New Canadian Cardiovascular Society guidelines support clinicians in practicing evidence-based medicine

HEART AND STROKE FOUNDATION OF CANADAOct 25 2010

Summaries of a number of new Canadian Cardiovascular Society guidelines and position statements offering the most up to date information to support clinicians in practicing evidence-based medicine were released at the Canadian Cardiovascular Congress 2010 this week. Among them are the following:

• CCS atrial fibrillation guidelines
• CCS antiplatelet therapy guidelines
• CCS position statement on smoking cessation
• CCS refractory angina guidelines
• CCS/CACR position on inpatient referral to cardiac rehabilitation  
• CCS position paper on the standardized approaches to the investigation of syncope

The manuscripts associated with these summary presentations are in press and will be published in the Canadian Cardiovascular Society (CCS) journal in 2011.

Guidelines are one of the highest priorities for the CCS.

"Feedback and surveys from the CCS membership and the broader cardiovascular community tell us that CCS guidelines are among our most important functions," says CCS president Dr. Charles Kerr. "As we embark on each new guideline project, we endeavor to identify strong co-chairs and expert panels so we can continue to support Canadian cardiovascular health care practitioners in delivering the highest level of evidence-based care."

This year, the CCS guidelines committee, chaired by Dr Michelle Graham, has overseen the release four position statements and four guidelines.

"This hard working group is responsible for selecting the topics each year for CCS guideline and position statements and ensuring that each is executed in a rigorous and highly transparent manner," says Dr. Graham.

The guidelines are an invaluable resource not only for members of the cardiovascular community, but for healthcare practitioners throughout Canada.

GUIDELINE HIGHLIGHTS

2010 CCS atrial fibrillation guidelines - Co-chaired by Drs. Anne Gillis and Allan Skanes

Atrial fibrillation (AF) is the most common sustained arrhythmia treated in clinical practice and is associated with substantial morbidity including frequent emergency department visits and hospitalizations for symptoms secondary to AF and an increased risk for stroke. AF is an emerging epidemic as the population ages and indeed, the lifetime risk of developing AF in individuals older than 40 years of age is one in four. The Canadian Cardiovascular Society last published a set of recommendations on the diagnosis and management of AF in 2005. Since then, major advances in the management of AF have occurred including the results of clinical trials providing guidance on pharmacologic therapies for management of AF, and antithrombotic therapies for prevention of systemic thromboembolism, the continuing evolution of catheter ablation for treatment of AF, and the development of a simple semi-quantitative scale that closely approximates patient-reported subjective measures of quality of life in AF.

What's new:

This is the first CCS guidelines panel to employ the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system of evaluation, replacing the ACC/AHA scale for level of evidence that was previously used. The approach separates the quality of evidence (very low, low, moderate, or high quality), from the strength of recommendations, (strong or conditional i.e., weak). GRADE allows acknowledgment of values and preferences in the provision of clinical care in determining the strength of recommendations.

We recommend that treatment for rate control of persistent/permanent AF/AFL should aim for a resting heart rate of less than 100 beats per minute. (Strong Recommendation, High Quality Evidence).

We recommend that the goal of rhythm control therapy should be improvement in patient symptoms and clinical outcomes, and not necessarily the elimination of all AF. (Strong Recommendation, Moderate Quality Evidence). The choice of antiarrhythmic drug therapy should be individualized based on the patients underlying heart disease and risk of adverse effects.

We recommend intermittent antiarrhythmic drug therapy ("pill in pocket") in symptomatic patients with infrequent, longer-lasting episodes of AF/AFL as an alternative to daily antiarrhythmic therapy. (Strong Recommendation, Moderate Quality Evidence)

We recommend radiofrequency ablation of AF in patients who remain symptomatic following adequate trials of antiarrhythmic drug therapy and in whom a rhythm control strategy remains desired. (Strong Recommendation, Moderate Quality Evidence)

We recommend that in most patients at low risk of stroke (CHADS ₂ = 1) should receive either Warfarin (INR 2 - 3) or Dabigatran.  (Strong recommendation, High Quality Evidence). However, based on individual risk/benefit considerations, we suggest that Aspirin is a reasonable alternative for some. (Conditional Recommendation, Moderate Quality Evidence).

We recommend that patients at moderate to high risk of stroke (CHADS ₂ ≥ 2) should receive either Warfarin (INR 2 - 3) or Dabigatran. (Strong recommendation, High Quality Evidence)

We suggest, based on its safety and efficacy profile, that Dabigatran is preferred over Warfarin. In general, the dose of Dabigatran 150 mg po bid is preferred over a dose of 110 mg po bid for overall stroke reduction (exceptions discussed in text). (Conditional Recommendation, High Quality Evidence)

What health professionals need to know:

CCS is using the GRADE system of evaluation, which separates the quality of the evidence from the strength of the recommendation for all future guidelines.

Aggressive treatment of underlying causes such as hypertension or sleep apnea is paramount to AF arrhythmia management.

