The manuscripts associated with these summary presentations are
in press and will be published in the Canadian Cardiovascular
Society (CCS) journal in 2011.
Guidelines are one of the highest priorities for the CCS.
“Feedback and surveys from the CCS membership and the broader
cardiovascular community tell us that CCS guidelines are among our
most important functions,” says CCS president Dr. Charles Kerr. “As
we embark on each new guideline project, we endeavor to identify
strong co-chairs and expert panels so we can continue to support
Canadian cardiovascular health care practitioners in delivering the
highest level of evidence-based care.”
This year, the CCS guidelines committee, chaired by Dr Michelle
Graham, has overseen the release four position statements and four
guidelines.
“This hard working group is responsible for selecting the topics
each year for CCS guideline and position statements and ensuring
that each is executed in a rigorous and highly transparent manner,”
says Dr. Graham.
The guidelines are an invaluable resource not only for members
of the cardiovascular community, but for healthcare practitioners
throughout Canada.
GUIDELINE HIGHLIGHTS
2010 CCS atrial fibrillation guidelines Co-chaired by Drs.
Anne Gillis and Allan Skanes
Atrial fibrillation (AF) is the most common sustained arrhythmia
treated in clinical practice and is associated with substantial
morbidity including frequent emergency department visits and
hospitalizations for symptoms secondary to AF and an increased risk
for stroke. AF is an emerging epidemic as the population ages and
indeed, the lifetime risk of developing AF in individuals older
than 40 years of age is one in four. The Canadian Cardiovascular
Society last published a set of recommendations on the diagnosis
and management of AF in 2005. Since then, major advances in the
management of AF have occurred including the results of clinical
trials providing guidance on pharmacologic therapies for management
of AF, and antithrombotic therapies for prevention of systemic
thromboembolism, the continuing evolution of catheter ablation for
treatment of AF, and the development of a simple semi-quantitative
scale that closely approximates patient-reported subjective
measures of quality of life in AF.
What’s new:
This is the first CCS guidelines panel to employ the GRADE
(Grading of Recommendations Assessment, Development, and
Evaluation) system of evaluation, replacing the ACC/AHA scale for
level of evidence that was previously used. The approach separates
the quality of evidence (very low, low, moderate, or high quality),
from the strength of recommendations, (strong or conditional i.e.,
weak). GRADE allows acknowledgment of values and preferences in the
provision of clinical care in determining the strength of
recommendations.
We recommend that treatment for rate control of
persistent/permanent AF/AFL should aim for a resting heart rate of
less than 100 beats per minute. (Strong Recommendation, High
Quality Evidence).
We recommend that the goal of rhythm control therapy should be
improvement in patient symptoms and clinical outcomes, and not
necessarily the elimination of all AF. (Strong Recommendation,
Moderate Quality Evidence). The choice of antiarrhythmic drug
therapy should be individualized based on the patients underlying
heart disease and risk of adverse effects.
We recommend intermittent antiarrhythmic drug therapy (“pill in
pocket”) in symptomatic patients with infrequent, longer-lasting
episodes of AF/AFL as an alternative to daily antiarrhythmic
therapy. (Strong Recommendation, Moderate Quality Evidence)
We recommend radiofrequency ablation of AF in patients who
remain symptomatic following adequate trials of antiarrhythmic drug
therapy and in whom a rhythm control strategy remains desired.
(Strong Recommendation, Moderate Quality Evidence)
We recommend that in most patients at low risk of stroke (CHADS
2 = 1) should receive either Warfarin (INR 2 3) or Dabigatran.
(Strong recommendation, High Quality Evidence). However, based on
individual risk/benefit considerations, we suggest that Aspirin is
a reasonable alternative for some. (Conditional Recommendation,
Moderate Quality Evidence).
We recommend that patients at moderate to high risk of stroke
(CHADS 2 ≥ 2) should receive either Warfarin (INR 2 3) or
Dabigatran. (Strong recommendation, High Quality Evidence)
We suggest, based on its safety and efficacy profile, that
Dabigatran is preferred over Warfarin. In general, the dose of
Dabigatran 150 mg po bid is preferred over a dose of 110 mg po bid
for overall stroke reduction (exceptions discussed in text).
(Conditional Recommendation, High Quality Evidence)
What health professionals need to know:
CCS is using the GRADE system of evaluation, which separates the
quality of the evidence from the strength of the recommendation for
all future guidelines.
Aggressive treatment of underlying causes such as hypertension
or sleep apnea is paramount to AF arrhythmia management.
The goals of AF therapy should be clearly defined and discussed
with the patient.
Heart rate targets for AF rate control can be liberalized to a
resting heart rate of < 100 bpm.
The decision to use a rate control strategy versus a rhythm
control strategy is based on patient preferences to balance relief
of symptoms and improvement in QOL and other clinical outcomes with
the potential greater adverse effects of Class I/III antiarrhythmic
drugs compared to rate control therapy.
