Canadian Cardiovascular Congress 2012

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Canadian Cardiovascular Congress 2012

Canadian Cardiovascular Society unveils newest guidelines for professionals

Posted: October 30, 2012

Toronto - Canadian Cardiovascular Society guidelines and position statements offering the most up-to-date information to support clinicians in practicing evidence-based medicine were released today at the Canadian Cardiovascular Congress.

They include:

  • CCS Guideline Update: Atrial Fibrillation–Recommendations for Stroke Prevention and Rate/Rhythm Control
  • CCS Guideline Update: The Use of Antiplatelet Therapy
  • CCS Guideline Update: Diagnosis and Treatment of Dyslipidemia and Prevention of CVD in the Adult
  • CCS Guideline Update: Acute and Chronic Heart Failure
  • CCS Guideline: Diagnosis and Early Management of Heart Failure in Children
  • CCS Cardiac Resynchronization Therapy Guideline– Evidence and Patient Selection
  • CCS Position Statement: Transcatheter Aortic Valve Implantation
  • CCS Position Statement: Radiation Exposure from Cardiac Imaging and Interventional Procedures
  • CHRS/CCS Position Statement: Remote Monitoring for Cardiovascular Implantable Electronic Devices

Cardiovascular guidelines are an invaluable resource not only for members of the cardiovascular community but for healthcare practitioners throughout Canada. Practice guidelines can play an important role in helping to improve the quality of patient care and manage limited resources. CCS Guidelines are published in the Canadian Journal of Cardiology.

Updates have been made to the landmark Atrial Fibrillation, Antiplatelet, Dyslipidemia and Heart Failure Guidelines and sees the highly anticipated debuts of topics including Cardiac Resynchronization Therapy, Transcatheter Aortic Valve Implantation and Pediatric Heart Failure.

“It’s been an important year for guidelines and position statements, with nine presentations at Congress this year,” says Michelle Graham, CCS guidelines chair. “The Canadian Cardiovascular Society would like to thank all of the experts involved for their hard work. In addition, the members of the guidelines committee, which oversees the development of all of these topics were integral in ensuring that our rigorous and transparent processes are followed.”

GUIDELINE HIGHLIGHTS

CCS 2012 GUIDELINES FOR THE USE OF ANTIPLATELET THERAPY
Co-chaired by Jean-François Tanguay and Shamir Mehta

What's New?

The 2012 Focused Update of the CCS Guidelines for the Use of Antiplatelet Therapy presents new recommendations for secondary prevention in the first year following acute coronary syndrome (ACS), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG) and the interaction between clopidogrel and proton pump inhibitors (PPI). Also, the use of novel oral anticoagulants in the context of antiplatelet therapy in patients with ACS merited the addition of new section of recommendations to the Guidelines.

The Focused Update adopted the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to evaluate evidence and determine the strength of recommendations. As values and preferences, these recommendations place greater emphasis on reduction of major cardiovascular events and stent thrombosis versus an increase in bleeding complications. They also take into account the clinical setting under which each of the antiplatelet drugs were evaluated and the more reliable bioavailability of prasugrel and ticagrelor compared with clopidogrel.

What Health Professionals Need to Know

  • In patients receiving DAPT, we suggest using ASA 81 mg daily
  • Prasugrel should be used only in ACS patients undergoing PCI. In patients ≥75 years of age or weight ≤60 kg, when available, prasugrel 5 mg daily could be considered
  • Ticagrelor can be used in ACS patients managed with either PCI, CABG, or medical therapy alone
  • In PCI for a non-ACS indication, in patients receiving a BMS who are unable to tolerate clopidogrel for 12 months (e.g. increased risk of bleeding or scheduled non-cardiac surgery), the minimum duration of therapy should be one month
  • For patients requiring surgery (CABG or non-CABG), the P2Y12 inhibitor could be withheld, if possible, as follows: clopidogrel five days prior, ticagrelor five days prior, and prasugrel seven days prior to the date of surgery
  • A selective use of PPIs in patients receiving DAPT at high risk of upper gastrointestinal bleeding. To use a PPI that minimally inhibits CYP2C19 in patients receiving a PPI with clopidogrel.

