Development of the Champlain primary care cardiovascular disease prevention and management guideline: tailoring evidence to community practice.

PROBLEM ADDRESSED: A well documented gap remains between evidence and practice for clinical practice guidelines in cardiovascular disease (CVD) care. OBJECTIVE OF PROGRAM: As part of the Champlain CVD Prevention Strategy, practitioners in the Champlain District of Ontario launched a large quality-improvement initiative that focused on increasing the uptake in primary care practice settings of clinical guidelines for heart disease, stroke, diabetes, and CVD risk factors. PROGRAM DESCRIPTION: The Champlain Primary Care CVD Prevention and Management Guideline is a desktop resource for primary care clinicians working in the Champlain District. The guideline was developed by more than 45 local experts to summarize the latest evidence-based strategies for CVD prevention and management, as well as to increase awareness of local community-based programs and services. CONCLUSION: Evidence suggests that tailored strategies are important when implementing specific practice guidelines. This article describes the process of creating an integrated clinical guideline for improvement in the delivery of cardiovascular care.

Thermal therapy: a viable adjunct in the treatment of heart failure?

The aim of this work was to review and provide a summary of published literature on the clinical impact of thermal therapy (ie, warm water immersion, traditional sauna bathing, and dry infrared sauna) in patients with heart failure. Medline and Embase database literature searches were conducted, and studies that included measurement of heart failure-related clinical parameters were reviewed. Thermal therapy was found to have a positive impact on key heart failure-related parameters across multiple studies. Significant improvements were noted across a wide scope of heart failure-related parameters in the areas of (1) endothelial function, (2) hemodynamics, (3) cardiac geometry, (4) neurohormonal markers, and (5) quality of life. Of special note, thermal therapy also conveyed a strong antiarrhythmic effect in heart failure patients. The clinical evidence highlights repeatable and compelling data showing that thermal therapy may provide an important and viable adjunct in the treatment of heart failure.

Combined angioplasty and pharmacological intervention versus thrombolysis alone in acute myocardial infarction (CAPITAL AMI study).

OBJECTIVES: We compared a strategy of tenecteplase (TNK)-facilitated angioplasty with one of TNK alone in patients presenting with high-risk ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Previous trials show that thrombolysis followed by immediate angioplasty for the treatment of STEMI does not improve ischemic outcomes compared with thrombolysis alone and is associated with excessive bleeding complications. Since the publication of these trials, however, significant pharmacological and technological advances have occurred. METHODS: We randomized 170 patients with high-risk STEMI to treatment with TNK alone (84 patients) or TNK-facilitated angioplasty (86 patients). The primary end point was a composite of death, reinfarction, recurrent unstable ischemia, or stroke at six months. RESULTS: At six months, the incidence of the primary end point was 24.4% in the TNK-alone group versus 11.6% in the TNK-facilitated angioplasty group (p = 0.04). This difference was driven by a reduction in the rate of recurrent unstable ischemia (20.7% vs. 8.1%, p = 0.03). There was a trend toward a lower reinfarction rate with TNK-facilitated angioplasty (14.6% vs. 5.8%, p = 0.07). No significant differences were observed in the rates of death or stroke. Major bleeding was observed in 7.1% of the TNK-alone group and in 8.1% of the TNK-facilitated angioplasty group (p = 1.00). CONCLUSIONS: In patients presenting with high-risk STEMI, TNK plus immediate angioplasty reduced the risk of recurrent ischemic events compared with TNK alone and was not associated with an increase in major bleeding complications.

Comparison of mortality patterns in patients with ST-elevation myocardial infarction arriving by emergency medical services versus self-transport (from the prospective Ottawa Hospital STEMI Registry).

Emergency medical services (EMSs) play a key role in the recognition and treatment of ST-elevation of myocardial infarction (STEMI). We sought to determine contemporary use of EMS in patients with STEMI and its relation to treatment, morbidity, and mortality patterns. Patients who arrived by EMS were compared with those who arrived by self-transport. Among 401 patients, 59.9% arrived by EMS and 40.1% by self-transport. Patients who arrived by EMS were older (p <0.001) and had higher Killip's scores (p <0.001). Door-to-needle and door-to-balloon intervals were shorter in patients who arrived by EMS (42 vs 57 minutes, p <0.001, and 124 vs 154 minutes, p <0.001, respectively). In-hospital mortality was higher in patients who used EMS (13.3% vs 5.0%, p <0.001). Patients who arrived by EMS also had higher mortality within the first hour of hospital arrival (4.2% vs 0%, p = 0.007). Multivariate analysis showed that only age and systolic blood pressure were predictors of mortality. Despite faster onset of reperfusion therapy in patients who arrived by EMS, mortality was higher. Almost 33% of these deaths occurred in the early in-hospital period, which was due to older and sicker patients having the tendency to come by EMS. Our results suggest that regional approaches are needed to trigger earlier reperfusion therapy in patients with STEMI who use EMS.

