Major changes in acute ST elevation myocardial infarction (STEMI) management prompted a comprehensive rewriting of the American College of Cardiology/American Heart Association Guidelines. The Canadian Cardiovascular Society (CCS) participated in both the writing process and the external review. Subsequently, a Canadian Working Group (CWG), formed under the auspices of the CCS, developed a perspective and adaptation for Canada. Herein, accounting for specific realities of the Canadian cardiovascular health system, is a discussion of the implications for prehospital care and transport, optimal reperfusion therapy and an approach to decision making regarding reperfusion options and invasive therapy following fibrinolytic therapy. Major recent developments regarding indications for implantable cardioverter defibrillator(s) (ICDs) also prompted a review of indications for ICDs and the optimal timing of implantation given the potential for recovery of left ventricular function. At least a 40-day, preferably a 12-week, waiting period was judged to be optimal to evaluate left ventricular function post-STEMI. A recommended algorithm for the insertion of an ICD is provided. Implementation of the new STEMI guidelines has substantial implications for resources, organization and priorities of the Canadian health care system. While on the one hand, the necessary incremental funding to provide tertiary and quaternary care and to support revascularization and device implantation capability is desirable, it is equally or more important to develop enhanced prehospital care, including the capacity for early recognition, risk assessment, fibrinolytic therapy and/or triage to a tertiary care centre as part of an enlightened approach to improving cardiac care.
To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension.
The diagnosis of hypertension is dependent on appropriate blood pressure measurement, the timely assessment of serially elevated readings, the degree of blood pressure elevation, the method of measurement (office, ambulatory, home) and associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk and determine the urgency, intensity and type of treatment required.
MEDLINE searches were conducted from November 2007 to October 2008 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed full-text articles only.
Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Key messages include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of global risk assessment and the need for ongoing monitoring of hypertensive patients to identify incident type 2 diabetes.
All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations were required to be supported by at least 70% of task force members. These guidelines will continue to be updated annually.
The link between physical activity (PA) and prevention of disease, maintenance of independence, and improved quality of life in older adults is supported by strong evidence. However, there is a lack of data on population levels in this regard, where PA level has been measured objectively. The main aims were therefore to assess the level of accelerometer-determined PA and to examine its associations with self-reported health in a population of Norwegian older adults (65-85 years).
This was a part of a national multicenter study. Participants for the initial study were randomly selected from the national population registry, and the current study included those of the initial sample aged 65-85 years. The ActiGraph GT1M accelerometer was used to measure PA for seven consecutive days. A questionnaire was used to register self-reported health. Univariate analysis of variance with Bonferroni adjustments were used for comparisons between multiple groups.
A total of 560 participants had valid activity registrations. Mean age (SD) was 71.8 (5.6) years for women (n=282) and 71.7 (5.2) years for men (n=278). Overall PA level (cpm) differed considerably between the age groups where the oldest (80-85 y) displayed a 50% lower activity level compared to the youngest (65-70 y). No sex differences were observed in overall PA within each age group. Significantly more men spent time being sedentary (65-69 and 70-74 years) and achieved more minutes of moderate to vigorous PA (MVPA) (75-79 years) compared to women. Significantly more women (except for the oldest), spent more minutes of low-intensity PA compared to men. PA differed across levels of self-reported health and a 51% higher overall PA level was registered in those, with "very good health" compared to those with "poor/very poor health".
Norwegian older adults PA levels differed by age. Overall, the elderly spent 66% of their time being sedentary and only 3% in MVPA. Twenty one percent of the participants fulfilled the current Norwegian PA recommendations. Overall PA levels were associated with self-reported health.
Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey.
