profiles = new Array( "HFCC - Home|Home About Us Contact Us What's New! Important Notices Search Welcome to the new HFCC site! Welcome to the CCC Heart Failure Consensus Conference Program Website. This site has been designed using the CCS Consensus Conference Closed Loop Development Model as its center for information triage and navigation. What is the CCS Consensus Conference Closed Loop Development Model? The CCS Heart Failure Consensus Conference Program has made an exciting long-term commitment to identifying best practices in knowledge translation through the development, dissemination, implementation and evaluation of the CCS Heart Failure Consensus Conference Recommendations. The CCS has adopted an innovative “closed-loop” model of CC development for the CCS Consensus Conference on the Diagnosis and Management of Heart Failure Update 2006. This model accommodates end-user and stakeholder input and evaluation on an ongoing basis in the spirit of collaborative development of timely, practical and effective CCs. In this process, end-user needs assessment and evaluation are actively sought with feedback integrated into the next iteration of CCS Consensus Conference in the Diagnosis and Management of Heart Failure. The closed-loop model also permits integration of industry quality standards for guidelines (AGREE Collaboration) in addition to ongoing performance measurements and incremental improvements on a cyclical basis. The Website Redesign The CCS Heart Failure Consensus Program has experienced significant and rapid growth since its inception 18 months ago. With this growth, there is need to revisit the initial design of the website. The CCS Heart Failure Website has been redesigned based on the CCS Consensus Conference Closed Loop Development Model. Information has been triaged into the 5 stages and the CCS Consensus Conference Closed Loop Development Model Graphic serves as the design for the navigation of the site. For your convenience we have included a site map located within the site map link on the bottom of the home page. If you have any problems or difficulties with this site or have suggestions for improving it please contact us at HFCC@CCS.ca Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/", "HFCC - Home|Home About Us Contact Us What's New! Important Notices Search The CCS Consensus Conference Development Model (mouse over the items to find out more) Stage 5: Evaluation & Recommendations Stage 1: End-User Needs Assessment Stage 4: Dissemination & Implementation Click Here to Learn More About This Unique Initiative Stage 2: Consensus Conference Update Stage 3: Program Specifications Upcomming events - Click here for a calendar of upcoming events • ACC Lake Louise - March 11-15, 2007 - Lake Louise , AB • ACC - March 24-27, 2007 - New Orleans, LA • Heart Failure Summit - June 7-9, 2007 - Toronto , ON Our Highlights • Join the CCS HFCC Program at the annual meeting of ACC Lake Louise, March 11-15, 2007... • The 2007 CCS Heart Failure Consensus Conference recommendations are now available online! • The CCS Heart Failure Consensus Conference Program offers you its Best Wishes for 2007! • Highlights from CCC 2006 in Vancouver! Download Educational Tools/Resources Heart Failure Consensus Slide Kit (version française disponible) Heart Failure Consensus Slide Kit (version française disponible) Heart Failure Pocket Reference Card HFCC Newsletter Sign-Up Enter your email address: Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/home/index.aspx", "HFCC - About Us|Home About Us Contact Us What's New! Important Notices Search About Us Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: About Us CCS has adopted an innovative 'closed-loop' model of CC development for the CCS Heart Failure Consensus Conference Program which accommodates end-user and stakeholder input and evaluation on an ongoing basis. In addition, CCS is committed to assessing impact of the CCS HFCC on both clinical practice and health outcomes. The development processes identified through this initiative will be entirely replicable and, therefore, of utility and interest to those dedicated to closing the gap 'between what we know and what we do'. Heart Failure is considered an ideal first topic for this new development process for a number of reasons. First, incidence and prevalence of heart failure, and associated direct and indirect care costs, are projected to increase in Canada over the next decade. Second, the balance of medical care delivered to this growing patient population is provided by community cardiologists, general practitioners and related health care professionals. Third, the 2006 CCS HFCC has recently (January 2006) been published in the Canadian Journal of Cardiology. CCS has elicited the support and active participation of 12 national health professional societies and organizations, patient support and advocacy groups, Federal, Provincial and Regional health governments, national health outcomes databases, international and national IT companies, national medical communications companies and pharmaceutical industries. Heart and Stroke Foundation of Canada, Canadian Institutes for Health Research, College of Family Physicians of Canada, Canadian Nurses Association, Canadian Pharmacists Association, Public Health Agency Canada, Canadian Cardiovascular Outcomes Research Team, Microsoft Canada and many others are among the participating organizations. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/about/index.aspx", "HFCC - Contact Us|Home About Us Contact Us What's New! Important Notices Search Contact Us Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Contact Us CCS is very interested in receiving your feedback regarding the Heart Failure Consensus Conference Website (HFCC). Your comments, suggestions and ideas for improvement are always welcome and can be submitted by contacting HFCC@ccs.ca or by filling out our Quick Submit Feedback Form found in the left side menu of this screen. Canadian Cardiovascular Society Heart Failure Consensus Conference Recommendations Program 222 Queen Street, Suite 1403 Ottawa , ON K1P 5V9 Tel: (613) 569-3407 Toll Free: (877) 569-3407 Fax: (613) 569-6574 email: hfcc@ccs.ca Further, feel free to contact John Parker, Director, Knowledge Translation ( parker@ccs.ca ), if you would like to learn more of this and other exciting initiatives at the CCS. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/contact/index.aspx", "HFCC - What's New|Home About Us Contact Us What's New! Important Notices Search Whats New! Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: What's New! Join the CCS HFCC Program at the annual meeting of ACC Lake Louise, March 11-15, 2007 for the first of its six 2007 National Heart Failure workshops! February 2nd, 2007 Physicians, trainees, nurses, pharmacists and others, please join us for this 90-minute interactive session. Be among the first Canadian health professionals to discuss, debate and provide feedback on the just published CCS Heart Failure Consensus Conference Update 2007 . Your participation in this workshop will help establish benchmarks of care for Canadian heart failure patients and will help define ongoing improvements for implementation as well as the next recommendations update planned for January 2008. The CCS has an ongoing commitment to establishing, promoting and assessing evidence-based recommendations for the treatment of heart failure in Canada. This continuous learning program relies on your active involvement, so please join us on March 13, 2007 from 16h30-18h00 at the annual meeting of ACC Lake Louise. Click here for full program details. They are here! The 2007 CCS Heart Failure Consensus Conference recommendations are now available online. January 25, 2007 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 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 AHF, and the current and future role of biomarkers in heart failure care. Click here to view the PDF document. And let us know what you think! The CCS Heart Failure Consensus Conference Program offers you its Best Wishes for 2007! January 16, 2007 2006 has been a landmark year for the program; this, in great part, is due to your commitment and participation in the care of Heart Failure in Canada. Approximately 1100 health care professionals, cardiologists, internists, family physicians, nurses, and pharmacists have attended and participated in the 7 heart failure workshops hosted by the CCS across Canada in 2006 400 workshop participants have provided us with their evaluation feedback which supplies the program with valuable information and direction as we move forward for 2007 and beyond Over 5000 heart failure handout kits, including heart failure pocket card and slide set, were distributed to health care professionals and organizations across the country in 2006 All of CCS Heart Failure resources have been made available on the Heart Failure website, including several French Version resources. The CCS Heart Failure website received 116 special requests since the launch of the new site in October 2006 Relaunched the CCS Heart failure web site in October 2006, with a new look and feel that included several easy to use tools such as the Download center where users can download tools such as the Pocket Card, the easy to use quick submit comment and feedback form etc. So 2007, here we come! The new 2007 Heart Failure Consensus Conference publication will be released this month A revised 2007 heart failure slide set will be released in March Our national workshop initiative for 2007 is all set; see below for the workshop schedule in your area ACC Lake Louise, Lake Louise, AB, March 11-17, 2007 Heart Failure Summit, Toronto, ON, June 7-9, 2007 NB Heart Centre, Saint John, NB, September 2007 Société Québécoise d’Insuffisance Cardiaque, Quebec City, QC, September 28-29, 2007 Family Medicine Forum, Winnipeg, MB, October 11-13, 2007 CCC 2007, Quebec City, QC, October 20-24, 2007 Based on the 2006 evaluation feedback, we will be developing new heart failure resources: a hand held device downloadable version of the 2007 consensus conference, a wall chart of the heart failure treatment algorithm… CCS’s goal is that the 2007 program will continue to contribute to the improvement of the delivery of best care and practices to heart failure patients in Canada and that this unique initiative will become the benchmark for all CCS Consensus Conferences. We welcome your suggestions or comments on the CC Heart failure program or website, for your convenience please use this contact us quick submit link or use the link provided within the contact us section of the Heart Failure website Highlights from CCC 2006 in Vancouver! December 4, 2006 As part of its 2006 National Workshop Initiative, the HFCC Program hosted 2 workshops and 1 plenary session at CCC 2006 in Vancouver. CCCN Pre-Conference Workshop, Sunday October 22nd, 2006 ‘ A Collaborative Effort to Shaping the Future of Heart Failure Management in Canada ’ << CCS Nurses Evaluation Self-Assessment Summary >> CCS Workshop, Tuesday October 24th, 2006 ‘ CCS Heart Failure Recommendations 2006 : Help Shape the Future of Heart Failure Care in Canada ’ << CCS-Workshop Global Audience Self Evaluation Summary >> << CCS-Workshop Doctors Self Evaluation Summary >> << CCS-Workshop Nurses Self Evaluation Summary >> CCS Consensus Conference Plenary, Tuesday October 24th, 2006 ‘ Heart Failure Consensus Conference Program : 2006 Recommendations, Diagnosis and Management ’ << Evaluation of the Consensus Conference Plenary - Global Audience >> << Evaluation of the Consensus Conference Plenary - Specialists >> << Evaluation of the Consensus Confernce Plenary - Nurses >> The sessions were a unique opportunity to share the 2006 HFCC recommendations and partner with health care professionals in helping to shape the future of heart failure care in Canada. In the spirit of the HFCC loop model, we are pleased to make available, for your reference, the tremendous quantity and quality of feedback that has been provided by attendees at these sessions. CCS is making a long-term and ongoing commitment to the process of establishing, promoting and assessing evidence-based recommendations for the treatment of heart failure. And this feedback is an important component for the future of the program. Please use our quick submit form and let us know your feedback!!! Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/whatsnew/index.aspx", "HFCC - Important Notices|Home About Us Contact Us What's New! Important Notices Search Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Important Notices Canadian Cardiovascular Society - Conflict of Interest Guidelines CCS Conflicts of Interest Guidelines and Disclosure Statements Disclaimer Statement Privacy Policy Hyperlink policy Standards and Guidelines Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/important_notices/index.aspx", "HFCC - Search Site|Home About Us Contact Us What's New! Important Notices Search Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Search Site Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/search/index.aspx", "HFCC - Site Map|Home About Us Contact Us What's New! Important Notices Search Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Site Map Home About Us Welcome Letter Executive Summary [PDF] Investors Advisory Round Table Members Terms of Reference [PDF] Contact Us Quick SubmitFeedback Form Stage 1: End User Needs Assessment Reports Needs Assessment - Executive Summary [PPT] Needs Assessment - Complete Report [PPT] Stage 2: Consensus Conference Update CCS and CC Process [PDF] Roles and Responsibilities [PDF] Supporting Documents Guidelines / Recommendations Secondary Panel Members Stage 3: Program Sepcifications National Workshop Initiative [PDF] Investors Primary Panel Members Core Development Team Members Terms of Reference [PDF] Stage 4: Dissemination & Implementation Dissemination Strategies Stage 5: Evaluation & Recommendations AGREE Standrard AGREE Instrument [PDF] CCS HF CC Compliance 2006 AGREE Assessment [PDF] 2006 CCC Heartfailure Workshop Initiative Impact Working Group Members Terms of Reference [PDF] What's New! 2006 Archives 2005 Archives 2003 Archives 2001 Archives 1994 Archives Important Notices Search Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/sitemap/index.aspx", "HFCC - Stage 5 -> CCS HF CC Compliance|Home About Us Contact Us What's New! Important Notices Search Stage 5: Evaluation & Recommendations Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation HFCC Newsletter Sign-Up Enter your email address: Stage 5: Evaluation & Recommendations This, with the end users needs assessment, is an important feedback mechanism in the closed loop model. The CCS Heart Failure Consensus Conference Program has provided its closed loop business model with an industry recognized evaluation mechanism: the AGREE instrument. This annual evaluation will assess the Consensus Conference process by reviewing 23 items organized in 6 domains: Scope and purpose Stakeholder involvement Rigor of development Clarity and presentation Applicability Editorial independence The CCS Heart Failure Consensus Conference Program has also ensured that all program specifications include evaluation mechanisms for the dissemination and implementation of the selected tools taken to the community. The objective if this stage is to allow recommendations to be made towards the future development and improvement of the program in the spirit of continued quality improvement. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage5/index.aspx", "HFCC - Stage 1: End-User Needs Assessment|Home About Us Contact Us What's New! Important Notices Search Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 1: End-User Needs Assessment This stage is the cornerstone of the entire closed loop model; the objective is to capture challenges, needs and expectations of CCS Heart Failure Consensus Conference end users defined as: Specialists General practitioners Pharmacists Nurses Policy-makers Patients And any others with direct vested interest in implementation of these guidelines Although this is identified at Stage 1, it is important to note that all of these stakeholders provide focused input and feedback to the Heart Failure Consensus Conference Program throughout all stages of the closed loop model. It is this feedback that allows the Primay Panel to determine the ‘how to’ to closing the gap between ‘what we know and what we do’. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage1/index.aspx", "HFCC - Stage 4: Dissemination & Implementation|Home About Us Contact Us What's New! Important Notices Search Stage 4: Dissemination & Implementation Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 4: Dissemination & Implementation This is the stage where all of the tools developed in stage 3 are taken to the end users in their community. The dissemination and implementation are aligned with the January publication of the guidelines i.e. are implemented in the 12-month time period post publication. The tools developed are meant to piggy-back on existing cardiology related events in Canada to better meet regional/provincial requirements and end-users. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage4/index.aspx", "HFCC - Stage 2 -> Primary Panel|Home About Us Contact Us What's New! Important Notices Search Stage 2: Consensus Conference Update Stage 1: End-User Needs Assessment Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 2: Consensus Conference Update Comprised of a multidisciplinary Primary Panel, Secondary Panel and Advisory Rountable, the Consensus Conference Update workgroup is responsible for developing world-class, evidence-based recommendations with the end-users in mind, following industry-recognized standards ( AGREE Collaboration) and enabling recurring performance measurement and quality improvement. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage2/index.aspx", "HFCC - Stage 3: Program Specifications|Home About Us Contact Us What's New! Important Notices Search Stage 3: Program Specifications Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 3: Program Specifications This first cycle of the CCS Heart Failure Consensus Conference confirmed the need to bring recommendations closer to the community by developing initiatives that would complement the traditional annual publication of the guidelines in the Canadian Journal of Cardiology. The purpose of Stage 3 is to lay out, in detail, the requirements and processes for the tools to fulfill the mandate set out in the Heart Failure Needs Assessment (Stage 1) report recommendations. For each selected tool, the program specifications will describe the purpose, goal, audience, format, content and media required. The program specifications, used by the Primary Panel and the Core Development Team, will translate the guidelines into easy-to-use tools. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage3/index.aspx", "HFCC - Upcoming Events|Home About Us Contact Us What's New! Important Notices Search Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Upcoming Events 2006-2007 Calendar of Events Name of meeting Dates Location Canadian Diabetes Association October 18-21, 2006 Toronto, ON Canadian Cardiovascular Congress 2006 October 21-25, 2006 Vancouver , BC Canadian Society Internal Medicine November 1-4, 2006 Calgary, AB Family Medicine Forum 2006 November 2-4, 2006 Quebec City , QC American Heart Association November 12-15, 2006 Chicago, IL ACC Lake Louise March 11-17, 2007 Lake Louise , AB ACC March 24-27, 2007 New Orleans, LA Heart Failure Summit June 7-9, 2007 Toronto , ON Heart Failure Society of America September 9-12, 2007 Washington Canadian Cardiovascular Congress 2007 October 20-24 Quebec City, QC Family Medicine Forum 2007 October 11-13, 2007 Winnipeg, MB NB Heart Centre September 20-22, 2007 Saint John, NB Société Québécoise d’Insuffisance Cardiaque September 28-29, 2007 Quebec City, QC Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/events/index.aspx", "HFCC - Educational Tools / Resources|Home About Us Contact Us What's New! Important Notices Search Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Educational Tools / Resources The CCS is committed to making these valuable resources and educational tools available to its members and the Canadian cardiovascular care community at-large to further disseminate the CCS Heart Failure Consensus Recommendations. Currently we offer resources and educational tools in both Microsoft PowerPoint and Adobe PDF versions, please see below for special instructions on using and viewing these file formats. Information about PowerPoint slides The slides are available in Microsoft PowerPoint 2003. To view the slides, you must have the PowerPoint program or the free PowerPoint Viewer on you computer and configured to work with you web browser to open files with the ppt extension. You may download a free Viewer from Microsoft. Warning! Downloading or opening these slides may take 15-20 minutes if you are using a modem to connect to the Internet. If you have problems downloading these slides - contact: HFCC@ccs.ca CCS Heart Failure Consensus Recommendations Slide Kit Insuffisance cardiaque : Recommandations 2006, diagnostic et prise en charge Information about Adobe PDF Documents The following resources/tools are available in Adobe . To view the slides, you must have the Adobe Reader program or the free Adobe Reader Viewer on you computer and configured to work with you web browser to open files with the PDF extension. You may download a free Viewer from Adobe If you have problems downloading these files - contact: HFCC@ccs.ca CCS Heart Failure Consensus Recommendations Slide Kit Insuffisance cardiaque : Recommandations 2006, diagnostic et prise en charge CCS Heart Failure Pocket Reference Card: Online Version (Requires Adobe Flash plugin) Printable Version Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/educational_tools/index.aspx", "HFCC - Contact Us: Quick Submit Feedback Form|Home About Us Contact Us What's New! Important Notices Search Contact Us Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Contact Us: Quick Submit Feedback Form Your comments are important to us! Personal information collected on this form is protected under the Privacy Act. I would like to provide comments on: HFCC Web Site in general The document that I was just using Please take a moment to answer the following questions. Your input will help us improve the HFCC Website and make it work better for you. l. After using the HFCC website how satisfied are you with the following: Extremely Satisfied Satisfied Unsatisfied Very unsatisfied N/A Ease of navigation: Site quality/layout Usefulness 2. How often do you use the HFCC Website? This is my first visit Almost daily Two or three times/month Less than once/month On rare occasions 3. Please use the space below for your comments. 4. Would you like us to contact you? Yes No If you answered yes to Question 4, please provide the following information: First Name: Last Name: Organization: City: Province/State: Country: Telephone: Ext.: Email: Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/contact/feedback.aspx", "2221_affiche_2.qx|Agenda 2007 CCS National Workshop Initiative Shaping the Future of Heart Failure Management in Canada So You Think You Know How to Treat Patients with Heart Failure! Lake Louise, Alberta Chair: Jonathan Howlett, Tuesday, March 13, 2007 4:30 p.m. – 6:00 p.m. (Reception at 4:00) MD Making a Difference in your Community! 4:00 p.m. – 4:30 p.m. Welcome Reception 4:30 p.m. – 4:35 p.m. Introductory Remarks Jonathan Howlett MD (Chair) 4:35 p.m. – 4:55 p.m. Balancing the Art and Science of HF Management: CCS HF Update 2007 Malcolm Arnold MD 4:55 p.m. – 5:15 p.m. CASE 1 Help me, I'm drowning!; management of acute decompensated HF Debra Lynne Isaac BN MD 5:15 p.m. – 5:35 p.m. CASE 2 How to Herd Cats (or treating heart failure with many comorbidities) Jonathan Howlett MD 5:35 p.m. – 5:55 p.m. CASE 3 Prevention of HF: Can We Stop the Unstoppable? Haissam Haddad MD 5:55 p.m. – 6:00 p.m. Closing Remarks Jonathan Howlett MD The CCS is coming to your community to deliver the first of its six 2007 National Heart Failure workshops! Physicians, trainees, nurses, and pharmacists, join us at this 90-minute hands-on session and be amongst the first Canadian health professionals to benefit of the ‘right off the press’ 2007 CCS Heart Failure Consensus Conference Update. Your participation and contribution at this workshop will benefit the establishment of benchmarks for the care of your patients and ongoing improvements for the next recommendations update publication in 2008. The CCS has an ongoing commitment to establishing, promoting and assessing evidencebased recommendations for the treatment of heart failure in Canada. This continuous learning program relies on your active involvement, so please join us on March 13, 2007 at the annual meeting of ACC Lake Louise. Leadership. Knowledge. Community. Canadian Cardiovascular Society||http:\/\/www.hfcc.ca/downloads/whatsnew/2007/2007CCSWorkshopatACCLakeLouise.pdf", "untitled|Can J Cardiol Vol 23 No 1 January 2007 21 Canadian Cardiovascular Society Consensus Conference recommendations on heart failure update 2007: Prevention, management during intercurrent illness or acute decompensation, and use of biomarkers J Malcolm O Arnold MD FRCPC (Chair)1, Jonathan G Howlett MD FRCPC (Co-Chair)2, Paul Dorian MD FRCPC3, Anique Ducharme MD FRCPC4, Nadia Giannetti MD FRCPC5, Haissam Haddad MD FRCPC6, George A Heckman MD FRCPC7, Andrew Ignaszewski MD FRCPC8, Debra Isaac MD FRCPC9, Philip Jong MD FRCPC3, Peter Liu MD FRCPC3, Elizabeth Mann MD FRCPC2, Robert S McKelvie MD FRCPC7, Gordon W Moe MD FRCPC3, John D Parker MD FRCPC3, Anna M Svendsen RN MS2, Ross T Tsuyuki PharmD FCSHP10, Kelly O’Halloran RN MScN7, Heather J Ross MD FRCPC3, Vivek Rao MD FRCSC3, Errol J Sequeira MD FCFP11, Michel White MD FRCPC4 1University of Western Ontario, London, Ontario; 2Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia; 3University of Toronto, Toronto, Ontario; 4Institut de Cardiologie de Montreal, Montreal, Quebec; 5McGill University, Montreal, Quebec; 6Ottawa Heart Institute, Ottawa; 7Hamilton Health Sciences, Hamilton, Ontario; 8St Paul’s Hospital, Vancouver, British Columbia; 9University of Calgary, Calgary, Alberta; 10University of Alberta, Edmonton, Alberta; 11Credit Valley Hospital, Mississauga, Ontario Correspondence: Dr Malcolm Arnold, Room C6-124D, University Hospital, London Health Sciences Centre, 339 Windermere Road, London, Ontario N6A 5A5. Telephone 519-663-3496, fax 519-663-3497, e-mail malcolm.arnold@lhsc.on.ca Received for publication December 11, 2006. Accepted December 12, 2006 SPECIAL ARTICLE ©2007 Pulsus Group Inc. All rights reserved JMO Arnold, JG Howlett, P Dorian, et al. Canadian Cardiovascular Society Consensus Conference recommendations on heart failure update 2007: Prevention, management during intercurrent illness or acute decompensation, and use of biomarkers. Can J Cardiol 2007;23(1):21-45. 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. Key Words: Acute heart failure; Comorbidities; Consensus statement; Drug therapy; Guidelines; Heart failure; Intercurrent illness; Natriuretic peptides; Prevention; Risk factors Mise à jour des recommandations issues de la Conférence de 2007 de la Société canadienne de cardiologie pour un consensus sur l’insuffisance cardiaque : Prévention, prise en charge lors de maladie intercurrente ou de décompensation aiguë et utilisation des biomarqueurs L’insuffisance cardiaque est fréquente et pourtant, elle reste difficile à traiter. Elle se manifeste sous des formes et dans des circonstances diverses, ce qui requiert une individualisation du traitement. La Société canadienne de cardiologie a publié en janvier 2006 une série complète de recommandations sur le diagnostic et la prise en charge de l’insuffisance cardiaque et la présente mise à jour se veut donc une version augmentée de ces recommandations de base. Selon les commentaires obtenus par le biais d’un programme national d’ateliers sur l’insuffisance cardiaque tenus en 2006, plusieurs priorités ont été dégagées en raison des défis qu’elles représentent pour les professionnels de la santé. De nouvelles recommandations fondées sur des preuves ont été rédigées selon une approche structurée de révision et d’évaluation des preuves retenues, préalablement décrite par la Société. Des recommandations et des conseils pratiques spécifiques ont été mis de l’avant pour la prévention de l’insuffisance cardiaque, sa prise en charge lors de maladie intercurrente, le traitement de l’insuffisance cardiaque aiguë et les rôles actuels et futurs des biomarqueurs dans le traitement de l’insuffisance cardiaque. Suite á la page suivanteArnold et al 22 Can J Cardiol Vol 23 No 1 January 2007 The Canadian Cardiovascular Society (CCS) has committed to a multiyear process of consensus conference panels to review evidence on topics of importance to the Canadian cardiovascular community. Heart failure was identified as the first topic to be rigorously reviewed within this mandate because it has a large burden on patients, families and health care resources, and also has a large body of clinical trial evidence to guide practice. A comprehensive set of evidencebased recommendations on the diagnosis and management of heart failure were published in January 2006 (1), and form the foundation on which the present 2007 update is based. The authors of the present update are the Primary Panel members, who were also responsible for identifying the scope of this review, reviewing the literature, determining relevance and strength of evidence, as well as formulating recommendations, which were agreed on by consensus. The systematic review strategy and methods for formulating the recommendations are described in more detail on the CCS Heart Failure Consensus Conference Program Web site, <hfcc.ccs.ca>. In particular, care was taken to consider not just the health benefits, but also the possible side effects and risks associated with implementation of the recommendations. The Secondary Panel members reflect a broad spectrum of the Canadian cardiovascular community and reviewed the paper, providing constructive feedback to the Primary Panel. The objective of the CCS Heart Failure Consensus Conference 2007 update is to provide Canadian clinical practitioners with evidence-based recommendations for the prevention of heart failure, the management of heart failure during intercurrent illness, the treatment of acute decompensated heart failure, and the current and future role of biomarkers in heart failure care. These topics were identified as priorities through ongoing needs assessments and evaluations provided by participants in the CCS National Heart Failure Workshop Initiative and were confirmed as priorities by the Primary Panel of the CCS consensus conference for heart failure. It is intended that the present update will complement the comprehensive paper published in 2006 (1), which focused on the diagnosis of new heart failure and the management of chronic heart failure. The clinical questions addressed by the current recommendations in the present paper 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 temporary discontinuation? What are the best therapeutic strategies for patients with an acute decompensation of heart failure? How can new biomarkers help in the treatment of heart failure, and when and how should natriuretic peptides (B-type or brain natriuretic peptides [BNP] and its prohormone [NTproBNP]) be measured in heart failure patients? In addition, practical tips are provided to aid health care providers in the management of their heart failure patients in circumstances that were not addressed in clinical trials and for which evidence-based recommendations cannot easily be made, but for which clinical experience and reports suggest a preferred approach to treatment. An extensive dissemination and implementation program has been developed for the CCS Heart Failure Consensus Conference Program. The CCS National Heart Failure Workshop Initiative is one aspect of this, but it has also been developed to involve Canadian clinical practitioners in the ongoing use and refinement of the CCS heart failure consensus conference process. Details of these and other initiatives, as well as the CCS ‘closed-loop’ model of consensus development may be found on the CCS Heart Failure Consensus Conference Program Web site. The class of recommendation and the grade of evidence were determined as follows: Class I: Evidence or general agreement that a given procedure or treatment is beneficial, useful and effective. Class II: Conflicting evidence or a divergence of opinion about the usefulness or efficacy of the procedure or treatment. Class IIa: Weight of evidence is in favour of usefulness or efficacy. Class IIb: Usefulness or efficacy is less well established by evidence or opinion. Class III: Evidence or general agreement that the procedure or treatment is not useful or effective and in some cases may be harmful. Level of evidence A: Data derived from multiple randomized clinical trails or meta-analyses. Level of evidence B: Data derived from a single randomized clinical trial or nonrandomized studies. Level of evidence C: Consensus of opinion of experts and/or small studies. 2006 – THE YEAR IN REVIEW Since the CCS heart failure recommendations were published in January 2006 (1), there have been many new publications and presentations. Some of these have been incorporated into this year’s update, where appropriate, and others are noteworthy but not sufficient to change the 2006 recommendations or be included here as new recommendations. A selection of some of these areas and topics of interest are reviewed to provide additional background and understanding of the impact of heart failure on individuals and society. Diastolic heart failure, or heart failure with preserved ejection fraction Although diastolic heart failure (or heart failure with normal or preserved ejection fraction – different studies have different left ventricular ejection fraction [LVEF] and other definitions) is present in nearly 50% of hospitalized heart failure patients (2), Les questions cliniques spécifiques abordées ont notamment été les suivantes. Comment détermine-t-on quels patients sont exposés à un risque élevé à l’égard de l’insuffisance cardiaque et quelles interventions doit-on appliquer? Quelles sont les complications susceptibles de survenir chez les insuffisants cardiaques présentant une maladie intercurrente? Comment ces patients doivent-ils être surveillés et quels médicaments devraient être ajustés ou cessés? Quelles sont les meilleures stratégies thérapeutiques pharmacologiques ou non pharmacologiques pour les patients qui souffrent d’insuffisance cardiaque aiguë? Comment les nouveaux biomarqueurs peuvent-ils aider au traitement de l’insuffisance cardiaque et à quel moment et de quelle manière doit-on mesurer le BNP chez les insuffisants cardiaques. Les objectifs de la présente mise à jour sont d’assurer l’application pratique des preuves les plus concluantes, de promouvoir le jugement clinique lorsque certaines stratégies spécifiques sont moins fructueuses et d’aider les médecins et autres professionnels de la santé à traiter le mieux possible les patients atteints d’insuffisance cardiaque de manière à exercer un impact mesurable sur la santé des patients et sur les résultats cliniques au Canada.evidence to guide health care policies and resources has generally relied on epidemiological data from systolic heart failure and relatively little evidence exists from large-scale randomized trials on diastolic heart failure to guide our treatment selections. Data from disease registries remind us of the poor outcomes for heart failure patients regardless of LVEF. In data from patients discharged from 103 Ontario hospitals in 2001 (3), 880 patients with LVEF greater than 50% were more likely to be older, female, and have atrial fibrillation and hypertension, but were less likely to have had a myocardial infarction compared with 1570 patients with LVEF lower than 40%. The oneyear mortality rate was not significantly different compared with patients with a low LVEF. In data from 4596 patients with heart failure admitted to hospital in Olmstead County over a 15-year period from 1986 to 2001 (4), several baseline differences were seen among 2429 patients with low LVEF, defined as that lower than 50%, and 2167 patients with LVEF of 50% or greater. There was a slight advantage in survival in those with LVEF of 50% or greater (hazard ratio [HR] 0.96, 95% CI 0.92 to 1.00). In a smaller study of 556 inpatients and outpatients with heart failure in Olmstead County (5), echocardiography showed LVEF of 50% or greater to be present in 55% of patients and was associated with older age, female sex and no history of myocardial infarction. Echocardiographic evidence of isolated diastolic dysfunction with preserved LVEF was present in 44% of patients. Moderate or severe diastolic dysfunction was common in patients with reduced LVEF. At six months, age- and sex-adjusted mortality (16%) were the same for both preserved and reduced LVEF heart failure, although the study was not powered to test for differences in mortality. These data re-emphasize the importance of diastolic dysfunction in all patients with heart failure. Future studies are needed to determine which factors are most important in determining diastolic function and may help to understand the poor correlation between symptoms and systolic function in patients with heart failure. The Perindopril in Elderly People with Chronic Heart Failure (PEP-CHF) study was recently published (6). In this study, 850 patients 70 years of age and older with a diagnosis of heart failure, diastolic dysfunction by echocardiography and diuretic treatment, but without substantial LV systolic dysfunction or valve disease, were randomly assigned to either perindopril 4 mg or placebo for a minimum of one year after which follow-up frequency was according to investigator judgement (median follow-up 2.1 years). After one year, a large number of patients discontinued their assigned medication and most were started on an open-label angiotensinconverting enzyme (ACE) inhibitor. Treatment with perindopril over the entire duration of follow-up did not significantly reduce the primary end point of composite all-cause mortality and unplanned heart failure related admission (HR 0.92, 95% CI 0.70 to 1.21, P=0.55). During the first year of follow- up, there was a significant 37% reduction in heart failure hospitalizations and an improvement in 6 min walk test in the perindopril group. These results are not unlike those seen in the Candesartan in Heart failure – Assessment of Reductions in Mortality and morbidity (CHARM-Preserved) trial (7), in which a modest reduction in hospitalization, but not mortality, was seen with the angiotensin receptor blocker (ARB) candesartan. Ahmed et al (8) reported the outcomes in 988 patients with LVEF of greater than 45% enrolled in the previously reported Digitalis Investigation Group (DIG) trial. Digoxin use was not associated with a reduction in death or all-cause hospitalization. There was a nonsignificant 21% reduction in heart failure hospitalization, which was offset by a nonsignificant 37% increase in hospitalization for unstable angina. These results suggest no role for the routine use of digoxin in heart failure patients with preserved LVEF who have normal sinus rhythm. The use of beta-blockers is well established in systolic heart failure patients, but randomized data have been lacking for heart failure patients with preserved LVEF. The Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalisation in Seniors with heart failure (SENIORS) (9) randomly assigned 2128 elderly patients with either heart failure- related hospitalization in the past year or LVEF lower than 35% to nebivolol or placebo. More than one-third of patients had a baseline LVEF greater than 35%. The HR for the primary end point (all-cause death or cardiovascular [CV] hospitalization) in patients with LVEF greater than 35% (HR 0.82, 95% CI 0.63 to 1.05) was similar to the overall group (HR 0.86, 95% CI 0.74 to 0.99) (P=0.04). There was a nonsignificant reduction of CV hospitalization with nebivolol in the overall group. In a separate retrospective study of 443 patients (10) admitted to a Dutch hospital with heart failure and preserved LVEF, 227 patients receiving beta-blockers at hospital discharge had lower mortality, even after correction for differences in baseline covariates (HR 0.57, P=0.01). These data provide increasing rationale to consider beta blockade for heart failure patients with preserved LVEF. Prevention of heart failure The Jikei heart study (unpublished data) investigated the addition of the ARB valsartan (average dose 75 mg) to optimal medical treatment in 3081 Japanese hypertensive patients whose blood pressure (BP) was under control (mean BP 139/81 mmHg). Most patients (67%) were taking calcium channel blockers, while 35% were taking ACE inhibitors and 32% were taking beta-blockers. The primary end point was a composite of CV morbidity and mortality, including stroke or transient ischemic attack, hospitalization for heart failure or angina, dissecting aneurysm of the aorta, lower-limb arterial obstruction, doubling of serum creatinine or transition to dialysis. The study was stopped early due to a highly significant 39% reduction in the primary end point, which included a significant 46% reduction in hospitalization due to heart failure (HR 0.54, 0.31 to 0.94, P=0.029). These as yet unpublished data tend to support the addition of ARB therapy to treated hypertensive Japanese patients, although it is unclear how these data may be extrapolated to other populations. Acute heart failure The typical approach to the treatment of acute heart failure (AHF) includes rapid diagnosis, intravenous diuretic and early consideration of vasodilator therapy. Two interesting studies that were reported this year, but have not yet been published, shed further light on the evolution of AHF diagnosis and management. The randomized Ultrafiltration Versus Intravenous (IV) Diuretics for Patients Hospitalized for Acute Decompensated Heart Failure (UNLOAD) study compared ultrafiltration with with a proprietary device against usual care with intravenous diuretics in 200 patients hospitalized for AHF, and the results were presented at the American College of Cardiology meeting Consensus conference recommendations on heart failure 2007 Can J Cardiol Vol 23 No 1 January 2007 23Arnold et al 24 Can J Cardiol Vol 23 No 1 January 2007 in March 2006. The patients were evaluated at 48 h and 90 days, and those randomly assigned to ultrafiltration lost more weight (5.0 kg versus 3.1 kg, P=0.001) and were less likely to be rehospitalized within 90 days (18 versus 32 patients readmitted, P=0.02). This promising therapy will be tested further in a phase III trial. The IMPROVE-CHF, a Canadian study of 501 patients, evaluated the diagnostic, clinical and cost outcomes associated with the addition of measuring NT-proBNP levels to usual clinical care in seven emergency departments. The use of NT-proBNP measurements was associated with positive clinical results (unpublished data). These results reinforce the increasingly important role of the measurement of natriuretic peptides in the diagnosis and management of acute decompensated heart failure. Immune modulation therapy Early reports had suggested that immune modulation may have significant clinical benefit in heart failure and other patient groups. The Advanced Chronic heart failure CLinical Assessment of Immune Modulation therapy (ACCLAIM) study exposed a patient’s own blood to specific oxidative stress then injected it intramuscularly into the same patient and the results were presented at the European Society of Cardiology meeting in September 2006 (unpublished data). In the study, 2408 patients with mild to moderate heart failure