Andrew Ignaszewski

Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: Diagnosis and management

Heart failure remains a common diagnosis, especially in older individuals. It continues to be associated with significant morbidity and mortality, but major advances in both diagnosis and management have occurred and will continue to improve symptoms and other outcomes in patients. The Canadian Cardiovascular Society published its first consensus conference recommendations on the diagnosis and management of heart failure in 1994, followed by two brief updates, and reconvened this consensus conference to provide a comprehensive review of current knowledge and management strategies. New clinical trial evidence and meta-analyses were critically reviewed by a multidisciplinary primary panel who developed both recommendations and practical tips, which were reviewed by a secondary panel. The resulting document is intended to provide practical advice for specialists, family physicians, nurses, pharmacists and others who are involved in the care of heart failure patients. Management of heart failure begins with an accurate diagnosis, and requires rational combination drug therapy, individualization of care for each patient (based on their symptoms, clinical presentation and disease severity), appropriate mechanical interventions including revascularization and devices, collaborative efforts among health care professionals, and education and cooperation of the patient and their immediate caregivers. The goal is to translate best evidence-based therapies into clinical practice with a measureable impact on the health of heart failure patients in Canada.

Self-Reported Morisky Score for Identifying Nonadherence with Cardiovascular Medications

BACKGROUND: The Morisky medication adherence scale is a commonly used adherence screening tool. It is composed of 4 yes/no questions about past medication use patterns and is thus quick and simple to use during drug history interviews. OBJECTIVE: To evaluate the use of the self-reported Morisky score as a screening tool for identifying patients who have been nonadherent with chronic cardiovascular medications. METHODS: Patients who had taken an angiotensin-converting enzyme inhibitor or lipid-lowering agent for at least 3 consecutive months were interviewed using a structured questionnaire including the Morisky scale. Nonadherence was defined as taking <80% of chronic cardiovascular medications based on prescription refill data over the previous 14 months. RESULTS: Forty-nine of 377 (13%) patients were categorized as nonadherent; however, only 12 (3%) patients had Morisky scores suggesting a high likelihood of nonadherence (3 or 4). While the Morisky score was a significant independent predictor of nonadherence by multivariate analysis, there was no threshold score or individual question that yielded concurrent high sensitivity and positive predictive values (PPVs) for identifying nonadherent patients. The internal consistency of the questions was low (α 0.32), as were item-to-total score correlations, suggesting that the individual questions were not measuring the same attribute. CONCLUSIONS: Using the Morisky scale to identify patients who have been nonadherent with chronic cardiovascular medications may be reasonable in some settings; however, the threshold score would have to be chosen based on a trade-off between sensitivity and PPV. These results were likely influenced by the low rate of nonadherence in this cohort. Rewording the questions, increasing the number of questions, and the use of graded response options may improve consistency.

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.

A systematic review of telemonitoring technologies in heart failure.

Heart failure (HF) results in characteristic signs and symptoms including oedema and breathing difficulties. Heart failure is particularly suited to telemonitoring, because patients’ signs and symptoms can be assessed remotely by healthcare providers, and deterioration can be quickly detected and addressed. In this paper, we review studies conducted in HF telemonitoring, to describe the nature of the modality, the methods, and the results.

The Psychology of Men and Women Recovering From Coronary Artery Bypass Surgery

BACKGROUND Little is known about the differences between mens and womens cardiac rehabilitation processes. What helps men during recovery may not necessarily aid womens recovery. Psychosocial variables are known to impact recovery in positive and negative ways. Unfortunately, it is not clear what variables are the most effective predictors of recovery outcomes for men and women. METHODS Ninety coronary artery bypass graft patients (60 men, 30 women) completed a battery of psychological questionnaires on or after the third day after surgery. RESULTS Results showed that women reported significantly more depressive symptoms than men. For women, pain was correlated positively with depressive symptomatology and functional impairment. For men, pain and functional impairment were correlated negatively with social support. In addition, the results of a multiple regression of pain on age, severity of disease, and two psychosocial variables (depressive symptomatology and social support) for the women showed that after controlling for age and severity of disease, depressive symptomatology and social support accounted for a significant 43% increment in the variance in pain. The psychosocial variables accounted for much less variance in pain in men. However, in a multiple regression of functional impairment on the same variables, depressive symptomatology and social support accounted for a significant 14% increment in the variance in pain in men but a nonsignificant increment for the women. CONCLUSIONS The results support the notion that psychosocial variables play different roles in the recovery paths of men and women. In consequence, cardiac rehabilitation programs would be more effective with gender-specific tailoring.