CCS 2012 ATRIAL FIBRILLATION UPDATE
Co-chaired by Allan C. Skanes and Jeff S. Healey

Focused 2012 Update of the Canadian Cardiovascular Society Atrial Fibrillation Guidelines: Recommendations for Stroke Prevention and Rate/Rhythm Control

What’s New?

  • For patients with atrial fibrillation (AF) within the CHADS2=0 category, we suggest oral anticoagulant (OAC) therapy for patients at highest risk within this category (age ≥65 or the combination of female sex and vascular disease); ASA (75-325 mg/day) for patients at lower risk within this category (female sex or vascular disease); and no antithrombotic therapy for those patients at lowest risk in this category (no additional risk factors) (Conditional Recommendation, Low-Quality Evidence)
  • We suggest, that when OAC is indicated, most patients should receive dabigatran, rivaroxaban, or apixaban (once approved by Health Canada), in preference to warfarin (Conditional Recommendation, High-Quality Evidence)
  • We recommend that dronedarone not be used in patients with permanent AF nor for the sole purpose of rate control (Strong Recommendation, High-Quality Evidence)
  • We recommend dronedarone not be used in patients with a history of heart failure or a left ventricular ejection fraction ≤0.40 (Strong Recommendation, Moderate-Quality Evidence)
  • We suggest dronedarone be used with caution in patients taking digoxin (Conditional Recommendation, Moderate-Quality Evidence)

What Health Professionals Need to Know

Based on new data, it is recognized that patients with AF within the traditional low risk category (CHADS2=0) can have their risk better resolved by considering age, sex and the presence of vascular disease. Based on these factors, the indications for OAC therapy has been expanded to include patients within the CHADS2=0 category. Two new oral anticoagulants, both factor X inhibitors, rivaroxaban and apixaban have joined dabigatran as preferred OACs for stroke prevention. The PALLAS study has refocused attention on the safe use of dronedaronefor AF. The use of dronedarone for rhythm control has been limited to patients with preserved left ventricular function and without a history of heart failure. Dronedarone should not be used as a rated control agent based on results of the PALLAS study.

CCS 2012 CONSENSUS ON THE USE OF CARDIAC RESYNCHRONIZATION THERAPY
Co-chaired by Derek V. Exner and Ratika Parkash

What's New?

  • Substantial revision of existing CRT guidelines
  • New criteria for patient selection
  • Altered recommendations for specific patient sub-groups
  • Focus on atrial fibrillation, non-left bundle branch block conduction, prior chronic pacing
  • Guidance related to CRT platform selection
  • Guidance on pre-selection with echocardiography

What Health Professionals Need to Know

There are new criteria for patient selection, based on the presence of absence of sinus rhythm, the QRS width and the type of conduction abnormality. The limitations of existing knowledge related to benefit from CRT are reviewed in detail and the new recommendations reflect these gaps in knowledge. The follow-up document, Part 2, Implementation of These Guidelines, will further deal with patient selection, operative factors, maximizing benefit from CRT, along with economic and geographical issues related to the Canadian healthcare system.

CCS 2012 HEART FAILURE MANAGEMENT GUIDELINES UPDATE: FOCUS ON ACUTE AND CHRONIC HEART FAILURE
Co-chaired by Robert S. McKelvie and Gordon W. Moe

What’s New?

