New CCS guidelines and position papers for physicians and nurse practitioners

Heart and Stroke Foundation of CanadaOct 28 2009

Several new guidelines and position papers offering the most up to date information to ensure that clinicians practice evidence-based medicine were released at the Canadian Cardiovascular Congress 2009 this week.

Among them are the following:

• 2009 CCS Canadian Cholesterol Guidelines
• 2009 CCS Consensus Conference Update on the Guidelines for the Management of Adults with Congenital Heart Disease
• CCS/Canadian Association of Radiologists Consensus Training Standards for Cardiac CT
• 2009 CCS Heart Failure Guidelines

Guidelines are one of the highest priorities of the Canadian Cardiovascular Society (CCS), says their president Dr. Charles Kerr. "They are one of our most important services and are the highest rated by clinicians," he says. "For example, the CCS heart failure guidelines website has received a huge number of hits this year − in the hundreds of thousands. They have an enormous impact."

The CCS usually puts out one set of guidelines each year. This year, the CCS guidelines committee, chaired by Dr Michelle Graham, coordinated the release of 10 guidelines and position statements.

The guidelines are an invaluable resource not only for members of the cardiovascular community, but for family physicians and nurse practitioners throughout Canada, she says.

Dr. Graham praises the dedication and drive of all of the contributors to the guidelines and position statements who went above and beyond the call of duty to produce rigorous, evidence based guidelines. "This is volunteerism at its best, with a view of improving the heart health of Canadians."

Guideline Highlights

2009 CCS Canadian Cholesterol Guidelines − Chaired by Dr. Jacques Genest

A joint effort with the Canadian Vascular Coalition and CIHR, the 2009 cholesterol guidelines have better defined secondary and high-risk prevention strategies and include clinical studies on end-stage disease (advanced heart failure and hemodialysis).

What's new:

• With regard to primary prevention, the 2009 cholesterol guidelines include cardiovascular risk evaluation tools and the Framingham Risk Score for cardiovascular disease.
• Intermediate risk is defined as a FRS 10-19% 10-year risk and family history is now part of risk stratification.
• hsCRP is part of the risk stratification in intermediate risk subjects.
• Simplified target levels.
• Secondary targets evaluated according to available evidence.

What doctors need to know:

For patients at high risk (those with CAD, PVD, atherosclerosis, most patients with diabetes, FRS>20%, RRS>20%)

• Consider treatment in all patients
• Primary LDL-C target < 2mmol/L or 50% reduction in LDL-C

For moderate risk patients (FRS 10-19%), initiate treatment if:

• LDL-C > 3.5 mmol/L.
• TC/HL-C > 5.0.
• hsCRP>2 in men >50 y and women > 60 y.
• Family history and hsCRP modulates risk (RRS).
• Primary target Class 1 level A recommendation is LDL-C < 2mmol/L or 50% reduction of LDL-C.

2009 Updated Guidelines for the Management of Adults with Congenital Heart Disease − Chaired by Dr. Candice Silversides

With advances in pediatric cardiology and cardiac surgery, the population of adults with congenital heart disease has grown and in the current era there are more adults with congenital heart disease than children. Since the 2001 Canadian Cardiovascular Society Consensus Conference report on the management of adults with congenital heart disease, there have been significant advances in our understanding of the late outcomes, genetics, medical therapy, and interventional approaches in the field of adult congenital heart disease. The updated guidelines for the management of adult congenital heart disease address these important issues.

What doctors need to know:

• Adults with congenital heart disease have a unique set of needs including genetic screening, antibiotic prophylaxis, and pregnancy/contraception.
• Other issues specific to adults with congenital heart disease include long-term and multisystemic effects of single ventricle physiology, cyanosis, systemic right ventricles, complex intracardiac baffles, and failing subpulmonary right ventricles.
• Complications in this population include distinctive forms of heart failure, pulmonary hypertension, thromboemboli, complex arrhythmias, and sudden death.
• Recommendations for medical therapy and indications for interventions for the common congenital cardiac lesions are available in the CCS 2009 Updated Guidelines for the Management of Adults with Congenital Heart Disease.

