death - trends
Drug Therapy, Combination
Electrocardiography
Female
Follow-Up Studies
Humans
Inpatients
Male
Middle Aged
Platelet Aggregation Inhibitors - therapeutic use
Prospective Studies
Registries
Survival Rate - trends
Treatment Outcome
Warfarin - therapeutic use
Abstract
The role of acetylsalicylic acid (ASA [aspirin]) and warfarin in secondary prevention after acute coronary syndromes (ACS) is well established. However, there are sparse data comparing the presentation and outcomes of patients who present with ACS while on ASA and/or warfarin therapy and those on neither.
Using data from the Canadian Global Registry of Acute Coronary Events (GRACE), we stratified 14,090 ACS patients into 4 groups according to prior use of antithrombotic therapies and compared in-hospital management and outcomes.
Among 14,090 ACS patients, 7411 (52.6%) were not on prior ASA or warfarin therapy, 5724 (40.6%) were on ASA only, 593 (4.2%) were on warfarin only, and 362 (2.6%) were on both ASA and warfarin. ACS patients taking ASA and/or warfarin were older with more comorbidities than the patients on neither drug. Patients receiving prior warfarin only or ASA and warfarin were less likely to receive guideline-recommended therapies. Patients who were taking prior warfarin only had higher unadjusted rates of death, death and/or reinfarction (re-MI), congestive heart failure (CHF), and major bleeding as compared with patients on no prior therapy. Furthermore, patients who were taking ASA and warfarin had higher unadjusted rates of death and/or re-MI and CHF than patients on prior ASA only.
ACS patients on prior warfarin are a high-risk population, yet they receive less guideline-recommended therapies and have higher unadjusted adverse event rates during their index hospitalization. With the increasing use of oral anticoagulants, clinical trials are needed to guide the optimal management of these ACS patients.
PubMed ID
22112683 View in PubMed
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Characteristics and evidence-based management of stable coronary artery disease patients in Canada compared with the rest of the world: insights from the CLARIFY registry.

https://arctichealth.org/en/permalink/ahliterature106123
Source
Can J Cardiol. 2014 Jan;30(1):132-7
Publication Type
Article
Date
Jan-2014
Author
Sumeet Gandhi
Paul Dorian
Nicola Greenlaw
Jean-Claude Tardif
P Gabriel Steg
Thao Huynh
Graham C Wong
Michael P Love
Paul Poirier
Shaun G Goodman
Author Affiliation
Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Source
Can J Cardiol. 2014 Jan;30(1):132-7
Date
Jan-2014
Language
English
Publication Type
Article
Keywords
Aged
Canada - epidemiology
Coronary Artery Disease - epidemiology - therapy
Evidence-Based Medicine - methods
Female
Follow-Up Studies
Guideline Adherence
Humans
Male
Prognosis
Prospective Studies
Registries
Risk Assessment - methods
Risk factors
Secondary Prevention - methods
World Health
Abstract
Previous Canadian high vascular risk registries have demonstrated suboptimal goal-directed reductions in cardiovascular risk factors and underutilization of guideline-recommended therapies in part because of physician underestimation of cardiovascular risk.
The Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease (CLARIFY) registry enrolled 33,438 stable coronary artery disease patients in 45 countries. In Canada, supplemental information was obtained specifying reasons that patients were not taking guideline-recommended medications.
In Canada, 1232 patients (9 provinces, 110 physicians) were enrolled and in comparison with the rest of the world, there were several differences in cardiovascular risk factors and medical history; in addition, the Canadian cohort had undergone less percutaneous coronary intervention, but more coronary artery bypass grafting. Among the Canadian cohort, many still continue to smoke (13%) and many do not meet secondary prevention targets for waist circumference (54%), body mass index (81%), physical activity (71%), cholesterol (43%), and systolic blood pressure (20%). Nevertheless, the use of guideline-recommended cardiovascular therapy was high and >90% reported partial/full financial coverage for medications. The number of patients not receiving guideline-recommended therapies because of apparent underestimation of risk was particularly low for antiplatelet agents (2%), ß-blockers (11%), and lipid-lowering therapies (1%).