Treating the right patient at the right time: access to specialist consultation and non-invasive testing.

The Council of the Canadian Cardiovascular Society commissioned working groups to examine issues of access to, and wait times for, various aspects of cardiovascular care. The present article summarizes the deliberations on targets for medically acceptable wait times for access to cardiovascular specialist evaluation and on the performance of noninvasive testing needed to complete this evaluation. Three categories of referral indications were identified: those requiring hospitalization due to substantial ongoing risk of mortality and morbidity; those requiring an expedited early review in an ambulatory setting; and, finally, a larger category in which delays of two to six weeks can be justified. The proposed wait time targets will provide guidance on the timeliness of care to busy clinicians charged with the care of patients with cardiovascular disease, help policy makers appreciate the clinical challenges in providing access to high quality care, and highlight the critical need for a thoughtful review of cardiology human resource requirements. Wait time implementation suggestions are also included, such as the innovative use of disease management and special need clinics. The times proposed assume that available clinical practice guidelines are followed for clinical coronary syndrome management and for treatment of associated conditions such as hypertension, diabetes, renal disease, smoking cessation and lipid disorders. Although media attention tends to focus on wait times for higher profile surgical procedures and high technology imaging, it is likely that patients face the greatest wait-related risk at the earlier phases of care, before the disease has been adequately characterized.

Hospitalization costs of primary stenting versus thrombolysis in acute myocardial infarction: cost analysis of the Canadian STAT Study.

BACKGROUND: We previously showed that primary stenting was more effective than accelerated tPA in reducing the 6-month composite of death, reinfarction, stroke, or repeat revascularization for ischemia. This study looks at the hospitalization costs of primary stenting compared with accelerated tPA. METHODS AND RESULTS: Initial and 6-month hospitalization costs were computed for all patients randomly assigned to primary stenting (n=62) or accelerated tPA (n=61) in the Stenting versus Thrombolysis in Acute myocardial infarction Trial (STAT). Costs and resource usage were collected in detail for each patient. Physician fees were obtained directly from billings to the Ontario Health Insurance Plan. The length of initial hospitalization was 6.7+/-11.3 days in the stent group and 8.7+/-6.7 days in the tPA group (P<0.001). Total hospitalization days at 6 months were 8.3+/-13 days in the stent group and 12.1+/-14.0 days in the tPA group (P=0.001). Hospitalization costs were less in the stent group for the initial hospitalization, 6354 dollars +/-6382 versus 7893 dollars +/-4429 (P=0.001), and at 6 months, 7100 dollars +/-7111 versus 9559 dollars +/-6933 (P=0.001). CONCLUSIONS: In centers in which facilities and experienced interventionists are available, primary stenting is less costly and more effective than thrombolysis.

Early effects of statin therapy on endothelial function and microvascular reactivity in patients with coronary artery disease.

BACKGROUND: Recent data suggest an early outcome benefit with reduction in cholesterol using statin therapy in patients with coronary artery disease (CAD). This may be caused by effects of low-density lipoprotein cholesterol (LDL-C) reduction on endothelial function and vascular reactivity in the coronary bed. The aim of this randomized placebo-controlled study was to examine the early effects of important reductions in LDL-C on myocardial perfusion and peripheral endothelial function. METHODS AND RESULTS: Seventy-two patients with CAD and LDL-C between 3.0 and 5.9 mmol/L (116-228 mg/dL) were randomized to receive simvastatin 20 mg daily, pravastatin 40 mg daily, or placebo for 8 weeks. At baseline, 2 weeks, and 8 weeks, patients underwent dynamic positron emission tomography perfusion imaging to quantify the retention of rubidium-82 as a measure of myocardial flow at rest and after dipyridamole stress. Patients also underwent brachial artery ultrasound to measure endothelium-dependent flow-mediated vasodilatation. At 2 and 8 weeks, the simvastatin and pravastatin groups showed a significant reduction (P < .001) in LDL-C compared with placebo. At 8 weeks, simvastatin led to an improvement in flow-mediated vasodilatation compared with placebo (6.86% +/- 4.4% vs 3.44% +/- 4.0%, P < .05), whereas pravastatin was not significantly different than placebo (5.62% +/- 4.1% vs 3.44% +/- 4.0%, P = NS). Despite this improvement in peripheral endothelial function with simvastatin, there were no significant differences observed in global stress flow and coronary flow reserve at 8 weeks with either drug. CONCLUSIONS: Short-term LDL reduction with simvastatin therapy improves peripheral endothelial function in patients with stable CAD, although an early effect on coronary vascular reactivity could not be demonstrated.

