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Competition Results 2019

For the fifth consecutive year, the Canadian Cardiovascular Society (CCS) is proud to announce the results of what in 2019 was newly named the Early Career Arrhythmia and Atrial Fibrillation (AF) Research Award (ECA3). This program, created to encourage clinical, health systems and population health research in the field of arrhythmia and AF, has become an important initiative supporting CCS members and early-career investigators.

This year, five awards totaling $600,000 have been granted - 41% of all full proposals received. Since 2015, CCS program partner, the Bristol-Myers Squibb/Pfizer Alliance has invested over $1,000,000 in the program, with a new contribution in 2019 from CANet of $300,000. Without this generous support, these prestigious early career research awards would not be possible.

All proposals are reviewed by an independent peer review committee comprised of CCS members. Awards include funds for salaries, supplies, and/or equipment. The start date for these awards is Aug 1, 2019. Principal Investigators are named below. Co-Applicants and/or additional authors may also be associated with these grants.

JE
 
  TC

Principle Investigators: Jodi Edwards and Thais Coutinho

Proposal Title: Do hypertensive disorders of pregnancy increase the risk of incident atrial fibrillation?

Duration: July 2019-June 2022 (3 years)

Project Outline: Rationale: Women with hypertensive disorders of pregnancy (HDP) have a 4-fold increased risk of chronic hypertension and heart failure (HF) compared to those with normotensive pregnancies. Chronic hypertension, atrial fibrillation (AF) and HF are closely inter-related; however, despite the dramatically increased risk of chronic HTN and HF in women with HDP, and evidence for links with AF, relatively little is known about the risk of AF in women with HDP. 

Objective: The objective of this study is to test whether the presence, severity and recurrence of HDP independently increase incident AF risk, whether chronic hypertension additively contributes to this risk, and whether incident AF contributes to the long-term risk of HF in women with HDP. 
Methods: The proposed research is uniquely poised to address these questions. Our multidisciplinary team will have immediate access to multiple linked databases currently available within ICES to examine associations between HDP and AF in women from the general population in Ontario using multivariable survival analyses with methods for competing risks and additive subdistribution modeling. 

Impact: This study represents a critical first step for the development of: 1) women-specific AF risk assessment scores which incorporate information on obstetric history,

2) effective screening strategies for the early detection of AF risk in women with HDP, and

3) urgently needed evidence-based guidelines to help clinicians reduce the risks of AF and other cardiovascular complications after HDP. Until this evidence is available, the opportunity to reduce gaps in cardiovascular health for women with HDP will not be realized.

NMH
 
  CBF

Principle Investigators: Nathaniel M. Hawkins and Christopher B. Fordyce

Proposal Title: Opportunities to prevent sudden cardiac death: the BC Cardiac Arrest registry

Duration: July 2019-June 2021 (2 years)

Project Outline: Rationale: Sudden cardiac death (SCD) is a major public health concern. A significant proportion present as out-of-hospital-cardiac arrest (OHCA). Survival to discharge is low despite advances in resuscitation. Uptake of implantable cardioverter defibrillators (ICDs) in survivors is suboptimal, and their role in patients with reversible causes is uncertain. This research aims to identify patients at risk of SCD, and opportunities to improve long-term outcomes, including preventing recurrence. 

Objectives: 1) Examine health care utilization and investigations in the two years prior to OHCA compared to matched populations to assess opportunities for intervention to prevent SCD; 2) Examine the rate, predictors and associated outcomes of ICD implant following OHCA in patients with shockable presenting rhythm and no reversible cause, in order to assess time trends, inequalities, and barriers to care; 3) Examine the risk and predictors of recurrent SCD/VT/VF in survivors of OHCA with ischemic and non-ischemic reversible causes, and association of ICD therapy with long-term outcomes.

Methods: The program comprises 3 projects which leverage a unique dataset combining the BC Cardiac Arrest registry with the BC provincial registry of cardiac procedures and administrative databases. Project 1 examines sentinel events preceding OHCA using a case control design. Projects 2 and 3 are retrospective cohort studies, in which reversible causes are defined using the linked databases including revascularization and coronary anatomy. Project 2 defines independent predictors of ICD implant using multivariable logistic regression, and outcomes using propensity matched cohorts. Project 3 employs survival analysis and examines predictors of outcomes using Cox regression models. 