Eosinophilic myocarditis: case series and review of literature.

Although the etiology of eosinophilic myocarditis (EM) is not always apparent, several causes are identified, including hypersensitivity to a drug or substance, with the heart as the target organ. However, symptoms and signs of hypersensitivity are not found in all patients. EM can lead to progressive myocardial damage with destruction of the conduction system and refractory heart failure. The present report describes three cases of biopsy-proven EM with different presentations, including acute coronary syndrome, cardiogenic shock and newly diagnosed heart failure. In one patient, hypersensitivity to sumatriptan was suspected to be the underlying cause. All patients responded well to treatment with steroids, angiotensin-converting enzyme inhibitors and beta-blockers. There was a complete recovery of the ventricular function in all cases.

Exercise stress testing : An overview of current guidelines

Exercise stress testing (ET) is an inexpensive noninvasive tool that provides valuable cardiopulmonary information in healthy and diseased populations. It is most commonly used for diagnosing coronary artery disease (CAD) and developing appropriate exercise prescriptions (EP). With its widespread use and application, it is imperative that safe and appropriate guidelines and procedures are used, as there are a number of risks associated with testing in a population with or suspected of having CAD. The focus should be on the patient’s safety: personnel must be properly trained and aware of all emergency procedures, contra-indications for ET and indications for test termination must be strictly adhered to.Three main types of testing are prevalent: submaximal, maximal and maximal utilising gas exchange. The maximal test is most commonly used, and the submaximal is appropriate for hospitalised patients. Gas exchange data is essential when assessing congestive heart failure and timing for heart transplantation.ET is commonly performed using a treadmill or a bicycle ergometer. The treadmill provides a more familiar exercise modality and has been shown to have greater diagnostic sensitivity than the bicycle ergometer; it is, however, more expensive and requires more space in the testing room. The bicycle ergometer is more appropriate for those individuals who are severely obese or have problems with extended periods of walking.Regardless of the modality used, an appropriate exercise protocol should be used. In North America, the Bruce protocol is the most common. However, the Bruce protocol, and others that estimate exercise capacity based on equations, tend to overestimate exercise capacity. They may be too demanding for those with limited exercise capacity, and too long for those with high exercise capacity. For these people, an exercise protocol that reaches maximal capacity in 8 to 12 minutes using smaller increments in workload should be considered.Once completed, the results of ET needs to be correctly interpreted. This includes reviewing the test results while considering the patient’s history, medications and indication for the test. ET can also be used to develop an EP for the participant. An EP should take into account the intensity, modality of exercise, frequency and duration, as well as being realistic for the individual and the goals to be achieved. All the information from the test results and the pre-test examination should be presented in a report that also includes the advised EP.

The use of milrinone in pre-transplant assessment of patients with congestive heart failure and pulmonary hypertension

