The 2011 Canadian Cardiovascular Society heart failure management guidelines update: focus on sleep apnea, renal dysfunction, mechanical circulatory support, and palliative care.
The 2011 Canadian Cardiovascular Society Heart Failure (HF) Guidelines Focused Update reviews the recently published clinical trials that will potentially impact on management. Also reviewed is the less studied but clinically important area of sleep apnea. Finally, patients with advanced HF represent a group of patients who pose major difficulties to clinicians. Advanced HF therefore is examined from the perspectives of HF complicated by renal failure, the role of palliative care, and the role of mechanical circulatory support (MCS). All of these topics are reviewed from a perspective of practical applications. Important new studies have demonstrated in less symptomatic HF patients that cardiac resynchronization therapy will be of benefit. As well, aldosterone receptor antagonists can be used with benefit in less symptomatic HF patients. The important role of palliative care and the need to address end-of-life issues in advanced HF are emphasized. Physicians need to be aware of the possibility of sleep apnea complicating the course of HF and the role of a sleep study for the proper assessment and management of the conditon. Patients with either acute severe or chronic advanced HF with otherwise good life expectancy should be referred to a cardiac centre capable of providing MCS. Furthermore, patients awaiting heart transplantation who deteriorate or are otherwise not likely to survive until a donor organ is found should be referred for MCS.
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Comment In: Can J Cardiol. 2011 Nov-Dec;27(6):871.e721885242
Canadian Cardiovascular Society Consensus Conference recommendations on heart failure update 2007: Prevention, management during intercurrent illness or acute decompensation, and use of biomarkers.
Heart failure is common, yet it is difficult to treat. It presents in many different guises and circumstances in which therapy needs to be individualized. The Canadian Cardiovascular Society published a comprehensive set of recommendations in January 2006 on the diagnosis and management of heart failure, and the present update builds on those core recommendations. Based on feedback obtained through a national program of heart failure workshops during 2006, several topics were identified as priorities because of the challenges they pose to health care professionals. New evidence-based recommendations were developed using the structured approach for the review and assessment of evidence adopted and previously described by the Society. Specific recommendations and practical tips were written for the prevention of heart failure, the management of heart failure during intercurrent illness, the treatment of acute heart failure, and the current and future roles of biomarkers in heart failure care. Specific clinical questions that are addressed include: which patients should be identified as being at high risk of developing heart failure and which interventions should be used? What complications can occur in heart failure patients during an intercurrent illness, how should these patients be monitored and which medications may require a dose adjustment or discontinuation? What are the best therapeutic, both drug and nondrug, strategies for patients with acute heart failure? How can new biomarkers help in the treatment of heart failure, and when and how should BNP be measured in heart failure patients? The goals of the present update are to translate best evidence into practice, to apply clinical wisdom where evidence for specific strategies is weaker, and to aid physicians and other health care providers to optimally treat heart failure patients to result in a measurable impact on patient health and clinical outcomes in Canada.
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Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada. Electronic address: Carolina.alba@uhn.ca.
Circulating progenitor cells (CPCs) are involved in the process of endothelial repair and are a prognostic factor in cardiovascular diseases. We evaluated the association between serial measurements of CPCs and functional capacity and outcomes in heart failure (HF).
We included 156 consecutive consenting ambulatory HF patients (left ventricular ejection fraction
Fewer patients are undergoing reoperative coronary artery bypass grafting (CABG). We investigated the prevalence of redo vs primary CABG and previous percutaneous coronary intervention (PCI), changing trends in preoperative risk profiles, and independent predictors of operative death.
Data on demographic characteristics, preoperative risk factors, and hospital outcomes were collected prospectively for patients undergoing isolated reoperative CABG from January 1, 1990, to December 31, 2009. To examine the effect of time on the prevalence of redo CABG cases and previous PCI, we divided patients into four groups: 1990 through 1994, 470; 1995 through 1999, 415; 2000 through 2004, 240; and 2005 through 2009, 79. To examine risk profiles and outcomes, we created two groups: 1990 through 1999, 885; 2000 through 2009, 319.
Redo CABG decreased from 7.2% (1990 through 1994) to 2.2% (2005 through 2009). PCI before redo CABG significantly increased from 14.5% (1990 through 1994) to 26.6% (2005 through 2009). Patients with diabetes, dyslipidemia, hypertension, peripheral vascular disease, and left main disease increased. In-hospital mortality did not change significantly, but postoperative low cardiac output syndrome dropped. Age (odds ratio [OR], 1.04), peripheral vascular disease (OR, 2), congestive heart failure (OR, 5.8), and preoperative shock (OR. 9.7) independently predicted higher operative mortality.
