Bibiana Cujec

Beta-blockers and angiotensin-converting enzyme inhibitors/receptor blockers prescriptions after hospital discharge for heart failure are associated with decreased mortality in Alberta, Canada.

OBJECTIVES We sought to evaluate the common utilization of beta-blockers and angiotensin-converting enzyme (ACE) inhibitors or receptor blockers (RBs) in congestive heart failure (CHF). BACKGROUND We assessed the association between prescriptions of beta-blockers and ACE inhibitors or RBs within three months after hospitalization and mortality for newly diagnosed CHF in Alberta, Canada seniors (age 65 years and older). METHODS Administrative hospital discharge abstracts and drug data during October 1, 1994, to December 31, 1999, were analyzed. RESULTS There were 11854 hospitalizations for newly diagnosed CHF. The use of beta-blockers within three months after hospitalization increased from 7.3% in 1994-1995 to 20.9% in 1999-2000. The use of ACE inhibitor or RBs within three months after hospitalization increased from 31.0% in 1994-1995 to 44.3% in 1999-2000. Adjusted one-year mortality was lower in seniors with prescriptions for beta-blockers (18.2%; 95% confidence interval [CI] 14.2 to 22.2), ACE inhibitors/RBs (22.3%; 95% CI 20.9 to 23.7), or both (16.6%; 95% CI 13.3 to 20.0), compared with those with no prescriptions (29.9%; 95% CI 28.8 to 31.0). Absolute adjusted risk reduction comparing no prescription with prescription of both beta-blockers or ACE inhibitors/RBs was 13.3% for a relative adjusted risk reduction of 44%. CONCLUSIONS This study of incident CHF hospitalizations among seniors demonstrates an association between decreased mortality and the use of beta-blockers, ACE inhibitors/RBs, or combination of both. The effectiveness of beta-blockers and ACE inhibitors/RBs for CHF should be more broadly tested in clinical trials that recruit older patients and those with diastolic dysfunction.

Hydroxychloroquine-Induced Cardiomyopathy: Case Report, Pathophysiology, Diagnosis, and Treatment

Drug-induced heart and vascular disease remains an important health burden. Hydroxychloroquine and its predecessor chloroquine are medications commonly used in the treatment of systemic lupus erythematosus, rheumatoid arthritis, and other connective tissue disorders. Hydroxychloroquine interferes with malarial metabolites, confers immunomodulatory effects, and also affects lysosomal function. Clinical monitoring and early recognition of toxicity is an important management strategy in patients who undergo long-term treatment with hydroxychloroquine. Retinal toxicity, neuromyopathy, and cardiac disease are recognized adverse effects of hydroxychloroquine. Immediate withdrawal of hydroxychloroquine is essential if toxicity is suspected because of the early reversibility of cardiomyopathy. In addition to recommended ophthalmological screening, regular screening with 12-lead electrocardiogram and transthoracic echocardiography to detect conduction system disease and/or biventricular morphological or functional changes should be considered in hydroxychloroquine-treated patients. Cardiac magnetic resonance imaging and endomyocardial biopsy are valuable tools to provide prognostic insights and confirm the diagnosis of hydroxychloroquine-induced cardiomyopathy. In conclusion, chronic use of hydroxychloroquine can result in an acquired lysosomal storage disorder, leading to a drug-induced cardiomyopathy characterized by concentric hypertrophy and conduction abnormalities associated with increased adverse clinical outcomes and mortality.

Effect of Invasive Coronary Revascularization in Acute Myocardial Infarction on Subsequent Death Rate and Frequency of Chronic Heart Failure

There is debate about whether therapies that reduce mortality in acute myocardial infarction (AMI) will increase the risk for heart failure. In this study, an inception cohort of patients hospitalized with AMIs from April 1, 1994, to March 31, 1999 (without previous diagnoses of heart failure or myocardial infarction), were followed for a mean of 32 months to explore whether invasive coronary revascularization during the index AMI hospitalization was associated with a trade-off between reduced mortality in the short term and increased heart failure in the intermediate term. Of 13,472 patients (mean age 65 +/- 13 years, 70% men), 3,278 (24%) underwent invasive coronary revascularization during their index AMI hospitalizations. Patients who underwent invasive revascularization during their index AMI hospitalizations were less likely to die (171 of 3,278 [5%] vs 1,688 of 10,194 [17%], p <0.0001) and were less likely to develop heart failure, either during the AMI hospitalization (571 of 3,278 [17%] vs 2,422 of 10,194 [24%], p <0.0001) or after discharge (144 of 3,278 [4%] vs 754 of 10,194 [7%], p <0.0001). These associations persisted after covariate adjustment (for heart failure, hazard ratio 0.68, 95% confidence interval 0.56 to 0.81; for death or heart failure, hazard ratio 0.60, 95% confidence interval 0.51 to 0.70). In conclusion, invasive coronary revascularization during AMI hospitalization is associated with lower rates of death and subsequent heart failure; there is no trade-off of 1 outcome for the other.

