online proceedings

Dear Colleague,

On behalf of the Division of Cardiology at St. Michael’s Hospital and our sponsors, thank you for attending this special educational event, the sixteenth in the series, entitled “Cardiology for the Practitioner: Critical Pathways” onSaturday, April 16, 2005 at the Metro Toronto Convention Centre.

In the tradition of previous years, we intend to provide a first class, interactive,educational experience for key community practitioners of cardiovascular medicine. The planning committee has worked hard to select subjects whichare of relevance to the contemporary practitioner with a particular focus oncoronary artery disease, electrophysiology, innovative therapies in heart disease, cardiac imaging, and a debate on the role of PCI versus surgery inmulti-vessel coronary disease. As well, we will provide you with details andanalysis of new clinical trials and the latest data from international meetings toensure that you have the most up-to-date information. The program is alsostructured to facilitate discussion and promote interaction between thespeakers and the audience. There will also be ample opportunities for informaldiscussion during the nutritional breaks and at the complimentary cocktailreception at the conclusion of the day.

We are pleased to inform you that this educational event has been approvedfor 5.5 MAINPRO-MI credits and as an Accredited Group Learning Activityunder Section 1of the Framework of CPD options for the Maintenance ofCertification Program of the Royal College of Physicians and Surgeons ofCanada (5.5 hours).

On behalf of the Division of Cardiology at St. Michael’s Hospital, I thank youfor joining us for what we believe will be an outstanding educational event andan otherwise enjoyable opportunity to meet with friends and colleagues.

Sincerely,

Thomas G. Parker M.D.Head, Division of Cardiology

I- New Strategies in STEMI Management David Fitchett p1

New ACC/AHA STEMI Guidelines in the Canadian context Shaun Goodman p2-4

Facilitated PCI for STEMI: The Transfer-AMI Trial Warren Cantor p5-7

Case Presentation/Panel Discussion/Questions Saleem Kassam p8

II- Not for the “ Faint” of Heart” Anthony Graham p9

“Wipe Out” An Approach to Syncope” Iqwal Mangat p10-12

Defibrillators for Dummies Victoria Korley p13-15

“Maybe You Can Drive My Car”Highlights from CCS driving guidelines Paul Dorian p16-18

III -Clinical Trials Chi-Ming Chow p19

IV- Pulmonary Hypertension – Today & Tomorrow Juan Carlos Monge p20

Today: Contemporary Approach to Management John Granton p21-23of Pulmonary Hypertension

Tomorrow: Stem Cell Therapy: The PHACET Trial Michael Kutryk p24

V- Cardiac Imaging & Challenging Aortic Disease Cases Stuart Hutchison p25-28

VI-Debate Be it resolved that: “Patients with three vessel disease Thomas Parker p29-31

are better served by surgery than PCI”Protagonist: Lee Errett Antagonist: Robert Chisholm

Table of Contents

Cardiology for Practitioner: Critical Pathways ~ Saturday, April 16, 2005 ~ Metro Toronto Convention Centre


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I - New Strategies in STEMI Management

David Fitchett, M.D.

BiographyDavid Fitchett studied at Cambridge University, where he graduated in physical sciences before entering medicine.He continued his clinical training at The Middlesex Hospital, London and cardiology training at The Brompton andHammersmith Hospitals. In 1978 he went to The Royal Victoria Hospital, Montreal where he became Director of the CCUand Medical Director of the cardiac transplant program. In 1997 he became CCU Director at St. Michael’s Hospital,University of Toronto. His research interests are clinical trials in acute coronary syndromes, and the delivery and assessment of gene therapy for myocardial angiogenesis.


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New ACC/AHA STEMI Guidelinesin the Canadian Context

Shaun Goodman, M.D.

BiographyDr. Shaun Goodman is a Staff Cardiologist and Associate Head in the Division of Cardiology, Department of Medicine,at St. Michael’s Hospital. He is the current Chair of the St. Michael’s Hospital Physician’s Association and the Co-Chairof the Canadian Heart Research Centre. He is an Associate Professor in the Department of Medicine, University of Toronto. He completed his Doctor of Medicine (1987) at McMaster University (Hamilton, Ontario) and a Masters of Science in Clinical Epidemiology in the Faculty of Medicine and Graduate Department of Community Health at theUniversity of Toronto (1998). He completed his training in Internal Medicine and Cardiology at the University of Toronto.He pursued a three year Heart & Stroke Foundation of Canada-funded research fellowship before joining the Divisionof Cardiology at St. Michael’s Hospital in 1995. Current areas of clinical research include acute and chronic ischemicheart disease. In his role as the Co-Chair of the Canadian Heart Research Centre, he has: (1) facilitated the conduct of clinical trials in acute coronary syndromes in Canada (e.g., INTERACT, SYNERGY); (2) established an electrocardiographic core laboratory evaluating the diagnosis and prognosis of both 12-lead (e.g., ASSENT-2) andcontinuous ECG monitoring (e.g., XANADU); and (3) served as either a national coordinator (e.g., GRACE) or principalinvestigator (e.g., Canadian ACS I and II, VP, and GOALL Registries) of several registries examining clinical practice andoutcomes in acute coronary syndromes and high vascular risk patients.