Reoperative CABG has significantly decreased. The increased prevalence of PCI before redo CABG is one of the reasons. Despite an increasing risk profile, hospital outcomes have remained largely the same. Preoperative shock and congestive heart failure are the most important predictors of operative mortality.
Patients undergoing emergency coronary artery bypass grafting represent a unique and high-risk population that remains challenging for cardiac surgeons. We examined the changing trends in patients undergoing emergency bypass grafting over the past 20 years.
We conducted a retrospective review of our database between 1990 and 2009 and patients were divided into 2 groups based on year of operation: 1990-1999, n = 393; 2000-2009, n = 184. The primary outcomes of interest for this study are operative mortality and incidence of low cardiac output syndrome.
The percentage of patients undergoing emergency coronary bypass grafting has decreased from 2.7% to 1.7% over time. The percentage of patients with dyslipidemia, hypertension, triple vessel disease, peripheral vascular disease, and left main disease increased over time (P
The purpose of this study is to describe the treatment preferences of patients with heart failure among three distinct treatment options--optimal medical management, oral inotropes or left ventricular device (LVAD) support--to determine if there were differences in preferences between patients with mild heart failure (New York Heart Association [NYHA] Class II) and severe heart failure (NYHA Class IV), and also to determine whether quality of life, perceived severity of symptoms and overall health influenced treatment preferences.
We enrolled 91 patients who completed the Minnesota Living with Heart Failure Questionnaire (MLHFQ); visual analog scales for depicting their perceived severity of overall health, dyspnea and fatigue; and a treatment trade-off tool.
The most preferred treatment options were oral inotropes, LVAD and standard medical management. There were no differences in treatment preferences between NYHA II and NYHA IV patients. Patient preferences correlated poorly with MLHFQ, symptom and overall health scores. Although not statistically significant, there was a trend toward patients with worse quality of life and symptom scores preferring more aggressive treatment.
The results of our study identified two distinct groups of patients: one group preferring treatments that prolonged survival time and another group that favored strategies that improved quality of life but reduced survival time. Treatment preferences were independent of functional or symptom status, suggesting that preferences may be decided early in the course of illness.
Octogenarians are the fastest growing population in Canada and have also been referred for coronary artery bypass grafting (CABG) with increasing frequency during the past decade.
To examine the changing trends in preoperative risk profiles, postoperative outcomes and hospital resource use in the octogenarian population.
A retrospective review was conducted to identify all patients 80 years of age or older who underwent isolated CABG at the Toronto General Hospital (Toronto, Ontario) between 1990 and June 2005. To examine the effect of time on preoperative risk, patients were divided into three groups based on year of operation: 1990 to 1994, n=92; 1995 to 1999, n=202; and 2000 to June 2005, n=314.
The preoperative risk profile of octogenarians undergoing CABG has changed over the years. The percentage of patients with diabetes, dyslipidemia, hypertension and left main disease increased over time (P
The most important limitation in organ transplantation is donor availability. Canada is facing a serious situation with respect to organ donation rates and transplantation. The number of patients listed for heart transplant continues to increase while the number of available donors has plateaued. Several steps can be taken to address this growing mismatch. The proper identification and assessment of potential donors together with improvements in medical management may increase the donor pool. Additionally, the use of marginal donors and the development of new organ preservation techniques may lead to an increase in the number of potential heart transplants in Canada. This paper summarizes the identification, evaluation and management of heart transplant donors, and defines strategies to improve procurement activity in heart transplantation.
Our objective was to examine whether preoperative non-dialysis-dependent renal dysfunction is associated with operative mortality or morbidity in isolated valve surgery.
We reviewed consecutive patients undergoing isolated aortic (n = 2132) or mitral valve (n = 1664) surgery, between 1996 and 2009. Preoperative renal dysfunction was defined as preoperative estimated glomerular filtration rate
BACKGROUND: Fixed pulmonary hypertension (FPH) is considered a contraindication to cardiac transplantation. Ventricular assist device (VAD) therapy through prolonged left ventricular unloading may reverse FPH. Our aim was to assess post-transplant outcomes and survival in patients with and without FPH undergoing VAD implantation as bridge to transplant. METHODS: Fifty-four patients received an intracorporeal left VAD (LVAD) as a bridge to transplant from 2000 to 2008 at two institutions (Rigshospitalet, Denmark, and the Toronto General Hospital, Canada). Twenty-two (41%) patients had fixed FPH (defined as pulmonary vascular resistance [PVR] >3 Wood units and resistant to pulmonary vasodilators) prior to VAD implant (FPH group) and were compared with 32 patients without FPH (NoFPH group). Baseline characteristics, pre- and post-transplant pulmonary pressures, incidence of complications and post-transplant survival were analyzed. RESULTS: Baseline characteristics were similar except that patients in the FPH group were older (46 +/- 11 years vs 39 +/- 13 years in the NoFPH group, p