2010 Canadian Cardiovascular Society/Canadian Society of Echocardiography Guidelines for Training and Maintenance of Competency in Adult Echocardiography

Guidelines for the provision of echocardiography in Canada were jointly developed and published by the Canadian Cardiovascular Society and the Canadian Society of Echocardiography in 2005. Since their publication, recognition of the importance of echocardiography to patient care has increased, along with the use of focused, point-of-care echocardiography by physicians of diverse clinical backgrounds and variable training. New guidelines for physician training and maintenance of competence in adult echocardiography were required to ensure that physicians providing either focused, point-of-care echocardiography or comprehensive echocardiography are appropriately trained and proficient in their use of echocardiography. In addition, revision of the guidelines was required to address technological advances and the desire to standardize echocardiography training across the country to facilitate the national recognition of a physicians expertise in echocardiography. This paper summarizes the new Guidelines for Physician Training and Maintenance of Competency in Adult Echocardiography, which are considerably more comprehensive than earlier guidelines and address many important issues not previously covered. These guidelines provide a blueprint for physician training despite different clinical backgrounds and help standardize physician training and training programs across the country. Adherence to the guidelines will ensure that physicians providing echocardiography have acquired sufficient expertise required for their specific practice. The document will also provide a framework for other national societies to standardize their training programs in echocardiography and will provide a benchmark by which competency in adult echocardiography may be measured.

The Correlation of Standard Heart Failure Assessment and Palliative Care Questionnaires in a Multidisciplinary Heart Failure Clinic

CONTEXT Heart failure (HF) is a leading cause of death and disability, and despite optimal care, patients may eventually require palliative care. Little is known about how palliative care questionnaires (the Edmonton Symptom Assessment Scale [ESAS] and the Palliative Performance Scale [PPS]) perform compared with HF assessment using the New York Heart Association (NYHA) functional class and the Kansas City Cardiomyopathy Questionnaire (KCCQ). OBJECTIVES To assess the utility of a palliative care questionnaire in patients with HF. METHODS One hundred and five patients (mean age=65 years, 76% male, mean ejection fraction=28%) followed in an HF clinic were surveyed with the NYHA, PPS, ESAS, and KCCQ. RESULTS The PPS and ESAS were each correlated to the NYHA class (P<0.0001 for both) and the KCCQ score (PPS: R(2)=0.57; ESAS: R(2)=-0.72; both P<0.0001). There were 33 patients who either died (10 deaths) or were hospitalized (26 patients) for more than one year. In addition to age and gender, a higher (worse) ESAS score trended toward significance (P=0.07) and a lower (worse) PPS was a significant (P=0.04) predictor of all-cause hospitalization or death. CONCLUSION In a cohort of HF patients, we found a modest correlation with NYHA class and KCCQ assessment with the PPS and ESAS, two standard palliative care questionnaires. Given the difficulty in identifying patients with HF eligible for palliative or hospice care, these tools may be of use in clinical practice.

Multifaceted Support for a New Medical School in Nepal Devoted to Rural Health by a Canadian Faculty of Medicine and Dentistry

Nepal and Alberta are literally a world apart. Yet they share a common problem of restricted access to health services in remote and rural areas. In Nepal, urban-rural disparities were one of the main issues in the recent civil war, which ended in 2006. In response to the need for improved health equity in Nepal a dedicated group of Nepali physicians began planning the Patan Academy of Health Sciences (PAHS), a new health sciences university dedicated to the education of rural health providers in the early 2000s. Beginning with a medical school the Patan Academy of Health Sciences uses international help to plan, deliver and assess its curriculum. PAHS developed an International Advisory Board (IAB) attracting international help using a model of broad, intentional recruitment and then on individuals’ natural attraction to a clear mission of peace-making through health equity. Such a model provides for flexible recruitment of globally diverse experts, though it risks a lack of coordination. Until recently, the PAHS IAB has not enjoyed significant or formal support from any single international institution. However, an increasing number of the international consultants recruited by PAHS to its International Advisory Board are from the University of Alberta in Edmonton, Alberta, Canada (UAlberta). The number of UAlberta Faculty of Medicine and Dentistry members involved in the project has risen to fifteen, providing a critical mass for a coordinated effort to leverage institutional support for this partnership. This paper describes the organic growth of the UAlberta group supporting PAHS, and the ways in which it supports a sister institution in a developing nation.