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Experts unveil new CVD guidelines and position papers
October 28, 2009Edmonton - 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.
Heart and Stroke Foundation of Canada
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.
Heart and Stroke Foundation of Canada
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Heart function significantly improved in children and young adults with single-ventricle congenital heart disease who have had the Fontan operation following treatment with sildenafil, a drug used to treat erectile dysfunction and pulmonary hypertension, say researchers from The Children's Hospital of Philadelphia.
Study raises concerns about outdoor second-hand smoke
Indoor smoking bans have forced smokers at bars and restaurants onto outdoor patios, but a new University of Georgia study in collaboration with the Centers for Disease Control and Prevention suggests that these outdoor smoking areas might be creating a new health hazard.
Night Beat, Overtime and a Disrupted Sleep Pattern Can Harm Officers' Health
A police officer who works the night shift, typically from 8 p.m. to 4 a.m., already is at a disadvantage when it comes to getting a good "night's" sleep.
Your Own Stem Cells Can Treat Heart Disease
The largest national stem cell study for heart disease showed the first evidence that transplanting a potent form of adult stem cells into the heart muscle of subjects with severe angina results in less pain and an improved ability to walk. The transplant subjects also experienced fewer deaths than those who didn't receive stem cells.
Vitamin B niacin offers no extra benefit to statin therapy in seniors already diagnosed with CAD
The routine prescription of extended-release niacin, a B vitamin (1,500 milligrams daily), in combination with traditional cholesterol-lowering therapy offers no extra benefit in correcting arterial narrowing and diminishing plaque buildup in seniors who already have coronary artery disease, a new vascular imaging study from Johns Hopkins experts shows.
Heart and bone damage from low vitamin D tied to declines in sex hormones
Researchers at Johns Hopkins are reporting what is believed to be the first conclusive evidence in men that the long-term ill effects of vitamin D deficiency are amplified by lower levels of the key sex hormone estrogen, but not testosterone.
New study links vitamin D deficiency to cardiovascular disease and death
While mothers have known that feeding their kids milk builds strong bones, a new study by researchers at the Heart Institute at Intermountain Medical Center in Salt Lake City suggests that Vitamin D contributes to a strong and healthy heart as well - and that inadequate levels of the vitamin may significantly increase a person's risk of stroke, heart disease, and death, even among people who've never had heart disease.
Early end to key study on benefits of niacin, a B vitamin, in keeping arteries open was premature
Heart experts at Johns Hopkins are calling premature the early halt of a study by researchers at Walter Reed Army Medical Center and Washington Hospital Center on the benefits of combining extended-release niacin, a B vitamin, with cholesterol-lowering statin medications to prevent blood vessel narrowing.
oo much selenium can increase your cholesterol
A new study from the University of Warwick has discovered taking too much of the essential mineral selenium in your diet can increase your cholesterol by almost 10%.
New evidence that dark chocolate helps ease emotional stress
The "chocolate cure" for emotional stress is getting new support from a clinical trial published online in ACS' Journal of Proteome Research.
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