Canadian patients with stable coronary artery disease did not meet several guideline-recommended secondary prevention targets, despite high use of evidence-based therapy, extensive financial coverage for these medications, and low physician underestimation of risk. Additional work is needed to identify and address the remaining barriers to effective risk factor control.
PubMed ID
24238756 View in PubMed
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Contemporary management of dyslipidemia in high-risk patients: targets still not met.

https://arctichealth.org/en/permalink/ahliterature168032
Source
Am J Med. 2006 Aug;119(8):676-83
Publication Type
Article
Date
Aug-2006
Author
Andrew T Yan
Raymond T Yan
Mary Tan
Daniel G Hackam
Kori L Leblanc
Heather Kertland
Jennifer L Tsang
Shahin Jaffer
Martin L Kates
Lawrence A Leiter
David H Fitchett
Anatoly Langer
Shaun G Goodman
Author Affiliation
Canadian Heart Research Centre and Terrence Donnelly Heart Centre, Division of Cardiology, Toronto, Ontario, Canada.
Source
Am J Med. 2006 Aug;119(8):676-83
Date
Aug-2006
Language
English
Publication Type
Article
Keywords
Aged
Canada - epidemiology
Cholesterol, HDL - blood
Cross-Sectional Studies
Dyslipidemias - drug therapy - epidemiology
Female
Humans
Hypolipidemic Agents - therapeutic use
Lipoproteins, LDL - blood
Male
Middle Aged
National Health Programs
Practice Guidelines as Topic
Risk factors
Abstract
Our objective was to evaluate treatment patterns and the attainment of current National Cholesterol Education Program (NCEP)-recommended lipid targets in unselected high-risk ambulatory patients.
Between December 2001 and December 2004, the prospective Vascular Protection and Guidelines Oriented Approach to Lipid Lowering Registries recruited 8056 outpatients with diabetes, established cardiovascular disease (CVD), or both, who had a complete lipid profile measured within 6 months before enrollment. The primary outcome measure was treatment success, defined as the achievement of LDL-cholesterol
PubMed ID
16887414 View in PubMed
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Disparities in management patterns and outcomes of patients with non-ST-elevation acute coronary syndrome with and without a history of cerebrovascular disease.

https://arctichealth.org/en/permalink/ahliterature144314
Source
Am J Cardiol. 2010 Apr 15;105(8):1083-9
Publication Type
Article
Date
Apr-15-2010
Author
Tony C Lee
Shaun G Goodman
Raymond T Yan
Francois R Grondin
Robert C Welsh
Barry Rose
Gabor Gyenes
Rodney H Zimmerman
Real Brossoit
Gustavo Saposnik
John J Graham
Andrew T Yan
Author Affiliation
Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Source
Am J Cardiol. 2010 Apr 15;105(8):1083-9
Date
Apr-15-2010
Language
English
Publication Type
Article
Keywords
Acute Coronary Syndrome - diagnosis - epidemiology - therapy
Aged
Aged, 80 and over
Canada - epidemiology
Cerebrovascular Disorders - complications - epidemiology
Coronary Angiography
Diagnosis, Differential
Early Diagnosis
Electrocardiography
Female
Follow-Up Studies
Healthcare Disparities - statistics & numerical data
Humans
Male
Middle Aged
Morbidity - trends
Myocardial Revascularization
Prospective Studies
Registries
Risk factors
Survival Rate - trends
Thrombolytic Therapy
Time Factors
Treatment Outcome
Abstract
Cerebrovascular (CVD) disease is commonly associated with coronary artery disease and adversely affects outcome. The goal of the present study was to examine the temporal management patterns and outcomes in relation to previous CVD in a contemporary "real-world" spectrum of patients with acute coronary syndrome (ACS). From 1999 to 2008, 14,070 patients with non-ST-segment elevation ACS were recruited into the Canadian Acute Coronary Syndrome I (ACS I), ACS II, Global Registry of Acute Coronary Events (GRACE/GRACE(2)), and Canadian Registry of Acute Coronary Events (CANRACE) prospective multicenter registries. We stratified the study patients according to a history of CVD and compared their treatment and outcomes. Patients with a history of CVD were older, more likely to have pre-existing coronary artery disease, elevated creatinine, higher Killip class, and ST-segment deviation on admission. Despite presenting with greater GRACE risk scores (137 vs 117, p
PubMed ID
20381657 View in PubMed
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Efficacy and safety of enoxaparin compared with unfractionated heparin in the pharmacoinvasive management of acute ST-segment elevation myocardial infarction: Insights from the TRANSFER-AMI trial.