Referral for AF ablation is an acceptable approach for patients
who remain symptomatic despite at least one trial of an
antiarrhythmic drug for maintenance of sinus rhythm.
Decisions on antithrombotic therapy selection should be based on
the use of a predictive index for risk of stroke and an index for
risk of bleeding.
Dabigatran based on its safety and efficacy profile may be
preferred over Warfarin for stroke prevention. However, the cost
benefit of this therapy is evolving.
2010 CCS Antiplatelet Guideline Co-chaired by Drs. Alan Bell
and Jean Francois Tanguay
Antiplatelet agents are a cornerstone therapy for patients with
manifest atherosclerotic vascular disease in the coronary,
cerebral, and peripheral beds. To provide a comprehensive, evidence
based, treatment centred statement on managing antiplatelet therapy
in Canadian outpatients who have existing, or are at risk of
developing, vascular disease, the Canadian Cardiovascular Society
antiplatelet guideline was created. The document provides
authoritative guidance for all health care professionals managing
vascular outpatients in wide range of clinical circumstance.
What’s new:
- Continuation of dual antiplatelet therapy beyond 12 months may
be considered in patients with a high risk of thrombosis and a low
risk of bleeding. - Dual antiplatelet therapy with ASA 75-162 mg daily plus
clopidogrel 75 mg daily in the first month after TIA or minor
ischemic stroke may be superior to aspirin alone in patients not at
a high risk of bleeding. - For men and women without evidence of manifest vascular
disease, the use of ASA at any dose is not recommend for routine
use to prevent ischemic vascular events. - There is currently no evidence to recommend routine use of ASA
at any dose for the primary prevention of vascular ischemic events
in patients with diabetes. - For individuals with heart failure of non-ischemic etiology,
routine use of antiplatelet agents is not recommended. - Patients taking dual antiplatelet therapy with clopidogrel and
ASA who require urgent surgery within six weeks of BMS placement or
12 months of DES placement should have both drugs continued in the
perioperative period whenever possible. - For cardio- or cerebrovascular disease in which antiplatelet
therapy would be indicated in non-pregnant women, there should be
similar considerations for its use in pregnancy. - In patients taking low-dose ASA (75-162 mg daily) for vascular
protection requiring an anti-inflammatory drug, specific COX-2
inhibitors (coxibs) should be chosen over traditional NSAIDS. - Until a definitive RCT is completed it is reasonable to avoid
the concomitant use of clopidogrel and specific CYP2C19-inhibiting
PPIs.
What health professionals need to know:
- Antiplatelet therapy should be continued for life in all
patients with manifest ischemic vascular disease unless
specifically contraindicated. - Long term dosing of ASA > 162 mg/day should be avoided due
increased bleeding risk and the lack of greater anti ischemic
benefit over lower doses. - Dual antiplatelet therapy with low dose ASA and an ADP P2Y12
receptor blocker is indicated in all patients with ACS unless
specifically contraindicated. Duration of therapy should be
individualized based on thrombotic and bleeding risk. - Dual antiplatelet therapy with low dose ASA and an ADP P2Y12
receptor blocker should be avoided in long term secondary stroke
prevention. - Antiplatelet therapy is not recommended for primary prevention
of ischemic vascular events in the presence or absence of
diabetes. - Antiplatelet therapy should not be discontinued for minor or
nuisance bleeding. - Use of antiplatelet agents in the perioperative period should
be individualized, based on the risks of thrombosis and
bleeding.
CCS position statement on smoking cessation Chaired by Dr.
Mark J. Eisenberg
What’s new:
The recognition that the management of smoking cessation has
been less than optimal in the cardiovascular community and that the
introduction of systematic approaches to the identification,
documentation, and provision of smoking cessation assistance can
distinctly improve the health of our smoker-patients and their
communities. Smoking cessation is acknowledged as the most
important preventive intervention and the members of the Canadian
Cardiovascular Society are committed to enhancing our ability to
address this fundamental preventive responsibility.
What health professionals need to know:
Smoking cessation is the most important preventive
responsibility of all clinicians who see smokers. Systematic
approaches to the identification of smokers and the provision of
cessation assistance can distinctly improve the likelihood of
quitting. All health professionals who see smokers should be
familiar with the provision of such assistance to their patients in
order to facilitate quit-attempts. Smoking is not a ‘habit’ −
it is a tenacious addiction and our patients will benefit from the
very specific assistance we can provide.
2011 Joint Canadian Cardiovascular Society Canadian Pain
Society Guidelines for the management of refractory angina Chaired
by Drs. Michael McGillion and Heather Arthur
Refractory angina (RFA) is a debilitating condition
characterized by severe, unremitting cardiac pain. Effective care
for Canadians with RFA is critical. The incidence and prevalence of
RFA is expected to rise as coronary artery disease-related survival
rates continue to increase and our population ages. These
guidelines represent a formal collaboration between the Canadian
Cardiovascular Society (CCS) and the Canadian Pain Society (CPS) to
tackle the problem of RFA.