  • Recommendation of a validated diagnostic scoring system for patients in whom the diagnosis of acute heart failure(HF) is being considered
  • Recommendation that in the clinical scenario when the clinical diagnosis of acute HF is of intermediate pre-test probability that a natriuretic peptide (NP) measure should be obtained to rule in or out HF
  • Recommend in chronic HF, if available, a NP level to rule in or out HF and obtain prognosis
  • Mineralocorticoid receptor antagonist (MRA) is recommended in mild to moderate HF (e.g., eplerenone)
  • Recommend CRT in NYHA class II patients with QRS ≥130 ms with LBBB morphology and EF ≤30%

What Health Professionals Need to Know

  • First line therapy for chronic HF remains angiotensin converting enzyme inhibitor (ACEi) and beta-blocker
  • Chronic HF patients in NYHA class II-IV after optimization of ACEi and beta-blocker should be considered for MRA (e.g., eplerenone)
  • If a drug with proven mortality or morbidity benefits is not tolerated, other concomitant drugs with less proven benefit can be reevaluated to determine whether their dose can be reduced or the drug discontinued to allow for better tolerance of the drug with proven benefit
  • It is important to understand that only beta-blockers that have been shown to improve clinical outcomes should be used (bisoprolol, carvedilol)

2012 CCS DYSLIPIDEMIA GUIDELINE UPDATE
Co-chaired by Todd Anderson and Jean Grégoire

What's New?

  • Introduction of the concept of Cardiovascular Age
  • Recommending more frequent monitoring of patients with FRS >5% and <10%
  • Using both apo B or non-HDL-C as alternate lipid markers
  • Removing hsCRP from the main treatment table
  • Addition of chronic kidney disease as a high risk feature
  • Specific recommendations about health behaviours
  • New recommendation about statin adverse effects
  • Use of GRADE recommendations and process

What Health Professionals Need to Know

Who to screen

Risk assessment remains the cornerstone of prevention

Statin treatment indicated for high risk individuals

No further testing or treatment required for very low risk individuals

For intermediate risk subjects current guidelines are based on previous randomized studies with LDL-C cut points. Newer approaches include a more liberal use of statins regardless of LDL-C vs. an approach that utilizes secondary testing to risk stratify.

Implement health behaviour changes in all subjects at risk

Statin therapy remains first line. Statin intolerance needs to be approached in a systematic fashion.

TRANSCATHETER AORTIC VALVE IMPLANTATION:
A CANADIAN CARDIOVASCULAR SOCIETY POSITION STATEMENT 2012
Chaired by John Webb

What’s New?

Patients with severe symptomatic aortic stenosis have a poor prognosis with medical management alone. Currently surgical valve replacement remains the treatment of choice for patients with aortic stenosis. However transcatheter aortic valve implantation (TAVI) has been demonstrated to improve survival, quality of life, and functional status in non-operable patients and to be a viable option for patients in whom the risk of open surgical morbidity or mortality is high.

What Health Professionals Need to Know

  • Transfemoral TAVI is recommended if
    a. the risk of open heart surgery is prohibitive
    b. significant improvement in duration or quality of life is likely and
    c. life expectancy with treatment is likely to exceed one to two years
  • TAVI is a reasonable alternative to surgery for patients at high risk of mortality or major morbidity and
    a. duration and quality of life is likely to be significantly improved by treatment
    b. life expectancy with treatment is likely to exceed one to two years with treatment
    c. there is a consensus amongst a multidisciplinary heart team including cardiologists and surgeons
  • Transcatheter valve-in-valve implants may be reasonable in patients with failed surgical bioprosthetic valves in whom there is a heart team consensus that:
    a. the risk of open heart surgery is prohibitive and
    b. a significant improvement in duration or quality of life is likely and
    c. life expectancy with treatment is likely to exceed one to two years

CCS 2012 PAEDIATRIC HEART FAILURE GUIDELINES DEVELOPMENT
Co-chaired by Paul Kantor, Adrian Dancea and Jane Lougheed

The Canadian Cardiovascular Society is the first in Canada to issue guidelines aimed at helping primary care and emergency physicians, as well as specialists, recognize and manage heart failure in children.