at 176 centres were randomly assigned to this monthly immune modulation therapy or placebo. The primary end point, all-cause mortality or CV hospitalization, was not different between the two groups, although post hoc analysis suggested a benefit in New York Heart Association (NYHA) functional class II patients. The significance of this finding, while interesting, is not known at present. Enhanced external counterpulsation The Prospective Evaluation of EECP in Congestive Heart failure (PEECH) trial (11) is the first randomized study of this therapy and involved 187 patients with mild to moderate heart failure. After six months of treatment, significantly more patients increased exercise time by more than 60 s in the treatment arm, but there was no difference in the more objective end point of peak oxygen consumption measurements. There was no difference in clinical events between the two groups. While the results of this study are interesting, the use of a subjective end point in a study that has inherent blinding difficulties is difficult to interpret, and no recommendation can be made at this time until further randomized data become available. PREVENTION OF HEART FAILURE Patients at risk of developing heart failure Recommendations • Clinical assessment is recommended in all patients to identify known or potential risk factors for heart failure (eg, hypertension, ischemic heart disease, diabetes mellitus, hyperlipidemia and smoking) (class I, level C). • All modifiable risk factors for heart failure, including those for coronary artery disease, such as hypertension, diabetes mellitus and hyperlipidemia, should be treated in accordance to current national guidelines (class I, level A). Patients with asymptomatic LV dysfunction Recommendations • ACE inhibitors should be used in all asymptomatic patients with LV dysfunction and EF lower than 40% (class I, level A if EF lower than 35%; class I, level B if EF 35% to 40%). • Beta-blockers should be considered in all patients with asymptomatic LV dysfunction and LVEF lower than 40% (if prior myocardial infarction class I, level B; if no myocardial infarction, class IIa, level C). Strategies to prevent heart failure include both primary and secondary prevention. In primary prevention, the goal is to prevent the development of asymptomatic or symptomatic LV dysfunction in patients who have risk factors but no history of symptomatic heart failure. In secondary prevention, the goal is to reduce heart failure-related morbidity and mortality in patients who already have symptomatic heart failure. Recommendations for secondary prevention were addressed previously in the 2006 CCS consensus recommendations (1). A number of factors have been documented as increasing the risk of heart failure (Table 1). Among these, hypertension, ischemic heart disease, diabetes mellitus, hyperlipidemia, smoking and obesity are the most important potential targets for the prevention of atherosclerosis and/or cardiac dysfunction. Moreover, in selected patients with multiple risk factors for heart failure, screening for ventricular dysfunction can identify individuals in whom more aggressive therapy is indicated. For patients found to have asymptomatic LV systolic dysfunction, early therapy with ACE inhibitors may decrease the subsequent risk of developing symptomatic heart failure and improve long-term survival (12,13). Hypertension and LV hypertrophy Hypertension has long been known to be a risk factor for heart failure. In the Framingham study (14), hypertension increased the risk of developing heart failure by two- to threefold. The risk appears to be continuous, with no clear threshold. Both diastolic and systolic dysfunction can arise in the setting of hypertension, with or without LV hypertrophy (15). Treatment of hypertension clearly reduces the risk of heart failure development. The Blood Pressure Lowering Treatment Trialists’ Collaboration, in a systematic review of 29 trials TABLE 1 Risk factors for the development of heart failure Hypertension* Excessive salt intake Ischemic heart disease* Cardiotoxic agents Diabetes mellitus*/the metabolic Familial history/genetic markers syndrome Low ejection fraction* Hyperlipidemia* Impaired diastolic function Smoking* Left ventricular hypertrophy Obesity Elevated neurohormonal biomarkers Older age Abnormal electrocardiogram Male sex Increased cardiothoracic ratio Ethnicity Microalbuminuria Physical inactivity Elevated resting heart rate Heavy alcohol use *Most important targets for preventioninvolving 162,000 patients (16), showed that treatment with ACE inhibitors, ARBs, diuretics and beta-blockers reduced the risk of development of heart failure (defined as hospital admission or death from heart failure). In contrast, a calcium channel blocker-based regimen had no significant effects on the prevention of heart failure (RR 1.21, 95% CI 0.93 to 1.58) and was less effective than regimens based on diuretics, betablockers or ACE inhibitors (16). LV hypertrophy is also associated with an increased risk of heart failure development (15,17). This risk is independent of its association with hypertension. Weight loss, sodium restriction, diuretics, beta-blockers, ACE inhibitors, ARBs and calcium channel blockers have been shown to reduce hypertrophy (15) and, presumably, the risk of developing heart failure. Ischemic heart disease Coronary artery disease has been cited as the cause of 52% of heart failure diagnoses in the general population (18). Approximately 40% of patients who experience a myocardial infarction will also experience heart failure over time (19). In patients with established heart failure, the occurrence of a new myocardial infarction increases the risk of subsequent death up to eightfold, with one-third of all deaths preceded by a major ischemic event (20). Similar data have also been reported in the Survival and Ventricular Enlargement (SAVE) trial (21). As such, preventive strategies for ischemic heart disease, such as those targeting dyslipidemia, hypertension, diabetes and smoking, are also effective in preventing heart failure. Diabetes mellitus Diabetes mellitus is a well-established risk factor for coronary artery disease. It is recognized, however, that diabetes mellitus may produce heart failure independently of coronary artery disease by causing a diabetic cardiomyopathy (15). Data from the National Health Examination Survey I (22) and the Framingham study (17) have shown the incidence of heart failure in patients with diabetes mellitus to be two- and fourfold higher, respectively, than in patients without diabetes mellitus. While an increase in glycosylated hemoglobin (HbA1C) among patients with diabetes mellitus is a recognized risk factor for heart failure (23-27), no study to date has demonstrated that improved glycemic control significantly reduces the incidence of heart failure (28). The Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada (29) recommends that most patients with type 1 or type 2 diabetes be targeted to achieve an HbA1C level of 7.0% or lower. Hyperlipidemia Both an elevated triglyceride level and a high ratio of total to high-density lipoprotein cholesterol have been found to be associated with an increased incidence of heart failure (30). In addition, retrospective analyses of clinical trial data have supported the role of statins in preventing heart failure (31). Data from the Scandinavian Simvastatin Survival Study (4S [32]) showed that only 8.3% of patients who received simvastatin were diagnosed with heart failure during follow-up, compared with 10.3% of patients who received placebo. In a cohort of elderly patients with prior myocardial infarction and lowdensity lipoprotein cholesterol of 3.2 mmol/L or higher, those who were receiving statin therapy had a 26% RR reduction for developing heart failure (33). Both the 2006 CCS position paper (34) on the recommendations for the diagnosis and treatment of dyslipidemia and prevention of CV disease, and the 2001 National Cholesterol Education Program report (35) on the detection, evaluation and treatment of high blood cholesterol in adults have provided detailed guidelines for the screening, risk assessment, diagnosis and treatment (pharmacological and nonpharmacological) of dyslipdemia. Smoking Cigarette smoking was found in 42% of men and 24% of women who developed heart failure in the Framingham study (36). In men, the relationship between cigarette smoking and the development of heart failure was greatest in the younger age group (30). In women, the relationship was less consistent, although there was a trend toward an increase in RR among older women (36). The National Health and Examination Survey I (22) demonstrated that smoking accounted for approximately 17% of all incident cases of heart failure. The Heart and Estrogen/Progestin Replacement Study (HERS [37]) showed smoking to be a predictor for the development of heart failure in women with established heart disease. A direct and independent relationship has been observed between smoking and the development of asymptomatic ventricular dysfunction (38-40). A dose-response relationship has also been found between the number of pack-years of smoking and reduced regional LV function in asymptomatic individuals (40). Quitting smoking can result in, within two years, a 30% reduction of mortality and morbidity among heart failure patients (41). Obesity In 2004, Statistics Canada reported that 36% of Canadians 18 years of age and older have a body mass index of 25 kg/m2 or higher (ie, overweight), and 23% have a body mass index of 30 kg/m2 or higher (ie, obese) (42). Overweight and obesity have been identified as independent risk factors for heart failure (22,43-45). Changes in LV structure and function have been documented in both overweight and obese individuals without overt heart disease, regardless of BP, age, sex and LV mass (46-48). Weight loss following bariatric surgery in morbidly obese heart failure patients has been associated with decreases in LV mass, as well as improvements in LV systolic function and diastolic filling (47,49,50). Reversal of heart failure after weight loss by dietary means has been described in a morbidly obese patient (51). Microalbuminuria Microalbuminuria is an independent risk factor for heart failure; the risk is highest for patients with concomitant risk factors such as diabetes mellitus. Among diabetic patients with no prior history of heart failure, the presence of elevated urinary albumin excretion increased the risk of heart failure by two- to fourfold (25,52). In both diabetics and nondiabetics, increasing the urinary albumin to creatinine ratio conferred a stepwise increase in the risk of heart failure development (52). Although there is good evidence that microalbuminuria increases heart failure risk, current data are insufficient to support the treatment of microalbuminuria to prevent heart failure. The Heart Outcomes Prevention Evaluation (HOPE) study and the Microalbuminuria, Cardiovascular and Renal Consensus conference recommendations on heart failure 2007 Can J Cardiol Vol 23 No 1 January 2007 25Outcomes-HOPE (MICRO-HOPE) substudy showed that ramipril significantly reduced urinary albumin excretion (53) and decreased the risk of new-onset heart failure (54). Caution is needed when interpreting such data, because any association in risk reduction between microalbuminuria and heart failure may be confounded by other clinical indications for ACE inhibitor use in the trial. In the Prevention of Renal and Vascular Endstage Disease Intervention Trial (PREVEND IT [55]), which primarily targeted the treatment of microalbuminuria wherein patients with confounding indications for ACE inhibitor use were excluded, fosinopril did not reduce the risk of heart failure, despite a 26% reduction in urinary albumin excretion. Screening for LV dysfunction There is currently no consensus on the optimal screening method that accurately detects asymptomatic LV dysfunction and is cost-effective in reducing the population burden of heart failure. Community-based epidemiological surveys of individuals without a prior history of heart failure have documented a prevalence of 1% to 6% with impaired systolic function (56) and 11% to 21% with isolated impaired diastolic function (57,58). Both circulating neurohormonal biomarkers and transthoracic echocardiography have been evaluated as screening tools. Elevated plasma levels of BNP and to a lesser extent, NT-atrial natriuretic peptide and NTproBNP, have been used to detect ventricular dysfunction (59). In community-based screening that used cut-off levels of greater than 18 pg/mL to 65 pg/mL to detect asymptomatic LV systolic dysfunction, BNP level was not consistent in either its sensitivity nor specificity to be an accurate screening tool when used in isolation (56). Caution is also advised against using a single cut-off value, because levels of natriuretic peptides are known to be influenced by age (60), sex (60) and lean body mass (61). Moreover, BNP levels cannot reliably differentiate between systolic and diastolic dysfunction (62). By contrast, parameters of systolic and diastolic ventricular function known to be predictive of heart failure risk are readily detectable by echocardiography (63). However, echocardiography is too impractical and expensive at present to be used as an initial screening tool in a community setting. In an attempt to address the limitations inherent in any single screening test, sequential screening has been proposed and aims to combine a relatively inexpensive initial test (such as a 12-lead electrocardiogram [ECG] or biomarker) with the more costly confirmatory test (echocardiography) in a multistaged strategy (64). Unfortunately, the low specificity of these initial tests necessitates the subsequent use of confirmatory tests that are too frequent to be practical. For example, using BNP levels to initially screen for asymptomatic ventricular dysfunction in the community would necessitate echocardiography in 10% to 40% of those screened, but would still miss 10% to 60% of those affected (62). As an alternative to general screening, selective screening has been suggested for patients in the community who are identified to be at higher risk for asymptomatic ventricular dysfunction (65). Subgroups at highest risk include those with ischemic heart disease, hypertension and diabetes mellitus (66), as well as certain ethnic groups (67,68) and the elderly (69). Practical tips: • BP should be controlled to less than 140/90 mmHg in most individuals and less than 130/80 mmHg in those with diabetes and/or kidney disease. • In high-risk patients with multiple risk factors for heart failure, it may be useful to reduce BP even if it is already within the normal range. • Patients with diabetes mellitus should have their glycemic control optimized to an HbA1C level of 7.0% or lower. • Hyperlipidemia should be treated aggressively with lipid-lowering drugs, especially statins. In high-risk patients for heart failure, a target level below 2.0 mmol/L for low-density lipoprotein cholesterol may be appropriate. • Smoking cessation and weight reduction for overweight or obese individuals are important preventive strategies for heart failure. • Patients at high risk for developing heart failure should be immunized against influenza (yearly) and pneumococcal pneumonia (if not received in the past six years). • Poor adherence to preventive measures is common; therefore, patients should be reassessed regularly to achieve and maintain the recommended targets. • Routine screening for asymptomatic LV dysfunction is not recommended. For selected patients with multiple risk factors at high risk for heart failure, the decision to screen (such as by echocardiography) should be individualized (Table 2). PATIENTS WITH HEART FAILURE AND INTERCURRENT ILLNESS Heart failure is an increasingly common condition in North America, with a lifetime risk of approximately 20% for those 40 years of age and older (70). Because heart failure incidence and prevalence increase with advancing age, heart failure is also more likely to occur in the setting of other significant illnesses. Indeed, the average patient with heart failure suffers from five or six concomitant medical conditions (71). Patients with increased comorbid disease burden, especially when elderly and hospitalized, are less likely to be enrolled in randomized clinical trials, and as such, have not been specifically addressed in previously published heart failure guidelines. Because major clinical trial data are lacking in this area, the following recommendations on selected conditions of common interest to those treating heart failure patients have relied in large part on results from systematic and self-directed literature review, which predominantly included small, randomized trials, observational data, retrospective data reviews and expert consensus opinion based on extensive clinical experience. Arnold et al 26 Can J Cardiol Vol 23 No 1 January 2007Heart failure in the elderly Recommendation • Elderly or frail heart failure patients who present with acute illness should be assessed for evidence of delirium and, before discharge, cognitive impairment (class IIa, level C). A relatively simple score can be used to characterize frail elderly patients who are clinically stable (72) (Figure 1). It may be useful to identify high risk patients who require more careful and detailed development of a multidisciplinary care plan. When frail elderly patients present with either an exacerbation of heart failure itself or another medical condition, they often appear confused. This may be due to acute delirium, chronic dementia or a combination of both. The relative contributions of each may be difficult to determine during acute illness, and may become apparent only when the aggravating illness(es) is controlled. Delirium should be suspected in the setting of an acute illness accompanied by an altered and fluctuating level of consciousness and/or cognition, and can be screened for using available tools (73,74). In many cases, discussion and development of complex treatment plans are delayed or made increasingly difficult when evidence of patient cognitive impairment becomes apparent. In addition, cognitive impairment may persist well beyond the resolution of the acute precipitating illness. To screen for persistent cognitive impairment in stable patients, several instruments have been developed that require varying degrees of time, effort and expertise to administer. The Mini Mental Status Examination, requires approximately 20 minutes to administer. It has been validated, and is moderately sensitive and specific, although some aspects of executive function are not well identified (75). The Montreal Cognitive Assessment test (76) has been developed to specifically identify mild cognitive impairment, especially if related to vascular disease, and is endorsed by the Canadian Stroke Network. It requires little training to administer and the short form may be performed in about 5 min. This short form includes the Montreal Cognitive Assessment subtests (five word memory task tests – registration, recall, recognition – six item orientation tests and one letter phonemic fluency test) and can be downloaded free for noncommercial purposes at <www.mocatest.org> (76). Because these instruments have been validated in medically stable patients, they may be best used once the heart failure patient is stabilized to choose appropriate care plans and discharge planning. Other instruments, according to the clinical need (ie, screening, documentation of mental status, complete neuropsychiatric evaluation), may be found in the National Institute of Neurological Disorders publication (75). Practical tip: • In a hospitalized elderly or frail heart failure patient, screening for chronic cognitive impairment is best performed pre-discharge once the patient has been stabilized. Consensus conference recommendations on heart failure 2007 Can J Cardiol Vol 23 No 1 January 2007 27 TABLE 2 Causes and precipitating factors in acute heart failure Decompensation of pre-existing chronic heart failure Precipitating factors: • noncompliance with treatment or diet (fluid and salt restriction or medication use) • inappropriate use of medications (prescribed or over-the-counter, including natural agents) • infections • arrhythmias or ischemia • deterioration of renal function • drug or alcohol abuse • after noncardiac surgery (volume overload) • pheochromocytoma Acute coronary syndromes Precipitating factors: • myocardial infarction/unstable angina with large extent of ischemia and ischemic dysfunction • mechanical complication of acute myocardial infarction • right ventricular infarction Hypertensive crisis Arrhythmia (ventricular tachycardia or fibrillation, atrial fibrillation or flutter, supraventricular tachycardia or severe bradycardia) Valvular regurgitation (endocarditis, rupture of chordae tendinae, etc) Severe aortic valve stenosis Acute myocarditis Cardiac tamponade Aortic dissection Postpartum cardiomyopathy High-output syndromes Precipitating factors: • septicemia • thyrotoxicosis crisis • anemia • presence of shunt Adapted from Ghali (148) Figure 1) The Canadian Study of Health and Aging (CSHA) clinical frailty scaleHeart failure and treatment of diabetes Recommendation • Elevated blood glucose in patients with heart failure should be treated according to current Canadian Diabetes Association guideline recommendations – aim for a target HbA1C level of 7.0% or fasting/preprandial blood glucose of 4.4 mmol/L to 7.0 mmol/L (class I, level A). Diabetes is present in more than one-third of patients with heart failure. Treatment choices involve dietary therapy, metformin, thiazoladinediones, biguanides, sulphonylureas and insulin, all of which have their own advantages and disadvantages. Metformin is an effective oral antidiabetic agent. Due to the presumed effects on pyruvate metabolism, metformin is approved for use under the ‘black box’ warning in the setting of ‘hypoxic’ conditions, such as renal insufficiency, congestive heart failure, liver disease and chronic obstructive pulmonary disease (COPD). This warning is based on isolated case reports and a biochemical rationale that these conditions predispose patients to lactic acidosis (a condition associated with decreased serum bicarbonate levels), anion gap acidosis and systemic lactate level greater than 5 mmol/L, with a mortality of 40% to 60%. In addition, two large meta-analyses and a smaller case series (77-79) have evaluated the outcomes and occurrence of lactic acidosis associated with use of metformin compared with placebo (nonrandomized) or other antidiabetic agents, such as sulphonylureas and insulin. The combined number of patients was in excess of 40,000 and included those with heart failure, COPD and renal disease. There was no increase in the occurrence of lactic acidosis and, in addition, CV outcomes of patients with heart failure taking metformin were better than those taking other antidiabetic therapies. While a precise renal function cut-off point for use of metformin was not apparent from these data, in general, only those with a serum creatinine level up to 150 ìmol/L were included in the meta-analyses and those with serum creatinine levels up to 200 ìmol/L were included in a smaller, single-centre study. Current evidence suggests that patients with heart failure and/or mild to moderate renal dysfunction (estimated glomerular filtration rate [eGFR] greater than 30 mL/min which correlates reasonably with a serum creatinine greater than 150 ìmol/L in women and greater than 180 ìmol/L in men unless at extremes of age or body weight) fare at least as well, if not better, with metformin than with other antidiabetic agents, and metformin should still be considered as first-line therapy in heart failure patients with mild to moderate renal dysfunction (77-79). Thiazolidinediones are known to cause fluid retention, although this is generally mild. Recent studies suggest this is not a direct toxic effect on the myocardium. The recently reported Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROACTIVE) study (80), in which pioglitazone was given to diabetic patients at risk for cardiac ischemic events, showed that thizoladinedione was associated with fewer cardiac ischemic events, but at the cost of an increase in heart failure hospitalizations (2% absolute excess over 2.8 years, or less than 1% per year). The recently completed Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) study (2×2 factorial design) tested whether development of diabetes could be prevented by rosiglitazone and/or ramipril. In more than 5000 patients, a significant reduction of new glucose intolerance and CV events (absolute 0.8% reduction) was seen with rosiglitazone, but a small excess of new-onset heart failure was also observed (absolute 0.4%) (81), similar to the the PROACTIVE study. A recently completed randomized trial that compared the efficacy of rosiglitazone, metformin or glyburide monotherapy in type 2 diabetics reported a significantly greater failure rate of monotherapy with glyburide or metformin than with rosiglitazone, but showed an increase in reported heart failure with rosiglitazone. When only adjudicated events were considered, there was no significant difference in CV- or heart failure-related mortality in any arm (82). Recent reports suggest that the fluid retention with this drug class may be safely managed with careful observation, taking care not to increase diuretic therapy in the absence of either symptoms or signs of central volume overload (rather than just peripheral edema) (78,79). As such, this medication remains a viable choice in stable heart failure patients without fluid retention, but such patients should be followed more closely for signs of fluid retention and pulmonary congestion. Practical tips: • Metformin may be considered a first-line agent for diabetes treatment if the eGFR is greater than 30 mL/min. However, care should be taken to temporarily discontinue metformin if renal function worsens significantly. • Oral antidiabetic therapy should be individualized; however, no compelling evidence exists to recommend one agent over another. Heart failure with renal dsyfunction Recommendations • Heart failure patients with stable renal function (serum creatinine levels less than 200 ìmol/L) should receive standard therapy with an ACE inhibitor, ARB or spironolactone, but monitoring of serum potassium and creatinine levels should be more frequent, especially if combination therapy is used or in the case of an acute concomitant illness that causes dehydration (class I, level B). • Patients with heart failure who continue to experience volume overload or increasing serum creatinine levels should be assessed for reversible causes such as concomitant medications (eg, nonsteroidal antiinflammatory drugs [NSAIDs]), hypovolemia, hypotension, urinary tract obstruction or infection (class I, level C). • The indications for the use of digoxin should be re-evaluated in heart failure patients with severe renal dysfunction; the trough digoxin level (at least 8 h after a dose) should be checked, and the dose should be adjusted to maintain a trough level less than 1 nmol/L. For patients with more rapid deterioration in renal function, digoxin should be withheld and reevaluated once renal function has stabilized (class I, level C). Arnold et al 28 Can J Cardiol Vol 23 No 1 January 2007• In oliguric heart failure patients who are hemodynamically stable, diuretics, ACE inhibitors, ARBs, spironolactone and nonheart failure drugs that impair renal function should be reviewed daily (class I, level C). • In stable heart failure patients who are not oliguric but have increasing serum creatinine levels of more than 30% from a previous stable baseline, the dose of diuretics, ACE inhibitors, ARBs and spironolactone may be reduced until renal function stabilizes (class 1, level C). • Routine use of ACE inhibitors, ARBs or spironolactone in the setting of severe renal dysfunction (serum creatinine levels greater than 250 ìmol/L or an increase of more than 50% from baseline) is not routinely recommended due to a lack of evidence for efficacy in heart failure patients (class IIa, Level C). • In heart failure patients not responding adequately to more than 240 mg intravenous furosemide daily, treatment options include: – More frequent or higher doses of intravenous boluses of diuretic (class IIb, level C); – Combination with thiazide diuretic, eg, hydrochlorothiazide or metolazone (class IIA, level B); or – Continuous intravenous furosemide infusion (class IIa, level B). The importance of renal dysfunction in the setting of heart failure is increasingly being recognized (83,84). Several studies have shown renal function to be one of the strongest predictors of adverse outcomes in heart failure patients (84-86). In general, adverse CV events increase once eGFR falls below 60 mL/min (83). In AHF, increasing creatinine levels by as little as 30 ìmol/L during hospitalization is associated with prolonged hospital stay, as well as early and late mortality (87). Renal dysfunction is typically multifactorial, and is frequently related to poor renal perfusion, vascular disease and effects of chronic hypertension and medications (NSAIDs and others), as well as diabetes and intrinsic renal disorders. In addition, renal dysfunction and heart failure tend to exacerbate each another, leading to a cycle of further worsening volume overload, peripheral vasoconstriction and hypoxia, followed by further deterioration of renal blood flow (cardiorenal syndrome). Erythropoietin, produced by the kidney, is critical to hemoglobin synthesis. Relative erythropoietin resistance is seen in heart failure, which results in anemia that can further aggravate renal dysfunction, and is a significant and independent predictor of outcomes; increased risk is generally present with hemoglobin levels less than 110 g/L to 120 g/L or hematocrit less than 35%. It is important to recognize worsening renal function early because there is a critical time period during which correction of reversible causes may re-establish stability. Several reversible factors frequently contribute to worsening renal function. The most important are systemic hypotension and volume depletion. In addition, concomitant drugs may contribute if they have a risk for adverse renal effects such as renin-angiotensin-aldosterone system inhibitors, ARBs and spironolactone, hypotensive agents (especially vasodilators), NSAIDs and cyclooxygenase 2 inhibitors (88,89). Systemic factors such as sepsis and urinary obstruction (especially chronic) are also important. In general, mild fluctuations in renal function are common in heart failure patients, but these usually do not exceed 30% of the baseline creatinine level and should simply be observed. However, oliguria or larger increases in serum creatinine levels should prompt action and increased surveillance. In a subset of patients with increased creatinine levels and severe volume overload, diuresis may actually result in improved renal function, presumably due to a left shift from the extreme right of the Starling curve, which allows stroke volume to increase. Patients with AHF require volume removal to relieve congestion and improve symptoms. Many patients respond promptly to intravenous furosemide in doses ranging from 40 mg to 120 mg, likely as a result of improved bioavailability. However, many patients do not respond to intravenous furosemide unless very high doses are used, a situation usually referred to as diuretic resistance. Several potential causes may underlie this important problem, such as magnesium or potassium deficiency (due to chronic loss from diuretics), severe reduction in GFR leading to excessive sodium resorption in the distal tubule, poor renal perfusion and reduced cardiac output, anemia and excessive vasodilation (85,86,90,91). To combat this, several strategies have been developed, such as repeated administration (often better than a large single dose) or addition of a thiazide-type diuretic to inhibit distal sodium resorption (92-98). Furosemide infusion is superior to, and at least as safe as, repeated large-dose boluses (95,99-103). A disadvantage of intravenous infusions is that many hospitals mandate that such infusions be given in intermediate or even intensive care settings. Some small studies suggest that simultaneous administration of hypertonic saline with intravenous furosemide enhances diuresis while limiting the risk of hyponatremia (95). This is not a widely used strategy and should only be used under the supervision of a physician with extensive expertise in its application. Several small studies have shown that ultrafiltration (slow continuous venovenous method or traditional dialysis) can be very effective in fluid removal and symptom improvement in a few highly selected patients with severe renal insufficiency and volume overload (104-108). These seem to be most effective when renal function is severe but stable, rather than acute. This should be performed in consultation with a nephrologist or a specialist physician who has experience using ultrafiltration and in a setting of close inpatient observation. Re-evaluation of medical therapy and drugs remains important in any situation of changing volume status. Thus, with any significant diuretic adjustment (especially intensification) repeat measurement of electrolytes and creatinine levels is suggested within at least seven days. In the setting of advanced heart failure, assessment should be within one to three days. It is also not uncommon for patients with a dehydrating illness to become volume-depleted, with associated electrolyte abnormalities, even when asymptomatic. This particularly occurs in elderly population. Measurement of renal function and electrolytes is therefore suggested in the setting of any acute dehydrating illness (85,89-91). Patients who improve with evidence-based heart failure therapy, especially with betablockers, may experience diminishing requirements for diuretics. Practical tips: • Acute renal dysfunction would generally be diagnosed when serum creatinine levels increase by more than Consensus conference recommendations on heart failure 2007 Can J Cardiol Vol 23 No 1 January 2007 2930% of baseline value over several days or when oliguria and rising serum creatinine are present. In this situation, volume status and clinical perfusion in heart failure patients must be carefully and repeatedly assessed, and this includes body weight, urine output, BP, serum electrolytes and renal function. These should be reviewed daily in hospitalized patients. • In the setting of worsening renal function, heart failure patients should be followed closely. Volume-overloaded patients who do not respond to bolus intravenous furosemide may respond much more favourably to continuous furosemide infusion. • In highly selected cases and under experienced supervision, hypertonic saline, in combination with a high-dose loop diuretic or intermittent slow continuous venovenous ultrafiltration, may be considered. • When diuretics are reduced, especially in the setting of a concomitant ACE inhibitor, ARB or spironolactone, serum electrolytes should be rechecked within two to four weeks to assess serum potassium levels (109). Heart failure patients with anemia Recommendation • Patients with heart failure and anemia (plasma hemoglobin less than 110 g/L or hematocrit less than 35%) should be carefully evaluated for underlying causes such as chronic blood loss or other inflammatory illness. Iron, vitamin B12 or folate deficiencies should be treated (class I, level C). Anemia is a frequent and significant contributor to symptoms and adverse events in patients with heart failure. In many cases, the etiology of the anemia is related to chronic disease, both the heart failure itself and often renal insufficiency. While the optimal hemoglobin level is not known, increased adverse events are seen when the plasma hemoglobin level is lower than 110 g/L or hematocrit lower than 35%. The increased event rate seems to be inversely related to hemoglobin below these levels (110-112). Early clinical trials have been performed with bone marrow-stimulating agents, such as erythropoietin and darbepoetin, in patients with heart failure (LVEF usually between 35% and 40%) and anemia. To date, studies such as the recently reported (but not yet published) Study of Anemia in Heart Failure-Heart Failure Trial (STAMINA-HeFT) suggest an improvement in symptoms and treadmill exercise time, but an uncertain effect on death and hospitalization. Similar strategies for patients with chronic kidney disease but without heart failure have also not shown benefit (113). It has been suggested that increasing hemoglobin aggressively may be associated with thrombotic events. The ongoing, multicentre, randomized study, Reduction of Events with Darbepoetin alfa in Heart Failure (RED-HF), will address these issues and is powered for morbidity and mortality. Practical tips: • Heart failure patients with severe anemia should be assessed by a physician who is experienced in the diagnosis and management of anemia, and underlying causes should be treated using intravenous means, if necessary. • There is currently insufficient evidence to support the routine use of bone marrow-stimulating drugs to increase hemoglobin levels in heart failure patients. • In general, plasma hemoglobin levels lower than 90 g/L are associated with increased symptoms of heart failure. In this setting, consideration may be given to blood transfusion or a bone marrow-stimulating agent if advanced symptoms are present and after substrate deficiencies have been corrected. Heart failure and acute intercurrent medical illness Recommendations • Beta-blockers should be initiated as soon as possible after diagnosis of heart failure, including during the index hospitalization, provided that the patient is clinically stable. Clinicians should not wait until hospital discharge to start a beta-blocker in stabilized patients (class I, level B). • Beta-blockers should be continued in patients hospitalized with AHF, unless they develop cardiogenic shock, refractory volume overload or symptomatic bradycardia (class IIa, level C). • Beta-blockers and ACE inhibitors should be continued at their usual dose during acute intercurrent illness (eg, pneumonia, exacerbation of COPD, other systemic infection, etc), unless they are not tolerated (eg, if significant reactive airways disease is present) (class IIa, level C). • In a life-threatening complication, beta-blockers and ACE inhibitors or ARBs may be discontinued abruptly, but generally, if there is concern about their use, the dose should be decreased by one-half, and the patient should be reassessed. If the dose is reduced, it should be uptitrated to the previous well-tolerated dose as soon as safely possible (class IIa, level C). • Heart failure patients with an acute dehydrating illness of any kind should undergo prompt evaluation and measurement of serum electrolytes, as well as blood urea nitrogen (BUN) and creatinine levels, even if not clinically volume-overloaded or -depleted. They should also be followed carefully until they return to their previous health state (class IIa, level C). • In an acute dehydrating illness with risk of worsening renal function, spironolactone may be temporarily withheld because hyperkalemia is more common in this setting (class I, level C). • Colchicine should be considered for acute gouty attack in heart failure patients. An oral or intra-articular steroid may also be considered (class IIa, level C). Arnold et al 30 Can J Cardiol Vol 23 No 1 January 2007• When noncardiac surgery requiring general anesthesia is contemplated, patients with heart failure should be evaluated preoperatively by a physician experienced in heart failure management (class I, level C). Initial recommendations for beta-blockers in heart failure patients with systolic dysfunction stipulated that they be used in clinically stable outpatients (114). Recent studies have shown that it is safe to initiate beta-blockers in hospital, provided the patient is clinically stable (111,112,114,115). Data from the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) trial (116) of patients with severe systolic heart failure showed that patients tolerated the betablocker carvedilol better than placebo while hospitalized and during the first month of therapy. Patients who are prescribed beta-blockers in hospital are more likely to be on treatment in the intermediate follow-up and are more likely to be at target doses without an increase in side effects or adverse events (117). This supports a strategy of beta-blocker administration before hospital discharge in stabilized patients (117-126). A recent substudy of the DIG trial (127) reported that heart failure patients who were on beta-blockers at hospital admission had lower morbidity and mortality than those not on beta-blockers. Patients with decompensated heart failure who continue beta-blockers have improved hemodynamic and heart rate response to dobutamine, and demonstrate less ventricular ectopy/tachycardia (119,120) compared with those not continued on beta-blockers. This is consistent with the notion that beta blockade upregulates the beta1-receptor in myocardium and suggests that these patients have the capacity to respond to inotropic infusion at least as well, if not better than, if beta blockade is not present. No study to date has suggested that the administration of a beta-blocker at hospital admission predisposes patients to cardiogenic shock. This is in contrast to the acute intravenous administration of a betablocker to naïve patients in the acute myocardial infarction setting. There are no data regarding the use of beta blockade in cardiogenic shock because in most cases, clinicians will withhold in this setting (100,106-113,128). Accumulated data now suggest that beta blockade is well tolerated and associated with improved outcomes in patients with COPD unless reactive airways disease is present (a greater than 20% response to bronchodilators or a clinical history of asthma). There is no other subgroup of patients that has been shown to experience increased adverse events or side effects (117-126). Patients with heart failure are at increased risk of gout due to low cardiac output, reduced renal function, chronic loop diuretic use and possibly increased total body water fluctuation. The standard therapy treatment for gouty arthritis, NSAIDs or cyclooxygenase 2 inhibitors, have known adverse renal effects and are associated with increased hospitalizations (and possibly death) in patients with heart failure (88,129-132). They should, therefore, be avoided when other adequate treatments are available. Oral colchicine is an effective therapy and is generally safe to use in heart failure patients. Alternatively, a short-term oral steroid for one to two weeks or an intra-articular steroid (when feasible, such as with a certain single joint involvement) may be used for a lower level of fluid retention and other side effects (133). Allopurinol may be started approximately two weeks after the acute episode is completed. Small studies have hypothesized that allopurinol may be beneficial in chronic heart failure, possibly due to its antioxidant properties, although this is has not been proven (84,129-131,134). Previously published risk scores to estimate cardiac morbidity and mortality for noncardiac surgery have included heart failure as an important risk factor (135). Heart failure patients with planned urgent noncardiac surgery have a lower than 10% risk, but this is still approximately double the risk of other patients with similar comorbid burden. One large series of patients (136) reported a 12% perioperative mortality and 20% hospital readmission within 30 days of urgent noncardiac procedures. Patients with heart failure should undergo electrocardiographic and vital sign monitoring, typically in a stepdown