BACKGROUND: Although primary care is the major target of coronary heart disease (CHD) clinical recommendations, little is known of how community physicians view guidelines and their implementation. The REACT survey was designed to assess the views, and perceived implementation, of CHD and lipid treatment guidelines among primary care physicians. METHODS: Semi-structured validated telephone interviews were conducted, in the relevant native tongue, with 754 randomly selected primary care physicians (GPs and family doctors) in five European countries (France, Germany, Italy, Sweden and the UK). RESULTS: Most physicians (89%) agreed with the content of current guidelines and reported use of them (81%). However, only 18% of physicians believed that guidelines were being implemented to a major extent. Key barriers to greater implementation of guidelines were seen as lack of time (38% of all physicians), prescription costs (30%), and patient compliance (17%). Suggestions for ways to improve implementation centred on more education, both for physicians themselves (29%) and patients (25%); promoting, publicizing or increasing guideline availability (23%); simplifying the guidelines (17%); and making them clearer (12%). Physicians perceived diabetes to be the most important risk factor for CHD, followed by hypertension and raised LDL-C. Most physicians (92%) believe their patients do associate high cholesterol levels with CHD. After establishing that a patient is 'at risk' of CHD, physicians reported spending an average of 16.5 minutes discussing risk factors and lifestyle changes or treatment that is required. Factors preventing this included insufficient time (42%), having too many other patients to see (27%) and feeling that patients did not listen or understand anyway (21%). CONCLUSIONS: Primary care physicians need more information and support on the implementation of CHD and cholesterol guideline recommendations. This need is recognized by clinicians.
To examine whether performance measures improve more in accredited hospitals than in non-accredited hospital.
A historical follow-up study was performed using process of care data from all public Danish hospitals in order to examine the development over time in performance measures according to participation in accreditation programs.
All patients admitted for acute stroke, heart failure or ulcer at Danish hospitals.
Hospital accreditation by either The Joint Commission International or The Health Quality Service.
The primary outcome was a change in opportunity-based composite score and the secondary outcome was a change in all-or-none scores, both measures were based on the individual processes of care. These processes included seven processes related to stroke, six processes to heart failure, four to bleeding ulcer and four to perforated ulcer.
A total of 27 273 patients were included. The overall opportunity-based composite score improved for both non-accredited and accredited hospitals (13.7% [95% CI 10.6; 16.8] and 9.9% [95% 5.4; 14.4], respectively), but the improvements were significantly higher for non-accredited hospitals (absolute difference: 3.8% [95% 0.8; 8.3]). No significant differences were found at disease level. The overall all-or-none score increased significantly for non-accredited hospitals, but not for accredited hospitals. The absolute difference between improvements in the all-or-none score at non-accredited and accredited hospitals was not significant (3.2% [95% -3.6:9.9]).
Participating in accreditation was not associated with larger improvement in performance measures for acute stroke, heart failure or ulcer.
Acute esophageal variceal bleeding (EVB) is a major cause of morbidity and mortality in patients with liver cirrhosis. Guidelines have been published in 1997; however, variability in the acute management and prevention of EVB rebleeding may occur.
Gastroenterologists in the provinces of British Columbia, Alberta, Manitoba and Saskatchewan were sent a self-reporting questionnaire.
The response rate was 70.4% (86 of 122). Intravenous octreotide was recommended by 93% for EVB patients but the duration was variable. The preferred timing for endoscopy in suspected acute EVB was within 12 h in 75.6% of respondents and within 24 h in 24.6% of respondents. Most (52.3%) gastroenterologists do not routinely use antibiotic prophylaxis in acute EVB patients. The preferred duration of antibiotic therapy was less than three days (35.7%), three to seven days (44.6%), seven to 10 days (10.7%) and throughout hospitalization (8.9%). Methods of secondary prophylaxis included repeat endoscopic therapy (93%) and beta-blocker therapy (84.9%). Most gastroenterologists (80.2%) routinely attempted to titrate beta-blockers to a heart rate of 55 beats/min or a 25% reduction from baseline. The most common form of secondary prophylaxis was a combination of endoscopic and pharmacological therapy (70.9%).
Variability exists in some areas of EVB treatment, especially in areas for which evidence was lacking at the time of the last guideline publication. Gastroenterologists varied in the use of prophylactic antibiotics for acute EVB. More gastroenterologists used combination secondary prophylaxis in the form of band ligation eradication and beta-blocker therapy rather than either treatment alone. Future guidelines may be needed to address these practice differences.