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Facilitated PCI for STEMI: The Transfer-AMI Trial

Warren cantor, M.D.

BiographyDr. Cantor received his medical degree at the University of Western Ontario, London, Ontario. He then completed his postgraduate internal medicine and cardiology training at the University of Toronto. After a clinical fellowship in interventional cardiology, he received a grant from the Royal College of Physicians & Surgeons of Canada to pursue atwo-year research fellowship at Duke University Medical Center, North Carolina. He completed the fellowship in 2000and accepted a position as Staff Interventional Cardiologist at St. Michael's Hospital and Assistant Professor of Medicineat the University of Toronto. He is the associate director of the cardiac catheterization laboratory, and a director for theUniversity of Toronto Interventional Cardiology Fellows course. His research interests include advances in percutaneouscoronary intervention, coronary angioplasty for acute myocardial infarction, and antithrombotic therapy for acute coronary syndromes. He has published over 50 peer-reviewed articles, book chapters and abstracts.


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Facilitated PCI for STEMI: The Transfer-AMI Trial

Warren cantor, M.D.

AbstractThe TRANSFER-AMI study is a randomized trial designed to determine the role of routine early percutaneous coronary intervention after thrombolysis (facilitated PCI) when timely primary angioplasty is not feasible. The goal is todetermine whether routine transfer of patients with acute myocardial infarction to an angioplasty centre immediately afterthrombolysis for coronary angiography and percutaneous intervention is safe and superior to a strategy of transferringonly those patients with evidence of failed thrombolysis. Most patients with AMI present to hospitals without cardiaccatheterization facilities. Although primary angioplasty may be the most effective reperfusion strategy when it can be car-ried out quickly, thrombolysis remains the standard of treatment in most hospitals in Canada and worldwide. However,thrombolysis fails to achieve reperfusion in up to 20% of patients, and may be complicated by reocclusion, reinfarctionor recurrent ischemia. N o n i nva s i ve assessment of reperfusion after thrombolysis is probl e m a t i c .Treating patients with pharmacotherapy on presentation followed by immediate transfer, cardiac catheterization and PCI,so-called ‘facilitated PCI’, offers the potential of combining the benefits of thrombolysis (early initiation of therapy) withp ri m a ry PCI (more complete and sustained reperfusion, less recurrent ischemia). The use of stents and potent antiplatelet therapy may reduce reocclusion after successful PCI. Although the strategy of facilitated PCI appearspromising based on post-hoc analyses and small trials, it has not been shown to be superior to standard thrombolysisin an adequately powered prospective randomized trial. The TRANSFER-AMI study will recruit approximately 1200patients with high-risk ST elevation MI presenting to non-PCI Canadian centres. The rationale, design and progress ofthe TRANSFER-AMI randomized trial will be presented, along with the results of the pilot feasibility study


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saleem kassam, M.D.

BiographyDr. Kassam is a staff cardiologist at Rouge Valley Centenary in Toronto’s East end. His practice is comprised of inter-ventional and general cardiology, as well as resident teaching and clinical research.

Dr. Kassam graduated from the University of Toronto in 1993 and completed training in Toronto in 2002. He also hasa Master’s degree in Clinical Epidemiology and spent the last 2 years at St Michael’s Hospital.

His hobbies include travel, sports, music and spending time with his family.

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Case Presentation/ Panel Discussion/Questions


anthony graham, M.D.

Biography

Dr. Graham is a clinical cardiologist and Director of Ambulatory Care for the Heart and Vascular Program at St.Michael’s Hospital. He is also a Professor of Medicine at the University of Toronto and has been Chief of theCardiology Division at the Wellesley Central Hospital. Dr. Graham continues as a leadership volunteer at theHeart and Stroke Foundation where he has been President of both the Ontario Foundation and the NationalFederation as well as the Heart and Stroke Scientific Research Corporation of Canada. He continues as a keymedia spokesperson for the Foundation.