The key recommendations for early recognition are:

  • Cardiomyopathy, or heart muscle disease, is one of the main causes of heart failure in children and should be excluded when a child presents with unexplained rapid heart rate or rapid breathing. This may be a familial condition caused by one of several gene abnormalities.
  • Myocarditis, a viral infection of the heart muscle, may be present when children present with abdominal pain and vomiting and have signs of poor circulation.
  • Specialized pediatric echocardiography is required to exclude heart failure and should be obtained in children with unexplained symptoms and signs of abnormal circulation.

Key recommendations for management after diagnosis are:

  • Admission to a hospital that has pediatric expertise for immediate care.
  • Ongoing care to be provided by an expert in pediatric cardiology.

“It is very important that these children receive expert care because they tend to deteriorate rapidly,” says Kantor. “They need to be admitted to a hospital that has pediatric expertise and be evaluated by a children’s heart specialist, with echocardiography done by that specialist.”

Key recommendations for treatment are:

  • Prompt use of diuretics.
  • Treatment with inotropic drugs to rescue the patient, and a transition to ACE inhibitors thereafter.
  • For myocarditis, the experts recommend supportive care, to allow the heart to recover on its own. This can mean giving the patient drugs to support blood pressure, circulation, and occasionally, use of a ventricular assist device, to improve the circulation while the heart recovers, giving it a chance to rest.

CCS PS: SAFETY AND RADIATION EXPOSURE DUE TO CARDIAC PROCEDURES
Co-chaired by Narinder Paul and Madhu Natarajan

Exposure to ionizing radiation is a consequence of many diagnostic and interventional cardiac procedures. Radiation exposure can result in detrimental health effects. However, with the levels experienced during cardiac procedures the risk of these effects can be difficult to quantify. Thus, healthcare providers and patients may not fully appreciate the risks associated with radiation exposure from cardiac procedures. The purpose of this position statement is fourfold. First, we provide the reader with a brief review of the current evidence regarding risks and effects of radiation exposure. Next, we describe the magnitude of exposures and estimated doses associated with cardiac procedures, with particular focus on the more common modalities: fluoroscopy-driven diagnostics and interventions, cardiac computed tomography, and radionuclide myocardial perfusion imaging. In the last two sections we provide discussion regarding monitoring and recording of radiation exposures and doses associated with cardiac procedures, and issues associated with communicating risk and the follow up of patients with relatively high exposures. At the end of each section recommendations and suggestions are presented, based on a synthesis of the available evidence through consensus of the document development committee.

JOINT CHRS/CCS PS ON DEVICE FOLLOW UP AND REMOTE MONITORING
Chaired by Raymond Yee

Remote monitoring (RM) is a technology that allows data from a patient’s pacemaker or implantable defibrillator (CIED) to be uploaded from virtually any location outside of a device clinic. Health professionals caring for the patient can then access these data whenever needed. Scientific evidence indicates that RM safely reduces the time to detect CIED abnormalities or arrhythmic events and the number of device clinic visits. Recent trials also report reductions in inappropriate ICD therapies and hospitalizations with RM. RM reduces direct patient costs, transportation and waiting time and can improve device clinic efficiency and is particularly useful when more intensive CIED surveillance is necessary.
This position statement focuses solely on examining the clinical utility and potential role of RM for PM, ICD and CRT patient follow-up in the Canadian healthcare context and provides practical advice on RM integration into the routine practice of the modern DFC.

CCS guidelines are developed following a thorough consideration of medical literature and the best available evidence and clinical experience. They represent the consensus of a Canadian panel comprised of multidisciplinary experts on a topic with a mandate to formulate disease-specific recommendations.

Guideline recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. These Guidelines are not intended to be a substitute for physicians using their individual judgement in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.

The Canadian Cardiovascular Society (ccs.ca) is the national voice for cardiovascular physicians and scientists. Its mission is to promote cardiovascular health and care through knowledge translation, professional development, and leadership in health policy.

The Heart and Stroke Foundation (heartandstroke.ca), a volunteer-based health charity, leads in eliminating heart disease and stroke and reducing their impact through the advancement of research and its application, the promotion of healthy living and advocacy.

Healthy lives free of heart disease and stroke. Together we will make it happen.





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