or intensive care setting (depending on the severity of heart failure, type of intervention and urgency of procedure) for up to 48 h following operative intervention. In these patients, collaboration with the attending surgeon and anesthetist is recommended to offer an unambiguous care plan. When possible, intravenous fluid administration during the operative procedure should be limited as much as possible to prevent development of volume overload postoperatively. The fluid and electrolyte balance should be carefully followed during the recovery phase and until the patient is clinically stable from both a surgical and heart failure perspective. If possible, all usual heart failure medications should be administered before and after noncardiac surgery, with the possible exception of diuretics in the stable patient without volume overload (135-137). While preoperative stress testing is usually recommended for patients with ischemic heart disease, no clear benefit has been shown with the routine use of intraoperative, invasive, central hemodynamic monitoring (pulmonary artery catheter) or transesophageal echocardiography (Figure 1) (138,139). AHF Definitions and diagnosis of patients with AHF AHF is a serious condition requiring urgent medical attention, which presents as a rapid onset of appropriate signs and symptoms, such as reduced cardiac output, decreased tissue perfusion and increased pulmonary and/or peripheral congestion, with or without previously known cardiac disease. Common presenting symptoms include shortness of breath on minimal effort or when lying down, cough, increasing abdominal girth, edema and fatigue. This clinical syndrome is attributed to systolic or diastolic myocardial dysfunction, valvular dysfunction or cardiac rhythm abnormalities, but may have the following clinical presentations: ‘de novo’; decompensation of known chronic heart failure; hypertension; pulmonary edema; cardiogenic shock; high-output failure (anemia, thyrotoxicosis, arrhythmias and Paget’s disease); or predominant right heart failure with increased jugular venous pressure, peripheral edema or ascites. The Acute Decompensated Heart Failure National Registry (ADHERE), an acute decompensated heart failure national registry from the United States, reported that at presentation, 89% of patients had dyspnea, 68% had rales and 66% had peripheral edema. Only 2% of patients had a systolic BP lower than 90 mmHg (140). Initial clinical evaluation Recommendations: • A thorough clinical evaluation of the AHF patient should include assessment of perfusion and volume status – cold or warm, wet or dry (class IIa, level C). Consensus conference recommendations on heart failure 2007 Can J Cardiol Vol 23 No 1 January 2007 31• Initial investigations should include testing serum creatinine and electrolyte levels, troponin measurements, complete blood count, ECG, chest x-ray and an echocardiogram if no recent echocardiogram is available (class I, level C). • A precipitating cause should to be sought in all patients presenting with AHF (class I, level C). A clinical assessment is based on a thorough and systematic history and physical examination for clinical findings related to peripheral temperature and vasoconstriction/perfusion, as well as assessment of congestion in the lungs, liver and extremities. The patients may be classifed as Group A (warm and dry), Group B (warm and wet), Group C (cold and wet) and Group D (cold and dry). Warm refers to well-perfused peripheries, whereas cold suggests that the peripheries are not adequately perfused (Figure 2) (141). Wet refers to congestion, whereas dry refers to no congestion. These profiles predict outcome, and should be used to guide investigation and therapy; these appear to be an excellent tool for assessing the patient with chronic heart failure who presents with an acute decompensation (141). Vital signs may reveal an increased respiratory rate and resting heart rate, although BP may be low, normal or high. The jugular venous pressure is useful to assess right ventricular (RV) filling, and in RV congestion, hepatomegaly may be present. Evaluation of LV filling pressures is difficult, but clues to increased LV end-diastolic pressure include rales and crackles on pulmonary auscultation. Cardiac examination may reveal tachycardia, irregular rhythm, murmurs or extra heart sounds (third and fourth heart sounds). Peripheral examination will reveal the level of perfusion and congestion, but may also detect the presence of atherosclerosis, with diminished or absent pulses or the presence of bruits. Although the diagnosis of AHF is based on clinical signs and symptoms, it should be confirmed by additional tests that may point to etiology and precipitating factors. Serum electrolytes, renal function (BUN and creatinine levels), troponin level and complete blood count are mandatory tests, and should be done at initial presentation. In addition, albumin, D-dimer, liver and thyroid function tests may be useful in selected patients. Arterial blood gas analysis may help in the assessment of oxygenation (partial pressure of oxygen), respiratory efficacy (partial pressure of carbon dioxide), acid-base metabolism (pH and lactate level) and should be performed in all patients who are vasoconstricted or in cardiogenic shock. Otherwise, pulse oximetry is an adequate alternative. Plasma BNP is released from the cardiac ventricles in response to increased wall stretch or volume overload, and has been extensively used for diagnosis and prognosis in patients with AHF. BNP is discussed in more detail later under the ‘Biomarkers’ section. Its use in excluding (‘ruling out’ and/or recognizing heart failure) in patients admitted to the emergency department for dyspnea is well established (142,143). A BNP concentration lower than 100 pg/mL or an NT-proBNP concentration lower than 300 pg/mL indicates a low probability of AHF. Conversely, a BNP concentration greater than 500 pg/mL or an NT-proBNP concentration greater than 900 pg/mL indicates a very high probability of AHF and carries prognostic information (for concentrations greater than 450 pg/mL in patients younger than 50 years of age or concentrations greater than 1800 pg/mL in patients older than 75 years of age, see the ‘Biomarkers’ section). However, in AHF of very rapid onset (‘flash’ pulmonary edema), BNP levels may be normal at the time of first presentation. Otherwise, BNP levels have a good negative predictive value in excluding heart failure (144). Clinical conditions that may affect BNP levels include renal failure and sepsis, which may raise BNP levels, and obesity, which may lower BNP levels. The role of BNP levels in non- AHF and community outpatient practice remains to be fully clarified (145). It is essential to perform an ECG in AHF, even though it may sometimes be normal. It assists in identifying rhythm abnormalities (atrial fibrillation, flutter or bradycardia and ventricular tachycardias), acute coronary syndromes (146), RV, LV or atrial hypertrophy or strain, as well as myopericarditis. Cardiac arrhythmias should be evaluated by a 12-lead ECG and continuous ECG monitoring. A chest x-ray should also be performed in all patients with suspected AHF within the first 1 h to 2 h of arrival to assess cardiac size and shape, pulmonary congestion and other pulmonary conditions. It is important for confirmation of the diagnosis, and may also be useful during follow-up for evidence of improvement or unsatisfactory response to therapy. In some cases, a thoracic computed tomography scan with or without contrast agent or ventilation-perfusion scintigraphy may help when pulmonary embolism or another pulmonary disease is suspected as the cause of AHF. Echocardiography with Doppler imaging is an essential tool in evaluating global and regional LV and RV function and geometry, LV diastolic function, valvular disease, pulmonary artery pressures, cardiac index, mechanical complications of acute coronary syndromes and disease of the pericardium (147). In cases in which AHF is considered secondary to an acute or recent coronary syndrome, coronary angiography should be considered because appropriate revascularization has been shown to improve prognosis (146). Patients presenting with AHF should be questioned about potential etiology and precipitating factors (Table 1 [see page 24]). In the vast majority of cases (75% to 80%) (148,149), an offender can be found. Failure to uncover the responsible precipitating factor may lead to intractable heart failure. Noncompliance with diet or medication intake, as well as infections, arrhythmias, pulmonary embolism and acute coronary syndrome, are frequent situations that may cause AHF. Arnold et al 32 Can J Cardiol Vol 23 No 1 January 2007 Increasing Congestion Dry & Warm Wet & Warm Dry & Cold Wet & Cold Increasing Perfusion Figure 2) Initial bedside assessment of perfusion and volume status in acute heart failure. Data from reference 141Initial management approach for AHF Recommendations • Heart rate, BP and oxygen saturation should be measured frequently until the patient is stabilized (class IIa, level C). • All patients with AHF should have careful monitoring of fluid balance, including urine output, and this may require bladder catheterization (class I, level C). • If the patient is in shock or has significant renal dysfunction, laboratory tests, particularly for serum electrolytes and renal function, should be checked regularly in the first 24 h of presentation (class I, level C). • Invasive monitoring with arterial lines or central venous pressure lines may be necessary for patients in cardiogenic shock or for those who require pressors (class II b, level C). Monitoring should be initiated as soon as possible, along with diagnostic procedures directed toward the underlying etiology. The extent of surveillance and monitoring required for a particular patient will depend on the severity of the illness and the response to initial therapy. Immediate therapy is directed toward hemodynamic stabilization, adequate oxygen delivery to the tissue, as well as symptom improvement (150,151). To reach these goals, AHF patients should be treated without delay by staff with skills in AHF management (152). Diagnostic (echocardiography) and therapeutic procedures (coronary percutaneous intervention or cardioversion for a persistent arrhythmia) should be available in a timely manner. Vital sign measurements should be made on a regular basis until stabilization of BP and oxygenation. Several laboratory tests have to be repeated regularly (at least daily in the first two to three days): electrolytes, BUN, creatinine and complete blood count if abnormal. Electrolyte abnormalities should be prevented (eg, by potassium supplementation with diuretics) or corrected promptly if they do occur. Patients with significant renal impairment may require more frequent laboratory tests to monitor renal function and electrolytes. A close interrelationship exists between AHF and renal failure, and both may cause, aggravate and influence each other. If the patient’s clinical status deteriorates despite initial therapy, closer supervision, such as transfer to an intensive care unit, is warranted. Patients with AHF who are in cardiogenic shock or those who have difficulty voiding should have a bladder catheter to monitor urinary output monitoring. The decision to insert an arterial line (usually radial) depends on the need for either continuous analysis of BP due to hemodynamic instability with low BP or the requirement for repeated arterial blood analyses. A central intravenous line depends on the need for either delivery of fluids and drugs or for monitoring central venous pressure and venous oxygen saturation, which provides an estimate of oxygen transport. However, in critically ill patients with AHF, right atrial pressure does not correlate well with left atrial and LV filling pressures. The insertion of a pulmonary artery catheter is not usually necessary for the diagnosis of AHF. It may, however, be useful in some patients to distinguish between cardiogenic and noncardiogenic shock, to guide therapy in the presence of severe diffuse pulmonary disease or in hemodynamically unstable patients who do not respond in a predictable fashion to the initial therapy (153). Medical treatment of AHF Recommendations • Any identified precipitating cause should be promptly corrected when possible (eg, cardioversion for a tachyarrhythmia) (class I, level B). • Oxygen should be given initially to all patients presenting with AHF and hypoxia (class I, level C). • Continuous positive airway pressure (CPAP), bilevel positive airway pressure (BIPAP) or endotracheal intubation should be considered if hypoxemia persists despite increasing incremental fraction of oxygen (class IIa, level B). • Intravenous diuretics should be given as first-line therapy for patients with AHF and congestion (class I, level B). • Vasodilators should be considered for patients with dyspnea at rest (class I, level C). • Positive inotropes should be reserved for patients in cardiogenic shock and/or volume overload with diuretic resistance. They should be used for short-term therapy to stabilize the patient. In hypotensive patients (systolic BP of 90 mmHg), dobutamine is preferred over milrinone (class I, level C). • ACE inhibitors are not recommended routinely in the first few hours of AHF. They should be introduced when the patient is stabilized (class I, level B). • Calcium channel blockers are not recommended in AHF; specifically, diltiazem and verapamil are to be avoided in AHF with systolic dysfuntion (class III, level B). • Diltiazem may be used in AHF with preserved systolic function in the setting of atrial fibrillation with rapid ventricular response (class I, level C). • For patients with refractory heart failure despite medical therapy, an intra-aortic balloon pump (IABP) may be considered (class IIb, level B). • Patients who remain in cardiogenic shock and have a low comorbid burden should be transferred early to a tertiary care centre in which circulatory mechanical support and transplantation are available (class I, level C). Adequate oxygen delivery to the tissues (systemic arterial oxygen saturation of 95%) is important to help prevent tissue hypoxia and multiple organ failure. This first implies a patent airway with administration of incremental fraction of oxygen. BIPAP or CPAP should be considered for patients with a high respiratory rate (more than 25 breaths/min), and who are breathing with great effort and use of accessory muscles, or have Consensus conference recommendations on heart failure 2007 Can J Cardiol Vol 23 No 1 January 2007 33persistent systemic arterial hypoxia despite high flow oxygen administration. Endotracheal intubation may be warranted if these less invasive modes of oxygen delivery fail to improve tissue oxygenation or if the patient is cardiogenic shock. Despite their broad acceptance, there are no outcome data derived from randomized clinical trials of the use of intravenous diuretics in AHF. However, intravenous diuretics increase urine output by excretion of sodium and water, leading to a decrease in plasma and extracellular fluid volume, total body water and sodium, a reduction in RV and LV filling pressures, as well as a decrease in peripheral congestion and pulmonary edema (154,155). Intravenous loop diuretics also cause an early (5 min to 30 min) decrease in right atrial and pulmonary wedge pressure through a vasodilatory effect (156). When using high intravenous doses (0.1 mg/kg), reflex vasoconstriction may occur. In AHF, by normalizing loading conditions, these high doses may reduce neurohormonal activation in the short term (157). Patients presenting with AHF and congestion should receive intravenous loop diuretics (furosemide, bumetanide or torasemide). Therapy may be initiated in the ambulance (158), heart failure clinic (159) or in hospital, and doses should be adjusted according to diuresis and clinical response (improved symptoms of shortness of breath and improved oxygenation). A combination of diuretics with thiazides (159-161) or spironolactone (162) has been proposed and seems to be effective, with fewer side effects than a higher dose of a loop diuretic. In patients with severe right heart failure, oral diuretics may not be adequately absorbed and may therefore be of little use. Dobutamine, milrinone, dopamine or nitrates (92,163) may also be used in combination with loop diuretics to promote diuresis while reducing side effects. This strategy may also be helpful in preventing diuretic resistance. There are limited data and randomized control trial information available regarding the use of positive inotropes or vasodilators for the treatment of AHF. The ADHERE registry of 65,180 patients with AHF from 263 hospitals showed that only 1% of AHF patients with preserved LVEF and 4% of AHF with reduced LVEF have a systolic BP of 90 mmHg or lower (164). However, positive inotropes (dobutamine, milrinone or dopamine) were used in 8% of patients with preserved LVEF and in 19% of patients with reduced LVEF. Vasodilators (nesiritide, nitroglycerin or nitroprusside) were used in 18% of patients with preserved LVEF and in 24% of patients with reduced LVEF and AHF; 16% of patients received more than one vasoactive therapy, which was associated with a longer length of intensive care unit or coronary care unit and hospital stay (165). Risk factors for increased mortality included BUN levels greater than 42 mg/dL (10.5 mmol/L) (OR 3.34), systolic BP of 115 mmHg or lower (OR 3.09), diastolic BP of 55 mmHg or lower (OR 2.87), serum sodium level of 134 mmol/L or lower (OR 2.26), creatinine level greater than 3.2 mg/dL (283 ìmol/L) (OR 1.99), age older than 78 years (OR 1.88), dyspnea at rest (OR 1.57) and heart rate of more than 84 beats/min (OR 1.20). For both adjusted and unadjusted OR, mortality was lower in patients treated with nitroglycerin or nesiritide versus dobutamine or milrinone. The unadjusted OR of mortality was higher in those treated with nesiritide versus nitroglycerin; however, the covariate and propensity scoreadjusted OR was 0.94 in favour of nesiritide. There is a need for further randomized controlled trials to assess treatment options in AHF with preserved and reduced LVEF, and in the setting of the hemodynamically stable patient. The Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF [166]) was a prospective, randomized, doubleblind, placebo-controlled trial of 951 patients in 78 community and tertiary care hospitals in the United States. Patients (mean age 65 years, NYHA class III to IV in 92%, mean LVEF of 23%), admitted with an exacerbation of systolic heart failure that did not require intravenous inotropic support, were randomly assigned to a 48 h infusion of milrinone (0.5 ìg/kg/min) versus saline placebo. New-onset atrial arrhythmias, worsening of heart failure and symptomatic hypotension requiring intervention occurred more frequently in the milrinone group. There was no difference in in-hospital mortality, or composite incidence of death or readmission at 60 days; however, a nonsignificant increase in the number of deaths in hospital and after 60 days was seen in the milrinone group. A posthoc analysis demonstrated a higher incidence of death or rehospitalization in patients with underlying ischemic etiology of heart failure (42% for milrinone versus 36% for placebo, P=0.01) (167). There are no placebo-controlled trials assessing dobutamine efficacy in AHF, but it is clearly associated with increased incidence of arrhythmias (168). Levosimendan, a calcium-sensitizing inodilator, has been reported to reduce mortality compared with dobutamine and placebo (169). In the Randomized Multicenter Evaluation of Intravenous Levosimendan Efficacy II (REVIVE-II) trial (169), levosimendan showed modest benefit over placebo, but there was more hypotension and atrial fibrillation, and mortality at 90 days was higher. In the Survival of Patients with Acute Heart Failure in Need of Intravenous Inotropic Support (SURVIVE) study (169), there was a trend to early benefit with levosimendan over dobutamine that was not evident past the period of hemodynamic efficacy of the drug; there was more atrial fibrillation, and mortality was comparable at the end of the study (169). Because there was no placebo-treated arm in this study, although levosimendan appeared to have better efficacy and safety than dobutamine, this is not to say that it is superior to placebo. Much data on nitroglycerin are nonrandomized and somewhat dated. However, a recent study (163) showed that highdose nitroglycerin was more effective than furosemide in controlling severe pulmonary edema. There are no randomized controlled trials assessing the safety and/or efficacy of nitroprusside in the treatment of AHF. The Vasodilator in the Management of Acute Heart Failure (VMAC) trial compared nesiritide (n=204), nitroglycerin (n=143) or placebo (n=142) added to standard therapy for 3 h, followed by nesiritide (n=278) or nitroglycerin (n=216) added to standard treatment for 24 h in AHF patients with dyspnea at rest. The study included a subset of 246 patients who received pulmonary artery catheterization. The primary end points of changes in pulmonary capillary wedge pressure and patient self-evaluation of dyspnea at 3 h were improved with nesiritide versus placebo. There was a significantly greater reduction in pulmonary capillary wedge pressure with nesiritide (–5.8 mmHg) versus nitroglycerin (–3.8 mmHg) at 3 h and 8 h (–8.2 mmHg versus –6.3 mmHg); however, there was no difference in dyspnea. Sixmonth mortality was similar (25.1% with nesiritide, 20.8% with nitroglycerin) (170). Since the VMAC trial, two metaanalyses pooled 12 randomized controlled trials evaluating nesiritide, three of which met all the inclusion criteria for the mortality assessment and five studies met the criteria for renal Arnold et al 34 Can J Cardiol Vol 23 No 1 January 2007dysfunction. The pooled results suggested an increased 30-day mortality with nesiritide (unadjusted HR 1.74, 95% CI 0.97 to 3.12, P=0.059; adjusted HR 1.80, 95% CI 0.98 to 3.31, P=0.057) (171,172). The RR of renal dysfunction with nesiritide across the studies was 1.52 (95% CI 1.16 to 2.00, P=0.003). Another retrospective review did not identify a significant safety concern (173). A large-scale trial prospective randomized trial of nesiritide in the treatment of AHF is currently planned to test safety and efficacy. Endothelin antagonists have been studied in the treatment of AHF, but a large randomized trial of tezosentan 1 mg/h versus placebo in 1400 AHF patients with dyspnea was stopped for futility without significant safety concerns (174-178). Cardiogenic shock refractory to medical therapy Three to five per cent of patients with AHF present in cardiogenic shock. A stepwise, graded approach to circulatory support based on the underlying cardiac pathology is required. Acute mechanical problems, such as acute mitral valve rupture or ventricular septal defect, may require surgical correction in appropriately selected patients. For patients who remain in cardiogenic shock, despite best treatments discussed above, timely institution of IABP may improve cardiac performance by increasing coronary artery perfusion and by assisting ventricular unloading. However, IABP support may augment cardiac output by only 10% to 15%. Contraindications to IABP support include descending thoracic or abdominal aortic disease and significant aortic insufficiency; the efficacy of IABP support is also questionable in young patients (younger than 40 years of age) who have very elastic and compliant aortas (179). For patients who remain in profound, refractory cardiogenic shock, but are expected to recover and are thought to be potential transplant candidates, mechanical cardiac support should be considered; extracorporeal membrane oxygenation (ECMO) may initially be considered. This allows diversion of a patient’s blood volume through an external circuit, which circulates the blood through an oxygenator and a heat exchanger before returning it to the patient. A dialysis membrane may also be added for renal replacement therapy. Despite the fact that ECMO may provide adequate perfusion and reverse metabolic acidosis, myocardial unloading is incomplete due to the absence of a compliance chamber and may, in turn, delay or impede recovery. In addition, the extended blood path of a typical ECMO circuit may damage circulating blood cells and activate inflammatory cascades, which may lead to multi-organ dysfunction. ECMO circuits require anticoagulation, and hemorrhagic complications are not uncommon. Although ECMO can be instituted rapidly and permit a timely evaluation of neurological status and transplant candidacy, prolonged support (more than four days) has been associated with poor survival. Early consideration should be given to conversion to a long-term ventricular assist device (VAD) in eligible candidates (180). Advanced options for circulatory support include VAD technologies for a small subset of the sickest patients and are limited in availability because of cost and expertise. VADs typically allow complete unloading of the native heart. They are implanted in a paracorporeal position, in which the blood pump is external and the cannulae traverse the skin to enter the mediastinum, or in the intracorporeal position, in which patients are tethered by a percutaneous driveline connecting the device to a computer and battery pack providing 2 h to 8 h of autonomy on a single charge, depending on the device and the energy demand. Rapid evolution in mechanical circulatory support technology has allowed the implementation of cardiac assist devices within clinical management algorithms for patients with end-stage heart disease or cardiogenic shock. As such, this standard of care presents opportunities and challenges for all those involved in the care of this complex population (181). The hub-and-spoke paradigm for mechanical cardiac assist has been developed with a view to extending mechanical circulatory support services to a broad geographic-based population, in a highly structured, organized network of nontransplant cardiac centres (spokes) collaborating with an identified multidisciplinary heart failure/mechanical assist/transplant program (hub). In keeping with this model, hub-centre and spoke-centre partnerships espousing this joint management philosophy, would, once established, agree on indications for patient entry into this clinical pathway, and appropriate technological and training resources would be shared. Successful implementation of such a program would be based on early and effective communication between centres, agreeing on device selection and management, patient stabilization strategies, and preparation and mechanisms for transport to a hub centre (182). Practical tips: • Vasodilators, including nitroglycerin (sublingual or intravenous), oral nitrates, intravenous nitroprusside and nesiritide (when available), may be useful in the initial management of AHF with systolic BP greater than 100 mmHg. • Patients who remain in cardiogenic shock but are expected to recover with further support or are heart transplant candidates should be considered for ECMO and VAD support. BIOMARKERS IN HEART FAILURE Recommendations • BNP/NT-proBNP levels should be measured to help confirm or rule out a diagnosis of heart failure in the acute or ambulatory care setting in patients in whom the clinical diagnosis is in doubt (class I, level A). • Measurement of BNP/NT-proBNP levels may be considered in patients with an established diagnosis of heart failure for prognostic stratification (class IIa, level A). • Sequential measurements of BNP/NT-proBNP levels may be considered to guide the therapy of patients with heart failure (class IIb, level B). The term ‘biomarker’ was first introduced in the late 1980s as a medical subject heading term: “measurable and quantifiable biological parameters...which serve as indices for healthand physiology-related assessments, such as disease risk, psychiatric disorders, environmental exposure and its effects, disease diagnosis, metabolic processes, etc” (183). In 2001, a National Institute of Health working group standardized the definition as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic Consensus conference recommendations on heart failure 2007 Can J Cardiol Vol 23 No 1 January 2007 35intervention”, and went on to define types of biomarkers (184). The expectation from a cardiac biomarker is that it can enhance clinicians’ abilities to optimally manage patients with a cardiac disorder. Indeed, some of the most exciting discoveries in cardiology in the past two decades have been the development of biomarkers. Blood assays have been developed for several markers that can be used as adjuncts in primary prevention and screening, as well as in diagnostic, prognostic and therapeutic strategies for a variety of CV diseases and their related clinical events. Biomarkers in heart failure One good example of the application of biomarkers is in the management of heart failure. The diagnosis of heart failure is usually based on history, physical examination, chest radiography and, if available, LV function assessment. However, in many instances, diagnosing heart failure based on conventional subjective measures may be very difficult (185). Furthermore, LV function assessment may not be readily available, particularly in the urgent care settings. Patients with heart failure and preserved systolic LV function may have unremarkable echocardiographic findings (186,187). Indeed, many studies have now demonstrated that diagnosis of heart failure based on clinical assessment and standard testing may be inadequate (188-190). For these reasons, there has been a great effort to develop biomarkers that would offer incremental value to conventional clinical tools to establish rapid and accurate diagnosis and risk stratification of patients with heart failure. The natriuretic peptides To date, the only biomarker that has been developed for clinical use in heart failure is the group of natriuretic peptides. The natriuretic peptide family consists of the atrial natriuretic peptide, BNP and three other structurally similar peptides: C-type natriuretic peptide, which is mostly of central nervous system and endothelial origin; urodilatin from the kidney; and dendroaspis natriuretic peptide, which is of unknown significance at present (191-193). Among the natriuretic peptides, BNP and the amino-terminal fragment of the prohormone (NTproBNP) have been at the most advanced stage of development for clinical use (193). BNP and NT-proBNP as diagnostic markers in heart failure Ample evidence exists attesting the use of BNP as a diagnostic marker to rule in and rule out heart failure in patients presenting to emergency departments with dyspnea. The development of a fluorescence immunoassay allowed for the point-of-care determination of BNP in whole blood and plasma. The largest study of the diagnostic utility of BNP is the Breathing Not Properly (BNP) Multinational Study (143,191). In this multicentre study, 1586 patients presenting to emergency departments with dyspnea had BNP levels determined using the rapid assay. Diagnosis of heart failure was adjudicated by cardiologists blinded to the BNP level results. BNP level was more accurate than clinical evaluation in identifying heart failure as the cause of dyspnea. Using a cut-off point of 100 pg/mL, the diagnostic accuracy was 83%. Similarly favourable results have been demonstrated with the use of the laboratory-based NTproBNP assay (194,195). In the single-institution N-terminal Pro-BNP Investigation of Dyspnea in the Emergency department (PRIDE) study (195), 600 patients presenting to an emergency department with dyspnea were prospectively evaluated. NT-proBNP levels at cut-off points greater than 450 pg/mL for patients younger than 50 years of age and more than 900 pg/mLfor patients 50 years of age and older were both sensitive and specific for the diagnosis of heart failure. An NTproBNP level lower than 300 pg/mL was optimal for ruling out heart failure, with a negative predictive value of 99% regardless of age. Equally favourable results were observed in Canadian urgent care settings from the recently presented Canadian multicentre Improved Management of Congestive Heart Failure (IMPROVE-CHF) trial (Figure 3). Other than in acute settings, several studies have also established the value of NT-proBNP levels in the diagnosis of heart failure in an outpatient setting (196-198). A potentially useful application of BNP levels is for the diagnosis of heart failure in patients with heart failure and preserved LVEF. By definition, these patients have normal LVEF, and therefore, heart failure cannot be easily diagnosed by an assessment of LV systolic function. BNP level is elevated in patients with heart failure or diastolic dysfunction based on Doppler filling characteristics (199). The area under the receiver-operating-characteristics curve to detect diastolic dysfunction in patients with heart failure with preserved LVEF was 0.96 using a traditional radioimmunoassay (200), and 0.92 in patients with or without symptoms using a commercial rapid assay (201). Although BNP level in heart failure in patients with preserved LVEF tends to be lower than that in patients with heart failure and systolic dysfunction, BNP level by itself cannot be used to differentiate between systolic and diastolic dysfunction. BNP level can increase in conditions other than heart failure. Indeed, plasma BNP and NT-proBNP levels increase with age, as well as in women, patients with renal failure, pulmonary disease, malignancy, beta blockade therapy and in any conditions that increase load to the cardiac ventricles (202). On the other hand, BNP level may be falsely low in obese individuals and in patients with flash pulmonary edema; in the latter case, there is not enough time for the ventricles to produce and release BNP to increase the circulating level (202-204). However, secondary reports of the BNP and PRIDE studies have shown preserved diagnostic use of BNP and NTproBNP in the presence of renal failure, although the cut-off points have to be adjusted (205,206). In summary, BNP/NT-proBNP testing is useful and complementary to clinical evaluations in diagnosing heart failure. The test is most useful in patients whose history, physical examination and chest radiographs are suggestive, but not clearly diagnostic of heart failure. In practice, in patients presenting with dyspnea and a BNP level measured from the point-of-care assay lower than 100 pg/mL or NT-proBNP level lower than 300 pg/mL, a diagnosis of heart failure is likely ruled out. For those with BNP levels 100 pg/mL to 500 pg/mL or NTproBNP levels 300 pg/mL to 450 pg/mL in those younger than 50 years of age, or 300 pg/mL to 900 pg/mL in those 50 to 75 years of age, a diagnosis of heart failure is possible, but other diagnoses such as chronic LV dysfunction, lung disease or pulmonary embolism should be considered. For patients with BNP levels less than 500 pg/mL and NT-proBNP levels greater than 450 pg/mL in those younger than 50 years of age, levels greater than than 900 pg/mL in those 50 to 75 years of age and levels greater than 1800 pg/mL in those older than 75 years of age, heart failure is very likely. Appropriate BNP levels that may be Arnold et al 36 Can J Cardiol Vol 23 No 1 January 2007used as clinical cut-off points for diagnosis and management are given in Table 3. BNP as a prognostic marker in heart failure BNP and NT-proBNP levels correlate with the severity of heart failure (207-209). A large body of evidence exists confirming BNP and/or NT-proBNP as independent predictors of total mortality, CV mortality and heart failure hospitalization in both acute and chronic heart failure (210-218). In patients presenting to the emergency department with dyspnea, BNP levels measured at the time of presentation were highly predictive of cardiac events over the next six months (214). A BNP value of 480 pg/mL had a sensitivity of 68%, a specificity of 88% and an accuracy of 85% for predicting a subsequent heart failure end point. Patients with BNP levels greater than 480 pg/mL had a 51% six-month cumulative probability of a heart failure event, whereas those with BNP levels less than 230 pg/mL had an excellent prognosis, with only a 2.5% incidence of heart failure end points. In a prospective evaluation of 142 consecutive patients with advanced heart failure referred for cardiac transplantation (217), an NT-proBNP level above the median was the only independent predictor of mortality and combined mortality and urgent transplantation. The Rapid Emergency Department Heart failure Outpatient Trial (REDHOT) examined the relationships between BNP levels, perceived heart failure severity, clinical decision-making and outcomes of patients presenting to emergency department with dyspnea (218); patients were followed up for 90 days. Of the 464 patients, 90% were hospitalized. Two-thirds of patients were perceived to be at NYHA functional class III or IV. BNP levels did not differ between patients who were discharged and those admitted. Emergency physicians’ intentions to admit or discharge patients had no influence on 90-day outcomes, although BNP level was a strong predictor of outcome. Of the admitted patients, 11% had BNP levels less than 200 pg/mL (66% of which were perceived NYHA functional class III or IV). The 90-day combined event rate (heart failure visits/admissions and mortality) in the group of patients admitted with BNP levels less than 200 pg/mL and greater than 200 pg/mL was 9% and 29%, respectively (P=0.006). In a one-year follow-up of patients in the PRIDE study (219), NT-proBNP concentrations obtained from the emergency department were found to predict one-year mortality, with an optimal cut-off point of 986 pg/mL, regardless of whether the patients had a diagnosis of heart failure. In summary, BNP and NT-proBNP are strong, independent predictors of adverse clinical outcomes in a variety of patient populations, including those with heart failure. This prognostic use of this biomarker could potentially aid clinicians in their decision-making and management of heart failure patients. The impact of a knowledge of BNP/NT-proBNP level results on the management of heart failure There is increasing evidence to support the concept that the provision of knowledge of plasma BNP levels may be translated to improved management in the form of improved clinical outcomes and cost savings. Data are still being accumulated because several randomized controlled trials are either ongoing or just being completed. A pilot study by Troughton et al (220) was the first attempt to evaluate such an approach. In the study, 69 patients with decompensated heart failure were randomly assigned to have therapy adjusted according to a preset clinical algorithm or to serial plasma levels of NT-proBNP. In the BNP-guided group, NT-proBNP levels above 200 pmol/L (approximately 1700 pg/mL) triggered intensification of therapy even when the clinical threshold was not exceeded. At 9.5 months’ follow-up, clinical outcomes were significantly improved in the BNPguided group. Nineteen adverse CV events in the NTproBNP- guided group compared favourably with 54 events in the clinically managed patients (P=0.02). Although the data were promising, the sample size of the study was small and the study was conducted in an era before contemporary heart failure therapy. In the multicentre Systolic heart failure Treatment Supported by BNP (STARS-BNP) randomized trial (221), which is still in abstract form, 220 patients with heart failure were randomly assigned to BNP versus clinically guided treatment. In a median follow-up period of 15 months, there were significantly fewer events – death or heart failure hospitalization – in the BNP group than in the clinical group. There are now randomized, controlled data to show that the use of BNP/NT-proBNP levels is also associated with cost savings in the management of patients presenting to emergency departments with dyspnea. In the Acute Shortness of Consensus conference recommendations on heart failure 2007 Can J Cardiol Vol 23 No 1 January 2007 37 TABLE 3 Brain natriuretic peptide (BNP) and prohormone of BNP (NT-proBNP) assay cut-off points for the diagnosis of heart failure Heart failure is possible, Heart but other Heart failure diagnoses failure Age is need to be is very (years) unlikely considered likely BNP* All <100 pg/mL 100 pg/mL – 500 pg/mL >500 pg/mL NT-proBNP <50 <300 pg/mL 300 pg/mL – 450 pg/mL >450 pg/mL 50–75 <300 pg/mL 450 pg/mL – 900 pg/mL >900 pg/mL >75 <300 pg/mL 900 pg/mL – 1800 pg/mL >1800 pg/mL *Point-of-care assay 1 - Specificity (false-positive) 0.0 0.2 0.4 0.6 0.8 1.0 1.0 0.8 0.6 0.4 0.2 0.0 Sensitivity (t rue-positive) No discrimination Clinical judgment (AUC=0.834) NT-proBNP (AUC=0.855) Clinical judgment & NT-proBNP (AUC=0.904) P<0.00001 NT-proBNP + clinical judgment vs clinical judgment alone Figure 3) Receiver-operating characteristics curves for clinical judgment alone, prohormone of brain natriuretic peptide (NT-proBNP) and combined NT-proBNP and clinical judgment in the Canadian Improved Management of Congestive Heart Failure (IMPROVECHF) study. AUC Area under the curveBreath Evaluation (BASEL) study of patients presenting to a single emergency department with dyspnea, 225 were randomly assigned to a strategy involving the measurement of BNP levels with the bedside assay, and 227 were assessed in a standard manner. The use of BNP levels reduced the need for hospitalization and intensive care. A cost reduction of 26% over a 30-day period and 25% over 180 days were reported (222,223). In the Canadian multicentre IMPROVE-CHF study 244 patients were randomly assigned to NT-proBNP-guided management and 251 to usual care. Knowledge of NT-proBNP results reduced the direct medical costs, including initial and subsequent emergency department visits, hospitalizations and outpatient services from $7405 to $6310 (P=0.017). In addition, the duration of the emergency department visit (6.3 h to 5.6 h, P=0.038) and the number of patients rehospitalized (51 to 33, P=0.044) were reduced (197). Although sequential changes of BNP and NT-proBNP levels over time correlate with treatment response and clinical outcome (208,224), it is still unproven whether using a treatment approach that is guided by BNP or NT-proBNP values would result in improved clinical outcomes. One such ongoing trial is evaluating management of heart failure based on knowledge of NT-proBNP levels (the BNP-Assisted Treatment To LEssen Serial CARdiac REadmissions and Death [BATTLESCARRED] trial). Other biomarkers and prognostic markers Other biomarkers that have been evaluated in patients with heart failure include the cardiac troponins. Although elevated troponin I and troponin T levels have been reported in patients with heart failure and have been shown to be associated with adverse clinical outcomes (225-229), these studies have typically involved relatively small numbers of patients. Furthermore, the sensitivity and specificity of cardiac troponins, as well as the optimal cut-off points for diagnosis and prognosis in heart failure, have not been properly defined. Finally, it is also unclear whether troponin results provide any information that is independent or incremental to those of BNP/NT-proBNP levels. There are other circulating markers of underlying patholological mechanisms operative in patients with heart failure that are not usually classified as biomarkers, but could be used as prognostic markers in these patients. These include simple demographic parameters, such as age and BP (230,231), measures of impaired renal function (232) and anemia, (233-235), as well as neurohormones, including noradrenaline, angiotensin II, arginine vasopressin and endothelin-1, which are not usually available for clinical use (236), but elevations of all of these parameters are related to prognosis in patients with heart