https://arctichealth.org/en/permalink/ahliterature127328
Source
Am Heart J. 2012 Feb;163(2):176-81.e2
Publication Type
Article
Date
Feb-2012
Author
Shahar Lavi
Warren J Cantor
Amparo Casanova
Mary K Tan
Andrew T Yan
Vladimír D┼żavík
David Fitchett
Eric A Cohen
Bjug Borgundvaag
Michael Heffernan
John Ducas
Shaun G Goodman
Author Affiliation
London Health Sciences Centre, Ontario, Canada.
Source
Am Heart J. 2012 Feb;163(2):176-81.e2
Date
Feb-2012
Language
English
Publication Type
Article
Keywords
Aged
Angioplasty, Balloon, Coronary - methods
Canada - epidemiology
Dose-Response Relationship, Drug
Electrocardiography
Enoxaparin - administration & dosage - therapeutic use
Female
Fibrinolytic Agents - administration & dosage - therapeutic use
Follow-Up Studies
Heparin - administration & dosage - therapeutic use
Humans
Male
Middle Aged
Myocardial Infarction - diagnosis - drug therapy - mortality
Survival Rate
Thrombolytic Therapy - methods
Treatment Outcome
Abstract
An early invasive strategy after fibrinolysis for ST-elevation myocardial infarction (STEMI) improves outcomes, but the relative efficacy and safety of enoxaparin compared with unfractionated heparin (UFH) as part of this approach are unknown.
In the TRANSFER-AMI trial, patients with high-risk STEMI received fibrinolysis and were then randomized to either standard treatment or to immediate transfer for coronary angiography. In this substudy, the outcome of patients aged
PubMed ID
22305834 View in PubMed
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How does the prognosis of diabetes compare with that of established vascular disease? Insights from the Canadian Vascular Protection (VP) Registry.

https://arctichealth.org/en/permalink/ahliterature176738
Source
Am Heart J. 2004 Dec;148(6):1028-33
Publication Type
Article
Date
Dec-2004
Author
Daniel G Hackam
Mary K K Tan
George N Honos
Lawrence A Leiter
Anatoly Langer
Shaun G Goodman
Author Affiliation
Division of Clinical Pharmacology and Toxicology, Sunnybrook and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada. danhackam@cogeco.ca
Source
Am Heart J. 2004 Dec;148(6):1028-33
Date
Dec-2004
Language
English
Publication Type
Article
Keywords
Aged
Canada - epidemiology
Cardiovascular Diseases - epidemiology - etiology
Coronary Disease - complications
Diabetes Complications
Drug Utilization
Female
Humans
Male
Middle Aged
Mortality
Prognosis
Prospective Studies
Registries
Risk factors
Vascular Diseases - complications
Abstract
Diabetes mellitus is a major risk factor for atherosclerotic cardiovascular disease. In a large, prospective, practice-based registry (the Vascular Protection Registry), we enrolled patients with vascular disease and/or diabetes, and compared the following features between diabetic and non-diabetic participants: (1) risk factor profiles, (2) utilization of cardioprotective medications, and (3) cardiovascular outcomes in short-term follow-up.
Patients were enrolled by participating physicians practicing in family medicine or specialty practices across Canada. The primary outcome was a composite of the first occurrence of any of the following vascular events: myocardial infarction, unstable angina, coronary revascularization, stroke, transient ischemic attack, or death. Patients were stratified according to the presence or absence of cardiovascular disease and diabetes.