Dr. Graham has been awarded the Order of Canada for his leadership in developing an Emergency CardiacCare Program in Canada, as well as for his contributions to the growth of Heart and Stroke Foundation ofOntario.

Dr. Graham and his wife Shannon, have three children and one grandchild. They all still enjoy summers in theGateneau north of Ottawa.

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II Not for the “Faint” of Heart


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Iqwal mangat, M.D.

BiographyGraduated from University of Toronto Medical School 1993Postgraduate Training in Internal medicine and Cardiology – University of Toronto, 1993-1999Cardiac Electrophysiology Fellowship – University of San Francisco, California, 1999-2001Clinical Instructor of Medicine – University of San Francisco, California, 2001-2002

Currently, Assistant professor of Medicine, University of Toronto, and staff Cardiac Electrophysiologist at St. Michael’sHospital

Clinical and Research Interests Include:Evaluation and management of patients with syncope, palpitations, risk factors for sudden cardiac death.Arrhythmia management including supraventricular and ventricular tachycardias, inherited arrhythmic syndromes includ-ing RV dysplasia, long QT syndrome and Brugada syndrome.

“Wipe Out” An Approach to Syncope


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Defibrillators for Dummies

victoria korley, M.D.

Biography

Dr. Victoria Korley joined St. Michael’s Hospital as an electrophysiolgist in 2000. She completed her B.Sc., medicalschool and internal medicine residency at McGill University. She then specialized in cardiology and electrophysiologyat Harvard University. Her interests include all aspects related to comprehensive arrhythmia diagnosis andmanagement including resynchronization therapy for heart failure.


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Defibrillators for Dummies

victoria korley, M.D.

Abstract

The use of implantable cardiac defibrillators has become more common in the last few years as the indications forimplantation have rapidly expanded. The benefit of these devices for secondary prevention of sudden cardiac death isundisputed and with new data suggesting a significant benefit for primary prophylaxis of sudden cardiac death, the numbers of patients expected to live with these devices is growing exponentially. As a result, all physicians need someknowledge of how to assess and treat patients with this device. The purpose of this session is to briefly address howthese devices function and how to mange such patients in an urgent or emergent situation.

Implantable cardiac defibrillators are programmed to first detect an arrhythmia by the heart rate. One a detection hasoccurred, the relationship between the atrial and ventricular intracardiac electrograms may be examined to differentiateventricular from supraventricular rhythms. Once a diagnosis is made, therapy is then initiated. In lower heart zones,antitachycardia pacing is usually employed to try and terminate the rhythm painlessly. Should this fail, intracardiac defibrillation is the second line of therapy. At higher heart rates, however, the device is often programmed for defibrillation as the first therapy.

One common problem is inappropriate shocks. These usually occur for fast supraventricular rhythms which are detected within the “tachycardia zone”. In rare cases, however, extraneous noise can be mistakenly detected as tachycardia. Defibrillation, sometimes on multiple occasions, while a patient is fully conscious, can be very traumatic.The use of a magnet to suspend sensing and prevent such inappropriate therapy will be emphasized.

The implantable cardiac defibrillator has become an integral component of cardiac care. A basic understanding of howdevices function and how to manage patients with these devices in urgent and emergent situations is a valuable assetto all health care personnel.

References

1. Josephson M, Wellens HJ. Implantable defibrillators and sudden cardiac death. Circ 2004;109(22):2685

2. Stone KR, McPherson A. Assessment and management of patients with pacemakers and implantable cardioverter defibrillators. Crit Care Med 2004;32 (suppl):S155


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“Maybe You Can Drive My Car...” Highlights FromCCS Driving Guidelines

paul dorian, M.D.

BiographyDr. Paul Dorian is currently the Director of the Cardiac Electrophysiology Program at St. Michael's Hospital in Toronto,Canada. He is Professor of Medicine in the Division of Cardiology and in the Division of Clinical Pharmacology at theUniversity of Toronto.

Dr. Dorian received his medical degree from McGill University in Montreal in 1976. He continued training in InternalMedicine and Cardiology at the University of Toronto, and received certification by the Royal College of Physicians andSurgeons of Canada in Internal Medicine in 1983 and certification in Cardiology in 1984. He completed training inClinical Pharmacology at the University of Toronto in 1982, and received an MSc in Pharmacology from the Universityof Toronto in 1982. From 1983 to 1985, he completed a Fellowship in Cardiac Electrophysiology at Stanford UniversityMedical Centre in California.