Effect of Orlistat in obese patients with heart failure: a pilot study.

Heart failure is the leading cause of hospitalization. Obesity is increasingly common and is a major public health problem. The aim of this study is to assess whether obese patients with heart failure can benefit from losing weight via an orlistat-assisted diet. This randomized clinical trial included obese patients with ejection fractions < or =40%. Orlistat and diet counseling were compared with diet counseling alone. Twenty-one consecutive obese patients with heart failure were recruited. Significant improvement in 6-minute walk test (45.8 m; 95% confidence interval, 5.2-86.4 m; p=0.031), functional class (-0.6+/-0.5, p=0.014), weight loss (-8.55 kg; 95% confidence interval, -13.0 to -4.1 kg; p<0.001) and also significant decreases in total cholesterol (p=0.017), low-density lipoprotein cholesterol (p=0.03), and triglycerides (p=0.036) were observed in the orlistat group. Orlistat can promote significant weight loss and symptoms of relief in obese patients with heart failure, as measured by 6-minute walk test and functional capacity. The lipid profile improved. Orlistat was safe and well tolerated.

The effect of vitamin therapy on the progression of coronary artery atherosclerosis varies by haptoglobin type in postmenopausal women.

OBJECTIVE: Antioxidant trials have not demonstrated efficacy in slowing cardiovascular disease but could not rule out benefit for specific patient subgroups. Antioxidant therapy reduces LDL oxidizability in haptoglobin 1 allele homozygotes (Hp 1-1), but not in individuals with the haptoglobin 2 allele (Hp 2-1 or Hp 2-2). We therefore hypothesized that haptoglobin type would be predictive of the effect of vitamin therapy on coronary atherosclerosis as assessed by angiography. RESEARCH DESIGN AND METHODS: We tested this hypothesis in the Women's Angiographic Vitamin and Estrogen (WAVE) trial, a prospective angiographic study of vitamins C and E with or without hormone replacement therapy (HRT) in postmenopausal women. Haptoglobin type was determined in 299 women who underwent baseline and follow-up angiography. The annualized change in the minimum luminal diameter (MLD) was examined in analyses stratified by vitamin use, haptoglobin type, and diabetes status. RESULTS: We found a significant benefit on the change in MLD with vitamin therapy as compared with placebo in Hp 1-1 subjects (0.079 +/- 0.040 mm, P = 0.049). This benefit was more marked in diabetic subjects (0.149 +/- 0.064 mm, P = 0.021). On the other hand, there was a trend toward a more rapid decrease in MLD with vitamin therapy in Hp 2-2 subjects, which was more marked in diabetic subjects (0.128 +/- 0.057 mm, P = 0.027). HRT had no effect on these outcomes. CONCLUSIONS: The relative benefit or harm of vitamin therapy on the progression of coronary artery stenoses in women in the WAVE study was dependent on haptoglobin type. This influence of haptoglobin type seemed to be stronger in women with diabetes.

Severe aortic insufficiency secondary to an aortic bioprosthesis tear.

A patient with a 10-year-old Medtronic Hancock II porcine aortic bioprosthesis developed severe aortic insufficiency. A transesophageal echocardiogram showed a long and mobile mass attached to the bioprosthesis which was consistent with a torn cusp. The patient underwent replacement of the prosthesis with a mechanical valve. Pathological examination showed two subacute tears arising from the same suture buttressing site. These two tears allowed a portion of the valve apparatus to prolapse.

Acute myocardial infarction in a young man with dilated cardiomyopathy: clinicopathological correlation.

