2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure.

Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.

The Canadian Cardiovascular Society Heart Failure Companion: Bridging Guidelines to Your Practice.

The Canadian Cardiovascular Society Heart Failure (HF) Guidelines Program has generated annual HF updates, including formal recommendations and supporting Practical Tips since 2006. Many clinicians indicate they routinely use the Canadian Cardiovascular Society HF Guidelines in their daily practice. However, many questions surrounding the actual implementation of the Guidelines into their daily practice remain. A consensus-based approach was used, including feedback from the Primary and Secondary HF Panels. This companion is intended to answer several key questions brought forth by HF practitioners such as appropriate timelines for initial assessments and subsequent reassessments of patients, the order in which medications should be added, how newer medications should be included in treatment algorithms, and when left ventricular function should be reassessed. A new treatment algorithm for HF with reduced ejection fraction is included. Several other practical issues are addressed such as an approach to management of hyperkalemia/hypokalemia, treatment of gout, when medications can be stopped, and whether a target blood pressure or heart rate is suggested. Finally, elements and teaching of self-care are described. This tool will hopefully function to allow better integration of the HF Guidelines into clinical practice.

Comparison of an in-pharmacy automated blood pressure kiosk to daytime ambulatory blood pressure in hypertensive subjects.

The objective of this study was to compare serial readings from an in-pharmacy automated blood pressure (BP) kiosk to mean daytime ambulatory BP. A total of 100 community-dwelling adults with hypertension underwent (1) three baseline automated office readings; (2) three in-pharmacy readings on each of four visits (12 total) using the PharmaSmart PS-2000 kiosk; and (3) 24-hour ambulatory BP monitoring between in-pharmacy visits two and three. Paired t-tests, Bland-Altman plots, and Pearson correlation coefficients were used for analysis. Mean BPs were 137.8 ± 13.7/81.9 ± 12.2 mm Hg for in-pharmacy and 135.5 ± 11.7/79.7 ± 10.0 mm Hg for daytime ambulatory (difference of 2.3 ± 9.5/2.2 ± 6.9 mm Hg [P ≤ .05]). Bland-Altman plots depicted a high degree of BP variability but did not show clinically important systematic BP differences. With ambulatory BP as the reference standard, in-pharmacy device results were similar to automated office results. The PharmaSmart PS-2000 closely approximated mean daytime ambulatory BP, supporting the use of serial readings from this device in the assessment of BP.

The relative importance of barriers to the prescription of warfarin for nonvalvular atrial fibrillation.

BACKGROUND AND PURPOSE: Despite the publication of a number of randomized, controlled trials demonstrating a substantial reduction in stroke with anticoagulation in patients with nonvalvular atrial fibrillation, the 'real world' use of warfarin is sub-optimal. Previous surveys have attempted to explain this problem but have significant limitations. The purpose of this study was to assess the relative importance of various barriers that may influence the prescription of warfarin in patients with nonvalvular atrial fibrillation. METHODS: This cross-sectional survey was mailed to all practising cardiologists, neurologists and internists, as well as a random sample of family physicians within Alberta. Physicians caring for patients with NVAF rated the relative importance of potential barriers using a Likert scale. RESULTS: Sixty-seven per cent of all physicians returned the survey. Overall, barriers pertaining to the patient's clinical characteristics were rated to be more important than those pertaining to the physician or to the organization required when prescribing these therapies. Specifically, an ongoing history of falls, a history of bleeding within the previous year and an inability to comply with therapy were rated as important barriers by 64%, 55% and 53% of physicians, respectively. Most physicians strongly believed that patients should receive information on the benefits and risks of warfarin (96%) and that patients should have a say in whether warfarin is prescribed (86%). IMPLICATIONS: This study suggests that most of the barriers to warfarin use pertain to patient clinical characteristics and the need for patients to be involved in the decision to initiate therapy. The use of decision support technologies would facilitate involvement of the patient and serve to educate both the patient and physician on the risks and benefits of warfarin therapy.