In all, 3297 patients were available for analysis (972 [30%] with diabetes but no cardiovascular disease; 899 [27%] with both diabetes and cardiovascular disease; and 1425 [43%] with cardiovascular disease but no diabetes). Most of the measured risk factors were worse for patients with diabetes. Compared to non-diabetic patients, diabetes was associated with substantial undertreatment with cardioprotective medications, including antiplatelet agents, beta blockers, and statins. During a mean follow-up of 10 (SD 3.3) months, patients with both diabetes and cardiovascular disease had the worst prognosis, with the primary outcome occurring at a rate of 16.3 per 100 person-years of follow-up.
Patient registries provide a powerful tool for examining treatment patterns, risk factors, and outcomes. Patients with both cardiovascular disease and diabetes had the highest rates of adverse vascular outcomes. Possible reasons include relatively worse risk factor profiles and undertreatment with proven cardiovascular medications.
PubMed ID
15632889 View in PubMed
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How many cardiovascular events can be prevented with optimal management of high-risk Canadians?

https://arctichealth.org/en/permalink/ahliterature157267
Source
Can J Cardiol. 2008 May;24(5):363-8
Publication Type
Article
Date
May-2008
Author
Daniel T Grima
Lawrence A Leiter
Shaun G Goodman
Cheryl L Attard
Chi-Ming Chow
Anatoly Langer
Author Affiliation
Cornerstone Research Group Inc., Burlington.
Source
Can J Cardiol. 2008 May;24(5):363-8
Date
May-2008
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Angiotensin-Converting Enzyme Inhibitors - therapeutic use
Aspirin - therapeutic use
Canada - epidemiology
Cardiovascular Diseases - drug therapy - epidemiology - prevention & control
Female
Humans
Hydroxymethylglutaryl-CoA Reductase Inhibitors - therapeutic use
Male
Middle Aged
Risk factors
Treatment Outcome
Abstract
Strong evidence exists to support the use of statins, acetylsalicylic acid (ASA) and angiotensin-converting enzyme inhibitors (ACEI) in patients at high risk of cardiovascular (CV) events; however, current practice pattern data indicate that a significant care gap exists between evidence and practice.
To quantify the reduction in CV events that may be obtained with the optimal use of vascular protection therapy in Canadians at high risk of cardiovascular events.
Canadian Community Health Survey data from 2003 were used to estimate the prevalence of heart disease and/or diabetes, which were applied to an age-specific population in Canada to calculate the total number of high-risk patients. The number of events over 10 years was estimated using a state transition model, published risk equations, practice pattern data from Canadian registries and published therapy efficacy from clinical trials.
Among 2.2 million high-risk Canadians, current care with statin, ASA and ACEI therapy has reduced the estimated occurrence of CV events over the next 10 years by approximately 400,000 from 1.01 million. Universal use of combination statin, ASA and ACEI therapy for high-risk patients, compared with current care, would prevent as many as 143,000 more CV events over the next 10 years.
Great advances in the management of CV disease have been made; however, CV disease remains a substantial burden to patients and to the Canadian health care system. Canadian physicians have the opportunity to further reduce this burden through optimal management of high-risk patients based on clinical guidelines.
Notes
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PubMed ID
18464939 View in PubMed
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Identification and management of patients at elevated cardiometabolic risk in canadian primary care: how well are we doing?

https://arctichealth.org/en/permalink/ahliterature115793
Source
Can J Cardiol. 2013 Aug;29(8):960-8
Publication Type
Article
Date
Aug-2013
Author
Hwee Teoh
Jean-Pierre Després
Robert Dufour
David H Fitchett
Lianne Goldin
Shaun G Goodman
Stewart B Harris
Anatoly Langer
David C W Lau
Eva M Lonn
G B John Mancini
Philip A McFarlane
Paul Poirier
Rémi Rabasa-Lhoret
Mary K Tan
Lawrence A Leiter
Author Affiliation
Division of Endocrinology and Metabolism, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada.