Cardiac involvement is commonly described in autopsy examinations of patients infected with human immunodeficiency virus (HIV). However, only a small percentage have clinically significant cardiac disease. Dilated cardiomyopathy is one of the most common HIV-related heart diseases. Cardiovascular complications of HIV infection are likely to become more common with improvements in treatment and survival. Coronary thromboembolism has rarely been reported in the setting of dilated cardiomyopathy. Coronary thromboembolism should be suspected in a patient presenting with acute myocardial infarction, normal coronary arteries at subsequent angiography and a potential source of embolus. A patient presenting with acute myocardial infarction subsequently diagnosed as a coronary artery embolism due to HIV cardiomyopathy is reported. Coronary artery embolism and HIV cardiomyopathy are briefly discussed.

CCORT/CCS quality indicators for acute myocardial infarction care.

BACKGROUND: Although quality indicators for the care of acute myocardial infarction (AMI) patients have been described for other countries, there are none specifically designed for the Canadian health care system. The authors' goal was to develop a set of Canadian quality indicators for AMI care. METHODS: A literature review identified existing quality indicators for AMI care. A list of potential indicators was assessed by a nine-member panel of clinicians from a variety of disciplines using a modified-Delphi panel process. After an initial round of rating the potential indicators, a series of indicators was identified for a second round of discussion at a national meeting. Further refinement of indicators occurred following a teleconference and review by external reviewers. RESULTS: To identify an AMI cohort, case definition criteria were developed, using a hospital discharge diagnosis for AMI of International Classification of Diseases-Ninth revision (ICD-9) code 410.x. Thirty-seven indicators for AMI care were established. Pharmacological process of care indicators included administration of acetylsalicylic acid, beta-blockers, angiotensin-converting enzyme inhibitors, thrombolytics and statins. Mortality and readmissions for AMI, unstable angina and congestive heart failure were recommended as outcome indicators. Nonpharmacological indicators included median length of stay in the emergency department, and median waiting times for cardiac catheterization, percutaneous coronary intervention and/or coronary artery bypass graft surgery. INTERPRETATION: A set of Canadian quality indicators for the care of AMI patients has been established. It is anticipated that these indicators will be useful to clinicians and researchers who want to measure and improve the quality of AMI patient care in Canada.

Impact of QRS morphology and duration on outcomes after cardiac resynchronization therapy: Results from the Resynchronization-Defibrillation for Ambulatory Heart Failure Trial (RAFT).

BACKGROUND: The impact of QRS morphology and duration on the effectiveness of cardiac resynchronization therapy (CRT) has been usually assessed separately. The interaction between these 2 simple ECG parameters and their effect on CRT has not been systematically assessed in a large-scale clinical trial. METHODS AND RESULTS: The Resynchronization-Defibrillation for Ambulatory Heart Failure Trial showed that implantable cardioverter defibrillator-CRT was associated with a significant reduction in the primary end point of all-cause mortality or heart failure hospitalization. For this substudy, we excluded patients in atrial fibrillation and those with a previous pacemaker. All baseline ECGs were reviewed by a panel of 3 experienced electrocardiographers. A total of 1483 patients were included in this study. Of these, 1175 had left bundle-branch block (LBBB) and 308 had non-LBBB. In patients with LBBB receiving implantable cardioverter defibrillator-CRT, there was a reduction in the primary outcome and in each individual component of the primary outcome. Furthermore, there was continuous relationship between QRS duration and extent of benefit. In patients with non-LBBB and QRS ≥160 ms, the hazard ratio for the primary outcome was 0.52 (0.29-0.96; P=0.033); in patients with QRS <160 ms, the hazard ratio was 1.38 (0.88-2.14; P=0.155). CONCLUSIONS: In patients with LBBB, there was a continuous relationship between broader QRS and greater benefit from implantable cardioverter defibrillator-CRT. However, our data do not support the use of implantable cardioverter defibrillator-CRT in patients with non-LBBB, especially when the QRS duration is <160 ms. There may be some delayed benefit when the QRS is ≥160 ms, but this needs further investigation. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00251251.

Motivational counselling for physical activity in patients with coronary artery disease not participating in cardiac rehabilitation.