His research interests include factors related to the induction and maintenance of ventricular fibrillation, defibrillation,and antiarrhythmic drug effects on ventricular fibrillation and defibrillation. His other interests also include quality oflife in patients with cardiac arrhythmias, and the clinical pharmacology of antiarrhythmic drugs.

He has recently completed a clinical trial in out of hospital cardiac arrest and continues collaborative trials in prehospital care.


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“Maybe You Can Drive My Car...” Highlights FromCCS Driving Guidelines

paul dorian, M.D.

AbstractMedical assessment of fitness to operate a motor vehicle requires balancing the right of society (to be protected fromharm to individuals) and the rights of individuals (to operate modes of transportation). The province of Ontario mandates(by legislation) physicians to report to the Ministry of Transportation those individuals who are felt to pose a risk. Implicitin the process of risk assessment is the risk of sudden incapacitation behind the wheel, corrected for the type of vehi-cle driven and the amount of time at risk (number of hours driving per day). In 2003, the Canadian CardiovascularSociety (http://www.ccs.ca/download/2003_CC_Exec_Summary.pdf) published consensus guidelines to assist physi-cians with the process of mandatory reporting.


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III Clinical Trials

Chi-Ming Chow, M.D.

Biography

Dr. Chi-Ming Chow is an attending staff cardiologist at St. Michael's Hospital. He is an assistant professor in theDepartment of Medicine, University of Toronto. He has an undergraduate degree in computer science from BrownUniversity, USA. He completed his Doctor of Medicine (1990) at McGill University (Montréal, Québec) and a Masters ofScience in Epidemiology at McGill University (1997). He completed his training in Internal Medicine and Cardiology atMcGill University. He then pursued his clinical and research echocardiography fellowship at Massachusetts GeneralHospital, Harvard University before joining the Division of Cardiology at St. Michael's Hospital in 2001.

Current areas of research include clinical epidemiology in coronary artery disease and valvular heart disease,ethnic differences in cardiovascular diseases, investigating new technologies in non-invasive imaging and medical informatics.


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IV- Pulmonary Hepertension - Today &Tomorrow

Juan Carlos Monge, M.D.

Biography

Dr. Juan Carlos Monge is currently a staff cardiologist at St. Michael’s Hospital in Toronto and an Associate Professor atthe University of Toronto. His clinical interests include invasive cardiology and cardiac intensive care.

Dr. Monge graduated from the University of Costa Rica School of Medicine and did his internship and Internal Medicinetraining at the Ochsner Foundation Hospital and Ochsner Clinic in New Orleans, Louisiana. He then completed a fouryear post-doctoral research fellowship at the National Heart, Lung and Blood Institute, National Institutes of Health inBethesda, Maryland. Subsequently he pursued his clinical training in Cardiology at the Barnes Hospital, WashingtonUniversity School of Medicine in St. Louis, Missouri.

Dr. Monge assumed his first faculty position at the Royal Victoria Hospital and McGill University in Montreal in 1990 andmoved to St. Michael’s Hospital and the University of Toronto in 1995.

His research interests include Molecular and Cell Biology of Endothelial Dysfunction, atherosclerosis, regulation of theendothelin system, hyperlipidemia, hypertension and endothelial dysfunction as well as the role of estrogens in cardiacremodeling following myocardial infarction and, in general, the effects of sex hormones on the cardiovascular system.He has been the recipient of numerous Heart and Stroke Foundation and MRC grants. Dr. Monge is the author of numerous research publications as well as clinical reviews and has been invited to present in multiple national and international scientific meetings.


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John granton, M.D.

BiographyDr. Granton is the Programme Director of Critical Care Medicine at the University of Toronto.

He is also the Director of the Pulmonary Hypertension Programme at the Toronto General Hospital.

Today: Contemporary Approach to Managementof Pulmonary Hypertension


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michael kutryk, M.D.

BiographyDr. Kutryk is a Staff Physician in the Division of Cardiology at St. Michael’s Hospital and is an Assistant Professor in theDepartment of Medicine at the University of Toronto. He received his medical degree and his Ph.D (CardiovascularPhysiology) at the University of Manitoba. He received his speciality certification in internal medicine at McGillUniversity.

Dr. Kutryk has published over 100 peer-reviewed articles, books, book chapters, and abstracts.

Tomorrow: Stem Cell Therapy: The PHACET Trial


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V - Cardiac Imaging & ChallengingAortic Disease Cases

Stuart hutchison, M.D.