To assess the utilization of antihypertensive drugs among uncomplicated hypertensive patients in Finland between 2000 and 2006 and to calculate the achievable reduction in cardiovascular morbidity, with intensified antihypertensive treatment.
From the databases of the Social Insurance Institution of Finland, 428,986 treated hypertensives without diabetes or cardiac disease (further named uncomplicated hypertensives) in 2000 and 591,206 in 2006, respectively, were identified. In addition, from the Health 2000 survey representing the whole Finnish adult population, 729 uncomplicated hypertensives were determined to assess their characteristics and control of hypertension. Applying Law's meta-analyses we calculated the reduction of blood pressure (BP) by intensifying the treatment with low-dose antihypertensive regimens for those with a BP =140/90?mmHg.
The nationwide data suggests a relative overuse of beta-blockers. Combination antihypertensive treatment increased relatively 8%, while at least three drug combinations increased from 19.8% to 21.6% between 2000 and 2006. However, calculated prevalence of controlled BP (
No study has documented whether physicians call poison control centres (PCC) for calcium channel blocker (CCB) poisoning or if interventions suggested by the PCC are being applied.
This study evaluated the compliance of physicians with the Quebec Poison Control Center's (QPCC) recommendations for the treatment of CCB poisoning. It also assessed the outcomes of these patients.
This retrospective chart review was conducted with CCB-poisoned adults who were admitted to a hospital in Quebec City or Montreal between January 2004 and November 2007. Using the sequence of interventions, it was determined whether or not the PPC recommendations were adhered to. Level of care provided, morbidity and mortality were reported. The researchers also used the QPCC database to verify if the poison centre was consulted for the care of the patient.
A total of 103 cases were identified. 42% (43/103) were classified as compliant (all PCC recommendations were followed) and 58% (60/103) non-compliant group (some or no PCC recommendations followed). The poison control centre (PCC) was contacted for 74% of the total cases (81% of cases in the compliant group and 68% in the non-compliant group). High-dose insulin euglycemia therapy (HIET) was not started when indicated or started at too low dosage in 20 cases. Glucagon was given, even if not indicated, in 14 cases and decontamination was inappropriate in at least 10 cases. For the entire sample, there was an average of 8 days of hospitalization, 47 h of intensive care, 11 h of vasopressor use, a morbidity of 50% and a mortality of 6%. Acute renal failure (35%), metabolic acidosis (25%), acute pulmonary oedema (15%), aspiration pneumonia (15%), rhabdomyolysis (8%), myocardial ischemia (7%), abnormal liver function tests (AST/ALT) (6%), cerebral anoxia (4%) and ileus (3%) were among the most frequent complications. The outcomes in the non-compliant group versus the compliant group showed a mortality of 10% versus 0% (95%CI 0.00-0.20, p-value
Although Canadian best practice recommendations regarding assessment and management of poststroke depression (PSD) have been established, the degree to which these evidence-based guidelines have been translated into practice is not known. The objectives of the present study are to compare current and recommended best practice and examine possible reasons for identified care gaps.
Practice audit by chart review was performed to identify recorded screening, assessment, and treatment for PSD in patients discharged from a specialized inpatient rehabilitation program over a 6-month period. A questionnaire was administered to all clinical staff addressing current screening practices as well as opinions regarding the importance and feasibility of identification and treatment of PSD.
Of 123 patients, 40 (32.5%) had been prescribed antidepressants at discharge. However, evidence of screening was found for 4.9% of patients; another 9.8% were referred for psychological consult. Treatment was associated with previous antidepressant use or history of depression, but not screening or assessment. Of the survey respondents, 56.2% were not aware of best practice recommendations. However, most felt screening and assessment to be important and treatment was regarded as both simple and effective.
Despite potential benefit associated with identification and treatment of PSD and the availability of evidence-based best practice recommendations, PSD may remain unrecognized and undertreated. Given the juxtaposition of perceived importance with the lack of documented best practice, education regarding standardized screening and the development of consistent clinical protocols including roles and responsibilities in the identification, diagnosis, and treatment of PSD are underway.