Graham Nichol, MD, MPH, FRCP(C) gnichol@ohri.ca

When someone suffers a heart attack, every second counts. Ambulances and paramedics are quite effective at treating people once they arrive, but they are rarely on the spot, and their services are already in high demand. Often, critical time is lost while the ambulance is on its way. That makes the question of public access to defibrillators important. If this equipment were available at, say, airlines or casinos, and if security guards, airline attendants, and other non-medical personnel were trained and certified to use it, perhaps the number of people who make a full recovery from cardiac arrest might be substantially increased. Lending urgency to this pursuit is the fact that in the case of sudden cardiac arrest (the rapid loss of effective pumping of the heart due to the loss of normal electrical activity), the current survival rate to hospital discharge in Ontario is only 5.5%.

In his primary research project, Dr. Graham Nichol has been collaborating with a group in the United States to evaluate the effectiveness and cost-effectiveness of such public access to defibrillation, or PAD, for the last six years. The first step was to challenge the manufacturers of defibrillation devices to make them smaller, simpler, and easier to use. This challenge has now been met. Defibrillators have been reduced to the size of a portable computer, and now have vocal and visual prompts to assist those who have been trained in how to use them. Built-in safety mechanisms have also been added, so that the machine will not work on a person who does not need its assistance.

Once the goal of small, easy-to-use devices was attained, Dr. Nichol turned his attention to the next phase of research. With a colleague in Arizona, he trained security guards in Las Vegas casinos, where cardiac arrests are a common problem, to administer aid with this new generation of user-friendly devices. In an observational study that has just been completed, the collaborators found that the security guards, who often did not have a high school education, were able to achieve the highest survival rates that anyone has ever reported.

However, treatment for cardiac arrest is influenced by many factors, such as how long it takes ambulance attendants to arrive, their level of skill, whether CPR was adminstered immediately, etc. Therefore, Dr. Nichol and his colleagues have begun another controlled study, in which they will evaluate the effectiveness and cost-effectiveness of PAD in 20 sites, compared to other health interventions. Dr. Nichol is confident that PAD will be shown to be effective, and thus will help a significant number of people.

In collaboration with Dr. Rob Beanlands of the Heart Institute, he has just embarked on the first multicentre randomized trial ever to test the effectiveness of a technique known as PET in identifying whether patients with heart failure would benefit from bypass surgery. Ultimately, a few hundred patients will be involved, from centres across Canada and Europe.

In another project, Dr. Nichol is using decision anaylsis to evaluate the long-term benefits and costs of drug treatments for heart failure. Because there are at least five effective drug treatments, patients can sometimes be obliged to take as many as 10 pills a day. This study will establish which combinations of these drugs are most effective, thereby not only reducing the number of drugs a patient might take, but also increasing both life expectancy and quality of life.

Working with fellow Loeb researchers such as Drs. George Wells and Ian Stiell, Dr. Nichol has also actively participated in a wide range of other investigations, including a meta analysis of antiarrhythmic drugs in patients with atrial fibrillation, and a study of the cost-effectivness of different treatments provided in Ontario ambulances for patients with sudden cardiac arrest, shortness of breath, or trauma. He has also undertaken an economic evaluation of defibrillation by firefighters in Ontario; meta analyses and predictive studies of survival after pre-hospital cardiac arrest; and investigations of the quality of life of heart-attack survivors.

As a member of the Canadian Society for International Health, Dr. Nichol has been called upon to advise the Croatian government on incorporating principles such as evidence-based medicine and economic evaluation into their health-care system reforms. This flows from his primary research interest: to develop, implement, and evaluate strategies to improve the efficiency of treatments for cardiovascular disease, which is the commonest and most costly group of disorders.

Thus building his investigations around very specific questions, Dr. Nichol works to improve medical science by determining the safest, most effective, and most economic ways to handle many different problems faced by thousands of patients every day.