What health professionals need to know:
- RFA is caused by coronary insufficiency, in the presence of
coronary artery disease, which cannot be controlled by a
combination of medical therapy, angioplasty, and/or coronary artery
bypass graft surgery. While the presence of reversible myocardial
ischemia must be clinically established to be the root cause, the
pain experienced may arise or persist with or without this
ischemia. - An understanding of how chronic ischemic and pain mechanisms
act in concert is critical to effective RFA assessment and
management. A comprehensive treatment approach targets ischemic as
well as pain mechanisms.
The 2011 joint CCS-CPS guidelines will present an assessment of
current and emerging therapies for RFA along with recommendations
for RFA management based on the GRADE system of evidence
evaluation, which was recently adopted as the standard for evidence
evaluation by the CCS. Recommendations for future directions in
RFA-related research and patient care in Canada are also
presented.
Systematizing Inpatient Referral to Cardiac Rehabilitation: A
joint policy position of the Canadian Association of Cardiac
Rehabilitation and Canadian Cardiovascular Society −
Co-chaired by Drs. Sherry Grace and Caroline Chessex
Cardiac rehabilitation (CR) is an outpatient chronic disease
management program, offering structured exercise and education for
risk reduction. Participation in cardiac rehabilitation
significantly reduces mortality and re-hospitalization and improves
quality of life. Despite its integral role in the continuum of
care, cardiac rehab is under-used. One of the chief reasons is
referral failure.
What’s new:
Obstacles to referral can be overcome through systematic
adoption of standing orders and other adjunct approaches for CR
referral of indicated hospitalized patients.
Systematic referral strategies can be characterized as the
implementation of standing referral orders to CR for indicated
patients. These strategies can be implemented through discharge
order sets or electronic medical records.
‘Liaison’ strategies are characterized by a healthcare provider
speaking to the inpatient at the bedside about CR and initiating
referral. This enables two-way communication regarding the nature
of CR, its benefits, and how to address any patient-perceived
barriers to participation.
Other strategies identified in the review include dissemination
of patient education materials or motivational letters to augment
CR utilization.
A combined referral strategy can achieve referral of
approximately 85% of patients. Inpatients should be targeted for
referral to ensure universal case-identification and timely access,
with a goal of 70% patient enrolment in cardiac rehab.
What health professionals need to know:
Appropriate cardiac patients are defined as those who have
experienced acute coronary syndrome, chronic stable angina or heart
failure, percutaneous coronary intervention, bypass surgery,
cardiac valve surgery, transplantation, or resyncronization
therapy.
Best practice in cardiac rehabilitation referral consists of
systematic inpatient mechanisms to ensure referral, as well as
discussion with the patient at the bedside.
Provider endorsement of cardiac rehabilitation has additive
benefit in terms of patient enrolment, over and above systematic
strategies.
CCS position paper on the standardized approaches to the
investigation of syncope Chaired by Dr. Robert Sheldon
What’s new:
Syncope is a very common presentation in the emergency room and
in hospital and the combination of a wide differential diagnosis, a
range of prognoses, and infrequent documentation of the faint leads
to a high proportion of patients being admitted. The high
proportion of patients with benign outcomes and the profound risk
aversion of health care providers make for expensive and
inefficient assessment. Emergency room decision rules, specialized
syncope monitoring units, and formal diagnostic algorithms have all
been developed to provide standardized approaches to the
investigation of syncope. Recognizing that there were no summary
documents on the merits and weaknesses of these approaches, the
Canadian Cardiovascular Society commissioned a position paper on
standardized approaches to syncope investigation in adults.
What health professionals need to know:
There is little high quality evidence addressing any of the
issues, but several key observations and recommendations were
made.
- In the first 7 days following discharge from ER, only
0.7% die and 4.5% have a procedure or an adverse event. - Patients with any one of heart failure, hypotension, an
abnormal ECG, or any history of heart disease should have a cardiac
assessment within two weeks. - Patients with any one of age >60y, cerebrovascular disease,
hypertension, dyspnea, a family history of sudden death, syncope
without prodrome or while supine or during exercise, or anemia
could be considered for urgent assessment. - Emergency room syncope decision rules may have prognostic
value, but is no compelling evidence that they improve diagnostic
accuracy or reduce costs, and they may increase costs
substantially. - Formal syncope units might increase diagnostic yield and
prevent unnecessary admissions and testing, but this may be
explained simply by advanced access to specialist assessment and
related testing. - Algorithmic testing coupled with implementation tools improves
diagnostic yield and may reduce costs. Key tactics include access
to specialist back-up, and provision of an on-line prompting
tool.