failure. Summary and conclusions The clinical use of the BNP and NT-proBNP levels as biomarkers in heart failure has been thoroughly evaluated. Indeed, the use of natriuretic peptides as an aid to diagnose heart failure has now been endorsed in several heart failure consensus guidelines, including the 2006 CCS Heart Failure Consensus Conference (236-239). Practical tips: • The use such biomarkers as BNP and NT-proBNP levels should be complementary to, but not replace, good clinical evaluation. • There are no compelling factors that favour the use of the BNP versus the NT-proBNP assay. The choice is dictated by availability as well as the clinician’s familiarity, particularly with respect to interpretation. • To rule out or rule in a diagnosis of heart failure in patients presenting to emergency departments with dyspnea and suspected heart failure, cut-off points of the two assays are given in Table 3. • In patients with BNP levels (point-of-care assay) less than 100 pg/mL or NT-proBNP level less than 300 pg/mL, a diagnosis of heart failure is very unlikely. In patients with BNP levels of 100 pg/mL to 500 pg/mL, or NT-proBNP levels of 300 pg/mL to 450 pg/mL in those younger than 50 years of age and 300 pg/mL to 900 pg/mL in those 50 to 75 years of age, a diagnosis of heart failure is possible, but other diagnoses such as chronic LV dysfunction, lung disease or pulmonary embolism should be considered. For patients with BNP levels greater than 500 pg/mL and NT-proBNP levels greater than 450 pg/mL in those younger than 50 years of age, greater than 900 pg/mL in those 50 to 75 years of age and greater than 1800 pg/mL in those older than 75 years of age, a diagnosis of heart failure is very likely. WHAT IS ON THE HORIZON? Our understanding of heart failure has grown exponentially over the past 20 years and has fuelled many landmark clinical trials that have given definitive answers. The recommendations in the present paper are based on clinical trials that have already been conducted. Fortunately, there are many trials that are currently in progress or planning. These cover all aspects, from innovative drugs and devices to new applications of current drugs, and health care research. They will provide new information and evidence to guide future recommendations and guidelines. Although it is not possible to list all such trials, Table 4 presents some that cover the range of exciting new areas of research, many of which involve centres in Canada. CONCLUSIONS The practice of medicine requires knowledge, experience, good judgment and compassion. Well-designed clinical trials may provide evidence-based treatment choices and algorithms for care, but physicians and other health care providers are also informed by peers they respect and by their own experience. The current recommendations and practical tips will provide advice and help in several challenging areas of heart failure management. The treatment recommendations from 2006 have been combined with those for prevention from 2007 to provide a summary algorithm of the approach to a patient (Figure 4), as well as the drugs and doses studied in landmark clinical trials (Table 5). Knowing how to recognize the problems and the appropriate options will result in improved care and outcomes. Dissemination of these recommendations will occur when they are published, but it will also depend on planned interactive educational workshops and the example of health care professionals who put the recommendations into practice. Tools are being developed to help in this process, but local opinion leaders will be critical to teach in local communities. If physicians and other health Arnold et al 38 Can J Cardiol Vol 23 No 1 January 2007care providers who are involved in the care of patients with heart failure are informed by the evidence and consensus opinion of experts, measurable improvements in health care outcomes can be achieved. It is recognized that barriers to implementation exist, because heart failure patients are treated in a variety of circumstances by physicians with differing training and in health care systems that may not provide sufficient resources. While we have blood tests that may help to diagnose heart failure more accurately, the tests are not available in all communities. AHF is often misdiagnosed, resulting in delays in treatment. Hospital lengths of stay may be prolonged when heart failure is precipitated or aggravated by other intercurrent illnesses. Early identification of those at risk may not occur because of competing pressures on time in a busy office practice. The goal of the present recommendations is to improve heart failure outcomes, but this will also require a national health care strategy for heart failure with adequate funding to help prevent and treat heart failure, which is a current health care epidemic, especially in the elderly. ACKNOWLEDGEMENTS: This consensus conference was supported by the CCS. The authors are indebted to John H Parker, Marie-Josee Martin and Lise Hodgson of the CCS, Jody McCombe and Kim Harrison for logistic and administrative support. Consensus conference recommendations on heart failure 2007 Can J Cardiol Vol 23 No 1 January 2007 39 TABLE 4 New and ongoing trials in heart failure* Exercise prescription • HF-ACTION Atrial fibrillation • AF-CHF (rate versus rhythm control) Anticoagulation • WARCEF (warfarin versus acetylsalicylic acid) Anemia • RED-HF (erythropoietin) Diastolic heart failure • I-PRESERVE (irbesartan), TOPCAT (spironolactone) Acute heart failure • UNLOAD (ultrafiltration) • ASCEND-HF (nesiritide) • REVIVE (levosimendan versus placebo), SURVIVE (levosimendan versus dobutamine) Vasopressin antagonist • EVEREST (tolvaptan) Ischemic heart disease • STICH (Surgical remodelling/revascularization versus medical therapy) Devices • RAFT, REVERSE, MADIT-CRT (all cardiac resynchronization therapies) *List is not exhaustive and provides examples only. AF-CHF Atrial Fibrillation in Congestive Heart Failure; ASCEND-HF Acute Study of Clinical Effectiveness of Nesiritide in. Decompensated Heart Failure; EVEREST Efficacy of Vasopressin Antagonism in hEart failuRE: Outcome Study With Tolvaptan; HF-ACTION Heart Failure: A Controlled Trial Investigating Outcomes of Exercise TraiNing; I-PRESERVE Irbesartan in heart failure with PRESERVEd systolic function; MADIT-CRT Multicenter Automatic Defibrillator Implantation Cardiac Resynchronization Therapy Trial; RAFT Resynchronization/defibrillation for Advanced Heart Failure Trial; RED-HF Reduction of Events with Darbepoetin alfa in Heart Failure; REVERSE REsynchronization reVErses Remodeling in Systolic left vEntricular dysfunction; REVIVE Randomized Multicenter Evaluation of Intravenous Levosimendan Efficacy; STICH Surgical Treatment for Ischemic Heart Failure; SURVIVE Survival of Patients with Acute Heart Failure in Need of Intravenous Inotropic Support; TOPCAT Trial of Aldosterone Antagonist Therapy in Adults With Preserved Ejection Fraction Congestive Heart Failure; UNLOAD Use of Nitroprusside in Left Ventricular Dysfunction and Obstructive Aortic Valve Disease; WARCEF Warfarin Versus Aspirin in Reduced Cardiac Ejection Fraction If systolic HF but LVEF <40% ACEI + Beta-blocker Titrate to target doses Clinically stable NYHA class III NYHA class IIIb-IV Spironolactone Digoxin/nitrates Prescribe ARB Prescribe ARB Continue prescription Intolerance Intolerance For all symptomatic patients with systolic HF: • Tailored diuretic prescription Persistent symptoms or combine diuretics If QRS >120ms, consider CRT referral If LVEF <30%, consider ICD referral Prevention and treatment of heart failure (HF) (HF) If HF symptoms but LVEF >40%, treat cause, eg, hypertension, ischemia Consider ACEI/ARB, beta-blocker Add ARB If refractory, consider transplant • Education on: HF syndrome Self-monitoring Drug therapy Warning signs and symptoms Prognosis To prevent HF: treat all cardiac RFs; if low LVEF, prescribe ACEI +/– beta-blocker Consider nitrate/hydralazine Figure 4) Algorithm of the prevention and treatment of heart failure. ACEI Angiotensin-converting enzyme inhibitor; ARB Angiotensin receptor blocker; CRT Cardiac resynchronization therapy; ICD Implantable cardioverter defibrillator; LVEF Left ventricular ejection fraction; NYHA New York Heart Association; RF Risk factors TABLE 5 Evidence-based drugs and oral doses as used in large clinical trials for prevention and treatment of heart failure Drug Start dose Target dose Angiotensin-converting enzyme inhibitors Captopril 6.25 mg – 12.5 mg tid 25 mg – 50 mg tid Enalapril 1.25 mg – 2.5 mg bid 10 mg bid Lisinopril 2.5 mg – 5 mg od 20 mg – 35 mg od Perindopril 2 mg 8 mg Ramipril 1.25 mg – 2.5 mg bid 5 mg bid* Trandolopril 1 mg 4 mg Beta-blockers Bisoprolol 1.25 mg od 10 mg od Carvedilol 3.125 mg bid 25 mg bid Metoprolol CR/XL† 12.5 mg – 25 mg od 200 mg od Angiotensin receptor blockers Candesartan 4 mg od 32 mg od Valsartan 40 mg bid 160 mg bid Aldosterone antagonists Spironolactone 12.5 mg od 50 mg od Eplerenone† 25 mg od 50 mg od Vasodilators Hydralazine 37.5 mg tid 75 mg tid Isorbide dinitrate 20 mg tid 40 mg tid *The Healing and Early Afterload Reducing Therapy (HEART) trial (239) showed that 10 mg once a day (od) was effective to attenuate left ventricular remodelling. †Not available in Canada. bid Twice a day; CR/XL Controlled release/extended release; tid Three times a dayArnold et al 40 Can J Cardiol Vol 23 No 1 January 2007 SECONDARY PANELISTS: Tom Ashton MD FRCPC (Penticton, British Columbia); Victor Huckell MD FRCPC (University of British Columbia, Vancouver, British Columbia); Marie-Helene Leblanc MD FRCPC (Hopital Laval, Sainte-Foy, Quebec); Gary E Newton MD FRCPC (Mount Sinai Hospital, Toronto, Ontario); Joel Niznick MD FRCPC (The Ottawa Hospital, General Campus, Ottawa, Ontario); Sherryn N Roth MD FRCPC (Scarborough General Hospital, Toronto, Ontario); Denis Roy MD FRCPC (Institut de Cardiologie de Montreal, Montreal, Quebec); Stuart Smith MD FRCPC (St Mary’s Hospital, Kitchener, Ontario); Bruce A Sussex MD FRCPC (Health Sciences Centre, St John’s, Newfoundland), Salim Yusuf MD FRCPC (McMaster University, Hamilton, Ontario). 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N-terminal pro B type natriuretic peptide, but not the new putative cardiac hormone relaxin, predicts prognosis in patients with chronic heart failure. Heart 2003;89:879-81. 213. Harrison A, Morrison LK, Krishnaswamy P, et al. B-type natriuretic peptide predicts future cardiac events in patients presenting to the emergency department with dyspnea. Ann Emerg Med 2002;39:131-8. 214. Hartmann F, Packer M, Coats AJ, et al. NT-proBNP in severe chronic heart failure: Rationale, design and preliminary results of the COPERNICUS NT-proBNP substudy. Eur J Heart Fail 2004;6:343-50. 215. Richards AM, Nicholls MG, Yandle TG, et al. Plasma N-terminal pro-brain natriuretic peptide and adrenomedullin: New neurohormonal predictors of left ventricular function and prognosis after myocardial infarction. Circulation 1998;97:1921-9. 216. Richards AM, Doughty R, Nicholls MG, et al. 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Guidelines for the diagnosis and treatment of chronic heart failure: Executive summary (update 2005): The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Eur Heart J 2005;26:1115-40. 239. Pfeffer MA, Greaves SC, Arnold JMO, et al. Early versus delayed angiotensin-converting enzyme inhibition therapy in acute myocardial infarction. The healing and early afterload reducing therapy trial. Circulation 1997;95:2643-51. Consensus conference recommendations on heart failure 2007 Can J Cardiol Vol 23 No 1 January 2007 45||http:\/\/www.hfcc.ca/downloads/stage2/2007/2007_HFCC_Update.pdf", "2006 Heart Failure Consensus Conference Recommendations Program |Evaluation Tabulation Evaluation and Self-Assessment Form Canadian Cardiovascular Congress–2006 CCCN Workshop October 22nd, 2006, Vancouver 1. Please rate the following learning objective statements Please use the following scale Not Familiar Somewhat Familiar Familiar Familiar Enough to Explain to Others 1 2 3 4 A) Learning Objective: To increase awareness of the CCS HF Recommendations 2006 and of their impact on clinical practice and outcomes Pre- Program Familiarity Post-Program Familiarity Relevance to My Practice 1 2 3 4 1 2 3 4 1 2 3 4 14.9% 14.9% 31.9% 40.4% 0% 2.3% 43.2% 54.4% 4.3% 8.5% 25.5% 61.7% B) Learning Objective: To develop strategies that facilitate integration of the HF Recommendations into daily clinical practice Pre- Program Familiarity Post-Program Familiarity Relevance to My Practice 1 2 3 4 1 2 3 4 1 2 3 4 8.9% 31.1% 40% 20% 0% 4.7% 41.9% 53.5% 2.3% 8.5% 25.5% 57.4% 1 of 62. Primary specialty ED nurse 5.3% CCU/ICU nurse 19.3% General cardiology nurse 14.0% Cath. lab/recovery unit nurse 3.5% Nurse practitioner 14.0% Other 43.9% 3. My principal role with heart failure patients is to: Educate 39.6% Reduce hospital LOS 3.7% Research 3.7% Phone 0% Reduce hospital re-admin. 3.7% Other 9.3% Provide in-patient care 27.8% HF clinic 11.1% 4. How many heart failure patients do you see per week: 0–8 2 % 1–2 12.2% 3–4 36.7% 5–10 20.4% 1–20 6.1% > 20 16.3% 2 of 65. I have read the CCS HF 2006 guidelines: Yes 49.1% No 50.9% 6. I like the current format of the CCS HF guidelines with clear nursing recommendations followed by a brief overview of the evidence to support the recommendations: Yes 95.1% No 0% Perhaps 4.9% 7. In future iterations of the CCS guidelines, the nursing issues in heart failure I would like to see addressed are: • Discharge planning • Caregiver literature • Clinical symptom management in end-stage HF? Palliative inotropes aerosol morphine – are these still in? • More specific teaching tools for patients and nurses to use • Reduce salt – not clear what for patients as most patients do not go to cardiac rehab • Handouts for patients e.g. because prior to seeing HF clinic • More emphasis on ethics – could we vs. should we 3 of 68. How best can the CCS obtain your feedback on guidelines as they are developed? Broader stakeholder input 10.8% Online written feedback 54.1% Release of “guidelines in progress” 32.4% Other 2.7% • Through online presentation and feedback 9. What changes, if any, do you intend to make in your clinical practice as a result of today’s program? • Caution each use of glucophage and kidney failure, increase referrals to psych RNS and geriatricians • Ongoing use of guidelines • Continue with suggestions reflective in my practice • Found the sessions very practical • Speak up more during rounds • Make sure proper teaching is done with patient family and all aspects addressed • Living will – try to develop a strategy to ensure this is in place • Learned lots. Thanks • Will be [illegible] that increase confusion/delirium could mean worsening heart failure • Too many to list! I’ve learned from every speaker and presentation tonight. Thank you! • HF assessment to manage in ICU population • Pay more attention to pain as a symptom in end-stage heart failure • More discussion of end-of-life issues • Increase geriatrician referrals • Initiate advanced care directives – discussion • Re-do our CHF pathway • Awareness 4 of 610. Please rate the following aspects of the program Poor Satisfactory Very Good Excellent 1 2 3 4 Program/Presenter: Over all Clarity 0.00% 1.78% 21.25% 77.26% Program/Presenter: Over all Relevance to your practice 0.00% 6.60% 18.39% 75.01% Program/Presenter: Over all Educational Value Perceived 0.49% 5.52% 21.08% 72.91% 11. Please rate the following aspects of the program Poor Satisfactory Very Good Excellent Overall, I would rate the workshop 0% 2.1% 31.9% 65.9% I found the facilities to be 0% 13% 54.3% 32.6% The audiovisual presentations were 2.2% 13% 45.7% 39.1% Conduciveness of the format to learning was 0% 4.3% 52.2% 43.5% 12. What topics would you like to see covered in future events? • Recall failure/dysfunction and CHF; meds and CHF staging • Dinner meeting with presentation • Management of diabetes and CAD • How to convince/justify to administration the start-up of an outpatient HF clinic? Agreed to do it then program was cut out • The photographer was annoyingly in front of line of view for screen and speakers • How to approach patient family re: end-of-life issue? • Counselling for adherence 5 of 6• I really liked the case studies • Metabolic syndrome related to CHF • ACS guidelines • Issues related to diastolic dysfunction • Definitely love to see more topics presented in this form • Transition from hospital to home 13. Other comments related to nursing and care of HF patients: • Feed us at this lecture • How to order more pocket tools? • Don’t use negatively worded questions “least likely not” • In hospital acute care of the decompensated • Case studies were very helpful • I would expect supper to be served at a session running from 18:30-20:30 • Great workshop 6 of 6||http:\/\/www.hfcc.ca/downloads/stage5/CCS_Nurses_Evaluation_Self_Assessment_Summary_02122006.pdf", "2006 Heart Failure Consensus Conference Recommendations Program |Evaluation and Self-Assessment Help Shape the Future of Heart Failure Care in Canada Workshop, October 24th, 2006 Canadian Cardiovascular Congress 2006 – Vancouver Global Audience 1. I have attended a previous CCS workshop on Heart Failure this year. Yes 29% No 71% 2. Please rate the following learning objective statements Please use the following scale Not Familiar Somewhat Familiar Familiar Familiar Enough to Explain to Others 1 2 3 4 A) Learning Objective: To review optimal management strategies for patients with co-morbidities and heart failure Pre- Program Familiarity Post-Program Familiarity Relevance to My Practice 1 2 3 4 1 2 3 4 1 2 3 4 0% 22% 52% 26% 0% 0% 37% 63% 0% 0% 11% 89% B) Learning Objective: To determine best practice for surgical interventions Pre- Program Familiarity Post-Program Familiarity Relevance to My Practice 1 2 3 4 1 2 3 4 1 2 3 4 0% 39% 52% 9% 0% 5% 53% 42% 0% 5% 37% 58% 1 of 8C) Learning Objective: To increase knowledge and control for end-of-life care in heart failure resulting in improved decision-making, autonomy and dignity Pre- Program Familiarity Post-Program Familiarity Relevance to My Practice 1 2 3 4 1 2 3 4 1 2 3 4 0% 36% 56% 18 % 0% 0% 28% 72% 0% 0% 17% 83% D) Learning Objective: To appreciate (evaluate) multidisciplinary involvement in heart failure patient care related to specific case presentations Pre- Program Familiarity Post-Program Familiarity Relevance to My Practice 1 2 3 4 1 2 3 4 1 2 3 4 0% 15% 65% 20% 0% 6% 31% 63% 0% 0% 31% 69% 3. Primary specialty Cardiology 27% Internal medicine 23% Pharmacology 0% Nursing 43% Other - Resident - Leadership and management (cardiac rehab and HF) 7% 4. Years of practice in current specialty <5 25% 6-10 12% 11-20 37% 20-30 14% >30 12% 2 of 85. With cardiology, my practice environment is primarily Community cardiology 44% Academic cardiology 18% Subspecialty cardiology 41% Intervention 8% Echocardiography/imaging 33% Electrophysiology 0% CHF/transplant 17% Other - Cardiac rehab - Pacemaker/ICD - HI clinic 42% 6. As a non MD my principal role with heart failure patients is to: Educate 44% Reduce hospital LOS 6% Phone 11% Reduce hospital re-admin. 17% Other : - Develop strategies/policies to improve HF care - Quality of 1 year improve 22% 3 of 87. How many heart failure patients do you see per week: 0 4% 1–2 13% 3–4 22% 5–10 22% 1–20 22% > 20 17% 8. I have read the CCS HF 2006 guidelines: Yes 76% No 24% 9. And I refer to them Daily 12% Weekly 18% Monthly 41% Other - Variable - As needed for policy development - Occasionally - Periodically 29% 10. I like the current format of the CCS HF guidelines with clear nursing recommendations followed by a brief overview of the evidence to support the recommendations: Yes 100% No 0% Perhaps 0% 4 of 811. To treat your patients, what other sources do you refer to? Literature - Published - Unpublished 36% 86% 14% Internet - Medical - Non-medical 31% 95% 5% Continuing Medical Education - Industry - Society - Medical schools 27% 52% 40% 8% Other sources - ACC CME, e.g. ACCEL - Electrophotographs Heart Society - Academic rounds in clinic setting - Weekly rounds 6% 12. Heart failure guidelines provide me with Primary document for the management of disease 30.5% Specific decision aid in patient management 25% Secondary document that allows me ready access to the key primary documents 22.25% Tools to compare my practice with those of my peers 22.25% Other 0% 5 of 813. In my practice the area(s) of greatest difficulty in the treatment of heart failure is/are Treating multi-system disease (which disease) - CKD 39% Pulmonary -Near end stage renal failure (pre-dialysis), chronic symptomatic hypotension Treating with polypharmacy (comment) - Especially elderly - Needing to expand Rx 22% Resource limitation (which ones?) - BNP 19% Access to expensive technologies (Biv/AICD) 11% Other - N/A to me personally but I am aware of all the challenges above - Preventing contrast-induced nephropathy with CF 8% 14. In future iterations of the CCS guidelines, the issues in heart failure I would like to see addressed are • Vasopressor inhibitors • Devices • Emphasize the key features on HL and review the exams technique; prevent DVT and AE • End-of-life – motivated suggestions recommendations • F/U after inhibitory treatment • Timelines (when) to (illegible) Na+ • Target drug doses • Chronic disease management/behaviour change • ICD psychosocial considerations • Promptness of discussion on end-of-life • Reversibility of decisions to put/stop VAD, ICO….with patients early on • Important (more emphasis) on multidisc and communication of • Therapeutic plan 6 of 815. How best can the CCS obtain your feedback on guidelines as they are developed? Broader stakeholder input 9.1% Release of “guidelines in progress” 36.4% Online written feedback 54.5% Other 0% 16. Please rate the following aspects of the program Poor Satisfactory Very Good Excellent 1 2 3 4 Program/Presenter: Over all Clarity 0% 5.3% 44.2% 50.5% Program/Presenter: Over all Relevance to your practice 0% 5.4% 43.2% 51.4% Program/Presenter: Over all Educational Value Perceived 1.6% 6.5% 55.1% 36.8% 17. Please rate the following aspects of the program Poor Satisfactory Very Good Excellent 1 2 3 4 Overall, I would rate the workshop 0% 15% 67% 18% I found the facilities to be 0% 19% 58% 23% The audiovisual presentations were 0% 19% 58% 23% Conduciveness of the format to learning was 0% 15% 50% 35% 7 of 818. What topics would you like to see covered in future events? • CHF diagnosis, treatment and use of other resources in elderly • Team interaction – RN, pharmacist, Kinesiologist, MD – how to bring about change • Drugs – options – forget cases 8 of 8||http:\/\/www.hfcc.ca/downloads/stage5/CCS_Workshop_Global_Audience_SELF_EVAL_03122006.pdf", "2006 Heart Failure Consensus Conference Recommendations Program |Evaluation and Self-Assessment Help Shape the Future of Heart Failure Care in Canada Workshop, October 24th, 2006 Canadian Cardiovascular Congress 2006 – Vancouver Special Participants 1. I have attended a previous CCS workshop on Heart Failure this year. Yes 30.8% No 69.2% 2. Please rate the following learning objective statements Please use the following scale Not Familiar Somewhat Familiar Familiar Familiar Enough to Explain to Others 1 2 3 4 A) Learning Objective: To review optimal management strategies for patients with co-morbidities and heart failure Pre- Program Familiarity Post-Program Familiarity Relevance to My Practice 1 2 3 4 1 2 3 4 1 2 3 4 0% 6.7% 60% 33.3% 0% 0% 16.7% 83.3% 0% 0% 8.3% 91.7% 1 of 7B) Learning Objective: To determine best practice for surgical interventions Pre- Program Familiarity Post-Program Familiarity Relevance to My Practice 1 2 3 4 1 2 3 4 1 2 3 4 0% 33.3% 52.3% 13.3% 0% 8.3% 25% 66.7% 0% 0% 27.3% 72.7% C) Learning Objective: To increase knowledge and control for end-of-life care in heart failure resulting in improved decision-making, autonomy and dignity Pre- Program Familiarity Post-Program Familiarity Relevance to My Practice 1 2 3 4 1 2 3 4 1 2 3 4 0% 35.7% 50% 14.3% 0% 0% 45.5% 54.5% 0% 0% 27.3% 72.7% D) Learning Objective: To appreciate (evaluate) multidisciplinary involvement in heart failure patient care related to specific case presentations Pre- Program Familiarity Post-Program Familiarity Relevance to My Practice 1 2 3 4 1 2 3 4 1 2 3 4 0% 16.7% 50% 33.3% 0% 12.1% 19.1% 68.7% 0% 0% 44.4% 55.5% 3. Primary specialty Cardiology 47.1% Internal medicine 41.2% Pharmacology 0% Nursing 0% Other - Resident - Leadership and management (cardiac rehab and HF) 11.8% 2 of 74. Years of practice in current specialty <5 33.3% 6-10 0% 11-20 40% 20-30 20% >30 6.7% 5. With cardiology, my practice environment is primarily Community cardiology 64.7% Academic cardiology 5.9% Subspecialty cardiology 29.4% Intervention 0% Echocardiography/imaging 80% Electrophysiology 0% CHF/transplant 0% Other - Cardiac rehab 20% 6. As a non MD my principal role with heart failure patients is to: Educate 0% Reduce hospital LOS 0% Phone 0% Reduce hospital re-admin. 0% Other : develop strategies/policies to improve HF care Quality of 1 year improve 100% 3 of 77. How many heart failure patients do you see per week: 0 0 % 1–2 15.4% 3–4 20% 5–10 20.% 1–20 20% > 20 15.4% 8. I have read the CCS HF 2006 guidelines: Yes 75% No 25% 9. And I refer to them Daily 11.1% Weekly 22.2% Monthly 33.3% Other - Variable - As needed for policy development - Occasionally - Periodically 44.4% 10. I like the current format of the CCS HF guidelines with clear nursing recommendations followed by a brief overview of the evidence to support the recommendations: Yes 100% No 0% Perhaps 0% 4 of 711. To treat your patients, what other sources do you refer to? Literature - Published - Unpublished 35.1% (82.4%) (17.6) Internet - Medical - Non-medical 29.7% (90%) (10%) Continuing Medical Education - Industry - Society - Medical schools 29.7% (44.4%) (44.4%) (11.1%) Other sources - ACC CME, e.g. ACCEL - Electrophotographs Heart Society 5.4% 12. Heart failure guidelines provide me with Primary document for the management of disease 27.8% Specific decision aid in patient management 27.8% Secondary document that allows me ready access to the key primary documents 27.8% Tools to compare my practice with those of my peers 16.7% Other 0% 5 of 713. In my practice the area(s) of greatest difficulty in the treatment of heart failure is/are Treating multi-system disease (which disease) - CKD 45.5% Pulmonary -Near end stage renal failure (pre-dialysis), chronic symptomatic hypotension Treating with polypharmacy (comment) - Especially elderly - Needing to expand Rx 27.3% Resource limitation (which ones?) - BNP 9.1% Access to expensive technologies (Biv/AICD) 18.2% Other - N/A to me personally but I am aware of all the challenges above 4.5% 14. In future iterations of the CCS guidelines, the issues in heart failure I would like to see addressed are • Vasopressor inhibitors • Devices • Emphasize the key features on HL and review the exams technique; prevent DVT and AE • End-of-life – motivated suggestions recommendations • F/U after inhibitory treatment • Timelines (when) to Na+ • Target drug doses • Chronic disease management/behaviour change 15. How best can the CCS obtain your feedback on guidelines as they are developed? Broader stakeholder input 9.1% Release of “guidelines in progress” 36.4% Online written feedback 54.5% Other 0% 6 of 716. Please rate the following aspects of the program Poor Satisfactory Very Good Excellent 1 2 3 4 Program/Presenter: Over all Clarity 0% 4.4% 26.5% 69.0% Program/Presenter: Over all Relevance to your practice 0% 5.8% 32.1% 62.0% Program/Presenter: Over all Educational Value Perceived 2.2% 8.6% 48.3% 40.8% 17. Please rate the following aspects of the program Poor Satisfactory Very Good Excellent 1 2 3 4 Overall, I would rate the workshop 0% 21.4% 50% 28.6% I found the facilities to be 0% 14.3% 50% 35.7% The audiovisual presentations were 0% 28.6% 35.7% 35.7% Conduciveness of the format to learning was 0% 14.3% 35.7% 50% 18. What topics would you like to see covered in future events? • CHF diagnosis, treatment and use of other resources in elderly • Team interaction – RN, pharmacist, Kinesiologist, MD – how to bring about change • Drugs – options – forget cases 7 of 7||http:\/\/www.hfcc.ca/downloads/stage5/CCS_Workshop_Doctors_SELF_EVAL_03122006.pdf", "2006 Heart Failure Consensus Conference Recommendations Program |Evaluation and Self-Assessment Help Shape the Future of Heart Failure Care in Canada Workshop, October 24th, 2006 Canadian Cardiovascular Congress 2006 – Vancouver Nurse Participants 1. I have attended a previous CCS workshop on Heart Failure this year. Yes 27.2% No 72.7% 2. Please rate the following learning objective statements Please use the following scale Not Familiar Somewhat Familiar Familiar Familiar Enough to Explain to Others 1 2 3 4 A) Learning Objective: To review optimal management strategies for patients with co-morbidities and heart failure Pre- Program Familiarity Post-Program Familiarity Relevance to My Practice 1 2 3 4 1 2 3 4 1 2 3 4 0% 50% 37.5% 12.5% 0% 0% 71.4% 28.6% 0% 0% 14.3% 85.7% B) Learning Objective: To determine best practice for surgical interventions Pre- Program Familiarity Post-Program Familiarity Relevance to My Practice 1 2 3 4 1 2 3 4 1 2 3 4 0% 50% 50% 0% 0% 0% 0% 100% 0% 14.3% 57.1% 28.6% 1 of 7C) Learning Objective: To increase knowledge and control for end-of-life care in heart failure resulting in improved decision-making, autonomy and dignity Pre- Program Familiarity Post-Program Familiarity Relevance to My Practice 1 2 3 4 1 2 3 4 1 2 3 4 0% 37.5% 37.5% 25% 0% 0% 0% 100% 0% 0% 0% 100% D) Learning Objective: To appreciate (evaluate) multidisciplinary involvement in heart failure patient care related to specific case presentations Pre- Program Familiarity Post-Program Familiarity Relevance to My Practice 1 2 3 4 1 2 3 4 1 2 3 4 0% 12.5% 87.5% 0% 0% 0% 42.9% 57.1% 0% 0% 14.3% 85.7% 3. Primary specialty Cardiology 0% Internal medicine 0% Pharmacology 0% Nursing 100% Other - Resident - Leadership and management (cardiac rehab and HF) 0% 4. Years of practice in current specialty <5 16.7% 6-10 25% 11-20 33.3% 20-30 8.3% >30 16.7% 2 of 75. With cardiology, my practice environment is primarily Community cardiology 9.1% Academic cardiology 27.3% Subspecialty cardiology 63.6% Intervention 14.3% Echocardiography/imaging 0% Electrophysiology 0% CHF/transplant 28.6% Other - Cardiac rehab - Pacemaker/ICD - HI clinic 57.1% 6. As a non MD my principal role with heart failure patients is to: Educate 50% Reduce hospital LOS 6.3% Phone 12.5% Reduce hospital re-admin. 18.8% Other 12.5% 7. How many heart failure patients do you see per week: 0 10% 1–2 10% 3–4 20% 5–10 20% 1–20 20% > 20 20% 3 of 78. I have read the CCS HF 2006 guidelines: Yes 75% No 25% 9. And I refer to them Daily 14.3% Weekly 14.3% Monthly 57.1% Other - Variable - As needed for policy development - Occasionally - Periodically 14.3% 10. I like the current format of the CCS HF guidelines with clear nursing recommendations followed by a brief overview of the evidence to support the recommendations: Yes 100% No 0% Perhaps 0% 4 of 711. To treat your patients, what other sources do you refer to? Literature - Published - Unpublished 37% (90.9%) (9.1 %) Internet - Medical - Non-medical 33.3% (100%) (0%) Continuing Medical Education - Industry - Society - Medical schools 22.2% (71.4%) (28.6%) (7.4%) Other sources - Academic rounds in clinic setting - Weekly rounds 7.4% 12. Heart failure guidelines provide me with Primary document for the management of disease 33.3% Specific decision aid in patient management 22.2% Secondary document that allows me ready access to the key primary documents 16.7% Tools to compare my practice with those of my peers 27.8% Other 0% 5 of 713. In my practice the area(s) of greatest difficulty in the treatment of heart failure is/are Treating multi-system disease (which disease) - CKD 28.6% Treating with polypharmacy (comment) - Especially elderly - Needing to expand Rx 14.3% Resource limitation (which ones?) - BNP 35.7% Access to expensive technologies (Biv/AICD) 7.15 Other - N/A to me personally but I am aware of all the challenges above - Preventing contrast-induced nephropathy with CF 14.3% 14. In future iterations of the CCS guidelines, the issues in heart failure I would like to see addressed are • ICD psychosocial considerations • Promptness of discussion on end-of-life • Reversibility of decisions to put/stop VAD, ICO….with patients early on • Important (more emphasis) on multidisc and communication of therapeutic plan 15. How best can the CCS obtain your feedback on guidelines as they are developed? Broader stakeholder input 9.1% Release of “guidelines in progress” 36.4% Online written feedback 54.5% Other 0% 6 of 716. Please rate the following aspects of the program Poor Satisfactory Very Good Excellent 1 2 3 4 Program/Presenter: Over all Clarity 0% 5.5% 64.4% 30.2% Program/Presenter: Over all Relevance to your practice 0% 6% 66.6% 27.4% Program/Presenter: Over all Educational Value Perceived 0% 1.8% 67.8% 30.4% 17. Please rate the following aspects of the program Poor Satisfactory Very Good Excellent 1 2 3 4 Overall, I would rate the workshop 0% 7.7% 84.6% 7.7% I found the facilities to be 0% 25% 66.7% 8.3% The audiovisual presentations were 0% 8.3% 83.3% 8.3% Conduciveness of the format to learning was 0% 16.7% 66.7% 16.7% 18. What topics would you like to see covered in future events? • N/A 7 of 7||http:\/\/www.hfcc.ca/downloads/stage5/CCS_Workshop_Nurses_SELF_EVAL_03122006.pdf", "2006 Heart Failure Consensus Conference Recommendations Program |Evaluation of the Consensus Conference Plenary Session October 24th, 2006, Vancouver Global Audience 1. Primary specialty: Cardiology 38.5% Internal Medicine 9% Nursing 48% Pharmacology 3% Other 1.5% 2. Years of practice in current specialty: < 5 36% 6-10 11% 11-20 22% 21-30 26% > 30 5% 3. Within cardiology my practice environment is primarily: Community cardiology 28% Academic cardiology 9% Subspecialty cardiology: Intervention 3.5% Echocardiography/imaging 1.75% Electrophysiology 3.5% CHF/transplant 5.25% Other: 1.75% Community & academic cardiology Community cardiology & Echocardiography/imaging 3.5% Academic cardiology & Echocardiography/imaging 3.5% Community cardiology, pacemakers (not EPS) & Echocardiography/imaging 1.75% 1 of 5Academic cardiology, Echocardiography/imaging, intervention & nuclear 1.75% Electrophysiology & CHF 3.5% Intervention & CHF/transplant 1.75% CSICU 1.75% Cardiac surgery 5.25% Academic cardiology & CHF/transplant 1.75% Clinic & research 1.75% Community cardiology & CHF/transplant 3.5% Intervention & echocardiography/imaging 1.75% Intervention & cardiac surgery 1.75% CCU 1.75% Academic cardiology & electrophysiology 1.75% In-patient cardiology 1.75% Community cardiology & Intervention 5.25% Pre and Post (illegible) 1.75% Device clinic (pacemaker/defib) 1.75% 4. As a non-MD my principal role with heart failure patients is to: Educate 40% Reduce hospital LOS 3.3% Phone 0% Reduce hospital re-adm. 0% Other: Educate & Reduce hospital LOS 13.3% Educate, Reduce hospital LOS & Reduce hospital re-adm. 10% Management/follow-up/drug (illegible) 3.3% Nurses care in CCU 3.3% Intervention – NP 3.3% Educate & device management 6.7% Educate, reduce hospital re-adm. & heart clinic 3.3% Educate, clinical nurse & research 3.3% Educate & reduce hospital re-adm. 3.3% Educate, Reduce hospital LOS & post-op cardiac surgery care 3.3% Educate, reduce hospital re-adm. & (illegible) 3.3% 2 of 55. How many heart failure patients do you see/manage per week? 0 3% 1-2 14% 3-4 24% 5-10 37% 11-20 16% > 20 6% 6. I have read the CCS HF 2006 guidelines: Yes 73.4% No 26.6% And refer to them: Daily 15.4% Weekly 18% Monthly 38.4% Other - PRN - As needed - Rarely - Variable - < Monthly - Periodically - Seldom - Occasionally - When needed 28.2% 7. I like the current format of the CCS HF 2006 guidelines: Yes 94.6% No 3.6% Perhaps: I will know better once I have read them properly 1.8% 3 of 58. Heart Failure Guidelines provide me with: A. Primary document for the management of a disease 26% B. Specific decision aid in patient management 15.5% C. Secondary document that allows me ready access to the key primary documents 7% D. Tools to compare my practice with those of my peers 5% Other: A & B 12% B & D 3.5% A & C 1.75% C & D 1.75% A, C & D 1.75% B & C 1.75% A & D 1.75% A, B & C 8.5% A, B & D 3.5% A, B, C & D 5% D & Education of my peers/colleagues 1.75% Tools for developing policy at my institution 1.75% A, D & (illegible) tool 1.75% 9. In future iterations of the CCS guidelines, the issues in heart failure would like to see addressed are: • BNP, Transplant work up, Lifestyle management / For whatever reason, everyone spoke too fast, in fact so fast that they were hard to understand. This is an important session, allow more time and slow down • Palliative care, end of life issues • Psychosocial issues with patients and family/what do families and clients struggle with • Lifestyle changes – the advent of motivational interviewing to initiate and maintain [triangle]s in patients lifestyle/more emphasis on ethical part, including discussion up front before insertion, the possibility/indication to deactivate ICD 4 of 5• Physical activity diagnostic tests/psychosocial community resources/multidisciplinary (breakdown involvement) • Distribution of materials to all Dr’s offices and walk in clinics/recruitment of nurse practitioners in big clinics (walk-in) for better patient assessment • Assessment of implementation • More practical tools for end of life decision making and depression/(illegible) function screen • Audio (illegible) testing/heart transplant/LVKD (illegible)/end of life/quality of life issues • Address management of patients with EF 40-50% • Future and on-going research addressed today by Dr. Liu should also be included in the paper/sex and illness • How long to keep on single or dual therapy in patients with marked improvements or normalization of EF • New treatments like devices and varopressin antagonists • Patient education tools “approved” websites for patient access booklets 10. Please rate the following aspects of the program Poor Satisfactory Very Good Excellent Overall, I would rate the workshop… 0% 11.5% 52.5% 36% I found the facilities to be… 0% 17% 53% 30% The audiovisual presentations were… 0% 8% 52% 40% Conduciveness of the format to learning was… 3% 15% 53% 29% 5 of 5||http:\/\/www.hfcc.ca/downloads/stage5/Evaluation_of_the_Consensus_Conference_Plenary-Global_02122006.pdf", "2006 Heart Failure Consensus Conference Recommendations Program |Evaluation of the Consensus Conference Plenary Session October 24th, 2006, Vancouver Specialists Participants 1. Primary specialty: Cardiology 73.5% Internal Medicine 17.6% Nursing 0% Pharmacology 5.9% Other 2. Years of practice in current specialty: < 5 36.4% 6-10 6.1% 11-20 18.1% 21-30 33.3% > 30 6.1% 3. Within cardiology my practice environment is primarily: Community cardiology 50% Academic cardiology 12.5% Subspecialty cardiology: Intervention 0% Echocardiography/imaging 3.1% Electrophysiology 3.1% CHF/transplant 9.4% 1 of 4Other: Community cardiology & echocardiography/imaging 6.3% Academic cardiology & echocardiography/imaging 6.3% Community cardiology & intervention 3.1% Community cardiology, echocardiography/imaging & Pacemakers (not EPS) 3.1% Academic cardiology, echocardiography/imaging, intervention & Nuclear 3.1% 4. How many heart failure patients do you see/manage per week? 0 6% 1-2 6% 3-4 14.7% 5-10 41% 11-20 23.5% > 20 8.8% 5. I have read the CCS HF 2006 guidelines: Yes 85.3% No 14.7% And refer to them: Daily 14.3% Weekly 10.7% Monthly 39.3% Other: - PRN - As needed - Rarely - Variable - < Monthly - Periodically - Seldom - Occasionally 35.7% 2 of 46. I like the current format of the CCS HF 2006 guidelines: Yes 96.7% No 3.3% Perhaps: I will know better once I have read them properly 0% • Love the practical tips 7. Heart Failure Guidelines provide me with: A. Primary document for the management of a disease 27.3% B. Specific decision aid in patient management 15.2% C. Secondary document that allows me ready access to the key primary documents 9% D. Tools to compare my practice with those of my peers 9% Other: 3.1% Tools for developing policy at my institution 12% A & B 12% A, B & C 3.1% A & C 3.1% C & D 3.1% A, C & D 3.1% A, B, C & D 8. In future iterations of the CCS guidelines, the issues in heart failure would like to see addressed are: • More practical tools for end of life decision making and depression/(illegible) function screen • Audio (illegible) testing/heart transplant/LVKD (illegible)/end of life/quality of life issues • Address management of patients with EF 40-50% • Future and on-going research addressed today by Dr. Liu should also be included in the paper/sex and illness • How long to keep on single or dual therapy in patients with marked improvements or normalization of EF 3 of 4• New treatments like devices and varopressin antagonists • Patient education tools “approved” websites for patient access booklets 9. Please rate the following aspects of the program Poor Satisfactory Very Good Excellent Overall, I would rate the workshop… 0% 22% 53% 25% I found the facilities to be… 0% 29% 45% 26% The audiovisual presentations were… 0% 13% 55% 32% Conduciveness of the format to learning was… 3% 23% 57% 17% 4 of 4||http:\/\/www.hfcc.ca/downloads/stage5/Evaluation_of_the_Consensus_Conference_Plenary-Specialists_02122006.pdf", "2006 Heart Failure Consensus Conference Recommendations Program |Evaluation of the Consensus Conference Plenary Session October 24th, 2006, Vancouver Nurse Participants 1. Primary specialty: Cardiology 0% Internal Medicine 0% Nursing 100% Pharmacology 0% Other 0% 2. Years of practice in current specialty: < 5 35.5% 6-10 16.1% 11-20 25.8% 21-30 19.4% > 30 3.2% 3. Within cardiology my practice environment is primarily: Community cardiology Academic cardiology 4% Subspecialty cardiology: Intervention 8% Echocardiography/imaging Electrophysiology 4% CHF/transplant Other: Community & academic cardiology 4% Electrophysiology & CHF 8% Intervention & CHF/transplant 4% CSICU 4% Cardiac surgery 12% 1 of 9Academic cardiology & CHF/transplant 4% Clinic & research 4% Community cardiology & CHF/transplant 8% Intervention & echocardiography/imaging 4% Intervention & cardiac surgery 4% CCU 4% Academic cardiology & electrophysiology 4% In-patient cardiology 4% Community cardiology & Intervention 8% Pre and Post (illegible) 4% Device clinic (pacemaker/defib) 4% 4. As a non-MD my principal role with heart failure patients is to: Educate 40% Reduce hospital LOS 3.3% Phone 0% Reduce hospital re-adm. 0% Other: Educate & Reduce hospital LOS 13.3% Educate, Reduce hospital LOS & Reduce hospital re-adm. 10% Management/follow-up/drug (illegible) 3.3% Nurses care in CCU 3.3% Intervention – NP 3.3% Educate & device management 6.7% Educate, reduce hospital re-adm. & heart clinic 3.3% Educate, clinical nurse & research 3.3% Educate & reduce hospital re-adm. 3.3% Educate, Reduce hospital LOS & post-op cardiac surgery care 3.3% Educate, reduce hospital re-adm. & (illegible) 3.3% 2 of 95. How many heart failure patients do you see/manage per week? 0 0% 1-2 24.1% 3-4 34.4% 5-10 31% 11-20 7% > 20 3.5% 6. I have read the CCS HF 2006 guidelines: Yes 60% No 40% And refer to them: Daily 18.2% Weekly 36.4% Monthly 36.4% Other: When needed 9% 7. I like the current format of the CCS HF 2006 guidelines: Yes 92% No 4% Perhaps: I will know better once I have read them properly 4% 8. Heart Failure Guidelines provide me with: A. Primary document for the management of a disease 24% B. Specific decision aid in patient management 16% C. Secondary document that allows me ready access to the key primary documents 4% D. Tools to compare my practice with those of my peers Other: 3 of 9A & B 12% B & D 8% B & C 4% A & D 4% A, B & C 4% A, B & D 8% A, B, C & D 8% D & Education of my peers/colleagues 4% A, D & (illegible) tool 4% 9. In future iterations of the CCS guidelines, the issues in heart failure would like to see addressed are: • BNP, Transplant work up, Lifestyle management / For whatever reason, everyone spoke too fast, in fact so fast that they were hard to understand. This is an important session, allow more time and slow down • Palliative care, end of life issues • Psychosocial issues with patients and family/what do families and clients struggle with • Lifestyle changes – the advent of motivational interviewing to initiate and maintain [triangle]s in patients lifestyle/more emphasis on ethical part, including discussion up front before insertion, the possibility/indication to deactivate ICD • Physical activity diagnostic tests/psychosocial community resources/multidisciplinary (breakdown involvement) • Distribution of materials to all Dr’s offices and walk in clinics/recruitment of nurse practitioners in big clinics (walk-in) for better patient assessment • Assessment of implementation 4 of 910. Please rate the following aspects of the program Poor Satisfactory Very Good Excellent Overall, I would rate the workshop… 0% 0% 52.7% 48.3% I found the facilities to be… 0% 3.4% 62.1% 34.5% The audiovisual presentations were… 0% 3.4% 48.3% 48.3% Conduciveness of the format to learning was… 3.4% 6.9% 48.3% 41.4% 11. My principal role with heart failure patients is to: Educate 39.6% Reduce hospital LOS 3.7% Research 3.7% Phone 0% Reduce hospital re-admin. 