Canadian Cardiovascular Society/Canadian Association of Radiologists Consensus Training Standards for Cardiac CT - Co-chaired by Dr. Benjamin Chow (CCS) and Dr. Carole Dennie (CAR)

What's new:

• Standards for training in cardiac CT have been developed as a consensus of the Canadian Association of Radiologists and the Canadian Cardiovascular Society and apply to both radiologists and cardiologists with the mutual goal of optimizing patient care.

Cardiac risk assessment prior to the use of stimulant medications in children and youth: a joint position statement by the Canadian Pediatric Society, the Canadian Cardiovascular Society, and the Canadian Academy of Child and Adolescent Psychiatry − CCS writing group chair is Dr. Andrew Warren

What doctors need to know:

• Analysis of patient-year exposure data for children on ADHD medications suggests that the rate of sudden death is similar to the general population but it is important for doctors to remain watchful.
• Patients with ADHD, like all pediatric patients, should undergo a careful history and physical examination that includes personal and family history details which may identify those at risk of sudden cardiac death. This should be performed by their primary care physician.
• Routine ECG assessment of ADHD patients prior to starting medication is not supported by evidence and is not recommended.
• For ADHD patients with known heart disease and followed by a cardiologist, the physician with expertise in ADHD likely remains the appropriate individual to evaluate benefit and risk and make recommendations for medication therapy, as there is little evidence that taking medication further increases the risk of sudden death.
• Discussion of treatment options with the cardiologist is appropriate with ultimate treatment decisions being made by consensus. "In-person" clinical review by the cardiologist specifically for ADHD risk assessment before starting treatment is generally unnecessary.
• For ADHD patients with suspected heart disease or identified risk factors for sudden death, assessment by a cardiologist is recommended. This would also be the case for a non-ADHD patient.
• A screening tool is provided with the guidelines to aid physicians in their clinical evaluation of children starting ADHD medication.

2009 Updated Guidelines for the Diagnosis and Management of Heart Failure − Chaired by Dr. Jonathan Howlett

The CCS commitment to delivery of timely and practical heart failure guidelines for health care providers continues. Due to results from needs assessments conducted nationwide, this year's heart failure update dealt with four important issues: the diagnosis and management of right-sided heart failure; diagnosis, investigation of myocarditis; updated intracardiac device therapy; and recommendations based upon recent landmark clinical trials.

What doctors need to know:

• The diagnosis of right-sided heart failure requires increased level of suspicion and a slightly altered approach. Treatment varies according to the underlying condition.
• The diagnosis of myocarditis also requires increased level of clinical suspicion. The role of cardiac magnetic resonance imaging, consideration of early referral to an experienced centre, and updated role of RV biopsy is discussed.
• With new evidence from clinical trials assessing the use of intracardiac device therapy now available, the role of this therapy in patients' heart failure and narrow QRS complex, atrial fibrillation, and other conditions is addressed.

Recommendations arising from landmark clinical trials of heart failure and specific conditions such as atrial fibrillation, dyslipidemia, anemia, and decompensated heart failure are discussed.

Canadian Cardiovascular Society/Canadian Heart Rhythm Society Recommendations for the use of Genetic Testing in the Evaluation of Inherited Cardiac Arrhythmias Associated with Sudden Cardiac Death − Chaired by Dr. Michael Gollob

What doctors and allied professionals need to know:

• Genetic testing for primary electrical and structural diseases of the heart associated with sudden cardiac death is now an expected component of patient/family care in many circumstances.
• Genetic testing may assist in the diagnosis of at-risk family members without clinically overt disease and impact on preventative medicine strategies.
• Genetic testing yields and interpretability of results differ between various genetic conditions, highlighting the need for expertise knowledge prior to ordering genetic tests.
• Decisions regarding the utility of genetic testing should be directed by clinical centres with specific expertise for these conditions, with assurance of pre-test genetic counselling by knowledgeable counsellors.