The goals of AF therapy should be clearly defined and discussed with the patient.

Heart rate targets for AF rate control can be liberalized to a resting heart rate of < 100 bpm.

The decision to use a rate control strategy versus a rhythm control strategy is based on patient preferences to balance relief of symptoms and improvement in QOL and other clinical outcomes with the potential greater adverse effects of Class I/III antiarrhythmic drugs compared to rate control therapy.

Referral for AF ablation is an acceptable approach for patients who remain symptomatic despite at least one trial of an antiarrhythmic drug for maintenance of sinus rhythm.

Decisions on antithrombotic therapy selection should be based on the use of a predictive index for risk of stroke and an index for risk of bleeding.

Dabigatran based on its safety and efficacy profile may be preferred over Warfarin for stroke prevention. However, the cost benefit of this therapy is evolving.

2010 CCS Antiplatelet Guideline - Co-chaired by Drs. Alan Bell and Jean Francois Tanguay

Antiplatelet agents are a cornerstone therapy for patients with manifest atherosclerotic vascular disease in the coronary, cerebral, and peripheral beds.  To provide a comprehensive, evidence based, treatment centred statement on managing antiplatelet therapy in Canadian outpatients who have existing, or are at risk of developing, vascular disease, the Canadian Cardiovascular Society antiplatelet guideline was created.  The document provides authoritative guidance for all health care professionals managing vascular outpatients in wide range of clinical circumstance.

What's new:

• Continuation of dual antiplatelet therapy beyond 12 months may be considered in patients with a high risk of thrombosis and a low risk of bleeding.
• Dual antiplatelet therapy with ASA 75-162 mg daily plus clopidogrel 75 mg daily in the first month after TIA or minor ischemic stroke may be superior to aspirin alone in patients not at a high risk of bleeding.
• For men and women without evidence of manifest vascular disease, the use of ASA at any dose is not recommend for routine use to prevent ischemic vascular events.
• There is currently no evidence to recommend routine use of ASA at any dose for the primary prevention of vascular ischemic events in patients with diabetes.
• For individuals with heart failure of non-ischemic etiology, routine use of antiplatelet agents is not recommended.
• Patients taking dual antiplatelet therapy with clopidogrel and ASA who require urgent surgery within six weeks of BMS placement or 12 months of DES placement should have both drugs continued in the perioperative period whenever possible.
• For cardio- or cerebrovascular disease in which antiplatelet therapy would be indicated in non-pregnant women, there should be similar considerations for its use in pregnancy.
• In patients taking low-dose ASA (75-162 mg daily) for vascular protection requiring an anti-inflammatory drug, specific COX-2 inhibitors (coxibs) should be chosen over traditional NSAIDS.
• Until a definitive RCT is completed it is reasonable to avoid the concomitant use of clopidogrel and specific CYP2C19-inhibiting PPIs.

What health professionals need to know:

• Antiplatelet therapy should be continued for life in all patients with manifest ischemic vascular disease unless specifically contraindicated.
• Long term dosing of ASA > 162 mg/day should be avoided due increased bleeding risk and the lack of greater anti ischemic benefit over lower doses.
• Dual antiplatelet therapy with low dose ASA and an ADP P2Y₁₂ receptor blocker is indicated in all patients with ACS unless specifically contraindicated. Duration of therapy should be individualized based on thrombotic and bleeding risk.
• Dual antiplatelet therapy with low dose ASA and an ADP P2Y₁₂ receptor blocker should be avoided in long term secondary stroke prevention.
• Antiplatelet therapy is not recommended for primary prevention of ischemic vascular events in the presence or absence of diabetes.
• Antiplatelet therapy should not be discontinued for minor or nuisance bleeding.
• Use of antiplatelet agents in the perioperative period should be individualized, based on the risks of thrombosis and bleeding.

CCS position statement on smoking cessation - Chaired by Dr. Mark J. Eisenberg

What's new:

The recognition that the management of smoking cessation has been less than optimal in the cardiovascular community and that the introduction of systematic approaches to the identification, documentation, and provision of smoking cessation assistance can distinctly improve the health of our smoker-patients and their communities. Smoking cessation is acknowledged as the most important preventive intervention and the members of the Canadian Cardiovascular Society are committed to enhancing our ability to address this fundamental preventive responsibility.

What health professionals need to know:

Smoking cessation is the most important preventive responsibility of all clinicians who see smokers.  Systematic approaches to the identification of smokers and the provision of cessation assistance can distinctly improve the likelihood of quitting.  All health professionals who see smokers should be familiar with the provision of such assistance to their patients in order to facilitate quit-attempts.  Smoking is not a 'habit' − it is a tenacious addiction and our patients will benefit from the very specific assistance we can provide. 