Krystina Lewis
 

Principle Investigator: Krystina B. Lewis, RN, MN, PhD

Proposal Title: Identifying effective strategies to engage patients in making decisions along the ICD

care pathway: A multi-province comparative case study

Duration: July 2019-June 2021 (2 years)

Project Outline: Implantable cardioverter-defibrillators (ICDs) are an effective treatment with known survival benefit for appropriately selected patients at risk of sudden death. However, in cases of advancing age, multi-morbidity, frailty, and cognitive dysfunction, the benefit attenuates, and hospitalizations and mortality rise. Further, living with an ICD is not without risk. To ensure appropriate use, an emphasis on ICD therapy as a trajectory of dynamic decisions that are subject to discussion may help patients, families, and clinicians adjust their expectations of ICD therapy, not as an irrevocable treatment but one of appropriate use based on the clinical situation and aligned with the patient’s evolving preferences and health goals. Patient decisions aids (PDAs) can facilitate such discussions. PDAs exist for the series of key ICD decisions, namely initial implantation, generator replacement and deactivation of tachytherapies, but are not yet used in practice.

The aim of this project is to establish a feasible and sustainable approach to PDA use across the ICD pathway. Guided by the Knowledge-to-Action framework, a comparative case study in three high volume implanting centres across two provinces aims to 1) identify determinants of PDA use across the ICD pathway, and 2) select implementation strategies tailored to context to overcome identified barriers. Participatory methods such as focus groups and interviews with clinicians, administrators, and patients and families will be used. Content analysis will occur within and across sites. Findings will inform our next phase, focused on the implementation, monitoring, and evaluation of PDA use on patient, clinician, and health system outcomes. 

MMS
 

Principle Investigator: Mouhannad M. Sadek, MD FRCPC

Proposal Title: Non-Invasive Evaluation of Pulmonary Vein Isolation

Duration: July 2019-June 2021 (2 years)

Project Outline: Rationale: Catheter ablation is associated with improved quality of life in patients with symptomatic recurrent AF. Multiple studies have shown that pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for AF. PV electrical reconnection of one or more PVs responsible for AF recurrence occurs in 21-80% of patients after catheter ablation for AF. Importantly repeat ablation in the setting of PV reconnection is known to improve outcomes; however, limited benefit is observed in patients without PV reconnection. Thus non-invasive assessment of PVI can significantly improve patient care as it may assist with the selection of patients most likely to benefit from catheter ablation. 
Study objectives are: (1) to assess the pattern of normal LA-PV electrical conduction using body surface potential mapping(BSPM) in patients with AF, and (2)to determine the accuracy of BSPM for the detection of partial and complete PVI after AF ablation. 

Methods: 30 patients with clinically indicated catheter ablation for AF will be enrolled. The correlation between BSPM findings will be compared to intracardiac mapping (gold standard). BSPM findings during normal LA-PV conduction, partial and complete PVI will be compared to intracardiac mapping. Data will be assessed by two blinded reviewers per patient. 

If we prove our hypothesis this will have major clinical value since BSPM may be used to assist in the selection of patients who are more likely to benefit from repeat catheter ablation, as incremental success rate is very modest for patients who do not have PV reconnection. 

EBC
 

Principle Investigator: Emilie Belley-Côté, MD, MSc

Proposal Title: Direct Oral Anticoagulation versus Warfarin after Cardiac Surgery (DANCE) Pilot Trial

Duration: July 2019-June 2021 (2 years)

Project Outline: Background: Of patients requiring cardiac surgery, 10% have a history of atrial fibrillation (AF) and AF is the most frequent complication after cardiac surgery, occurring in up to 60% of patients. Anticoagulation prevents embolic complications in patients with AF and direct oral anticoagulants (DOACs) are generally the treatment of choice. However, in the cardiac surgical population, a small phase II trial suggested a higher risk of complications with DOACs. The existing evidence to guide OAC after cardiac surgery is of very low quality. Thus, a large, randomized controlled trial is required to definitively determine whether DOACs are safe in patients early after cardiac surgery. 

Study Design: The Direct Oral Anticoagulation versus Warfarin after Cardiac Surgery (DANCE) will be a prospective, randomized, open-label, blinded end-point, multicentre non-inferiority clinical trial. The intervention of interest is DOAC at full AF recommended dose, adjusted for renal function if required. The comparator is warfarin. Adults within 7 days after cardiac surgery who have an indication for anticoagulation will be eligible. We will exclude patients with a mechanical valve, with antiphospholipid syndrome, or with a contraindication to DOACs or warfarin. In the 200-patient pilot trial, we will assess whether it is feasible to conduct a large trial evaluating whether DOACs are noninferior to warfarin with regards to major bleeding at 30 days in patients with an indication for anticoagulation early after cardiac surgery. 

Organization: The pilot trial will be conducted in 5 Canadian centres and led from the Population Health Research Institute in Hamilton, Canada.

     
     
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