3.7% Other 9.3% Provide in-patient care 27.8% HF clinic 11.1% 5 of 912. How many heart failure patients do you see per week: 0–8 2 % 1–2 12.2% 3–4 36.7% 5–10 20.4% 1–20 6.1% > 20 16.3% 13. I have read the CCS HF 2006 guidelines: Yes 49.1% No 50.9% 14. I like the current format of the CCS HF guidelines with clear nursing recommendations followed by a brief overview of the evidence to support the recommendations: Yes 95.1% No 0% Perhaps 4.9% 15. In future iterations of the CCS guidelines, the nursing issues in heart failure I would like to see addressed are: • Discharge planning • Caregiver literature • Clinical symptom management in end-stage HF? Palliative inotropes aerosol morphine – are these still in? • More specific teaching tools for patients and nurses to use 6 of 9• Reduce salt – not clear what for patients as most patients do not go to cardiac rehab • Handouts for patients e.g. because prior to seeing HF clinic • More emphasis on ethics – could we vs. should we 16. How best can the CCS obtain your feedback on guidelines as they are developed? Broader stakeholder input 10.8% Online written feedback 54.1% Release of “guidelines in progress” 32.4% Other 2.7% • Through online presentation and feedback 17. What changes, if any, do you intend to make in your clinical practice as a result of today’s program? • Caution each use of glucophage and kidney failure, increase referrals to psych RNS and geriatricians • Ongoing use of guidelines • Continue with suggestions reflective in my practice • Found the sessions very practical • Speak up more during rounds • Make sure proper teaching is done with patient family and all aspects addressed • Living will – try to develop a strategy to ensure this is in place • Learned lots. Thanks • Will be [illegible] that increase confusion/delirium could mean worsening heart failure • Too many to list! I’ve learned from every speaker and presentation tonight. Thank you! 7 of 9• HF assessment to manage in ICU population • Pay more attention to pain as a symptom in end-stage heart failure • More discussion of end-of-life issues • Increase geriatrician referrals • Initiate advanced care directives – discussion • Re-do our CHF pathway • Awareness 18. Please rate the following aspects of the program Poor Satisfactory Very Good Excellent 1 2 3 4 Program/Presenter: Over all Clarity 0% 1.78% 21.25% 77.26% Program/Presenter: Over all Relevance to your practice 0% 6.60% 18.39% 74.94% Program/Presenter: Over all Educational Value Perceived 0.55% 5.70% 20.91% 72.84% 19. Please rate the following aspects of the program Poor Satisfactory Very Good Excellent 1 2 3 4 Overall, I would rate the workshop 0% 2.1% 31.9% 65.9% I found the facilities to be 0% 13% 54.3% 32.6% The audiovisual presentations were 2.2% 13% 45.7% 39.1% Conduciveness of the format to learning was 0% 4.3% 52.2% 43.5% 8 of 920. What topics would you like to see covered in future events? • Recall failure/dysfunction and CHF; meds and CHF staging • Dinner meeting with presentation • Management of diabetes and CAD • How to convince/justify to administration the start-up of an outpatient HF clinic? Agreed to do it then program was cut out • The photographer was annoyingly in front of line of view for screen and speakers • How to approach patient family re: end-of-life issue? • Counselling for adherence • I really liked the case studies • Metabolic syndrome related to CHF • ACS guidelines • Issues related to diastolic dysfunction • Definitely love to see more topics presented in this form • Transition from hospital to home 21. Other comments related to nursing and care of HF patients: • Feed us at this lecture • How to order more pocket tools? • Don’t use negatively worded questions “least likely not” • In hospital acute care of the decompensated • Case studies were very helpful • I would expect supper to be served at a session running from 18:30-20:30 • Great workshop 9 of 9||http:\/\/www.hfcc.ca/downloads/stage5/Evaluation_of_the_Consensus_Conference_Plenary-Nurses_02122006.pdf", "Microsoft Word - CCS HF CC Web Site - Conflict of Interest Guidelines_V2 .1_205|- 1 - CCS conflict of interest guidelines and disclosure statement-V2.1_02142006 Canadian Cardiovascular Society Conflict of Interest Guidelines INTRODUCTION: The governing ethical principles of the Canadian Cardiovascular Society are honesty, beneficence, non-malfeasance, justice and equity. A conflict of interest can arise when any choice is made. The purpose of these guidelines is to indicate to members and employees of the Society, minimal standards of behavior, vis-à-vis conflicts of interest. Definition: Conflict of interest arises when an individual or organization considers choices in which conflicting interests or benefits exist. A duality of commitments exists. Conflict is present when the choice which provides personal benefit is selected over the choice most in accord with the above ethical principles and public interest. Such conflicts may involve financial benefits, enhancement of position, or other benefits to the individual. Disclosure of such conflicts prior to the process of choice is essential. Disclosure however per se, is inadequate if other means are used to inappropriately influence decision-making. Members and employees of the Canadian Cardiovascular Society are in a position of trust in fostering the goals and objectives of the Society. GUIDELINES: 1) Given the mission of the Canadian Cardiovascular Society, the Society should not exploit its reputation which is a public trust, by engaging in commercial ventures to solely benefit the Society. Such commercial ventures may limit the capability of the Society to enunciate policy, which would be beneficial to the public’s cardiovascular health. 2) The Canadian Cardiovascular Society should avoid endorsements of organizations or individuals where such endorsements may be exploited for gains which when known, would damage the reputation of the Canadian Cardiovascular Society. An example of such an occurrence would be the organization endorsing a specific product where the evidence that it was beneficial for cardiovascular- 2 - CCS conflict of interest guidelines and disclosure statement-V2.1_02142006 health above other products, was insufficient. Such an activity would damage the reputation of the Society. 3) All proceedings, notes, lists, etc. which are part of the function of the Canadian Cardiovascular Society are the property of the Society and must be retained by the Society and must be retained by the Society office after the individual is no longer in position of trust in the Society. This particularly applies to executives and staff of the Society. 4) Individual members of the Society, staff, or executives may not use information gained during the course of the Society’s business for personal gain. Where an individual has gained proprietary information concerning the functioning of the society, such information and/or skills may not be used by that individual to gain employment or hold office, based on the information, for a period of at least three years following separation from the Society. 5) Executives and staff must indicate in writing all affiliations with other bodies who do business with the Canadian Cardiovascular Society, particularly if these affiliations provide a personal benefit unknown to the Society and others. This includes being an officer in a company, holding stock, consulting agreements and other activities which would benefit the individual or those associated with the individual, while the person is in a position of fiduciary trust with the Canadian Cardiovascular Society. 6) Members, executives and staff in the course of presenting either at meetings or as representatives of the Society have an obligation to make it known that there is a dual commitment on their part. That is, by communicating the information, they will or may receive an unknown personal benefit. The audience has a right to know when such potential conflict of interest exists. Compliance with this guideline applies to those presenting at Canadian Cardiovascular Society meeting or when representing the Society. They must indicate that the potential conflict of interest exists at the time of the presentation. The existence of a potential bias which results from either real or potential personal benefit, or support for research is part of the information required by the audience for their evaluation of the presentation. All members and guests presenting at meetings of the CCS or those meetings sponsored by the Society must sign a declaration indicating that they will provide this information to the audience in an unequivocal manner.- 3 - CCS conflict of interest guidelines and disclosure statement-V2.1_02142006 A PROCESS FOR MAINTAINING CONFORMITY WITH GUIDELINES: The Executive Committee, staff and members of the Canadian Cardiovascular Society have a fiduciary obligation to maintain ethical behavior during the course of their affiliation with the Society. They are in a position of trust in dealing with conflict of interest. The Executive and Ethics Committees are responsible for assuring that adherence to these guidelines occur. During the course of engaging in the Society's business, if a failure to adhere to these guidelines occurs, it should be brought to the attention of the Executive and the Ethics Committee of the Society. They shall act as the recipients of such complaints. The ethics committee will have the responsibility of setting up a review process based upon natural justice and confidentiality to investigate the validity of any complaint. The executives shall be informed concerning the investigation. Funds to perform the investigation will be made available by the treasurer from the budget of the Society. If an action is recommended as a result of the investigation, the Executive and subsequently the membership at the annual meeting must approve it. Sanctions from the Executive for failure to adhere to the guidelines may include expulsion from the Society and publication of the Ethics Committee’s findings. Approval for sanction will be held by a simple majority of a quorum. It is the responsibility of the chair of the Ethics Committee to monitor the process and to recommend changes in the guidelines to make them more effective based upon the experiences of the Society.- 4 - CCS conflict of interest guidelines and disclosure statement-V2.1_02142006 STATEMENT RE: CONFLICT OF INTEREST POLICY I have read the Guidelines on Conflict of Interest adopted by the Canadian Cardiovascular Society in September 1998. I understand in particular that Society staff and Society members acting on behalf of the CCS must indicate in writing all affiliations with other bodies who do business with the CCS, particularly if these affiliations provide a personal benefit to such individuals. This includes being an officer or holding stock in such a company, consulting agreements and other activities that would benefit the individual, or those associated with the individual, while the person is in a position of fiduciary trust with the Canadian Cardiovascular Society. I accept the Conflict of Interest Guidelines and confirm that I am in compliance with them at this time (unless otherwise noted below). I will abide by these guidelines while representing the Canadian Cardiovascular Society. Should a conflict of interest on my part arise, I will promptly notify in writing the Secretary of the Society. Name: __________________________________________________ (Please Print) Signed:___________________________________________________ Date: ___________________________________________________- 5 - CCS conflict of interest guidelines and disclosure statement-V2.1_02142006 Conflict of Interest Disclosure Statement Names of companies and others related to the statement of conflict of interest Nature of the conflict of interest It is my understanding that this information will be retained in the files of the CCS Secretariat and will not be made public. I understand that the information may be shared with the Executive of the CCS. Name: __________________________________________________ (Please Print) Signed:___________________________________________________||http:\/\/www.hfcc.ca/downloads/important_notices/Conflict_of_Interest_Guidelines.pdf", "Microsoft Word - Disclosure Statements_V3.1_03292006.doc|- 1 - 2006 CCS Heart Failure Consensus Conference Disclosure Statements_V3.2_04082006 CCS CONFLICTS OF INTEREST GUIDELINES AND DISCLOSURE STATEMENTS Discloser Statements are listed as bullet points below the member’s name and are as follows: Malcolm Arnold MD FRCPC (Chair) • Chair of the Canadian CHF Clinics Network Inc (a not for profit organization) • Speaker honoraria • Ad hoc industry advisory board honoraria Catherine Demers MD FRCPC • Astra Zeneca - honoraria • Eli Lilly Canada - honoraria • Merck Frosst - honoraria and research grant support • Takeda - honoraria Paul Dorian MD FRCPC • Medtronic Inc - receipt of research grants and honoraria • St. Jude Medical Inc - receipt of research grants and honoraria • Guidant Inc - receipt of research grants and honoraria. Nadia Giannetti MD FRCPC • Astra Zeneca - lecturer • Novartis - lecturer CCS has a conflict of interest policy that requires faculty to disclose any real or apparent commercial financial affiliations related to the content of their presentations/materials. It is not assumed that these financial interests or affiliations will have an adverse impact on their participation; they are simply noted in this supplement to fully inform.- 2 - 2006 CCS Heart Failure Consensus Conference Disclosure Statements_V3.2_04082006 Jonathan Howlett MD FRCPC • AstraZeneca - research grants, consultant honoraria, advisory boards, speaking engagements • Boeringer Ingelheim - consultant honoraria, advisory boards, speaking engagements • Bristol Meyers Squibb - honoraria, advisory boards, speaking engagements • Merck Frosst - research grants, consultant, honoraria, advisory boards, speaking engagements • Novartis - research grants, consultant honoraria, advisory boards, speaking engagements • Ortho Biotech - consultant honoraria, advisory boards, speaking engagements • Pfizer - consultant honoraria, advisory boards, speaking engagements • Schering - speaking engagements • Servier - consultant honoraria, advisory boards, speaking engagements Victor Huckell MD FRCPC • Speaking engagements, developed educational programs for each company in Canada that manufacturers cardiovascular products Andrew Ignaszewski MD FRCPC • Merck - honoraria for speaking engagements or attendance at scientific meetings • Novartis - honoraria for speaking engagements or attendance of scientific meetings • AstraZeneca - honoraria for speaking engagements or attendance of scientific meetings • Pfizer - honoraria for speaking engagements or attendance of scientific meetings • Roche - honoraria for speaking engagements or attendance of scientific meetings • Aventis - honoraria for speaking engagements or attendance of scientific meetings- 3 - 2006 CCS Heart Failure Consensus Conference Disclosure Statements_V3.2_04082006 • Fournier - honoraria for speaking engagements or attendance of scientific meetings • Servier - honoraria for speaking engagements or attendance of scientific meetings • Solvay - honoraria for speaking engagements or attendance of scientific meetings • OrthoBiotech - honoraria for speaking engagements or attendance of scientific meetings David E. Johnstone MD FRCPC • Pfizer -Imagine Study Executive, speaker • Adventure - Prevention Advisory Board • GSK - Advisory Board • National Institutes of Health/ Veterans Administration, US Data Safety Mandatory Board - Courage Study Robert S. McKelvie MD FRCPC • Astrazeneca - honoraria/research grants • BMS/Sanofi - honoraria/research grants Gordon Moe MD FRCPC • Ortho Biotech – advisory boards and receives research grant for BNP related research • Roche Diagnostics – receive research grants and lead investigator for BNP related research Joel Niznick MD FRCPC • Abbot Laboratories - speaker honoraria, unrestricted educational grants or website support • Fournier Pharma Inc - speaker honoraria, unrestricted educational grants or website support- 4 - 2006 CCS Heart Failure Consensus Conference Disclosure Statements_V3.2_04082006 • AstraZeneca - speaker honoraria, unrestricted educational grants or website support • Biovail - speaker honoraria, unrestricted educational grants or website support • Boehringer Ingelheim - speaking honoraria, unrestricted educational grants or website support • Bristol Myers Squibb - speaker honoraria, unrestricted educational grants or website support • Glaxo Smith Kline - speaker honoraria, unrestricted educational grants or website support • Merck Frosst/Schering - speaker honoraria, unrestricted educational grants or website support • Novartis - speaker honoraria, unrestricted educational grants or website support • Pfizer - speaker honoraria, unrestricted educational grants or website support • Sanofi-aventis - speaker honoraria, unrestricted educational grants or website support • Servier - speaker honoraria, unrestricted educational grants or website support Heather Ross MD FRCPC • Wyeth - consultant, research • Fujisawa - Astellas - consultant, research • Novartis - consultant, research Sherryn Roth MD FRCPC • Small holdings of publicly traded drug and pacemaker companies listed on major exchanges. None that are affected by my work for CCS Stuart J. Smith MD FRCPC • Pfizer Pharma - consultant committee (October 2005) Bruce Sussex MD FRCPC • Astra Zeneca - research projects and honoraria for CME events • BMS - research projects and honoraria for CME events • Merck frost - research projects and honoraria for CME events- 5 - 2006 CCS Heart Failure Consensus Conference Disclosure Statements_V3.2_04082006 • Pfizer - research projects and honoraria for CME events • Novartis - research projects and honoraria for CME events • Aventis - research projects and honoraria for CME events • Solvay - research projects and honoraria for CME events Koon K. Teo MBBch FRCPC • Oryx Pharmaceutical - honoraria for lecture and advisory committee on Niaspan/Advicon • Boeringer Ingelheim - research support Ross Tsuyuki Pharm D FCSHP • Merck Frosst Canada - cardiovascular Advisory Board, speaking honoraria, research grants • BMS - Clopidogrel advisory board and research grants • Sanofi-aventis - Clopidogrel advisory board and research grants • Novartis - speaker honoraria • Abbott/Fournier - speaker honoraria • Pfizer - research grants • Ortho Biotech - speaker honoraria, nesiritide advisory board • Astra Zeneca - speaker honoraria, research grants • Apotex - speaker honoraria, research grants Michel White MD FRCPC • Atellas Pharma -consultant, grant support, research • Sanofi-aventis - grant support research • Astra Zeneca - grant support research • Wyeth - grant support research • PFizer - grant support research Salim Yusuf MD FRCPC • Sanofi-Aventis - Research grants, honoraria and consulting fees • BMS - Research grants, honoraria and consulting fees- 6 - 2006 CCS Heart Failure Consensus Conference Disclosure Statements_V3.2_04082006 • GSK- Research grants, honoraria and consulting fees • Merck Frosst- Research grants, honoraria and consulting fees • Servier- Research grants, honoraria and consulting fees • BT- Research grants, honoraria and consulting fees • Novartis- Research grants, honoraria and consulting fees • Astra Zeneca- Research grants, honoraria and consulting fees • King Pharma- Research grants, honoraria and consulting fees • Research Grants, Honoraria and Consulting Fees There are no conflicts listed for: .. Debra Isaac MD FRCPC .. John D. Parker MD FRCPC .. Errol Sequeira MD FCFP .. Haissam Haddad MD FRCPC .. Denis Roy MD FRCPC .. Vivek Rao MD FRCPC .. Anna Svendsen RN MS .. Philip Jong MD FRCPC .. Marie Hélène Le Blanc MD FRCPC .. George A. Heckman MD FRCPC||http:\/\/www.hfcc.ca/downloads/important_notices/Disclosure_Statements.pdf", "HFCC - Important Notices: Disclaimer Statement|Home About Us Contact Us What's New! Important Notices Search Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Important Notices: Disclaimer Statement These recommendations reflect emerging clinical and scientific advances as of the date issued and are subject to change. These consensus conference statements are intended to assist practitioners in clinical decision-making by describing a range of generally acceptable approaches for the diagnosis, management, or prevention of specific diseases or conditions. The information is not to be construed as dictating an exclusive course of treatment or procedure to be followed and variations may be appropriate. Each cardiovascular specialist must exercise his or her own professional judgment in determining the proper course of action in each patient's differing circumstances. The CCS assumes no responsibility or liability arising from any error or omission in or from the use of any information contained herein. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/important_notices/disclaimer.aspx", "HFCC - Important Notices: Privacy Policy|Home About Us Contact Us What's New! Important Notices Search Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Important Notices: Privacy Policy The Canadian Cardiovascular Society The Canadian Cardiovascular Society (the CCS ) is a society of cardiovascular physicians and scientists. The CCS promotes cardiovascular health in Canada by disseminating information and organizing and promoting educational publications, conferences, seminars and other events. Commitment to Privacy of Personal Information CCS is committed to protecting the privacy of its members and others who use CCS services. This Personal Information Protection Policy (the Policy ) describes the policies and practices of the CCS with respect to the collection, use and disclosure of personal information. The CCS collects uses and discloses personal information only with the consent of the individual, except as otherwise permitted or required by law. The Policy may be updated from time to time, with updates approved by the CCS Council to reflect developments in its practices, new technology or the law. Updates will be made available in the same ways as the Policy. The CCS' collection, use and disclosure of personal information will be governed by the version of this Policy in effect at the time. Personal Information Personal information is any information that can be used to distinguish, identify or contact a specific individual. This Policy applies to personal information of members and prospective members, others who have expressed an interest in the CCS or have participated in an event sponsored or organized by the CCS. The personal information that the CCS generally collects and uses include: name, address, telephone number, e-mail address, banking or credit card information (card number, type and expiry date). From members, the CCS also collects information related to the member's involvement in the CCS, such as speciality, certification, medical school affiliation, major interests and interest in the serving the CCS. Accountability The CCS is responsible for all personal information under its custody or control, including information which it may transfer to a third party for processing. The Executive Director of the CCS has been appointed as Privacy Officer for the CCS. The Privacy Officer may delegate day-to-day responsibility for administration of this Policy to other employees but the Privacy Officer remains accountable for the CCS's handling of personal information. The Privacy Officer may be contacted at: 1403-222 Queen Street, Ottawa, ON, K1P 5V9, 1-613-569-3407 ext. 403. CCS is responsible for personal information sent to third parties who provide services to CCS. CCS requires any such third parties to use the personal information only for the purposes for which it is provided to them, and to protect the privacy of the personal information in accordance with privacy laws and in a manner that is consistent with this Policy. The CCS stores and processes personal information in Ottawa, Canada. Information Received From Other Sources The CCS sometimes uses mailing lists from other organizations with whom CCS participates in organizing or sponsoring programs, publications, seminars, conferences or other events. When the CCS does so, the organization is required to provide only names of individuals who have consented to the sharing of their information. If the CCS contacts individuals on one of these lists, the CCS will ask whether further communications from CCS is desired. The CCS will respect the wishes of the individual. Purposes for Collecting, Using and Disclosing Personal Information Membership Information . CCS collects and uses personal information from members and individuals who are applying to become members of CCS for the following purposes: to process a membership application or renewal; to collect and process membership dues; to keep members informed about the activities of the CCS by sending them the regular CCS Online and the Canadian Journal of Cardiology; to keep members informed about information, activities and events of other organizations on topics related to the aims of the CCS; to respond to members' questions and communications; to advise members about meetings, conferences, workshops and seminars made available by other reputable organizations that may be of interest to members; to analyse the demographics of the membership for future planning purposes; to contact members with respect to requesting their participation in the affairs of the CCS. Donations. The CCS collects donations from members for the Association's sister organization, the Canadian Cardiovascular Academy (the Academy ) to support their activities in the fields of education and research, such as scholarships and bursaries. For the purpose of such donations the CCS collects name, contact information and credit card information. This information is provided to the Academy and used only to process and administer donations and issue tax receipts. Participants in Conferences and Events. The CCS collects and uses personal information of participants in conferences and other events for the following purposes: to process registration before the event; to carry out the organization and administration of the event; to make a list of attendees available at an event; to provide the names of attendees to all organizations who participate in the event and to allow such organizations to advise attendees of any side meetings, symposia or other activities related to the conference; to invite participants to future events that are likely to be of interest to them; and to notify participants about the benefits of joining CCS. Disclosure of personal information To streamline the membership application and renewal process for members of organizations concerned with cardiovascular health, the CCS collects membership dues on behalf of other organizations. The CCS then passes on the dues and the member's contact information to the other organization. Once information has been passed to the other organization, it is no longer in the control of CCS and becomes subject to the privacy practices and procedures of the recipient organization. The CCS also occasionally discloses personal information of members to other organizations or companies that provide information or sponsor events likely to be of interest to our members. On the CCS application form and Membership renewal forms, members have the opportunity to opt out of the disclosure and use of their personal information for these purposes. In addition, a member may withdraw consent at any time by contacting the Coordinator - Membership Services, CPD and Internet. The CCS takes careful steps to ensure it complies with individual's wishes with respect to disclosure and use of personal information. For the convenience of members, the CCS prepares and makes available a directory of members. The directory is available to members only and can be obtained from the Coordinator - Membership Services, CPD and Internet for a hard copy or accessed on the website. A member may request not to have his or her name included in the directory. Other than as outlined here, and as permitted or required by law, the CCS does not disclose personal information unless it has obtained the individual's consent. Consent The CCS uses personal information only with the consent of the individual, except as otherwise permitted or required by law. When an individual submits a membership application or membership renewal, or registers for an event, the individual will be given an opportunity to opt out of receiving further information from the CCS or from any third parties. In addition, an individual may withdraw his or her consent to the use of personal information for any purpose at any time by contacting the CCS at the address above. The CCS will explain the consequences of withdrawing consent. Please allow three (3) months to process any request to withdraw consent. Website The CCS provides information and some member services via its website (the Site ). By using the Site, users agree that information may be collected, used and disclosed in accordance with this Policy. Registration. Some of the material on the Site is made available only to healthcare professionals. In order to access this information, a user is asked to register and to provide personal information, including information about professional qualifications. This information is used for the purpose of verifying the user's status as a healthcare professional. The CCS may also use it to send a user further information about CCS website activities in accordance with the wishes the user expresses on the registration form. Lists of registrants on the Site are not disclosed to other organizations. Cookies. The Site uses cookies which are small amounts of data that are transferred to a user's browser. Cookies are used to customize the site to an individual's interests or to retain personal information, such as a password, for the next visit. A user can set his or her browser not to accept cookies and still access the Site, although as a result certain areas of the Site may be unavailable or difficult to use. Non-Personal Information. As is typical with many websites, the Site automatically collects certain non-personal information regarding website users, such as the date and time you linked to the site. The Site also collects non-personal data which are used for system administration purposes and to update the website. Links. The Site contains links to other third party websites, such as those of CCS Affiliates. These links are provided for the convenience of users. The CCS has no responsibility or liability for, or control over, those websites or their collection, use and disclosure of an individual's personal information. Accuracy The CCS seeks to ensure that the personal information it uses is accurate and up to date. Please assist the office by advising staff of any inaccuracies so that appropriate corrections can be made. Limiting Retention of Personal Information The CCS retains personal information as long as it is needed for the purpose for which it was collected and in order to meet legal and regulatory requirements. Safeguards The CCS protects personal information against such risks as loss or theft, unauthorized access, disclosure, copying, modification and destruction by using appropriate security measures. The CCS's employees with access to personal information are required to respect the confidentiality of that information pursuant to their employment agreement with CCS. Employees also participate in privacy training. The CCS implements methods of protecting personal information that include limiting access to the information, restricting access to offices where information is held and technological measures such as passwords. Access An individual may request access to the information held about him or her at any time by contacting the Privacy Officer at 1-613-569-3407 ext. 403. The CCS will endeavour to respond to any such request as quickly as possible and, in any event, within the legally required time periods. Subject to certain exceptions and limitations prescribed by law, an individual will be given access to any personal information the CCS holds about the individual. The CCS will correct or amend personal information that is shown to be incomplete or inaccurate. Questions and Complaints For further information about this Policy or the practices of the CCS related to personal information, or to make a complaint, please contact the CCS Privacy Officer at 1-613-569-3407 ext. 403. The CCS will investigate all complaints and take appropriate action as a result of such investigation. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/important_notices/privacy.aspx", "HFCC - Important Notices: CCS Hyperlink Policy|Home About Us Contact Us What's New! Important Notices Search Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Important Notices: CCS Hyperlink Policy Introduction The Canadian Cardiovascular Society (CCS) has established a formal policy regarding hyperlinking from or to its suite of Web sites. The purpose of the policy is to insure that CCS members, partners, stakeholders and interested parties are provided access to both credible content and not-for-profit professional organizations recognized for their commitment to cardiovascular health and care. Policy Overview This policy applies only to the suite of CCS Web sites. The CCS does not endorse the content, products, services or viewpoints expressed within external Web sites. Further, the CCS is not responsible for the currency, accuracy or completeness of content published within external sites. Further, CCS Web sites deliver to end-users information and services relevant and applicable to its mission. Hyperlinking to CCS Web sites is permitted under limited conditions. The criteria below are used by CCS to determine the suitability of links to and from its suite of Web sites. In both cases, requests must be submitted to CCS using the application form found in Appendix A. Links from CCS Web sites In general, CCS will provide links from its sites to national or international not-for-profit professional organizations with a formal interest in and commitment to cardiovascular health and care. CCS may review requests to link to other types of Web sites at its own discretion. CCS considers the following criteria when reviewing requests for hyperlinks to external sites: the content of the external site is consistent with the aims, objectives and mandate of CCS; the creation of a link does not provide unfair competitive advantage through endorsements of third party interests. Links are provided for convenience purposes only and are not an endorsement or rating of the content of the sites to which they are made; the site is not considered inappropriate due to its content or its affiliations; the content of the site complies with the laws of Canada , which includes such items as copyright, privacy, etc.; the content of the site is kept current and accurate; all external hyperlinks, once accessed on a CCS Web site, will open a new browser window, leaving the referring CCS Web site browser intact; Changes to an external Web site’s URL must be provided to CCS in writing. CCS is not responsible for the accuracy of hyperlinks to external Web sites; the external Web site must list contact information that includes the following: Full name of organization Complete mailing address e-mail contact person phone number. Links to CCS Web sites In general, CCS will allow links to its sites from national or international not-for-profit professional organizations with a formal interest in and commitment to cardiovascular health and care. CCS may review requests to link to its sites from other types of Web sites at its own discretion. CCS considers the following criteria when reviewing requests for hyperlinks to external sites: The link referring to a CCS Web site is text-only; The link referring to a CCS Web site must not use any manner of CCS logo or image; The creation of a link does not confuse the user as to the source of the information through such practices as framing; The links provided respect the copyright policy that governs materials published on CCS sites; The external Web site is responsible for maintaining currency and accuracy of hyperlinks to CCS Web sites. Appendix A Linking Agreement Application Form Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/important_notices/links.aspx", "HFCC - Important Notices: Standards and Guidelines|Home About Us Contact Us What's New! Important Notices Search Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Important Notices: Standards and Guidelines HFCC.ca adheres to and is consistent with the following standards: Design: ISO 13407 Human Centred Design Processes for Interactive Systems, 1999 Technology: The World Wide Web Consortium (W3C) Built on Microsoft® Technology using Microsoft® Best Practices Medical Information: The Stanford University Guidelines for Web Credibility, 2005 NIH Research-Based Web Design & Usability Guidelines, 2003 Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/important_notices/standards.aspx", "HFCC - About Us: Welcome to the CCS Heart Failure Consensus Conference (HFCC) Program!|Home About Us Contact Us What's New! Important Notices Search About Us Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: About Us: Welcome to the CCS Heart Failure Consensus Conference (HFCC) Program! On behalf of the Canadian Cardiovascular Society (CCS), please accept our genuine thanks for taking the time to visit our new website and to learn more about this innovative program. The CCS has made a long-term commitment to identifying best practices in Knowledge Translation through the development, dissemination, implementation and evaluation the CCS Heart Failure Consensus Conference Recommendations. Through this website, we hope to provide an opportunity for those across Canada, who share an interest in heart failure care, to learn more of our efforts and to become actively involved in this exciting and long-term initiative. Over the past year, our 'closed-loop' approach to guidelines development has resulted in a number of innovative achievements including: CCS' first formal, multi-disciplinary Primary Panel Establishment of the CCS Heart Failure Consensus Conference Advisory Round table Completion of first-ever CCS end-user Needs Assessment Detailed program specifications for dissemination, implementation and evaluation Deployment of Core Development Teams (CDTs) Completion and publication of 2006 Heart Failure Consensus Recommendations in the Canadian Journal of Cardiology (CJC) January 2006 Publication of the 2006 Consensus Recommendations in four professional journals March 2006 A national program of regional workshops for the 2006 Consensus Recommendations scheduled for Lake Louise, Toronto, St. John and Montreal Creation of the multi-disciplinary, multi-organization Impact Working Group CCS' first-ever AGREE Review Completion of community-based slidekit Please feel free to browse the content of this website and return again on a regular basis as we will be providing regular updates of our progress. Further, feel free to contact John Parker, Director, Knowledge Translation ( parker@ccs.ca ), if you would like to learn more of this and other exciting initiatives at the CCS. Your interest and involvement in the CCS Heart Failure Consensus Conference Recommendations Program will prove invaluable in identifying and better understanding potential links between evidence-based recommendations and impact on clinical practice patterns and health outcomes. We are genuinely grateful for your continued support and interest and look forward to your comments and ongoing collaboration. Kindest regards, Heather Ross MD Chair, CCS Consensus Conference Committee Malcolm Arnold MD Chair, CCS Heart Failure Consensus Conference John Parker MN Director, Knowledge Translation Jonathan Howlett MD Co-Chair, CCS heart Failure Consensus Conference Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/about/welcome.aspx", "Microsoft Word - Exec Summary_V.3.0_03292006.doc|- 1 – CCS HF CC Web Site Exec Summary-V.2.0_03292006 2006 Heart Failure Consensus Conference Recommendations Program Executive Summary- 2 – CCS HF CC Web Site Exec Summary-V.2.0_03292006 Table of Contents Letter of Introduction – Executive Summary…………………………………….3 Background………………………………………………...……………………….4 Project Summary…………………………………………………………………...8 Project Assumptions………………………………………………………………10 CCS Closed Loop Development Model…………………………………………11 Development Cycles………………………………………………………………12 Business Model……………………………………………………………………13- 3 – CCS HF CC Web Site Exec Summary-V.2.0_03292006 Letter of Introduction – Executive Summary RE: CCS Heart Failure Consensus Conference – Executive Summary On behalf of the Canadian Cardiovascular Society (CCS), we wish to draw your attention to the CCS Heart Failure Consensus Conference Recommendations Program – Update 2006. To help you better understand this innovative and exciting initiative, we have prepared this Executive Summary. In this package you will find a summary of the Consensus Conference Initiative, including its business model and development strategies and timelines. Over the past year, our ‘closed-loop’ approach to guidelines development has resulted in a number of innovative achievements including: • CCS’ first formal multi-disciplinary Primary Panel • Establishment of the CCS Heart Failure Consensus Conference Advisory Roundtable • Completion of CCS’ first-ever end-user needs assessment • Detailed program specifications for dissemination, implementation and evaluation • Deployment of Core Development Teams • Completion and publication of 2006 Heart Failure Consensus Recommendations in CJC January 2006 • Publication of 2006 Consensus Recommendations in four professional journals March 2006 • National program of regional workshops for the 2006 Consensus Recommendations scheduled for Lake Louise, Toronto, St. John and Montreal • Creation of the multi-disciplinary and –organization Impact Working Group We believe the business and investment models for this project are similarly innovative and should enable investors, developers and stakeholders alike to concentrate their efforts and expertise on development of a world-class Knowledge Translation Program. Please feel free to contact John Parker (parker@ccs.ca) at any time. John will be happy to address your questions and comments on any aspect of this initiative. Kindest regards, Heather Ross MD Chair, CCS Consensus Conference Committee John Parker MN Director, Knowledge Translation Malcolm Arnold MD Chair, CCS Heart Failure Consensus Conference Jonathan Howlett MD Co-chair, CCS heart Failure Consensus Conference- 4 – CCS HF CC Web Site Exec Summary-V.2.0_03292006 Background The Canadian Cardiovascular Society (CCS) has a fifty-nine year history as a not-forprofit organization serving as Canada’s professional association for physicians who specialize in cardiology, cardiovascular surgery and cardiovascular research. According to its mission: The CCS is the national voice for cardiovascular physicians and scientists. The CCS mission is to promote cardiovascular health and care through knowledge translation, including dissemination of research and encouragement of best practices, professional development, and leadership in health policy. Recently, the CCS recognized the need to better understand the needs and expectations of its membership. Given that the majority of its current operating budget of approximately $3M is provided through unrestricted grants from the pharmaceutical industry and others, CCS needed to ascertain whether its current suite of programs and services were providing tangible and measurable value for its members. CCS also recognized the need to become more ‘business-like’ in its decision-making and day-to-day operations. The increasingly competitive funding landscape served as powerful motivation to begin applying due diligence in evaluating current and proposed programs and services. In doing so, CCS understood that it would be better positioned to sustain its current funding model, explore more innovative means of resource procurement and, ultimately, be more accountable to its supporters, stakeholders and membership.