BACKGROUND: Many patients with coronary artery disease (CAD) fail to attend cardiac rehabilitation following acute coronary events because they lack motivation to exercise. Theory-based approaches to promote physical activity among non-participants in cardiac rehabilitation are required. DESIGN: A randomized trial comparing physical activity levels at baseline, 6, and 12 months between a motivational counselling (MC) intervention group and a usual care (UC) control group. METHOD: One hundred and forty-one participants hospitalized with acute coronary syndromes not planning to attend cardiac rehabilitation were recruited at a single centre and randomized to either MC (n = 69) or UC (n = 72). The MC intervention, designed from an ecological perspective, included one face-to-face contact and eight telephone contacts with a trained physiotherapist over a 52-week period. The UC group received written information about starting a walking programme and brief physical activity advice from their attending cardiologist. Physical activity was measured by: 7-day physical activity recall interview; self-report questionnaire; and pedometer at baseline, 6, and 12 months after randomization. RESULTS: Latent growth curve analyses, which combined all three outcome measures into a single latent construct, showed that physical activity increased more over time in the MC versus the UC group (µ(add) = 0.69, p < 0.05). CONCLUSION: Patients with CAD not participating in cardiac rehabilitation receiving a theory-based motivational counselling intervention were more physically active at follow-up than those receiving usual care. This intervention may extend the reach of cardiac rehabilitation by increasing physical activity in those disinclined to participate in structured programmes.

Man's best friend? Infective endocarditis due to Capnocytophaga canimorsus.

Infective endocarditis caused by zoonotic microorganisms is an uncommon clinical entity. A 55-year-old man was diagnosed with endocarditis due to Capnocytophaga canimorsus, a commensal bacterium contained in the saliva of dogs, that involved the aortic and tricuspid valves and was complicated by a para-aortic valve abscess and aorta-to-right atrial fistula. The patient was successfully treated with antibiotic therapy and surgical intervention. C canimorsus endocarditis should be considered in patients with culture-negative endocarditis, particularly in immunosuppressed, asplenic or alcoholic individuals who have recently suffered a dog bite or have had close contact with dogs.

Degree and correlates of patient trust in their cardiologist.

RATIONALE AND OBJECTIVES: Trust in one's doctor has been associated with increased treatment adherence, patient satisfaction and improved health status. This study investigated the level and correlates of patient trust in their cardiac specialist. METHODS: All 386 urban cardiologists in Southern Ontario (95 participating, response rate = 30%) were approached to recruit a sample of their coronary artery disease outpatients. A total of 1111 recent and consecutive patients consented to participate (approximately 13 patients per cardiologist, 317 female (26.7%); response rate = 60%), and clinical data were extracted from their medical charts. Participants completed a mailed survey including the Trust in Physicians scale, in addition to an assessment of socio-demographic, clinical and psychosocial correlates. RESULTS: The mean trust score was equivalent to that reported in studies of primary care patients. Results of the significant multivariate model (F = 7.631, P < 0.001) revealed that less education (P < 0.001), higher systolic blood pressure (P = 0.022), less perceived cyclical/unpredictable illness timeline (P = 0.007) and greater perceived personal control over their heart condition (P = 0.004), were significant correlates of greater trust in cardiologist care. CONCLUSIONS: The significance of education is corroborated by findings of lower satisfaction with cardiac care among those of higher socio-economic status, despite having generally greater access to care in Ontario. Moreover, the relationship between hypertension and greater trust may suggest that such perceptions are not based on doctor competence. Future studies should further investigate the correlates of trust, as well as the impact of trust on cardiac health outcomes.

Cardiologists' charting varied by risk factor, and was often discordant with patient report.

OBJECTIVE: To assess the completeness of cardiac risk factor documentation by cardiologists, and agreement with patient report. STUDY DESIGN AND SETTING: A total of 68 Ontario cardiologists and 789 of their ambulatory cardiology patients were randomly selected. Cardiac risk factor data were systematically extracted from medical charts, and a survey was mailed to participants to assess risk factor concordance. RESULTS: With regard to completeness of risk factor documentation, 90.4% of charts contained a report of hypertension, 87.2% of diabetes, 80.5% of dyslipidemia, 78.6% of smoking behavior, 73.0% of other comorbidities, 48.7% of family history of heart disease, and 45.9% of body mass index or obesity. Using Cohen's k, there was a concordance of 87.7% between physician charts and patient self-report of diabetes, 69.5% for obesity, 56.8% for smoking status, 49% for hypertension, and 48.4% for family history. CONCLUSION: Two of four major cardiac risk factors (hypertension and diabetes) were recorded in 90% of patient records; however, arguably the most important reversible risk factors for cardiac disease (dyslipidemia and smoking) were only reported 80% of the time. The results suggest that physician chart report may not be the criterion standard for quality assessment in cardiac risk factor reporting.