Where you Live in Nova Scotia Can Significantly Impact Your Access to Lifesaving Cardiac Care: Access to Invasive Care Influences Survival

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 Queen Elizabeth II Health Sciences Centre (QEII-HSC). Methods: All consecutive patients diagnosed with ACS and CS in 2009-2013 in Nova Scotia were included. Data were obtained from the clinical database of Cardiovascular Health Nova Scotia. The primary outcome was in-hospital mortality. Results: A total of 418 patients with ACS and CS were admitted to the hospital. Access to invasive care was limited to 309 (73.9%) of these patients. For those who presented elsewhere in the province, 64.2% were transferred to the QEII-HSC. The mortality rate among the 309 patients with access to invasive care was significantly lower than that among the 109 patients who did not have access (41.7% vs 83.5%; P < 0.0001). Unadjusted mortality was lowest among patients undergoing primary percutaneous coronary intervention (33.1%). After adjustment for clinical differences, access to cardiac catheterization remained an independent predictor of survival (odds ratio, 0.2; 95% confidence interval, 0.11-0.36). Heat map analysis revealed that access was lowest in regions furthest from Halifax. Conclusions: ACS complicated by CS has a high mortality rate. We demonstrate that access to health care centres offering cardiac catheterization is independently associated with survival, and public health initiatives that improve access should be considered. Patients presenting furthest from Halifax were the least likely to be transferred, suggesting that geography remains an important barrier to livesaving care.