- 5 – CCS HF CC Web Site Exec Summary-V.2.0_03292006 For these reasons, CCS engaged the Ivey Business Consulting Group of the Richard Ivey School of Business, University of Western Ontario, to design, execute and report on a nation-wide survey of its membership. The purpose of this survey was, through a world-class third party, to ascertain whether CCS’ current programs and services were ‘on target’ for its membership, to identify what refinements, modifications and new programming were needed by the membership and to crystallize a value proposition for the organization that enabled implementation of a ‘member-centric’ business model. Through becoming a member-centric and –driven organization, CCS believed it could build upon its historical successes and set the stage for sustainability, scalability and growth. Further, the necessary discipline required to establish a financially sound organization would enable CCS to become a leader within the Canadian and international cardiovascular communities and health care communities at large. Results of the national member needs survey were tabled with the CCS Council October 2004 and, since that time, CCS has embarked upon a series of strategic initiatives which better align its programs and services with its newly defined and implemented ‘membercentric’ business model. Briefly, these strategic initiatives include complete revamping of the CCS’ corporate information technology (IT) infrastructure and both communications and customer service plans. CCS has established collaborative partnerships with both Microsoft Canada and others to develop and execute strategic and tactical plans across these corporate requirements. In addition, CCS has introduced significant changes to its annual meeting, known as the Canadian Cardiovascular Congress (CCC), again driven by detailed feedback provided by attendees, sponsors and stakeholders. The CCC is the largest annual health care professional meeting in Canada and the flagship of CCS programs and services. The meeting involves collaborative relationships with 11 national health care societies and organizations which include physicians, researchers, nurses and allied health personnel included among their memberships.- 6 – CCS HF CC Web Site Exec Summary-V.2.0_03292006 Evaluative feedback was captured by both the Ivey Business Consulting Group working in partnership with the Haskayne School of Business, University of Calgary. Development of evidence-based guidelines is the second major activity of CCS. Since 1991, CCS has developed 24 sets of such guidelines covering a broad spectrum of subspecialty interests in cardiovascular medicine. In that time, approximately $10M has been invested in the creation of these documents. While this significant effort has resulted in publication of numerous world-class documents, CCS, like many organizations similarly dedicated to creating guidelines, did not address the issue of impact of these recommendations on standards of clinical practice and, as importantly, health outcomes. Further, CCS did not consult with those involved in the day-to-day provision of care to ascertain the relevance, practicality and effectiveness of its guidelines. Consequently, CCS was unable to provide those who underwrite this significant effort with evidence of impact on clinical practice and health outcomes. This rendered more difficult the ongoing procurement of funding and resources to sustain this very important activity for CCS. Recognizing the need to revisit its process of developing guidelines, CCS has made a long term commitment to a fundamentally new and innovative development model. Referred to as a ‘closed-loop’ model’, CCS is now implementing enhancements to its CC development process by introducing formal collaboration with health care professionals involved in delivery of cardiovascular care in Canada, introduction of detailed needs assessment and evaluation development stages, impact analyses on clinical practice patterns and health outcomes and incorporation of internationally recognized standards for guidelines development. Further, CCS has consolidated many duplicative and often redundant development processes which has resulted in realization of immediate and significant resource efficiencies and the funding model has been redesigned to become a long term investment opportunity for those with a vested interest in Canadian cardiovascular guidelines.- 7 – CCS HF CC Web Site Exec Summary-V.2.0_03292006 The CCS has identified its Diagnosis and Management of Heart Failure Guidelines to be the first set of guidelines to go through this closed-loop development process with a commitment to evaluate its effectiveness through to January 2010. Incidence and prevalence and associated direct and indirect care costs of heart failure are projected to increase in Canada through the current decade. Heart failure poses ongoing diagnostic, treatment and management challenges where the balance of this care is delivered by community cardiologists, general practitioners, nurses and allied health personnel across Canada. CCS has elicited the support and active participation of 12 national health professional societies and organizations, patient support and advocacy groups, Federal, Provincial and Regional health governments, national health outcomes databases, international and national IT companies, national medical communications companies and pharmaceutical industries. Heart and Stroke Foundation of Canada, Canadian Institutes for Health Research, College of Family Physicians of Canada, Canadian Nurses Association, Canadian Pharmacists Association, Public Health Agency Canada, Canadian Cardiovascular Outcomes Research Team, Microsoft Canada and many others are among the participating organizations.- 8 – CCS HF CC Web Site Exec Summary-V.2.0_03292006 Project Summary The Consensus Conference (CC) process advances the mission of CCS through the provision of evidence-based recommendations for specialists, general practitioners and others in Canada involved in cardiovascular care. Additional goals of the CC process include improving quality of cardiovascular care, patient outcomes and cost effectiveness in addition to highlighting areas of future research need. The CCS library of CCs continues to grow and, more recently, CCS has collaborated with others, including the American College of Cardiology, American Heart Association and Canadian Society of Echocardiography, in the development of evidence-based recommendations. This impressive growth is accompanied by a number of emergent challenges including significant resource and support requirements, evolving development processes and growing numbers of related national and international guidelines developed on an annual basis. To address these changes, CCS will adopt an innovative ‘closed-loop’ model of CC development for the CCS Consensus Conference on the Diagnosis and Management of Heart Failure – Update 2006. This model accommodates end-user and stakeholder input and evaluation on an ongoing basis in the spirit of collaborative development of timely, practical and effective CCs. In the long-term, CCS will be positioned to assess impact of the Consensus Conference on the Diagnosis and Management of Heart Failure on both clinical practice and health outcomes. In addition, the development processes identified through this initiative will be entirely replicable and, therefore, of utility and interest for all those dedicated to translating new knowledge into clinical and public health practice. Heart Failure is considered an ideal first topic for this new development process for a number of reasons. First, incidence and prevalence of heart failure, and associated- 9 – CCS HF CC Web Site Exec Summary-V.2.0_03292006 direct and indirect care costs, are projected to increase in Canada over the next decade. Second, the balance of medical care delivered to this growing patient population is provided by community cardiologists, general practitioners and related health care professionals. Third, the CCS Consensus Conference on Diagnosis and Management of Heart Failure is scheduled for an update in early 2006.- 10 – CCS HF CC Web Site Exec Summary-V.2.0_03292006 Project Assumptions A number of assumptions underlie this initiative: • Consensus Conference (CC) development is a strategic priority of CCS • Content of all CC must be objective, balanced and represent true consensus • Development of original CC documents must be supported through noncommercial means • Selection of CC topics is free of third party influence • Consensus Conference development is a collaborative process wherein the input and evaluation of all stakeholders involved in delivery of care are actively sought and integrated in evidence-based recommendations • The rigorously developed content of CC represents world class intellectual capital of CCS and its partners • CCS CCs aspire to complete compliance with internationally recognized guidelines development standards • CCS is committed to ascertaining potential impact of its CCs on clinical practice patterns and health outcomes.- 11 – CCS HF CC Web Site Exec Summary-V.2.0_03292006 CCS Closed Loop Development Model The Closed-Loop development model adopted for this project is illustrated below: Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Program Dissemination& Implementation Stage 5: Evaluation & Recommendations CCS Closed Loop Guideline Development Model In this process, end-user needs assessment and evaluation are actively sought with feedback integrated into the next iteration of CCS Consensus Conference in the Diagnosis and Management of Heart Failure. The closed-loop model also permits integration of industry quality standards for guidelines (AGREE Collaboration) in addition to ongoing performance measurements and incremental improvements on a cyclical basis.- 12 – CCS HF CC Web Site Exec Summary-V.2.0_03292006 Development Cycles How the recurring closed-loop development cycles for the CCS Heart Failure Consensus Conference Recommendations Program relate to time is illustrated in the diagram below: Cycle 1 12 Months Jan ‘05 Jan ‘06 Cycle 2 12 Months Cycle 3 12 Months Cycle 4 12 Months Cycle 5 12 Months Jan ‘07 Jan ‘08 Heart Failure Heart Failure Heart Failure Heart Failure Heart Failure Jan ‘09 Jan ‘10 2005 Canadian Cardiovascular Society Acute Coronary Syndrome Arrhythmia Given the cyclical nature of the closed-loop development model, efficiencies within various development processes will be identified over time. This will result in overall and ongoing cost reductions. Further, as needs assessment, dissemination, implementation and evaluation processes become refined, CCS will be positioned to consider careful introduction of additional Consensus Conferences which utilize CCS-identified/- developed best practices. Note that the investment request for this project extends through the third development cycle depicted above – January 2008.- 13 – CCS HF CC Web Site Exec Summary-V.2.0_03292006 Business Model The business model developed for this project is illustrated below along with brief descriptions of roles and responsibilities: CCS Public/Private Supporters CCS Heart Failure Program Advisory Roundtable $ CCS Heart Failure Program $ Business/ Policy/Patient Advice $ HF Consensus Recommendations End-Users Accountability HF CC Reporting – Progress HF Consensus Recommendations/ IWG Research Input/ Feedback HF CC Reporting- Business Interaction MCG Project Manager CCS IWG Project World Class CC Public/Private Supporters: Public and/or commercial entities which provide annual investment directly to CCS with minimum 3 three year commitment. Provided opportunities to interact with end-users (physicians, pharmacists, nurses, others), receive regular updates from CCS and participate on the Heart Failure Consensus Conference Advisory Roundtable Heart Failure Consensus Conference End-users: Specialists, general practitioners, pharmacists, nurses, policy-makers, patients and others with direct and vested interest in implementation of these Guidelines. Provide focused input and feedback to the Heart Failure Consensus Conference Primary Panel throughout all development cycles Canadian Cardiovascular Society: Represents 1400 cardiovascular physicians, surgeons and researchers from across Canada and ideally positioned to lead a national standards initiative for heart failure care in Canada. Provides necessary funding and- 14 – CCS HF CC Web Site Exec Summary-V.2.0_03292006 resources to the Heart Failure Consensus Conference Primary Panel which in return, is accountable to CCS. Provides modest support to public sector representatives on the Heart Failure Consensus Conference Advisory Roundtable Heart Failure Consensus Conference Primary Panel: Comprised of representation from CCS, in addition to, College of Family Physicians of Canada, Canadian Pharmacist Association, Canadian Geriatric Society and the Canadian Nurses Association. Are accountable to CCS, seek focused input/advice/counsel from the Heart Failure Consensus Conference Advisory Roundtable and, in return, provide regular reports and updates and, finally, provide world class Heart Failure Consensus Conference to endusers Heart Failure Consensus Conference: World class, evidence-based recommendations developed with the end-user in mind, following industry-recognized development standards (AGREE Collaboration) and enabling recurring performance measurement and quality improvement Heart Failure Consensus Conference Advisory Roundtable: Consists of Noncommercial and Commercial representation and provides ongoing expert counsel and advice to development teams assembled for each stage of the closed-loop cycle of consensus conference development. Heart Failure Consensus Conference Impact Working Group: Consists of multiple representation of national-level health care organizations who are developing, resourcing and executing a five year CCS Heart Failure Consensus Conference Recommendations clinical practice pattern and health outcomes impacts strategy. Mezzanine Business Consulting (MBC): Brings world-class project management skills and coordinates development and execution of communication, branding, needs assessment, consensus conference update dissemination, implementation and evaluation stages. Has access to advice and counsel of the faculty of the Richard Ivey School of Business, University of Western Ontario.||http:\/\/www.hfcc.ca/downloads/about/Exec_Summary.pdf", "HFCC - About Us: Investors|Home About Us Contact Us What's New! Important Notices Search About Us Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: About Us: Investors The CCS Heart Failure Consensus Conference Recommendations Program is supported, by way of three-year unrestricted grants provided directly to CCS, by the following investment group: PLATINUM GOLD SILVER BRONZE These unrestricted grants are sufficient to see the Program though completion of the first three years of its five-year plan. HOW TO BECOME AN INVESTOR CCS continues to seek unrestricted support for the CCS Heart Failure Consensus Conference Recommendations Program from not-for-profit and for-profit investors. For more information on the levels of investment or to become an investor, please contact John Parker, Director Knowledge Translation ( parker@ccs.ca ). Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/about/investors.aspx", "HFCC - About Us: Advisory Round Table|Home About Us Contact Us What's New! Important Notices Search About Us Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: About Us: Advisory Round Table Heart failure involves many disciplines, sectors and governments who each face unique challenges in providing leading-edge, evidence-based heart failure care across Canada. CCS recognizes these challenges and understands that the process of developing these recommendations greatly benefits from the insights, counsel and advice of those who represent the diverse community of heart failure care in Canada. For this reason, CCS has assembled an Advisory Roundtable for the CCS Heart Failure Consensus Conference Recommendations Program. Currently, close to forty individuals, representing national health care discipline organizations, national health care agencies, federal and provincial ministries of health and both not-for-profit and for-profit interests, are members of the Advisory Roundtable. Terms of Reference for the Advisory Roundtable and it membership can be found here. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/about/advisory_round_table.aspx", "HFCC - About Us: Advisory Round Table - Members|Home About Us Contact Us What's New! Important Notices Search About Us Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: About Us: Advisory Round Table - Members Dr. Bernard Marlow The College of Family Physicians of Canada Mississauga, ON Dr. Denis Drouin Centre Medicale Cardinal-Rouleau Quebec, QC Dr. Isra G. Levy Canadian Medical Association Ottawa, ON Dr. Jay G. Mercer GlobalMedic Inc. Ottawa, ON Dr. Neala Gill HalifaxInfirmary Halifax, ON Ms. Ginette Bernier MERCK FROSST Canada Ltd. Kirkland, QC Dr. Ian Graham University of Ottawa Ottawa, ON Mr. Mark Healy Mezzanine Business Consulting Toronto, ON Mr. Robert Chalmers Biovail Pharmaceuticals Canada Mississauga, ON Ms. Anna Svendsen Canadian Nurses Association Ottawa, ON Ms. Beverly Tedford New Brunswick Department of Health and Wellness Fredericton, NB Ms. Christine Struthers University of Ottawa Heart Institute Ottawa, ON Dr. Helen Johansen Statistics Canada Ottawa, ON Dr. Janice D. Stewart Canadian College of HealthServices Executives Ottawa, ON Dr. David Johnstone Mazankowski, Albert Heart Institute Edmonton, AB Ms. Karen MacRury-Sweet HalifaxInfirmary Halifax, NS Dr. Dylan A. Taylor University of Alberta Edmonton, AB Ms. Lisa Shepherd Mezzanine Business Consulting Toronto, ON Dr. Eldon R. Smith University of Calgary Calgary, AB Ms. Margaret Proctor Microsoft Canada Mississauga, ON Dr. Guy Tremblay Centre Médical Berger Québec City, QC Ms. Mary Elizabeth Harriman Heart and Stroke Foundation of Canada Ottawa, ON Dr. Heather J. Ross Toronto General Hospital Toronto, ON Dr. Michelle Gibson St. Mary’s of the Lake Hospital Kingston, ON Hon. Senator Wilbert J. Keon Senate of Canada Ottawa, ON Dr. Sylvie Desjardins Public Health Agency of Canada Ottawa, ON Dr. Jack V. Tu Institute for Clinical Evaluative Sciences Toronto, ON Mr. Nick Antoniadis AstraZeneca Canada Inc. Mississauga, ON Dr. Andreas Wielgosz University of Ottawa Ottawa, ON Mr. Stephen Bucic ROCHE Diagnostics Laval, QC Ms. Paule Maltais Sanofis-Aventis Laval, QC Mr. Konrad Noronha Biovail Pharmaceuticals Canada Mississauga, ON Dr. Claude Lenfant National Heart, Lung, and Blood Institute Gaithersburg, MD Dr. Normand Racine Institut de Cardiologie de Montréal Montréal, QC Dr. Norm Campbell University of Calgary Faculty ofMedicine Calgary, AB Dr. John Lavis McMaster University Hamilton, ON Ms. Susanne Cookson Boehringer Ingelheim Canada Ltd Burlington, ON Ms. Marie-Josée Martin Sunergia Management Montréal, QC Mr. John Parker Canadian Cardiovascular Society Ottawa, ON Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/about/art_members.aspx", "Terms_of_Reference_ART.pdf|||http:\/\/www.hfcc.ca/about/Terms_of_Reference_ART.pdf", "HFCC - Stage 1 -> Reports|Home About Us Contact Us What's New! Important Notices Search Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 1: Reports Understanding the needs, expectations and challenges of those who, on a daily basis, strive to provide evidence-based care to heart failure patients and their families is a critical step toward successful dissemination and implementation of guidelines. By end users we mean cardiovascular specialists, community cardiologists, internal medicine physicians, geriatricians, nurses, pharmacists and patients and their families. The Heart Failure Consensus Conference Recommendations Program provided CCS with its first-ever opportunity to undertake a thorough needs assessment of these various end-users. Surveys, questionnaires and one-on-interviews were conducted across three pilot representative sites. Both the Executive Summary and complete report of this needs assessment are provided here. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage1/reports.aspx", "Microsoft Word - CC Web Site-CCProcess_V3.0_03292006.doc|- 1 - 2006 CCS Web Site-CC Process_V3.0_03292006 2006 Heart Failure Consensus Conference Recommendations Program CCS Consensus Conference Process- 2 - 2006 CCS Web Site-CC Process_V3.0_03292006 CCS Consensus Conference Process Overview Consensus conferences deal with topics of clinical relevance where there is sufficient literature but where clinical practice patterns are contentious or where literature is conflicting in terms of management. The purpose is to synthesize and analyze the literature available to provide evidence-based guidelines for practitioners. Welldeveloped guidelines have the ability to improve the quality of cardiovascular care, lead to better patient outcomes, improve cost effectiveness and highlight areas of further research needs. The creation of consensus conferences has been a key activity of the Canadian Cardiovascular Society (CCS) for over ten years and the presentation of consensus conferences has become an anticipated portion of each year’s annual meeting. Purpose of the Working Group on the consensus conference process Consensus conferences serve an important role in supporting the mission of the CCS “to advance the cardiovascular health and care of Canadians through advocacy, continuing professional education and the promotion and dissemination of research.” However, the production of CCS consensus conferences each year requires a considerable amount of member expertise, time and financial resources of the CCS. As a result, the Working Group was charged with developing recommendations to Council on a wide range of issues relating to the development and implementation of both new and updated consensus conferences. Council agreed that the following areas would be addressed regarding the consensus conference process: • Topic selection process • Chair/co-chair selection and responsibilities/accountability • Primary and Secondary Panel selection process • Standards for Grading of evidence- 3 - 2006 CCS Web Site-CC Process_V3.0_03292006 • Procedure manual for consensus conference committees (writing groups) • Publication policy • Implementation of consensus conference recommendations Other issues • Sponsorship guidelines • Intellectual property • International collaboration and collaboration with other organizations (i.e. coproduction, translation, endorsement of other organizations’ guidelines) Issues relating specifically to consensus conference updates • Timing of updates • Topic selection process • Chair selection and accountability • Primary Panel composition guidelines • Grading of evidence standards • Procedure manual for updates • Publication Policy Consensus conference process Standing Committee on consensus conferences As consensus conference development is an important activity of the CCS and addresses a key aspect of it’s mission, there is a need to have a small standing committee that defines the process for developing consensus conferences, recommends topics to undertake in a thoughtful manner, develops an impact assessment mechanism and addresses issues affecting consensus conferences in general. This committee does not write consensus conferences. The Standing Committee should be composed of four to six members selected by Council, with the Chair as a member of Council and a staff member assigned to the committee. Other members should have experience with undertaking consensus conferences and represent a broad- 4 - 2006 CCS Web Site-CC Process_V3.0_03292006 range of interests in the cardiovascular field. The term of participation would be two years with a one-term renewal option. Topic selection process Consensus conference topic selection is an important consideration that currently is undertaken at the June council meeting with input from Council members. Currently there are no guidelines with respect to considerations for topic selection or the topic selection process. Given the financial and human resource commitment required to develop consensus conferences, it is proposed that the mandate of the Standing Committee on Consensus Conferences should include the recommendation of topics for consensus conference and consensus conference updates each year. It is proposed that topics be selected using the following process and guidelines: • A call for topics will be issued in December for topics to be undertaken the following year. The call will be made via CCS Online and the CCS website. • Concurrently, a review of guidelines being produced by other established cardiovascular medical professional organizations will be undertaken to determine if there is potential overlap or if they can be co-authored or endorsed. • Past chairs of consensus conferences will be contacted every year to determine if an update is required in the upcoming year. • The Standing Committee will present a recommendation to Council for the June council meeting of each year as to whether or not a topic should be undertaken and if so, what topic should be addressed. Topics chosen for CCS consensus conferences should address the following considerations: • They fulfill the mission of the CCS to “advance the cardiovascular health and care of Canadians” • They use the expertise within the CCS membership • They address issues of clinical importance facing cardiovascular specialists and others treating cardiovascular disease. This would include ethical and economical aspects and issues.- 5 - 2006 CCS Web Site-CC Process_V3.0_03292006 • Development of a consensus conference on the topics has the potential to have a significant contribution to the management/treatment of cardiovascular disease • They are of manageable scope to be completed within an 18-month time line (i.e. from first meeting to publication). The Standing Committee on consensus conferences also reserves the right to recommend not undertaking a new consensus conference topic for any given year for the following reasons: • No topic has been recommended • The topic is being done by another reputable organization and is applicable to the Canadian system • The topic scope is too large/small • The topic does not fit the mission of the CCS Chair selection and responsibilities • Given the increasing complexity of consensus conferences and the increasing demands being placed on cardiovascular specialists, it is proposed that all new consensus conferences be developed by two co-chairs. • The Standing Committee recommends chairs that are selected based on their expertise in the chosen topic area. • Chairs are responsible for developing the consensus conference to completion, managing the budget and co-coordinating administrative work with CCS staff. • Chairs will provide a written status report to Council for each council meeting • Chairs will be considered as chair of a particular consensus conference until an update is written (within 2-5 years). The existing Chairs will be given right of first refusal to conduct the update or help in the selection of the new Update Chair(s).- 6 - 2006 CCS Web Site-CC Process_V3.0_03292006 Primary and Secondary Panels The Primary Panel is the main writing committee for the consensus conference and is comprised of CCS members with expertise in the topic area. They decide the substantive content of the document. Secondary panel members provide feedback and guidance on drafts and provide a wider perspective on the topic. Secondary panel members may not be CCS members but have internationally recognized topic expertise or are key members of the targeted audience group. • It is recommended that the Co-chairs of the consensus conference identify and contact the Primary and Secondary panel members. • The Co-chairs of the consensus conference Committee should choose Secondary Panel members with input from other Primary Panel members. Primary Panels should reflect the following: • Content expertise for the topic addressed • The diversity of the CCS membership with respect to geography and type of practice as they apply to the topic area • The audience of health professionals that will use the material including family practitioners, IM specialists and others as applicable. Secondary Panels should reflect the following: • Secondary panel members may be topic experts but not necessarily CCS members. • Secondary panel members have the capacity to consult on consensus conference drafts in terms of content, presentation and relevance to the audience addressed.- 7 - 2006 CCS Web Site-CC Process_V3.0_03292006 Standards for grading of evidence Grading of the evidence for guideline development allows conclusions to be developed in a manner that is supportable by the data. In the past, the CCS has adopted Sackett’s rules of evidence for the grading of evidence for consensus conferences, although the ACC guidelines have also been used. For the sake of uniformity and possible future collaborations with other organizations, it is proposed that the ACC rules for the grading of evidence be used for future CCS consensus conferences. Procedure manual for consensus conference committees As consensus conferences are substantial undertakings, a manual outlining administrative procedures, and process guidelines would be beneficial for each new committee. This is a task to be undertaken by the Standing Committee on consensus conferences and staff. The manual should include the following information: Methods for creating consensus conferences • Scope guidelines • Timelines • Outline of steps from beginning to publication • Other Administrative process • Budget parameters • Communication process guidelines (i.e. number of meetings, emails, etc) • Secretarial support guidelines • Reporting guidelines (i.e. each Council meeting) • Role and responsibilities of CCS staff • Other (e.g. copyright transfer agreement)- 8 - 2006 CCS Web Site-CC Process_V3.0_03292006 Publication policy Draft consensus conferences Until 2001, draft consensus conference documents have been translated, printed and mailed to all members of the CCS so that members could provide input into each document prior to final publication. Frequently, drafts were made available to delegates at the CCS Annual Meeting prior to the consensus conference presentation at the meeting. This process was very expensive and of limited value in terms of feedback to the Primary Panel. The update of the Congestive Heart Failure consensus conference was circulated via email and feedback to the Committee was immediate and helpful. The following process is recommended for all future new and updated consensus conferences: • Given the availability of the CCS website and email access by most members, it is proposed that draft documents be circulated one month prior to the CCS Annual Meeting via the CCS website and email notification. • Printed copies will be made available on an individual request basis only. • Copies of the executive summary of the consensus conference will be available at the time of presentation at the CCS annual meeting. • As the CCS is a national society, draft versions of the consensus documents will be available in English and French. Final version of consensus conferences • The executive summary of the final version of the consensus conference will be published in the Canadian Journal of Cardiology, listing all participating authors. • Full text of the final version of the consensus conference will be published on the CCS website. It is recommended that the consensus conference be published (either on the website or in hardcopy format) within 18 months of the first meeting of the Primary Panel.- 9 - 2006 CCS Web Site-CC Process_V3.0_03292006 • As the CCS is a national society, final versions of the consensus documents should be available in English and French. Implementation of consensus conference recommendations The increasing complexity of consensus conferences has resulted in information-loaded documents that need to be formatted to address the needs of busy clinicians in their daily practice. Implementation tools and CPD initiatives can address this area in ways that a larger document cannot. Therefore, the following recommendations are made regarding implementation of consensus conference findings: • Consensus documents will be created with the explicit understanding that the information in the document will be disseminated using practical “implementation tools” such as pocket guides, Palm-based guides CPD learning modules, etc. that encourage adaptation of the recommendations by clinicians in their practice. • The development of implementation tools will be a role of the CPD function of the Society in consultation with the consensus conference Writing Committee. Sponsorship guidelines • Consensus conferences are considered a core function of the CCS and therefore, the CCS should have complete ownership of each document. • As stated in the 2000 recommendations of the CCS Sponsorship Working Group, CCS resources should fund the development of CCS consensus conferences, without support by third parties. • Once the document has been published in its final form, dissemination and learning tools derived from the original document may be funded through unrestricted grants from third parties, as long as development of the learning tools • has been conducted by the CCS CPD department in conjunction with the consensus conference Writing Committee.- 10 - 2006 CCS Web Site-CC Process_V3.0_03292006 • Publication of the consensus conferences in the Canadian Journal of Cardiology can be supported by advertising revenue generated by Pulsus once the final version of the consensus conference has been completed. • Web publication is provided by Conceptis Technologies. Conceptis may generate advertising revenue in support of the dissemination of the document. Intellectual property issues • All information contained in CCS consensus conferences is the property of the CCS. • All consensus conference authors should sign a copyright transfer agreement prior to beginning work on the document. • All requests for reprints or reproduction received by Pulsus, Chairs of individual consensus conferences and others should be referred to the CCS Secretariat for consideration. It is proposed that the CCS develop guidelines regarding requests for reprints and other uses of the CCS. • The CCS should encourage the dissemination of the guidelines for use in clinical practice for the purpose of advancing the cardiovascular health and care of Canadians. International co-operation Translation into languages other than English or French Use by other countries of CCS consensus conferences is encouraged. However, translations vary in quality and can often change the sense and meaning of a document. It is proposed that the CCS allow translations of consensus conferences under the following circumstances: • The translation is performed by a reputable translator. • The translation can be read by a CCS member, when possible, for accuracy of the translation. • The cost of the translation is borne by the requesting party.- 11 - 2006 CCS Web Site-CC Process_V3.0_03292006 Co-production with other organizations Co-production with other organizations includes co-writing consensus conferences with other organizations or endorsing other organization’s consensus conferences. Co-writing of consensus conferences Co-written consensus conferences may be beneficial to the CCS in many ways by: • Supporting the development of North American guidelines (if written in conjunction with the ACC/AHA) • Increasing the profile of the CCS internationally • Bringing together a larger group of international specialists in a particular area • Sharing costs on the development of consensus conferences The CCS should consider co-writing consensus conferences when: • the co-writing organization(s) are well recognized for quality guidelines; • there would be a significant overlap of content if two separate documents were undertaken; • the CCS can “Canadianize” recommendations as needed; • the costs of the development is proportionally divided between all participating organizations. Endorsing consensus conferences From time to time, the CCS is approached to endorse the consensus conferences of other organizations. Endorsement of consensus conferences should be considered on a case by case basis following the CCS policy on guideline endorsement. Issues relating specifically to updates of consensus conferences Consensus conference updates are needed to communicate new information that may affect practice.- 12 - 2006 CCS Web Site-CC Process_V3.0_03292006 Many of the recommendations pertaining to new consensus conference topics will apply to updates with the following exceptions that will be addressed in this section: • Timing of updates • Chair selection • Process for updating • Publication/distribution of updates Timing of updates Consensus conference updates should be undertaken upon the recommendation of the most recent Chair(s) of the most recently published consensus conference on the stated topic, or after 5 years has passed since last publication, whichever comes first. Update recommendations should be made to the Standing Committee, who will determine if the update should be undertaken. More than one topic may be updated in any given year, if there are sufficient financial resources available and the cardiovascular community requires the updates. Most updates should be completed within one year of the confirmation of the Primary Panel. Chair selection for updates Chair(s) of the original consensus conference should be asked to Chair the first update or recommend a replacement Chair(s). It is recommended that, for continuity, the replacement chair(s) be a CCS member who was on the Primary Panel of the original consensus conference. Chairs of updates will choose the Primary Panel, using panel members from the original document or choosing new members as required.- 13 - 2006 CCS Web Site-CC Process_V3.0_03292006 Update process Generally, an update should focus on the areas of the original consensus conference where significant changes have occurred and when new information needs to be presented. As a result, the document can be significantly shorter than the original publication. Given the availability of email and the nature of updates, it is recommended that most updates of consensus conferences be conducted by email to minimize expense and travel time. As with new consensus conference topics, updates will be circulated by email for input prior to final publication. Publication Updates will be published on the CCS website and in the Canadian Journal of Cardiology.||http:\/\/www.hfcc.ca/downloads/stage2/CC_Process.pdf", "Microsoft Word - Roles and Responsibililties_V3.0_03292006.doc|- 1 - 2006 CCS HF Consensus Conference Recommendations – Roles & Responsibilities-V.3.0_03292006 2006 CCS Heart Failure Consensus Conference Recommendations Program Primary and Secondary Panel Roles and Responsibilities- 2 - 2006 CCS HF Consensus Conference Recommendations – Roles & Responsibilities-V.3.0_03292006 Table of Contents Letter of Introduction – Panel Roles……… …………………………………….3 CC Roles and Responsibilities ………………………………………………….4- 3 - 2006 CCS HF Consensus Conference Recommendations – Roles & Responsibilities-V.3.0_03292006 Letter of Introduction – Panel Roles RE: CCS Consensus Conference on Heart Failure – Roles and Responsibilities On behalf of the Canadian Cardiovascular Society (CCS), we wish to welcome you to the Primary Panel of the CCS Heart Failure Consensus Conference Recommendations. To help you better understand this innovative and exciting initiative, we have prepared this package of background information. In this package you will find a summary of the roles and responsibilities of Co-chairs and both Primary and Secondary Panel members. We are extremely encouraged by the interest and excitement growing around this ambitious initiative. Indeed, several precedents have already been set with respect to formal representation of several national affiliate groups on the Primary Panel and multisector representation on the CCS Consensus Conference on Heart Failure Advisory Roundtable. We believe the business and investment models for this project are similarly innovative and should enable investors, developers and stakeholders alike to concentrate their efforts and expertise on development of a world-class Knowledge Translation Program. Please feel free to contact John Parker (parker@ccs.ca) at any time. John will be happy to address your questions and comments on any aspect of this initiative. We look forward to working with you on this ambitious and important initiative. Kindest regards, Heather Ross MD Chair CCS Consensus Conference Committee John Parker MN Director Knowledge Translation Malcolm Arnold MD Chair CCS Heart Failure Consensus Conference Jonathan Howlett MD Co-Chair CCS heart Failure Consensus Conference- 4 - 2006 CCS HF Consensus Conference Recommendations – Roles & Responsibilities-V.3.0_03292006 CC Roles and Responsibilities Overview Consensus conferences deal with topics of clinical relevance where there is sufficient literature but where clinical practice patterns are contentious or where literature is conflicting in terms of management. The purpose is to synthesize and analyze the literature available to provide evidence-based guidelines for practitioners. Welldeveloped guidelines have the potential to improve the quality of cardiovascular care, lead to better patient outcomes, improve cost effectiveness and highlight areas of further research needs. The creation of consensus conferences has been a key activity of the Canadian Cardiovascular Society (CCS) for over ten years and the presentation of consensus conferences has become an anticipated event at each year’s annual Canadian Cardiovascular Congress (CCC). Consensus conferences serve an important role in supporting the mission of the CCS “to advance the cardiovascular health and care of Canadians, through advocacy, continuing professional education and the promotion and dissemination of research.” However, the production of CCS consensus conferences each year requires a considerable amount of member expertise, time and financial resources of the Society. The following pages contain a synopsis of existing CCS policy for development of consensus conferences. Special considerations of the “closed-loop” development model with respect to this existing policy conclude this section.