BiographyDr. Stuart Hutchison received his MD from McGill University, where he also completed internal medicine andcardiology residencies. After one year on staff as an attending cardiologist at the Montreal General Hospital, heperformed a two year echo/TEE fellowship in Los Angeles under the supervision of Drs. Chandraratna and Rahimtoola,and a 2-year clinical instructorship in San Francisco, in vascular physiology under the supervision of Drs. KanuChatterjee and William Parmley.

He returned to Canada in 1996 as an Assistant Professor at the University of Toronto, where he has been the Directorof the Echocardiography and Vascular Ultrasound Labs since 1998, and the Cardiology Residency Coordinator since2000 and the Educational Director for the Division of Cardiology since 2005 at St. Michael’s Hospital. He has receivedseveral teaching awards, including a provincial PAIRO Award for Excellence in Teaching in 2002.

Teaching integration of detailed knowledge of diagnostic imaging and clinical cardiology is his foremost teachingphilosophy, and development of print-based and computer-based learning aids his most enjoyable work.


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V - Cardiac Imaging & ChallengingAortic Disease Cases

Stuart hutchison, M.D.

Abstract

Assessment of chest pain, part i c u l a rly in the ER setting, requires consideration of a range of possible underlying causes.C o n s i d e ration of aortic disease is usually prompted by the severe nature of chest pain, an abnormal CXR, or by ex c l u s i o nof ischemic causes.

Dissection is the usual aortic pathology that is considered; however multiple aortic pathologies may be responsible for“an acute aortic syndromes”, including hemorrhage into the wall of the aorta (IntraMural Hematoma – IMH),atherosclerotic ulceration into/through the wall of the aorta (Penetrating Aortic Ulcer – PAU), and penetrating aorticatherosclerotic ulcers that cause intramural hematomas. It is estimated that intramural hematomas constitute 10-5% ofsuspected dissection cases. A dissection of the aorta is relatively easy to image and identify in most cases, as the flapis readily visible by most imaging modalities (ultrasound, CT, MRI, aortography). In contradistinction, the imagingappearance of intramural hematomas is subtle, and penetrating ulcers are small and may be hidden amongatherosclerotic surface irregularities. IMHs and PAUs are constituted new.

Data is accumulating on the natural history and possible management strategies for these lesions. Intramuralhematomas may progress into overt dissection, and have a short-term natural history somewhat similar to dissection;therefore, they are generally managed similarly to acute dissections. Penetrating ulcers are less well understood, buthave been successfully detected and managed.

Therefore clinical suspicion, perseverance and attention to imaging detail are essential to recognize these other aorticlesions - “Ruling-out dissection” is no longer adequate as it will fail to make a positive diagnosis. Cardiovascular maging modalities continue to improve; concurrently increasing suspicion of these other aortic lesions should lead tobetter recognition of these other life-threatening, and manageable, aortic pathologies.


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VI - Debate Be It Resolved That: “Patients With ThreeVessel Disease Are Better Served By Surgery Than PCI”

Thomas Parker, M.D.

BiographyDr. Parker is presently Head, Division of Cardiology, and the inaugural recipient of the Brazilian Ball Research Chair in Cardiology Research, at St. Michael’s Hospital, and Associate Professor of Medicine, University of Toronto. Hereceived his MD degree from the University of Western Ontario and undertook postgraduate clinical training at the University of Toronto and a Research Fellowship in Molecular Cardiology at Baylor College of Medicine, Houston,Texas. On his return to Toronto, he established a research laboratory at the Toronto General Hospital with an interest inthe molecular control of cardiac muscle growth and hypertrophy. He was recruited to St. Michael’s Hospital in July, 2003,where he has established a research program funded by the Canadian Institutes of Health Research focusing on molec-ular genetic approaches to cardiac dysfunction post-infarction and their clinical applications.


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Robert Chisholm, M.D.

BiographyDr. Chisholm is an Interventionalist and Director of the Cath Lab at St. Michael’s Hospital.



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Lee Errett, M.D.

BiographyDr. Errett has been the Chief of Cardiovascular and Thoracic Surgery at St. Michael's Hospital and University of Torontosince 1994. Prior to that, his university appointments have been at Yale, McGill, and Oxford Universities. His cardiacsurgical training was at McGill University in Montreal and fellowship at Duke University. His main research focus hasbeen in clinical trials. His laboratory focus is based on nutrigenomics which is basically the control of genes with nutrition.


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online proceedings

Documents

division of cardiology

cardiology training

university of toronto

clinical training

canadian heart research

department of medicine

middlesex hospital

robert chisholm cardiology