2011 Joint Canadian Cardiovascular Society - Canadian Pain Society Guidelines for the management of refractory angina - Chaired by Drs. Michael McGillion and Heather Arthur

Refractory angina (RFA) is a debilitating condition characterized by severe, unremitting cardiac pain. Effective care for Canadians with RFA is critical. The incidence and prevalence of RFA is expected to rise as coronary artery disease-related survival rates continue to increase and our population ages. These guidelines represent a formal collaboration between the Canadian Cardiovascular Society (CCS) and the Canadian Pain Society (CPS) to tackle the problem of RFA.   

What health professionals need to know:

• RFA is caused by coronary insufficiency, in the presence of coronary artery disease, which cannot be controlled by a combination of medical therapy, angioplasty, and/or coronary artery bypass graft surgery. While the presence of reversible myocardial ischemia must be clinically established to be the root cause, the pain experienced may arise or persist with or without this ischemia.
• An understanding of how chronic ischemic and pain mechanisms act in concert is critical to effective RFA assessment and management. A comprehensive treatment approach targets ischemic as well as pain mechanisms.

The 2011 joint CCS-CPS guidelines will present an assessment of current and emerging therapies for RFA along with recommendations for RFA management based on the GRADE system of evidence evaluation, which was recently adopted as the standard for evidence evaluation by the CCS. Recommendations for future directions in RFA-related research and patient care in Canada are also presented.  

Systematizing Inpatient Referral to Cardiac Rehabilitation: A joint policy position of the Canadian Association of Cardiac Rehabilitation and Canadian Cardiovascular Society − Co-chaired by Drs. Sherry Grace and Caroline Chessex

Cardiac rehabilitation (CR) is an outpatient chronic disease management program, offering structured exercise and education for risk reduction. Participation in cardiac rehabilitation significantly reduces mortality and re-hospitalization and improves quality of life. Despite its integral role in the continuum of care, cardiac rehab is under-used. One of the chief reasons is referral failure.

What's new:

Obstacles to referral can be overcome through systematic adoption of standing orders and other adjunct approaches for CR referral of indicated hospitalized patients.

Systematic referral strategies can be characterized as the implementation of standing referral orders to CR for indicated patients. These strategies can be implemented through discharge order sets or electronic medical records.

'Liaison' strategies are characterized by a healthcare provider speaking to the inpatient at the bedside about CR and initiating referral. This enables two-way communication regarding the nature of CR, its benefits, and how to address any patient-perceived barriers to participation.

Other strategies identified in the review include dissemination of patient education materials or motivational letters to augment CR utilization.

A combined referral strategy can achieve referral of approximately 85% of patients.

Inpatients should be targeted for referral to ensure universal case-identification and timely access, with a goal of 70% patient enrolment in cardiac rehab.

What health professionals need to know:

Appropriate cardiac patients are defined as those who have experienced acute coronary syndrome, chronic stable angina or heart failure, percutaneous coronary intervention, bypass surgery, cardiac valve surgery, transplantation, or resyncronization therapy.

Best practice in cardiac rehabilitation referral consists of systematic inpatient mechanisms to ensure referral, as well as discussion with the patient at the bedside.

Provider endorsement of cardiac rehabilitation has additive benefit in terms of patient enrolment, over and above systematic strategies.

CCS position paper on the standardized approaches to the investigation of syncope - Chaired by Dr. Robert Sheldon

What's new:

Syncope is a very common presentation in the emergency room and in hospital and the combination of a wide differential diagnosis, a range of prognoses, and infrequent documentation of the faint leads to a high proportion of patients being admitted. The high proportion of patients with benign outcomes and the profound risk aversion of health care providers make for expensive and inefficient assessment. Emergency room decision rules, specialized syncope monitoring units, and formal diagnostic algorithms have all been developed to provide standardized approaches to the investigation of syncope. Recognizing that there were no summary documents on the merits and weaknesses of these approaches, the Canadian Cardiovascular Society commissioned a position paper on standardized approaches to syncope investigation in adults.

What health professionals need to know:

There is little high quality evidence addressing any of the issues, but several key observations and recommendations were made.

• In the first 7-30 days following discharge from ER, only 0.7% die and 4.5% have a procedure or an adverse event.
• Patients with any one of heart failure, hypotension, an abnormal ECG, or any history of heart disease should have a cardiac assessment within two weeks.
• Patients with any one of age >60y, cerebrovascular disease, hypertension, dyspnea, a family history of sudden death, syncope without prodrome or while supine or during exercise, or anemia could be considered for urgent assessment.
• Emergency room syncope decision rules may have prognostic value, but is no compelling evidence that they improve diagnostic accuracy or reduce costs, and they may increase costs substantially.
• Formal syncope units might increase diagnostic yield and prevent unnecessary admissions and testing, but this may be explained simply by advanced access to specialist assessment and related testing.
• Algorithmic testing coupled with implementation tools improves diagnostic yield and may reduce costs. Key tactics include access to specialist back-up, and provision of an on-line prompting tool.

Statements and conclusions of study authors are solely those of the study authors and do not necessarily reflect Foundation or CCS policy or position. The Heart and Stroke Foundation of Canada and the Canadian Cardiovascular Society make no representation or warranty as to their accuracy or reliability.