Source
Can J Cardiol. 2013 Aug;29(8):960-8
Date
Aug-2013
Language
English
Publication Type
Article
Keywords
Adult
Aged
Body mass index
Canada - epidemiology
Cardiovascular Diseases - diagnosis - drug therapy - etiology
Diabetes Mellitus, Type 2 - diagnosis - drug therapy
Dyslipidemias - diagnosis - drug therapy
Female
Humans
Hypertension - diagnosis - drug therapy
Male
Middle Aged
Obesity - diagnosis - drug therapy
Physician's Practice Patterns - statistics & numerical data
Primary Health Care
Risk assessment
Risk factors
Abstract
We evaluated the risk assessment and management patterns employed by primary care physicians in patients at elevated cardiometabolic risk.
Between April 2011 and March 2012, multiple physicians from 9 Primary Care Teams (PCTs) and 88 physicians from traditional nonteam (Solo) practices completed a practice assessment on the management of 2461 patients > 40 years old with no clinical evidence of cardiovascular disease and diagnosed with at least 1 of the following: dyslipidemia, type 2 diabetes mellitus (T2DM), or hypertension.
Individuals with dyslipidemia, T2DM, or hypertension tended to have a body mass index = 25 kg/m(2). Waist circumference measurements, obtained for only 392/829 (47.0%) Solo patients, revealed that 88.9% of these individuals were abdominally obese and that at least 52.2% of Solo patients had metabolic syndrome. Cardiovascular risk, determined by the physicians for 83.5% of all patients without T2DM and typically performed using traditional risk engines, was often miscalculated (43.2% PCTs, 58.8% Solo; P = 0.0007). Healthy behavioural modifications were infrequently recommended ( 70%) but treatment targets were infrequently met. The composite outcome of guideline-recommended low-density lipoprotein cholesterol, glycemic, and blood pressure targets was met by 9.0% and 8.1% of patients managed by PCT and Solo physicians respectively.
Obesity and cardiovascular risk were underassessed and the latter often underestimated. Patients were infrequently counselled on the benefits of healthy behavioural changes. A paradigm change in assessing and managing obesity and cardiovascular risk via aggressive lifestyle interventions is warranted in individuals at elevated cardiometabolic risk.
PubMed ID
23465284 View in PubMed
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Lower is better: implications of the Treating to New Targets (TNT) study for Canadian patients.

https://arctichealth.org/en/permalink/ahliterature167615
Source
Can J Cardiol. 2006 Aug;22(10):835-9
Publication Type
Article
Date
Aug-2006
Author
David H Fitchett
Lawrence A Leiter
Shaun G Goodman
Anatoly Langer
Author Affiliation
Division of Cardiology, St. Michael's Hospital, Toronto, Ontario. fitchettd@smh.toronto.on.ca
Source
Can J Cardiol. 2006 Aug;22(10):835-9
Date
Aug-2006
Language
English
Publication Type
Article
Keywords
Canada - epidemiology
Cholesterol, LDL - blood - drug effects
Death, Sudden, Cardiac - prevention & control
Dyslipidemias - blood - drug therapy - epidemiology
Heptanoic Acids - administration & dosage - therapeutic use
Humans
Hypolipidemic Agents - administration & dosage - therapeutic use
Myocardial Infarction - prevention & control
Pyrroles - administration & dosage - therapeutic use
Randomized Controlled Trials as Topic
Risk assessment
Stroke - prevention & control
Abstract
Recent clinical trials have indicated that lowering low-density lipoprotein cholesterol (LDL-C) levels below currently recommended targets results in favourable surrogate and clinical end points. The Treating to New Targets (TNT) study now confirms that aggressive cholesterol lowering to a mean LDL-C of 2.0 mmol/L with atorvastatin 80 mg daily, compared with the previous target of 2.5 mmol/L with atorvastatin 10 mg daily, results in improved clinical outcomes in high-risk patients with coronary artery disease. A lower LDL-C target of less than 2.0 mmol/L will present therapeutic challenges, because approximately only one-half of high-risk patients will achieve this target using monotherapy with the newer and more powerful statins. Furthermore, registry data show that one-half of these patients are not even achieving the current LDL-C target of 2.5 mmol/L. Causes of the care gap are discussed and possible remedies to achieve the new lower targets are suggested.
Notes
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Comment In: Can J Cardiol. 2007 Apr;23(5):397-8; author reply 39817489153
PubMed ID
16957800 View in PubMed
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27 records – page 1 of 3.