BACKGROUND Pulmonary hypertension in patients with congestive heart failure (CHF) is a risk factor for increased mortality after orthotopic cardiac transplantation. Reversibility of elevated pulmonary vascular resistance (PVR) by pharmacologic agents predicts improved outcomes. Milrinone, a phosphodiesterase inhibitor with vasodilating and positive inotropic properties, has been shown to lower PVR in one previous study. However, no study has documented outcomes after cardiac transplantation in patients in whom reversibility of pulmonary hypertension was demonstrated after administration of milrinone. METHODS We retrospectively reviewed 19 patients with CHF and pulmonary hypertension defined as PVR > or = 3 Wood units, PVRI (pulmonary vascular resistance index) > or = 4 resistance units, or TPG (transpulmonary gradient = mean pulmonary artery pressure--mean capillary wedge pressure) > or = 12 mmHg being assessed for cardiac transplantation. A sub-group of 14 patients with severe pulmonary hypertension defined as PVR > or = 4, PVRI > or = 6 and TPG > or = 15 was also examined. Milrinone was administered as a bolus (50 ug/kg) and hemodynamic parameters were measured at 5, 10 and 15 minutes. Six patients received cardiac transplants. RESULTS Administration of milrinone significantly lowered PVR, PVRI, mean pulmonary artery pressure (PAM)(all p = 0.002) and pulmonary capillary wedge pressure (PCWP)(p = 0.006). Cardiac output (CO) increased significantly (p = 0.001). TPG did not change (p = 0.33). In patients with severe pulmonary hypertension, the magnitude of these changes was greater. In addition, TPG was significantly lowered (p = 0.02). CONCLUSION Milrinone lowered PVR by decreasing PAM and increasing CO significantly. In addition, PCWP was significantly lowered. These finding confirm both vasodilatory and inotropic effects of milrinone. Patients with severe pulmonary hypertension had more pronounced effects. There were no deaths in the group of patients proceeding to cardiac transplantation. Our study demonstrates the efficacy of milrinone in lowering PVR as well as suggesting safety in use in patients undergoing cardiac transplantation.

Comparative outcomes in cardiogenic shock patients managed with Impella microaxial pump or extracorporeal life support.

OBJECTIVE Cardiogenic shock is associated with poor clinical outcomes. Extracorporeal life support is used in most centers for short-term circulatory support. Alternatively, the Impella LP 5.0 and right direct (RD) microaxial ventricular assist device (Abiomed, Danvers, Mass) can provide isolated left and right ventricular support, respectively. METHODS A retrospective, single center review was performed on all patients receiving circulatory assistance with either extracorporeal life support or Impella ventricular assist device. All Impella LP 5.0 were inserted via the femoral artery, while the RD system required sternotomy. RESULTS Twenty-nine patients received ventricular assist device support (Impella LP 5.0; n = 24; and Impella RD; n = 5), whereas 32 patients were placed on extracorporeal life support. The baseline characteristics of patients with cardiogenic shock, assisted by Impella or extracorporeal life support, were similar, but the etiology of cardiogenic shock was distributed differently in the 2 groups (P = .008). Forty-one percent of the Impella patients and 47% of the extracorporeal life support patients were weaned from support. The 30-day mortality (44% in the extracorporeal life support vs 38% in the Impella group) and proportion of patients discharged home (41% in the extracorporeal life support vs 59% in the Impella group) were not statistically different between the 2 groups. Arterial thrombosis was less frequent in the Impella group (3.4% vs 18.8%; P = .04). Blood product transfusions were less frequent in the Impella group (P < .001). CONCLUSIONS Both extracorporeal life support and axial flow pumps provided adequate support in patients with various etiologies of cardiogenic shock. Axial-flow pump may be an optimal type of support for patients with univentricular failure, whereas extracorporeal life support could be reserved for patients with biventricular failure or combined respiratory and circulatory failure.

The Impact of Dietary Changes and Dietary Supplements on Lipid Profile

With a growing number of dietary interventions that claim to improve lipid profile, it is important to ensure that these claims are evidence based. The objective of this study was to make recommendations for dietary regimens by analyzing their effectiveness and the level of evidence. We searched MEDLINE as well as the Cochrane Database of Systematic Reviews for nutritional studies. Meta-analyses and randomized controlled trials published in English and including data on the effect on blood lipid levels were used. Randomized controlled trials were included if they were at least 4 weeks in duration and had a minimum of 50 participants. We identified 22 different dietary interventions and reviewed 136 studies published between January 1990 and December 2009 that met our inclusion criteria. Our literature review showed that to improve lipid profile, the following regimens can be recommended fully: Mediterranean and Portfolio diets; low-fat diet; diet high in soy protein, fibre, or phytosterols; whole grain foods, and omega-3 fatty acid supplementation. The consumption of nuts, a diet high in carbohydrates and protein, green tea, and red wine, as well as the supplementation with policosanol and red yeast rice extract, can be considered for improvement of the lipid profile, while the supplements of guggulipid, garlic, chromium, vitamin C, magnesium-pyridoxal-phosphate-glutamate, tocotrienols, and absorbitol cannot be recommended.