- 5 - 2006 CCS HF Consensus Conference Recommendations – Roles & Responsibilities-V.3.0_03292006 Chair Selection and Responsibilities Given the increasing complexity of consensus conferences and the increasing demands being placed on cardiovascular specialists, it is proposed that all new consensus conferences be developed by 2 co-chairs. The Standing Committee recommends Chairs that are selected based on their expertise in the chosen topic area. Chairs are responsible for developing the consensus conference to completion; managing the budget and co-coordinating administrative work with CCS Staff. Chairs will provide a written status report to Council for each council meeting. Chairs will be considered as the Chair of a particular consensus conference until an update is written (within 2-5 years). The existing Chairs will be given right of first refusal to conduct the update or help in the selection of the new Update Chair(s). It is recommended that the Co-chairs of the consensus conference identify and contact the Primary and Secondary panel members. The co-chairs of the consensus conference committee should choose Secondary panel members with input from other Primary panel members. Primary and Secondary Panels The Primary Panel is the main writing committee for the consensus conference and is comprised of CCS members with expertise in the topic area. They decide the substantive content of the document. Together, the Primary Panel reflects content expertise for the topic addressed in addition to the diversity of the CCS membership with respect to geography and type of practice as they apply to the topic area. The Primary Panel should also be representative of the audience of health professionals that will use the material including family practitioners, IM specialists and others as applicable. Secondary Panel members provide feedback and guidance on drafts and provide a- 6 - 2006 CCS HF Consensus Conference Recommendations – Roles & Responsibilities-V.3.0_03292006 wider perspective on the topic. Secondary Panel members may not be CCS members, but have internationally recognized topic expertise or are key members of the targeted audience group. Secondary Panel members may be topic experts but not necessarily CCS members. Secondary Panel members have the capacity to consult on consensus conference drafts in terms of content, presentation and relevance to the audience addressed. Publication Policy Until 2001, draft consensus conference documents have been translated, printed and mailed to all members of the CCS so that members could provide input on each document prior to final publication. Frequently, drafts were made available to delegates at the CCS Annual Meeting prior to the consensus conference presentation at the meeting. This process was very expensive and of limited value in terms of feedback to the Primary Panel. The update of the Congestive Heat Failure Consensus Conference was circulated via email and feedback to the Committee was immediate and helpful. The following process is recommended for all future new and updated consensus conferences: • Given the availability of the CCS website and email access by most members, it is proposed that draft documents be circulated one month prior to the CCS Annual Meeting via the CCS website and email notification. • Printed copies will be made available on an individual request basis only. • Copies of the Executive Summary of the consensus conference will be available at the time of presentation at the CCS Annual Meeting. • As the CCS is a national society, draft versions of the consensus documents will be available in English and French.- 7 - 2006 CCS HF Consensus Conference Recommendations – Roles & Responsibilities-V.3.0_03292006 • Final version of consensus conferences. • The executive summary of the final version of the consensus conference will be published in the Canadian Journal of Cardiology, listing all participating authors. • Full text of the final version of the consensus conference will be published on the CCS web site. It is recommended that the consensus conference be published (either on the website or in hardcopy format) within 18 months of the first meeting of the Primary Panel. • As the CCS is a national society, final versions of the consensus documents should be available in English and French. Implementation of Consensus Conference Recommendations The increasing complexity of consensus conferences has resulted in information-loaded documents that need to be formatted to address the needs of busy clinicians in their daily practice. Implementation tools and CPD initiatives can address this area in ways that a larger document cannot. Therefore the following recommendations are made regarding implementation of consensus conference findings: • Consensus documents will be created with the explicit understanding that the information in the document will be disseminated using practical “implementation tools” such as pocket guides, Palm-based guides CPD learning modules, etc. that encourage adaptation of the recommendations by clinicians in their practice. • The development of implementation tools will be a role of the CPD function of the CCS in consultation with the consensus conference Writing Committee.- 8 - 2006 CCS HF Consensus Conference Recommendations – Roles & Responsibilities-V.3.0_03292006 Sponsorship Guidelines Consensus conferences are considered a core function of the CCS and therefore the CCS should have complete ownership of each document. As stated in the 2000 recommendations of the CCS Sponsorship Working Group, CCS resources should fund the development of CCS consensus conferences, without support by third parties. Once the document has been published in its final form, dissemination and learning tools derived from the original document may be funded through unrestricted grants from third parties, as long as development of the learning tools has been conducted by the CCS CPD department in conjunction with the consensus conference Writing Committee. Publication of the consensus conferences in the Canadian Journal of Cardiology can be supported by advertising revenue generated by Pulsus once the final version of the consensus conference has been completed. Intellectual Property Issues The following principles apply to the intellectual property of CCS Consensus Conferences: • All information contained in CCS consensus conferences is the property of the CCS. • All consensus conference authors should sign a copyright transfer agreement prior to beginning work on the document. • All requests for reprints or reproduction received by Pulsus, Chairs of individual consensus conferences and others should be referred to the CCS Secretariat for consideration.- 9 - 2006 CCS HF Consensus Conference Recommendations – Roles & Responsibilities-V.3.0_03292006 • The CCS should encourage the dissemination of the guidelines for use in clinical practice for the purpose of advancing the cardiovascular health and care of Canadians. Updates of Consensus Conferences Consensus conference updates should be undertaken upon the recommendation of the most recent Chair(s) of the most recently published consensus conference on the stated topic, or after five years has passed since last publication, whichever comes first. Update recommendations should be made to the Standing Committee, who will determine if the update should be undertaken. More than one topic may be updated in any given year, if there are sufficient financial resources available and the cardiovascular community requires the updates. Most updates should be completed within one year of the confirmation of the Primary Panel. Chair(s) of the original consensus conference should be asked to chair the first update or recommend a replacement Chair(s). It is recommended that, for continuity, the replacement Chair(s) be a CCS member that was on the Primary Panel of the original consensus conference. Chairs of updates will choose the Primary Panel, using Panel members from the original document or choosing new members, as required. Generally, an update should focus on the areas of the original consensus conference where significant changes have occurred and when new information needs to be presented. As a result, the document can be significantly shorter than the original publication. As with new consensus conference topics, updates will be circulated by email for input prior to final publication. Updates will be published on the CCS website and in the Canadian Journal of Cardiology.- 10 - 2006 CCS HF Consensus Conference Recommendations – Roles & Responsibilities-V.3.0_03292006 Closed-Loop Model Considerations Adopting the closed-loop model for the CCS Consensus Conference on the Diagnosis and Management of Heart Failure – Update 2006 has a number of important implications for the consensus conference development process. These implications are highlighted below and detailed in the following sections. Questions regarding these changes can be directed to John Parker (parker@ccs.ca). 1. Term of Co-Chair: • Two years on a staggered basis to provide continuity • One year as past chair to improve continuity • Identification of new Co-chair determined by Primary Panel and approved by CCS Consensus Conference Committee • Nominated Chairs should have served a minimum of two years as Primary Panel Member 2. Term of Primary Panel Members: • Three years on a staggered basis • Identification of new Primary Panel members determined by existing Primary Panel and Co-chairs • The Primary Panel should be regarded as a professional development opportunity for younger members of the Canadian cardiovascular community • Primary Panel will be representative of the Canadian cardiovascular community atlarge 3. Responsibilities and term of Secondary Panel Members: • Three years on a staggered basis • Identification of new Secondary Panel members determined by Co-chairs- 11 - 2006 CCS HF Consensus Conference Recommendations – Roles & Responsibilities-V.3.0_03292006 These fundamental changes in consensus conference development have a number of important implications, especially as they relate to time commitments of members of the Primary Panel. Primary Panel members can expect to participate in the following events as the entire team works together to identify and refine best practices within the closedloop model of development: Primary Panel Activity Per Development Cycle Estimated Time Commitment (Hours) Two face-to-face meetings 16 Four teleconferences 8 Development of evidence-based recommendations 10 First and final draft of content 20 TOTAL 54||http:\/\/www.hfcc.ca/downloads/stage2/Roles_and_Responsibilities.pdf", "HFCC - Stage 2: Primary Panel Members|Home About Us Contact Us What's New! Important Notices Search Stage 2: Consensus Conference Update Stage 1: End-User Needs Assessment Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 2: Supporting Documents The Canadian Cardiovascular Society and knowledge translation: Turning best evidence into best practice Clinical Research to Clinical Practice - Lost in Translation? Claude Lenfant, M.D. Closing The Gap Between Science And Practice: The Need For Professional Leadership The Growing Burden of Heart Disease and Stroke in Canada 2003 Guideline-Based Standardized Care Is Associated With Substantially Lower Mortality in Medicare Patients With Acute Myocardial Infarction ACC/AHA Clinical Performance Measures for Adults With Chronic Heart Failure Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage2/supporting_documents.aspx", "HFCC - Stage 2 -> Guidelines / Recommendation|Home About Us Contact Us What's New! Important Notices Search Stage 2: Consensus Conference Update Stage 1: End-User Needs Assessment Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 2: Guidelines / Recommendations 2007 Articles Canadian Cardiovascular Society Consensus Conference recommendations on heart failure update 2007: Prevention, management during intercurrent illness or acute decompensation, and use of biomarkers 2006 Articles Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: Diagnosis and management 2003 Articles The 2002/3 Canadian Cardiovascular Society Consensus Guideline Update for the Diagnosis and Management of Heart Failure 2001 Articles The 2001 Canadian Cardiovascular Society Guideline Update for the Management and Prevention of Congestive Heart Failure. 1994 Articles The 1994 Canadian Cardiovascular Society Guidelines for Diagnosis and Management of Heart Failure Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage2/guidelines.aspx", "HFCC - Stage 2: Secondary Panel|Home About Us Contact Us What's New! Important Notices Search Stage 2: Consensus Conference Update Stage 1: End-User Needs Assessment Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 2: Secondary Panel A critical stage in the development of CCS Consensus Recommendations is review by the so-called Secondary Panel. Secondary Panel members may not be CCS members, but have internationally recognized topic expertise or are key members of the target audience group. Secondary Panel members have the capacity to consult on consensus conference drafts in terms of content, presentation and relevance to the audience addressed. In addition, Secondary Panel review is one more step CCS takes in the Consensus Recommendations development process to insure both balance and objectivity within the final document. CCS is very grateful for the contributions of the 2006 Heart Failure Recommendations Secondary Panel and is proud to acknowledge the critical participation of Secondary Panel members. A complete list of Secondary Panel Members can be found here. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage2/secondary_panel.aspx", "HFCC - Stage 2: Secondary Panel - Members|Home About Us Contact Us What's New! Important Notices Search Stage 2: Consensus Conference Update Stage 1: End-User Needs Assessment Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 2: Secondary Panel - Members Dr. Gary Newton Mount Sinai Hospital Toronto, ON Dr. Joel M. Niznick Ottawa, ON Dr. Salim Yusuf Hamilton General Hospital McMaster Clinic Hamilton, ON Dr. Stuart Smith Westheights Cardiology Kitchener, ON Dr. Thomas Ashton Penticton, BC Dr. Victor F. Huckell Vancouver Hospital Division of Cardiology Vancouver, BC Dr Marie H. Le Blanc Institut de cardiology de Québec Sainte-Foy, QC Dr. Sherryn N. Levinoff Roth University of Toronto Toronto, ON Ms. Marie-Josée Martin Sungeria Management Montréal, QC Mr. John Parker Canadian Cardiovascular Society Knowledge Translation Ottawa, ON Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage2/secondary_panel_members.aspx", "Microsoft Word - National Workshop Initiative Planning Doc_V3.1_04012006 .doc|- 1 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 2006 Heart Failure Consensus Conference Recommendations Program National Workshop Initiative Planning Document- 2 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 Table of Contents Workshop Planning Document - Letter of Introduction………………………...3 Workshop Initiative Planning Document - Purpose…………………………….4 National Workshop Schedule……………………………………………………..5 ACC- LL Workshop – RCPSC Compliance……………………………………...6 ACC-LL Faculty Background……………………………………………………...13 ACC-LL Equipment Requirements……………………………………………….14 ACC-LL Expectations of Faculty………………………………………………….15 ACC-LL Project Management…………………………………………………….16 Appendix A: ACC-KK – Needs Assessment……………………………………17 Appendix B: CCS Disclosure Statement...………………………………………18 Appendix C: CCS Business Plan and Investment Model...……………………19- 3 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 Letter of Introduction RE: CCS Heart Failure Consensus Recommendations Program – National Workshop Initiative We wish to take this opportunity to express our sincerest gratitude for your interest in the CCS Heart Failure Consensus Recommendations Program – National Workshop Initiative. We are pleased to offer the enclosed document which outlines the workshop initiative including objectives, compliance with Section 1 learning activities as defined by the Royal College of Physicians and Surgeons of Canada and overall activities and expectations of Faculty. We are also pleased that ACC-Lake Louise will be the first of four venues across Canada where we will be conducting highly innovative and interactive workshops throughout 2006. These Workshops are part of an ambitious CCS program designed to identify best practices in Knowledge Translation and how they might impact both clinical practice patterns and health outcomes. As such, the workshops form a key strategy for the overall dissemination and implementation of the 2006 CCS Heart Failure Consensus Recommendations. Further, the workshops are designed to actively engage the Canadian cardiovascular community in the ongoing usage and refinement of these evidence-based recommendations. Please feel free to contact John Parker (parker@ccs.ca) who will be happy to address your questions and comments on any aspect of this initiative. Your interest and participation in the National Workshop Initiative will prove invaluable in realizing the important goals of the CCS Heart Failure Consensus Recommendations Program. We are genuinely grateful for your continued support and interest and look forward to completing this important next stage of this project with you. Kindest regards, Heather Ross MD Chair CCS Consensus Conference Committee John Parker MN Director Knowledge Translation Malcolm Arnold MD Chair CCS Heart Failure Consensus Conference Jonathan Howlett MD Co-Chair CCS heart Failure Consensus Conference- 4 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 Planning Document Purpose • To integrate the National 2006 CCS Heart Failure Consensus Recommendations Workshops into the overall CCS Heart Failure Consensus Recommendations Program • To address the major recommendation of the 2005 CCS Member Needs Survey that CCS must return to a grass roots organization to better fulfill the needs and expectations of its membership • To insure the ACC-LL workshop, and all subsequent workshops, achieve RCPSC Section 1 Learning Activity adherence/compliance • To clearly identify Learning Needs, Planning Committee, Learning Objectives and Ethical Standards of the National Workshop Initiative- 5 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 National Workshop Schedule The CCS 2006 Heart Failure Consensus Recommendations Workshops will be offered at four established cardiovascular meeting venues during 2006. Together, these four workshops comprise the National Workshop Initiative of the CCS Heart Failure Consensus Recommendations Program. Efforts will be made to elicit and integrate feedback into each successive workshop. This will allow the Workshop Planning Committee to continuously measure workshop performance and introduce incremental program improvements on an as-indicated basis. Given the national workshops are part of a broader integrated strategy for dissemination and implementation of the 2006 CCS Heart Failure Consensus Recommendations Program, alignment with the broad objectives of this Program is critical. The venues and dates of the four workshops proposed for 2006 are depicted below. National 2006 CCS Heart Failure Consensus Recommendations Workshop Schedule ACC – LL March 28 HFS Toronto June 14-16 NB Heart Symposium September CFPC Montreal December- 6 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 ACC-LL Workshop – RCPSC Compliance The CCS has identified four development criteria for program planners that fulfill compliance requirements for a Section 1 Learning Activity as defined by the Royal College of Physicians and Surgeons of Canada (RCPSC) – Learning Needs, Planning Committee, Learning Objectives and Ethical Standards. Given CCS is an accredited provider of the RCPSC, fulfillment of these criteria enables CCS to approve the ACC-LL Workshop as an approved Section 1 activity. Each of these four criteria is addressed below. 1. Learning Needs: the activity must address the learning needs of the target audience * Who comprises the Target Audience? • Regional/local opinion leaders, community specialists, nurses, CV Residents/Trainees How were the learning needs of the target audience identified? • Face-to-face interviews involving patients, general practitioners, nurses, internists, community cardiologists and specialists across three heart failure clinic pilot sites • Surveys and interviews involving the Primary Panellists of the 2006 CCS Heart Failure Consensus Recommendations Program • Surveys and interviews involving the thirty-five member Advisory Roundtable of the CCS Heart Failure Consensus Recommendations Program- 7 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 What academic, observed and/or perceived sources of information were used to define the content of this activity? • CCS’ formal consensus conference update process applied to CCS Heart Failure Consensus Recommendations Program • Face-to-face interviews, surveys and online questionnaires What gaps in knowledge, skills and/or attitudes were identified for this activity? • Guidelines are relatively unknown in Canada except among specialist communities • Target audience is unaware of CCS Heart Failure Consensus Recommendations Program • Target audience infrequently refers to CCS Heart Failure Consensus Recommendations Program in day-to-day practice • Current CCS Heart Failure Consensus Recommendations Program has limited impact on clinical practice patterns • Currently few educational opportunities for CCS Heart Failure Consensus Recommendations Program * See Appendix A for complete end-user needs assessment report 2. Planning Committee: the activity’s Planning Committee must be representative of the target audience Who are the members of the planning committee? • Jonathan Howlett MD • Simon Jackson MD • Debra Isaacs MD • John Parker MN • CCS Support Staff- 8 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 How is the Planning Committee reflective of the target audience? • Representative of multi-disciplinary end-users • Consistent with end-users involved in needs assessment • Representative of geographic interests across Canada Who is the Chair of the Planning Committee? • Jonathan Howlett MD Who serves as the CCS Representative on the Planning Committee? • Simon Jackson MD 3. Learning Objectives: Must address learning needs identified by target audience What are the learning objectives for this activity? • To address learning needs identified in end-user needs assessment • To broaden usage of CCS HF guidelines • To better understand CCS HF guidelines and their implications in day-today practice • To improve integration of CCS HF guidelines into daily practice • Familiarize use of CCS HF clinical learning/implementation tools • To facilitate further dissemination of HF guidelines to primary care settings How are the learning strategies linked to the program evaluation strategy? • The evaluation focuses on specific changes in knowledge, attitudes and perceived skill as a consequence of the workshop • E.g. pre/post test, questionnaire, face-to-face interview, follow-up phone/web-based interview • Collaborate with known guidelines development expertise – Simon Jackson, Jack Tu, Ian Graham- 9 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 What changes in knowledge, skills and/or attitudes will be achieved through this activity? • Heightened awareness of CCS guidelines • Increased numbers of active participants/contributors to ongoing guidelines development and refinement • Active/enthusiastic/committed participants in dissemination and implementation of guidelines • Engaged end-users who are knowledgeable about guidelines tools and use • Improvements in understanding HF recognition, disease management and treatment skills What interactive activities will be integrated into this activity? The Planning Committee has considered a number of possible options including - 1. Case-based, touch pad technology where cases are discussed, options are given in multiple choice format with open discussion followed by display of answer • Questions should be of varying degrees of difficulty to engage participants • Follow-up questions i.e. “which of the following would cause you NOT to do that?” where the answer is one of two options • E.g. starting ACEI – four options, then, which of the following would cause you not to choose the recommended option (e.g. ARF, allergy, diarrhea, no money) 2. video of patient interview, interaction • ‘Merck’ video produced by J Howlett parsed into case-based, touch pad technology questions 3. three or four cases, each offered using a different strategy • video, conventional case presentation, • ‘where’s Waldo format o i.e. “how many level 1 recommendations were broken/followed in this case”, demonstration of implementation tools- 10 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 • MUST complete evaluation 4. three or four cases of where’s Waldo format utilizing, touch pad, open discussion 5. one diagnosis, one disease management (video), remaining will be collage of primarily therapeutic cases – each case emphasizing one or more Level One Recommendations What are the activity schedule, timing and sequence of learning strategies and faculty for this activity? • Pre-test and snack • Greeting & Introduction & House Keeping • CCS Guideline and Implementation Process and Why this Workshop Matters • Case 1 (straight forward case) • Case 2 (Video) • Case 3 (Where’s Waldo – competition for room night, one-day registration fee, or similar prize) • Demonstration of Tools • Wrap-up • Post-test & Evaluation • Open Invitation to Participate • Invitation to participate in Toronto, St John, Montreal How Many Times will the activity be repeated? • Four – ACC-LL, Toronto Heart Failure Summit, New Brunswick Heart Symposium, CFPC Meeting What opportunities will enable participants to identify learning and impact on practice? • comparison of individual knowledge, attitudes and skills with others through touch pad technology opportunities and interaction with faculty and co-participants • Pre-test and post-evaluation of success of meeting learning objective- 11 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 How will the Participants be encouraged to reflect on the content of the activity? • Through provision/demonstration of learning and implementation tools • Through active and open encouragement for ongoing participation in CCS HF CC Initiative • Completion of formal evaluation questionnaire • Accredited Section 1 learning activity 4. Ethical Standards: The learning activity must adhere to CMA/CEMCQ standards Does the Planning Committee have complete control over topic, content and invited speakers? • Yes What steps has the Planning Committee taken to unsure scientific validity, objectivity and completeness of content? • CCS Consensus Conference Development Process (Primary Panel update development, Secondary Panel/CCS Membership Review) • Established evidence review/rating system • CCS unrestricted, pooled-investment model • End-user needs assessment by third party • Multi-disciplinary Primary Panel • Complete disclosure of all members of the Primary Panel(see Appendix B) • Compliance to AGREE standard • Mandatory conflict disclosure for Primary Panel and Planning Committee Are members of the Planning Committee and Faculty required to formally disclose potential conflicts of interest? • Yes – Refer to Appendix B for CCS Disclosure Statement- 12 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 Have all forms of unrestricted funding been identified? • Yes – Refer to Appendix C for Executive Summary of the CCS 2006 Heart Failure Consensus Recommendations business plan and funding model What steps are taken to insure that specific commercial products are not identified in all print, electronic, advertising and presentation media? • generic drug naming, no advertisements, acknowledgement of support as unrestricted grants- 13 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 ACC-LL Faculty Background Each faculty member is to provide a brief (two paragraph summary of CV along with photo, if possible). Proposed Faculty include: – J Howlett, Chair – Heart Failure Expert, Transplantation, Extensive experience serving on national/international guidelines committees, Chaired national symposia for heart failure, residency training committees, Chair/Planner of RCPSC-approved CPD programs and regional meetings – S Jackson – Heart Failure Expert, Transplantation, adult education training (Dundee), pulmonary arterial hypertension expertise, Chair/Planner of RCPSC-approved programs and regional meetings, Director of Residency Training Committee – N Gianetti – Nadia Giannetti is a cardiologist who specializes in heart failure and heart transplantation. She trained in medicine, internal medicine, and cardiology at McGill University, and pursued her fellowship training in heart failure and transplantation at Stanford University. Dr. Giannetti set-up the Heart Failure and Heart Transplant Centre at the McGill University Health Centre, and holds the position of Medical Director there. Her main research interests involve gender-related issues in heart failure and long-term postheart transplantation complications. – D Isaacs – Dr. Debra Isaac started her career in health care as a registered nurse, working as a staff nurse and nurse educator in the Intensive Care and Cardiac Intensive Care Units in Winnipeg and Calgary. She obtained her MD degree and completed her residency training in Internal Medicine at the University of Calgary. She then completed a fellowship in Cardiology at Northwestern University in Chicago, and has also completed clinical and research fellowships in Echocardiography, Heart Failure, and Cardiac Transplantation.- 14 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 She is currently an Associate Clinical Professor of Medicine at the University of Calgary, Director of Cardiac Transplant at the Foothills Medical Centre, and Medical Director of the Echocardiography Lab at Rockyview General Hospital. She also runs a heart failure clinical research program at the University of Calgary’s Heritage Medical Research Clinic. – M Arnold - Malcolm Arnold graduated first in his class from Queen’s University Belfast, and received many undergraduate awards. He graduated with first class honours in Physiology and with honours in his medical degree (awarded to four individuals in the graduating class). He received further post-graduate training at Harvard Medical School and Brigham Women’s Hospital in Boston, Massachusetts when he was a British-American Fellow of the British Heart Foundation and the American Heart Association. On appointment to the University of Western Ontario, he received a Career Health Scientist Award from the PMAC Health Research Foundation for five years, and is presently staff cardiologist at London Health Sciences Centre, Victoria Campus in London, Ontario, and Professor of Medicine, Physiology, and Pharmacology at the University of Western Ontario in London, Ontario, Canada. He also holds the position of Director of Research Affairs for the Division of Cardiology, and is the Circulation Group Program Leader at Lawson Health Research Institute. Dr. Arnold is Chair of the Canadian CHF Clinics Network, has served as Chair of the University of Western Ontario Department of Medicine Research Committee, and received the Dean’s Award of Excellence for Research. At Victoria Hospital, he established both a clinical and research program in heart failure, which has achieved national and international recognition- 15 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 In 1988, he received the Kenneth Piafsky Young Investigator Award from the Canadian Society for Clinical Pharmacology, and his current research is supported by both the Heart and Stroke Foundation of Ontario and the Canadian Institutes for Health Research. He is a frequent invited lecturer at national and international meetings, and has authored more than twenty book chapters, theses, and reviews, and has written more than one hundred and twenty manuscripts, more than two hundred abstracts, and many CME publications. He has been Chair of the Medical Advisory Committee of the HSFC, and has acted as referee for many granting agencies and journals. Dr. Arnold has been a member of the Cardiovascular B Committee of the MRC and CIHR Grants Review Committee, the Senior Personnel Awards Committee, and the Cardiovascular Review Committee of the Heart and Stroke Foundation of Canada, and sits on the Editorial Board of the Canadian Journal of Cardiology and the Journal of Cardiac Failure. He has served as a member of the Canadian Cardiovascular Society Scientific Program Committee, and was Chair of the Committee for 1997 and 1998. He has been a member of the Steering Committee for many important clinical trials, including CARE, SAVE, HEART, HOPE, RESOLVD, ELITE-2, OVERTURE, AF/CHF, STICH, and others. He has supervised many undergraduate and post-graduate students, and has had ten MSc students and two PhD students. Dr. Arnold’s particular areas of research interest are the therapeutic management of patients with heart failure, changes in the sympathetic nervous system and vasculature in patients with heart failure, the prevention of ischemic heart disease, and the application of clinical trials to clinical practice.- 16 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 ACC-LL Equipment Requirements The following is a preliminary list of equipment requirements for the ACC-LL Workshop. Final requirements will be determined by final format and logistical possibilities of the ACC-LL Workshop. • Plenary Room • Three break out rooms • Foyer with food set-up • Amphitheater format (half circle, broken in middle) • Two screens • Two LCDs, PA system, table for handouts and tools • Reprints of HF Guidelines • One computer with uploaded files • Raised dais with lectern • Portable mics (2), one floor mic, four table mics • Touch pads- 17 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 ACC-LL Expectations of Faculty The Faculty members are expected to meet the following requirements of the preparation and delivery of the ACC-LL Workshop: following is a preliminary list of equipment requirements for the ACC-LL Workshop. – Each faculty member deals with one case – During the meeting, each is the primary discussant of this case – Each Faculty must submit to Jonathan one case, along with touch pad compatible questions – Jonathan will determine the topic, format and supply the graphics – Teleconference Schedule 1. Goals, action items and Schedule (end-January) 2. Confirm deliverables, address outstanding issues (End-February, Early March) 3. Additional Teleconferences (as needed) – Face-to-face meeting day before/of at Lake Louise – Pre and Post Tests and questionnaires exploring knowledge, skills and attitudes will be prepared by a sub-committee of Simon Jackson and John Parker, working with appropriate expertise including Jack Tu (CCORT) and I Graham (AGREE)- 18 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 ACC-LL Project Management CCS has engaged the services of Expert Opinions Clinical Impact for overall coordination of Workshop preparation and logistical management of the workshop at ACC-LL. This coordination and management includes: • Confirmation and logistic support of all Faculty members (see above) • Travel arrangements for faculty and CCS • Venue selection and liaison with conference organizing committee • Liaison with CCS for administration, scheduling and programs • Pre and Post event coordination of secondary suppliers (Catering, AV, Hallmark Meeting Service, Ground Transportation) • Payment and management of secondary supplier invoices • Invitations-Coordination of design, content, printing and distribution to CCS members, ACC-LL delegates, CV nurses, hospital based pharmacists and heart failure clinics in AB and BC • Programs-Coordination of design, content and printing • Agenda-Coordination of speakers’ presentations and printed materials, coordination of 3 faculty conference calls, coordination of touch-pad questions with faculty case studies • Evaluation-Coordination of pre and post program evaluation and summary to CCS and faculty • Approval of all of the above by John Parker (CCS) and Jonathan Howlett (Faculty Chair)- 19 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 Appendix A: ACC-LL- Needs Assessment The imbedded document contains the Executive Summary of the needs assessment conducted by CSS for the 2006 Heart Failure Recommendations Program. The complete report is available from John Parker. This document is not for general distribution. C:\\Documents and Settings\\john\\My Doc Executive Summary: Needs Assessment of the 2006 CCS Heart Failure Consensus Recommendations Program (To access document, double-click icon)- 20 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 Appendix B: CCS Disclosure Statement The document below contains the CCS Conflict of Interest disclosure statement. All Faculty involved in the ACC-LL MUST complete this form. C:\\Documents and Settings\\john\\My Doc The document below contains a disclosure summary of the CCS Heart Failure Primary Panel participants. C:\\Documents and Settings\\john\\My Doc CCS Conflict of Interest Statement (To access document, double-click icon) CCS Heart Failure Primary Panel Disclosure Summary (To access document, double-click icon)- 21 - 2006 CCS HFCC – National Initiative Planning Document_V.3.1_04012006 Appendix C: CCS Business Plan and Investment Model The imbedded document contains the Executive Summary of the business plan and investment model for the 2006 CCS Heart Failure Consensus Recommendation Program. This document is not for general distribution. C:\\Documents and Settings\\john\\My Doc Executive Summary - 2006 CCS Heart Failure Consensus Recommendation Program (To access document, double-click icon)||http:\/\/www.hfcc.ca/downloads/stage3/National_Workshop_Initiative_Plan.pdf", "HFCC - Stage 3: Program Specifications|Home About Us Contact Us What's New! Important Notices Search Stage 3: Program Specifications Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 3: Investors The CCS Heart Failure Consensus Conference Recommendations Program is supported, by way of three-year unrestricted grants provided directly to CCS, by the following investment group: PLATINUM GOLD SILVER BRONZE These unrestricted grants are sufficient to see the Program though completion of the first three years of its five-year plan. HOW TO BECOME AN INVESTOR CCS continues to seek unrestricted support for the CCS Heart Failure Consensus Conference Recommendations Program from not-for-profit and for-profit investors. For more information on the levels of investment or to become an investor, please contact John Parker, Director Knowledge Translation ( parker@ccs.ca ). Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage3/investors.aspx", "HFCC - Stage 3 -> Primary Panel|Home About Us Contact Us What's New! Important Notices Search Stage 3: Program Specifications Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 3: Primary Panel The Primary Panel for the 2006 CCS Heart Failure Consensus Conference Recommendations was Chaired by Malcolm Arnold MD and Co-Chaired by Peter Liu MD. In all, the Primary Panel consists of 21 experts from across Canada recognized for their expertise in heart failure science and care. For the 2007 Update, CCS is very pleased to announce that Jonathan Howlett will serve as the new Co-Chair. We look forward to Jonathan’s contribution to these important Recommendations. Peter Liu has moved on to fulfill his new role as Scientific Director of the Institute for Respiratory and Circulatory Health of the Canadian Institutes of Health Research. Thankfully, Peter will remain an active member of the Impact Working Group for this initiative. The Primary Panel also includes formal representation from the College of Family Physicians of Canada, Canadian Nurses Association, Canadian Pharmacists Association, Canadian Geriatric Society, Canadian Society of Internal Medicine and the Canadian Association of Advanced Practice Nurses. These Primary Panel members brought exciting ideas to the document development process. The net result is a set of evidence-based recommendations which reflect the multi-disciplinary perspectives of those who provide heart failure care across Canada. Once completed, the recommendations were reviewed by the 12 members of the Secondary Panel for balance, objectivity and accuracy. Terms of Reference for the Primary Panel and its members can be found here. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage3/pp.aspx", "HFCC - Stage 3: Primary Panel Members|Home About Us Contact Us What's New! Important Notices Search Stage 3: Program Specifications Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 3: Primary Panel Members Dr. Malcolm Arnold LondonHealth Sciences Centre University Hospital London, ON Dr. Catherine Demers McMaster University Hamilton Health Sciences Corporation Hamilton, ON Dr. Paul Dorian St. Michael’s Hospital Cardiology Toronto, ON Dr. Anique Ducharme Institute de Cardiologie de Montréal Montréal, QC Dr. Nadia Giannetti CUSM- Hopital Royal Victoria Montréal, QC Dr. Haissam Haddad University of Ottawa Ottawa, ON Dr. George Heckman St. Joseph’sHealthcare Hamilton, ON Dr. Andrew Ignaszewski St. Paul’sHospital Vancouver, BC Dr. Debra Isaac Foothills Hospital Cardiology Calgary, AB Dr. David Johnstone Mazankowski, Alberta Heart Institute Edmonton, AB Dr. Philip Jong University of Toronto Toronto, ON Dr. Peter Liu Toronto General Hospital Toronto, ON Dr. Elizabeth Mann Queen Elizabeth II HSFC General Internal Medicine Halifax, NS Ms. Marie-Josée Martin Sunergia Management Montréal, QC Dr. Robert McKelvie McMaster University Hamilton, ON Dr. Gordon Moe St. Michaels’ Hospital Cardiology Toronto, ON Ms. Kelly O’Halloran Canadian Association of Advanced Practice Nurses Hamilton, ON Dr. John D. Parker Mount Sinai Hospital Toronto, ON Mr. John Parker Canadian Cardiovascular Society Knowledge Translation Ottawa, ON Dr. Vivek Rao Toronto General Hospital Division of Cardiovascular Surgery Toronto, ON Dr. Heather J. Ross Toronto General Hospital NCSB11-1203 Toronto, ON Dr. Errol Sequeira Streetsville Medical Center College of Family Physicians of Canada Mississauga, ON Ms. Anna Svedsen Canadian Council of Cardiovascular Nurses Ottawa, ON Dr. Koon Kang Teo McMaster University Chief of Cardiology Hamilton, ON Dr. Ross T. Tsuyuki University of Alberta Division of Cardiology-Epicore Ctr Edmonton, AB Dr. Michel White Institut de Cardiologie de Montréal Verdun, QC Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage3/pp_members.aspx", "HFCC - Stage 3: Core Development Team|Home About Us Contact Us What's New! Important Notices Search Stage 3: Program Specifications Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 3: Core Development Team The CCS has assembled a 'core development team' comprised of information technology, design, communications and business management expertise. These core development teams are charged with the responsibility of developing functional and technical specifications for dissemination, implementation and end-user evaluation stages of the Program. In doing so, the core development teams have access to expertise on Primary and Secondary Panels, Advisory Roundtable, Impact Working Group and end-users across currently three pilot sites involved in the Program. Terms of reference and current members of the core development teams can be found here. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage3/core_dev_team.aspx", "HFCC - Stage 3: Core Development Team - Members|Home About Us Contact Us What's New! Important Notices Search Stage 3: Program Specifications Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 3: Core Development Team - Members Mr. John Leggitt Nova Networks Ottawa, ON Ms. Marie-Josée Martin CCS Heart Failure Program Manager Montréal, QC Ms. Jody McCombe McCombe Design Ottawa, ON Ms. Marilyn Sinclair Co-President CME Solutions Canada Ltd Markham, ON Mr. Marc J. Villeneuve Nova Networks Ottawa, ON Ms. Vivianne Vinet Co-President CME Solutions Canada Ltd. Markham, ON Mr. Kevin Watters Nova Networks Ottawa, ON Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage3/core_dev_team_members.aspx", "Microsoft Word - TOR Core Development Team_V3.0_04082006.doc|- 1 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 2006 Heart Failure Consensus Conference Recommendations Program Terms of Reference for Core Development Teams- 2 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 Table of Contents Letter of Introduction…………………………………………………………...…...3 Milestones of Core Development Team………………………………………….4 Composition of Core Development Teams…..…………………………………..6 Needs Assessment Core Development Team...………………………………...9 Primary/Secondary Panel Core Development Team…………………………...11 Dissemination Core Development Team.………………………………………..13 Implementation Core Development Team...……………………………………..14 Evaluation Core Development Team……………………………………………..15- 3 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 Letter of Introduction RE: CCS Heart Failure Consensus Conference Recommendations Program – CDT Terms of Reference This document summarizes processes involved in completing the first cycle of the CCS Closed-loop Model of Consensus Conference development. These processes will be revised with each successive development cycle. Each stage of this development process consists of a ‘Core Development Team’ which is responsible for fulfilling stage-specific timelines, milestones and deliverables. Each Core Development Team consists of skill sets and expertise requisite for successful fulfillment of development stage requirements. Each Core Development Team is expected to access relevant advisory expertise of the Advisory Roundtable. The Advisory Roundtable represents pooled expertise which provides world-class counsel in the following areas: public and patient education, enduser information and access, continuing education and publishing, information technology, health policy and administration, guideline standards and outcomes and marketing and sales. Please feel free to contact John Parker (parker@ccs.ca) at any time. John will be happy to address your questions and comments on any aspect of this initiative. We are genuinely grateful for your continued support and interest and look forward to completing this important next stage of this project with you. Kindest regards, Heather Ross MD Chair CCS Consensus Conference Committee John Parker MN Director Knowledge Translation Malcolm Arnold MD Chair CCS Heart Failure Consensus Conference Jonathan Howlett MD Co-Chair CCS Heart Failure Consensus Conference- 4 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 Milestones of Core Development Teams The diagram below illustrates top-line milestones and deliverables for each of the five successive development cycles of the CCS Heart Failure Consensus Conference Recommendations Program: Milestones and Deliverables for CCS Heart Failure Consensus Conference Recommendations Program January 2006 Heart Failure Heart Failure Heart Failure Heart Failure Heart Failure Proof of Concept – Close the Development Loop – Needs Assessment Identify Development Processes and Prototypes Initiate Clinical Practice Impact and Health Evaluation Planning Participate in CIHR HF KT Barriers Research Develop/Execute Communication Strategy and Plan January 2007 January 2008 January 2009 January 2010 Integration of User Evaluation Analyses and Recommendations Share Dissemination/Implementation Tools & Evaluation Results with ART Refine and Augment Development Processes Finalize Practice and Health Outcome Impact Evaluation Planning Develop Publishing/Research Plan Integration of User Evaluation Analyses and Recommendations Refine and Augment Development Processes Initiate Practice and Health Outcome Impact Evaluation Replicate Closed Loop Development Processes With ACS Publish First Evaluation Results Integration of User Evaluation Analyses and Recommendations National Deployment Secure Long-Term Federal/Provincial Funding Continue Practice and Health Outcome Impact Evaluation Continue with ACS Closed Loop Development Integration of User Evaluation Analyses and Recommendations Secure Long-Term Federal/Provincial Funding Continue Practice and Health Outcome Impact Evaluation Report Initial Practice and Health Outcome Impact Initiate Closed Loop Development Processes with Arrhythmias- 5 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 Each of the above development cycles consists of five stages as depicted in the following ‘closed-loop’ development model adopted for this project: CCS Closed Loop Guidelines Development Model Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Program Dissemination& Implementation Stage 5: Evaluation & Recommendations CCS Closed Loop Guideline Development Model- 6 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 Composition of Core Development Teams A Core Development Team (CDT), comprised of essential skill sets and expertise, is assigned to each development stage. The composition of each CDT is outlined in the following table: Core Development Teams for CCS Heart Failure Consensus Conference Development Stage Core Development Team 1. Needs Assessment CCS Consensus Conference Chair/ Co-Chairs CCS Continuing Professional Development Chair CCS Director Knowledge Translation Mezzanine Business Consulting 2. Consensus Conference Update CCS Consensus Conference Chair/ Co-Chairs CCS Membership College of Family Physicians of Canada Canadian Pharmacists Society Canadian Geriatric Society Canadian Nurses Association CCS Staff CCS Director Knowledge Translation 3. Dissemination CCS Consensus Conference Chair/ Co-Chairs Microsoft Canada Nova Networks Canada CCS Staff CCS Director Knowledge Translation- 7 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 4. Implementation CCS Consensus Conference Chair/ Co-Chairs Microsoft Canada Nova Networks Canada CCS Staff CCS Director Knowledge Translation 5. Evaluation CCS Consensus Conference Chair/ Co-Chairs Microsoft Canada Nova Networks Canada CCS Staff CCS Director Knowledge Translation The essential skills and expertise of each CDT are augmented, on an as-needed basis, through ongoing access to the Advisory Roundtable and the CCS membership. The Advisory Roundtable consists of the following representation divided into seven expertise categories: CCS Heart Failure Consensus Conference Advisory Roundtable – Expertise Pools Canadian Institute for Health Information Canadian Institutes of Health Research BoehringerIngelheim Canada Statistics CanaCanadian Geriatric da Society Canadian Institute for Biovail Canada Health information Canadian College of Health Service Executives Canadian Congestive Heart Failure Clinics Network Canadian Pharmacists Association Roche Diagnostics Canada Institute of Circulatory and Respiratory Health Ministry of Health– British Columbia Canadian Journal of Cardiology Canadian Nurses Association Canadian AstraZenecaCanada Hypertension Education Program Ministry of Health– New Brunswick Global Medic – A CMA Company Royal College of Physicians and Surgeons of Canada College of Family Physicians of Canada Public Health Agency of Canada Ottawa Health Merck F rosstCanada Research Institute Ministry of Health– Nova Scotia College of Family Nova Networks Physicians of Canada Canadian Medical Association Heart and Stroke Foundation of Canada Canadian Sanofi- AventisCanada Cardiovascular Outcomes Research Team Public Health Agency of Canada Canadian Microsoft Canada Cardiovascular Society Canadian Cardiovascular Society Heart Failure Patient Support Group– Ottawa Heart Institute Communication, Marketing& Sales Guideline Standards and Outcomes Policy & Administration Information Technology Continuing Education & Publishing End- User Information and Access Patient & Public Education Canadian Canada- 8 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 The five stages of the first development cycle is scheduled for completion January 2006. The approximate timeline for the first development cycle is illustrated below: First Development Cycle Timeline for CCS Heart Failure Consensus Conference January 05 June 05 1 Needs Assessment Primary & Secondary Panels Dissemination Implementation Evaluation Pilot Testing, Evaluation, Analyses & Recommendatio4 ns Dissemination, Implementation & Evaluation Tools and Final HF CC Update Document 3 2 Dissemination, Implementation & Evaluation Plans 1 Final Needs Assessment Report 4 Recommendations 2 3 September 05 December 05 February 06 4- 9 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 Needs Assessment Core Development Team Purpose: The Needs Assessment identifies critical challenges, needs and expectations of those who, on a day-to-day basis, strive to utilize evidence-based recommendations to deliver high quality heart failure care to this Canadian patient population. For this first development cycle of the Program, the Needs Assessment included the Primary Panel, a representative sample of CCS membership and members of the Advisory Roundtable. In addition, three pilot sites, representative of the day-to-day delivery of heart failure care, were included in the needs assessment. In all, specialists, community-based cardiologists, internal medicine specialists, family physicians, pharmacists, nurses and patients from across Canada provided valuable insight into the challenges of applying evidence-based recommendations to the provision of day-today heart failure care. Once analyzed, the data of the Needs Assessment provided: • essential guidance for the Primary Panel as it considers the balance, validity, reliability, relevance, practicality and cost implications of evidence-based, heart failure care recommendations • critical strategic and tactical direction for Dissemination, Implementation and Evaluation core development teams • a precedent-setting opportunity to collaborate with and learn more of the needs and challenges of Canadian disciplines and sectors involved in delivery of heart failure care • opportunity for CCS to take a leading role in applying the Appraisal of Guidelines Research and Evaluation (AGREE) Collaboration Instrument, the development standards.- 10 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 The initial Needs Assessment defined the requirements of health care professionals and patients to achieve successful dissemination and implementation of evidence-based recommendations. Deliverable: The Needs Assessment team tabled a completed needs assessment for review by the Primary and Secondary Panels and Dissemination, Implementation and Evaluation Teams. The Needs Assessment report includes data analyses and recommendations relevant to Dissemination, Implementation and Evaluation Stages of the first development cycle.- 11 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 Primary/Secondary Panel Core Development Teams Purpose: The Primary Panel is the main writing committee for the consensus conference and is comprised of CCS members with expertise in the topic area. Through the established CCS development process, they decide the substantive content of the document. Together, the Primary Panel reflects content expertise for the topic addressed in addition to the diversity of the CCS membership with respect to geography and type of practice as they apply to the topic area. The Primary Panel should also be representative of the audience of health professionals that use the material including family practitioners, IM specialists and others, as applicable. Secondary Panel members provide feedback and guidance on drafts and provide a wider perspective on the topic. Secondary panel members may not be CCS members but have internationally recognized topic expertise or are key members of the targeted audience group. Secondary panel members may be topic experts but not necessarily CCS members. Secondary panel members have the capacity to consult on consensus conference drafts in terms of content, presentation and relevance to the audience addressed. Specific terms of reference for each panel are summarized below: 1. Term of Co-Chair: • Two years on a staggered basis to provide continuity • One year as past chair to improve continuity • Identification of new Co-Chair determined by Primary Panel and approved by CCS Consensus Conference Committee- 12 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 • Nominated Chairs should have served a minimum of two years as Primary Panel Member 2. Term of Primary Panel Members: • Three years on a staggered basis • Identification of new Primary Panel members determined by existing Primary Panel and Co-Chairs • The Primary Panel should be regarded as a professional development opportunity for younger members of the Canadian cardiovascular community • Primary Panel will be representative of the Canadian cardiovascular community at-large 3. Responsibilities and term of Secondary Panel Members: • Three years on a staggered basis • Identification of new Secondary Panel members determined by Co-Chairs Deliverable: The Primary and Secondary Panels prepare and deliver a final document representing world-class, evidence-based recommendations suitable for delivery in the Canadian health care context. Once complete, the document is passed on to the Dissemination Team for development of dissemination strategies and tactics. The 2006 CCS Heart Failure Consensus Conference Recommendations was completed December 15, 2005 and published in the Canadian Journal of Cardiology in January 2006. Similar updates are planned for publication in the Canadian Journal of Cardiology in January 2007 and 2008.- 13 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 Dissemination Core Development Teams Purpose: The Dissemination Team develops specifications for integrated strategies and tools designed to broaden awareness, acceptance, uptake and adherence of CCS guidelines by those health care practitioners and patients involved in delivery of day-today care. The Team receives the final report and recommendations from the Needs Assessment Team in addition to the final CCS Consensus Conference on the Diagnosis and Management of Heart Failure – Update 2006 from the Primary Panel Co-Chairs. After considering the results and recommendations of the Needs Assessment, the Dissemination Team consolidates, refines and augments existing CCS dissemination efforts. In addition, the Dissemination Team develops and implements an effective communications strategy and plan which build upon current CCS corporate-level investments in both communications and IT. Deliverables: These may include specifications for didactic presentations and participatory workshops, online document retrieval, practice audits, hand-held device applications and various paper-based products including ’pocket cards’. These efforts will be seamlessly integrated into CCS corporate-level IT, communications and customer service strategies and programs currently in development. The Dissemination Team will be responsible for identifying, developing, testing and delivering components of the dissemination strategy. In addition, the Dissemination Team will begin development of a longer-term implementation plan which encompasses the remaining four development cycles of the Program.- 14 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 Implementation Core Development Teams Purpose: The Implementation Team will deliver integrated tools designed to broaden voluntary and recurring use of guidelines by health care practitioners and patients involved in day-to-day heart failure care. The Implementation Team receives the final report and recommendations from Needs Assessment Team, the final CCS Consensus Conference on the Diagnosis and Management of Heart Failure – Update 2006 from the Primary Panel Co-Chairs and technical specifications developed by the Dissemination Team. Deliverables: The deliverables of this development stage will be seamlessly integrated into CCS corporate-level IT, communications and customer service strategies and programs currently in development. The Implementation Team will be responsible for identifying, developing, testing and delivering components of the dissemination strategy for the first development cycle. These may include a paper-based pocket, online practice audit and series of participatory workshops. In addition, the Implementation Team will develop communication tactics following specifications of the Dissemination Team and in alignment with CCS corporate-level activities in this regard.- 15 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 Evaluation Core Development Teams Purpose: The first cycle of the HF CC will involve four concurrent streams of evaluation activity including: o Strategy, tactics and processes of the close-loop model of CC development o Functionality and usability of dissemination and implementation strategies and tools o Degree of compliance with the Appraisal of Guidelines Research and Evaluation (AGREE) Instrument o Initial consideration and preparation for longer-term evaluation of impact on clinical practice patterns and health outcome The Evaluation Team receives the final report and recommendations from Needs Assessment Team, the final CCS Consensus Conference on the Diagnosis and Management of Heart Failure – Update 2006 from the Primary Panel Co-Chairs and technical specifications and tools developed by Dissemination and Implementation Teams. Deliverables: The deliverables of this development stage will be seamlessly integrated into CCS corporate-level IT, communications and customer service strategies and programs currently in development. The Evaluation Team will be responsible for: o Development of strategy for integration of recommendations into Cycle 2 of CCS HF CC. o Development of strategy for ongoing research, reporting and publication of program- 16 - 2006 CCS HFCC – TOR CDT_V.3.0_04082006 From a long-term perspective, CCS has assembled its first-ever Guidelines Clinical Practice Impact and Health Outcomes Working Group comprised of the following representation: • CCS Consensus Conference Chair/Co-Chairs • Primary Panel Members • Canadian Cardiovascular Outcomes Research Team • Canadian Institute for Health Information • Canadian Institutes of Health Research • Heart and Stroke Foundation of Canada • Canadian Cardiovascular Outcomes Research Team • Canadian Congestive Heart Failure Clinics Network • Mezzanine Business Consulting • CCS Staff||http:\/\/www.hfcc.ca/downloads/stage3/Terms_of_Reference_CDT.pdf", "HFCC - Stage 4 -> Dissemination Strategies|Home About Us Contact Us What's New! Important Notices Search Stage 4: Dissemination & Implementation Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: Stage 4: Dissemination Strategies Participants of the end-user needs assessment identified several dissemination strategies and tools which, in their view, would enhance understanding, acceptance and recurring application of the Heart Failure Consensus Conference Recommendations in day-to-day practice. Of these strategies, CCS is currently developing a pocket card for quick reference, an online practice audit, a slide kit and a series of four regional, highly interactive workshops scheduled for 2006. In addition, CCS is collaborating with a number of other professional societies for publication of the Heart Failure Consensus Conference Recommendations in four professional journals in March 2006 including: Canadian Family Physician (College of Family Physicians of Canada), Canadian Nurse (Canadian Nurses Association), Geriatrics Today (Canadian Geriatrics Association) and the Canadian Pharmacists Journal (Canadian Pharmacists Association). Functional specifications for these dissemination strategies are found here. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage4/dissemination_strategies.aspx", "HFCC - Stage 5 -> CCS HF CC Compliance|Home About Us Contact Us What's New! Important Notices Search Stage 5: Evaluation & Recommendations Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation HFCC Newsletter Sign-Up Enter your email address: Stage 5: AGREE Standard AGREE stands for Appraisal of Guidelines Research and Evaluation. It originates from an international collaboration of researchers and policy makers who work together to improve the quality and effectiveness of clinical practice guidelines by establishing a shared framework for their development, reporting and assessment. (Adapted from the AGREE Collaboration Website: http:\/\/www.agreecollaboration.org/intro/ , February 2006). CCS has adopted the AGREE approach for the Heart Failure Consensus Conference Recommendations Program. In doing so, CCS hopes to benchmark its efforts in this Program against internationally recognized standards of guidelines development and set the stage for ongoing evaluation and improvement of the Heart Failure Consensus Conference Recommendations. The AGREE Instrument for evaluating guidelines and CCS' AGREE Compliance rating for 2006 can be found here. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage5/agree_standard.aspx", "AGREE_Instrument_AGREE_Collaboration_2001.pdf|APPRAISAL OF GUIDELINES FOR RESEARCH & EVALUATION INSTRUMENT The AGREE Collaboration September 2001COPYRIGHT AND REPRODUCTION This document is the product of an international collaboration. It may be reproduced and used for educational purposes, quality assurance programmes and critical appraisal of clinical practice guidelines. It may not be used for commercial purposes or product marketing. Approved non-English language versions of the AGREE Instrument are being prepared, and must be used where available. Offers of assistance in translation into other languages are welcome, provided they conform to the protocol set out by the AGREE Collaboration. DISCLAIMER The AGREE Instrument is a generic tool designed primarily to help guideline developers and users assess the methodological quality of clinical practice guidelines. The authors do not take responsibility for the improper use of the AGREE Instrument. © St George’s Hospital Medical School, London, June 2001 Reprinted with amendments September 2001 ISBN 1 8981 8321 X SUGGESTED CITATION: The AGREE Collaboration. Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument. www.agreecollaboration.org FUNDING: The development of the AGREE Instrument was funded by a grant from the EU BIOMED2 Programme (BMH4-98-3669) FOR FURTHER INFORMATION ABOUT THE INSTRUMENT CONTACT: Françoise Cluzeau Email: f.cluzeau@sghms.ac.uk or Jako Burgers Email: j.burgers@hsv.kun.nl Typeset by CA Group, LondonThe purpose of the Appraisal of Guidelines Research & Evaluation (AGREE) Instrument is to provide a framework for assessing the quality of clinical practice guidelines. Clinical practice guidelines are ‘systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances’1. Their purpose is ‘to make explicit recommendations with a definite intent to influence what clinicians do’2. By quality of clinical practice guidelines we mean the confidence that the potential biases of guideline development have been addressed adequately and that the recommendations are both internally and externally valid, and are feasible for practice. This process involves taking into account the benefits, harms and costs of the recommendations, as well as the practical issues attached to them. Therefore, the assessment includes judgements about the methods used for developing the guidelines, the content of the final recommendations, and the factors linked to their uptake. The AGREE Instrument assesses both the quality of the reporting, and the quality of some aspects of recommendations. It provides an assessment of the predicted validity of a guideline, that is the likelihood that it will achieve its intended outcome. It does not assess the impact of a guideline on patients’ outcomes. Most of the criteria contained in the AGREE Instrument are based on theoretical assumptions rather than on empirical evidence. They have been developed through discussions between researchers from several countries who have extensive experience and knowledge of clinical guidelines. Thus, the AGREE Instrument should be perceived as reflecting the current state of knowledge in the field. The AGREE Instrument is designed to assess guidelines developed by local, regional, national or international groups or affiliated governmental organisations. These include: 1. New guidelines 2. Existing guidelines 3. Updates of existing guidelines The AGREE Instrument is generic and can be applied to guidelines in any disease area including those for diagnosis, health promotion, treatment or interventions. It is suitable for guidelines presented in paper or electronic format. 1 Lohr KN, Field MJ. A provisional instrument for assessing clinical practice guidelines. In: Field MJ, Lohr KN (eds). Guidelines for clinical practice. From development to use. Washington D.C. National Academy Press, 1992. 2 Hayward RSA, Wilson MC, Tunis SR, Bass EB, Guyatt G, for the Evidence-Based Medicine Working Group. Users’ guides to the Medical Literature. VIII. How to Use Clinical Practice Guidelines. A. Are the Recommendations Valid? JAMA, 1995;274, 570-574. 2 AGREE APPRAISAL INSTRUMENT INTRODUCTION Purpose of the AGREE Instrument. Which guidelines can be appraised with the AGREE Instrument.3 The AGREE Instrument is intended to be used by the following groups: i) By policy makers to help them decide which guidelines could be recommended for use in practice. In such instances, the instrument should be part of a formal assessment process. ii) By guideline developers to follow a structured and rigorous development methodology and as a selfassessment tool to ensure that their guidelines are sound. iii) By health care providers who wish to undertake their own assessment before adopting the recommendations iv) By educators or teachers to help enhance critical appraisal skills amongst health professionals. The following sources have been used for developing the AGREE Instrument criteria. Lohr KN, Field MJ. A provisional instrument for assessing clinical practice guidelines. In: Field MJ, Lohr KN (eds). Guidelines for clinical practice. From development to use. Washington D.C. National Academy Press, 1992. Cluzeau F, Littlejohns P, Grimshaw J, Feder G, Moran S. Development and application of a generic methodology to assess the quality of clinical guidelines. International Journal for Quality in Health Care 1999;11:21-28. Grol R, Dalhuijzen J, Mokkink H, Thomas S, Veld C, Rutten G. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ 1998;317:858-861. Lohr KN. The quality of practice guidelines and the quality of health care. In: Guidelines in health care. Report of a WHO Conference. January 1997, Baden-Baden: Nomos Verlagsgesellschaft, 1998. AGREE APPRAISAL INSTRUMENT INTRODUCTION Who can use the AGREE Instrument? Key references4 1. Structure and content of the AGREE Instrument AGREE consists of 23 key items organised in six domains. Each domain is intended to capture a separate dimension of guideline quality. Scope and purpose (items 1-3) is concerned with the overall aim of the guideline, the specific clinical questions and the target patient population. Stakeholder involvement (items 4-7) focuses on the extent to which the guideline represents the views of its intended users. Rigour of development (items 8-14) relates to the process used to gather and synthesise the evidence, the methods to formulate the recommendations and to update them. Clarity and presentation (items 15-18) deals with the language and format of the guideline. Applicability (items 19-21) pertains to the likely organisational, behavioural and cost implications of applying the guideline. Editorial independence (items 22-23) is concerned with the independence of the recommendations and acknowledgement of possible conflict of interest from the guideline development group. 2. Documentation Appraisers should attempt to identify all information about the guideline development process prior to appraisal. This information may be contained in the same document as the recommendations or it may be summarised in a separate technical report, in published papers or in policy reports (e.g. guideline programmes). We recommend that you read the guideline and its accompanying documentation fully before you start the appraisal. 3. Number of appraisers We recommend that each guideline is assessed by at least two appraisers and preferably four as this will increase the reliability of the assessment. 4. Response scale Each item is rated on a 4-point scale ranging from 4 ‘Strongly Agree’ to 1 ‘Strongly Disagree’, with two mid points: 3 ‘Agree’ and 2 ‘Disagree’. The scale measures the extent to which a criterion (item) has been fulfilled. • If you are confident that the criterion has been fully met then you should answer ‘Strongly Agree’. • If you are confident that the criterion has not been fulfilled at all or if there is no information available then you should answer ‘Strongly Disagree’. • If you are unsure that a criterion has been fulfilled, for example because the information is unclear or because only some of the recommendations fulfil the criterion, then you should answer ‘Agree’ or ‘Disagree’, depending on the extent to which you think the issue has been addressed. 5. User Guide We have provided additional information in the User Guide adjacent to each item. This information is intended to help you understand the issues and concepts addressed by the item. Please read this guidance carefully before giving your response. AGREE APPRAISAL INSTRUMENT INSTRUCTIONS FOR USE Please read the following instructions carefully before using the AGREE Instrument.5 6. Comments There is a box for comments next to each item. You should use this box to explain the reasons for your responses. For example, you may ‘Strongly Disagree’ because the information is not available, the item is not applicable, or the methodology described in the information provided is unsatisfactory. Space for further comments is provided at the end of the instrument. 7. Calculating domain scores Domain scores can be calculated by summing up all the scores of the individual items in a domain and by standardising the total as a percentage of the maximum possible score for that domain. Note: The six domain scores are independent and should not be aggregated into a single quality score. Although the domain scores may be useful for comparing guidelines and will inform the decision as to whether or not to use or to recommend a guideline, it is not possible to set thresholds for the domain scores to mark a ‘good’ or ‘bad’ guideline. 8. Overall assessment A section for overall assessment is included at the end of the instrument. This contains a series of options ‘Strongly recommend’, ‘Recommend (with provisos or alterations)’, ‘Would not recommend’ and ‘Unsure’. The overall assessment requires the appraiser to make a judgement as to the quality of the guideline, taking each of the appraisal criteria into account. AGREE APPRAISAL INSTRUMENT INSTRUCTIONS FOR USE Please read the following instructions carefully before using the AGREE Instrument. Example: If four appraisers give the following scores for Domain 1 (Scope & purpose): Appraiser 3 Item 1 Item 2 Item 3 Total Appraiser 1 2 3 3 8 Appraiser 2 3 3 4 10 Appraiser 3 2 4 3 9 Appraiser 4 2 3 4 9 Total 9 13 14 36 Maximum possible score = 4 (strongly agree) x 3 (items) x 4 (appraisers) = 48 Minimum possible score = 1 (strongly disagree) x 3 (items) x 4 (appraisers) = 12 The standardised domain score will be: obtained score – minimum possible score Maximum possible score – minimum possible score 36–12 24 48–12 36 = = 0.67 x 100 = 67% =6 4 3 2 1 Comments Strongly Agree 1. The overall objective(s) of the guideline is (are) specifically described. Strongly Disagree Comments Comments 2. The clinical question(s) covered by the guideline is(are) specifically described. 3. The patients to whom the guideline is meant to apply are specifically described. AGREE APPRAISAL INSTRUMENT SCOPE AND PURPOSE Strongly Agree 4 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree7 This deals with the potential health impact of a guideline on society and populations of patients. The overall objective(s) of the guideline should be described in detail and the expected health benefits from the guideline should be specific to the clinical problem. For example specific statements would be: • Preventing (long term) complications of patients with diabetes mellitus; • Lowering the risk of subsequent vascular events in patients with previous myocardial infarction; • Rational prescribing of antidepressants in a cost-effective way. 1. A detailed description of the clinical questions covered by the guideline should be provided, particularly for the key recommendations (see item 17). Following the examples provided in question 1: • How many times a year should the HbA1c be measured in patients with diabetes mellitus? • What should the daily aspirin dosage for patients with proven acute myocardial infarction be? • Are selective serotonin reuptake inhibitors (SSRIs) more cost-effective than tricyclic antidepressants (TCAs) in treatment of patients with depression? 2. There should be a clear description of the target population to be covered by a guideline. The age range, sex, clinical description, comorbidity may be provided. For example: • A guideline on the management of diabetes mellitus only includes patients with non-insulin dependent diabetes mellitus and excludes patients with cardiovascular comorbidity. • A guideline on the management of depression only includes patients with major depression, according to the DSM-IV criteria, and excludes patients with psychotic symptoms and children. • A guideline on screening of breast cancer only includes women, aged between 50 and 70 years, with no history of cancer and with no family history of breast cancer. 3. USER GUIDE SCOPE AND PURPOSE8 4. The guideline development group includes individuals from all the relevant professional groups. 5. The patients’ views and preferences have been sought. 6. The target users of the guideline are clearly defined. 7. The guideline has been piloted among target users. AGREE APPRAISAL INSTRUMENT STAKEHOLDER INVOLVEMENT Comments Comments Comments Comments Strongly Agree 4 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree9 This item refers to the professionals who were involved at some stage of the development process. This may include members of the steering group, the research team involved in selecting and reviewing /rating the evidence and individuals involved in formulating the final recommendations. This item excludes individuals who have externally reviewed the guideline (see Item 13). Information about the composition, discipline and relevant expertise of the guideline development group should be provided. 4. Information about patients’ experiences and expectations of health care should inform the development of clinical guidelines. There are various methods for ensuring that patients’ perspectives inform guideline development. For example, the development group could involve patients’ representatives, information could be obtained from patient interviews, literature reviews of patients’ experiences could be considered by the group. There should be evidence that this process has taken place. 5. The target users should be clearly defined in the guideline, so they can immediately determine if the guideline is relevant to them. For example, the target users for a guideline on low back pain may include general practitioners, neurologists, orthopaedic surgeons, rheumatologists and physiotherapists. 6. A guideline should have been pre-tested for further validation amongst its intended end users prior to publication. For example, a guideline may have been piloted in one or several primary care practices or hospitals. This process should be documented. 7. USER GUIDE STAKEHOLDER INVOLVEMENT10 8. Systematic methods were used to search for evidence. 9. The criteria for selecting the evidence are clearly described. 10. The methods used for formulating the recommendations are clearly described. 11. The health benefits, side effects and risks have been considered in formulating the recommendations. AGREE APPRAISAL INSTRUMENT RIGOUR OF DEVELOPMENT Comments Comments Comments Comments Strongly Agree 4 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree11 Details of the strategy used to search for evidence should be provided including search terms used, sources consulted and dates of the literature covered. Sources may include electronic databases (e.g. MEDLINE, EMBASE, CINAHL), databases of systematic reviews (e.g. the Cochrane Library, DARE), handsearching journals, reviewing conference proceedings and other guidelines (e.g. the US National Guideline Clearinghouse, the German Guidelines Clearinghouse). 8. Criteria for including /excluding evidence identified by the search should be provided. These criteria should be explicitly described and reasons for including and excluding evidence should be clearly stated. For example, guideline authors may decide to only include evidence from randomised clinical trials and to exclude articles not written in English. 9. There should be a description of the methods used to formulate the recommendations and how final decisions were arrived at. Methods include for example, a voting system, formal consensus techniques (e.g. Delphi, Glaser techniques). Areas of disagreement and methods of resolving them should be specified. 10. The guideline should consider health benefits, side effects, and risks of the recommendations. For example, a guideline on the management of breast cancer may include a discussion on the overall effects on various final outcomes. These may include: survival, quality of life, adverse effects, and symptom management or a discussion comparing one treatment option to another. There should be evidence that these issues have been addressed. 11. USER GUIDE RIGOUR OF DEVELOPMENT12 AGREE APPRAISAL INSTRUMENT RIGOUR OF DEVELOPMENT Comments 12. There is an explicit link between the recommendations and the supporting evidence. Comments Comments 13. The guideline has been externally reviewed by experts prior to its publication. 14. A procedure for updating the guideline is provided. Strongly Agree 4 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree13 USER GUIDE RIGOUR OF DEVELOPMENT There should be an explicit link between the recommendations and the evidence on which they are based. Each recommendation should be linked with a list of references on which it is based. 12. A guideline should be reviewed externally before it is published. Reviewers should not have been involved in the development group and should include some experts in the clinical area and some methodological experts. Patients’ representatives may also be included. A description of the methodology used to conduct the external review should be presented, which may include a list of the reviewers and their affiliation. 13. Guidelines need to reflect current research. There should be a clear statement about the procedure for updating the guideline. For example, a timescale has been given, or a standing panel receives regularly updated literature searches and makes changes as required. 14.14 AGREE APPRAISAL INSTRUMENT CLARITY AND PRESENTATION 15. The recommendations are specific and unambiguous. 16. The different options for management of the condition are clearly presented. 17. Key recommendations are easily identifiable. 18. The guideline is supported with tools for application. Comments Comments Comments Comments Strongly Agree 4 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree15 A recommendation should provide a concrete and precise description of which management is appropriate in which situation and in what patient group, as permitted by the body of evidence. • An example of a specific recommendation is: Antibiotics have to be prescribed in children of two years or older with acute otitis media if the complaint last longer than three days or if the complaint increase after the consultation despite adequate treatment with painkillers; in these cases amoxycillin should be given for 7 days (supplied with a dosage scheme). • An example of a vague recommendation is: Antibiotics are indicated for cases with an abnormal or complicated course. However, evidence is not always clear cut and there may be uncertainty about the best management. In this case the uncertainty should be stated in the guideline. 15. A guideline should consider the different possible options for screening, prevention, diagnosis or treatment of the condition it covers. These possible options should be clearly presented in the guideline. For example, a recommendation on the management of depression may contain the following alternatives: a. Treatment with TCA b. Treatment with SSRI c. Psychotherapy d. Combination of pharmacological and psychological therapy 16. Users should be able to find the most relevant recommendations easily. These recommendations answer the main clinical questions that have been covered by the guideline. They can be identified in different ways. For example, they can be summarised in a box, typed in bold, underlined or presented as flow charts or algorithms. 17. For a guideline to be effective it needs to be disseminated and implemented with additional materials. These may include for example, a summary document, or a quick reference guide, educational tools, patients’ leaflets, computer support, and should be provided with the guideline. 18. USER GUIDE CLARITY AND PRESENTATION16 AGREE APPRAISAL INSTRUMENT APPLICABILITY Comments 19. The potential organisational barriers in applying the recommendations have been discussed. Comments Comments 20. The potential cost implications of applying the recommendations have been considered. 21. The guideline presents key review criteria for monitoring and/or audit purposes. 4 Strongly Agree 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree17 USER GUIDE APPLICABILITY Applying the recommendations may require changes in the current organisation of care within a service or a clinic which may be a barrier to using them in daily practice. Organisational changes that may be needed in order to apply the recommendations should be discussed. For example: i. A guideline on stroke may recommend that care should be co-ordinated through stroke units and stroke services. ii. A guideline on diabetes in primary care may require that patients are seen and followed up in diabetic clinics. 19. The recommendations may require additional resources in order to be applied. For example, there may be a need for more specialised staff, new equipment, expensive drug treatment. These may have cost implications for health care budgets. There should be a discussion of the potential impact on resources in the guideline. 20. Measuring the adherence to a guideline can enhance its use. This requires clearly defined review criteria that are derived from the key recommendations in the guideline. These should be presented. Examples of review criteria are: • The HbA1c should be < 8.0%. • The level of diastolic blood pressure should be < 95 mmHg. • If complaints of acute otitis media lasts longer than three days amoxicillin should be prescribed. 21.18 AGREE APPRAISAL INSTRUMENT EDITORIAL INDEPENDENCE FURTHER COMMENTS 22. The guideline is editorially independent from the funding body. 23. Conflicts of interest of guideline development members have been recorded. Comments Comments Strongly Agree 4 3 2 1 Strongly Disagree Strongly Agree 4 3 2 1 Strongly Disagree19 FURTHER COMMENTS Some guidelines are developed with external funding (e.g. Government funding, charity organisations, pharmaceutical companies). Support may be in the form of financial contribution for the whole development, or for parts of it, e.g. printing of the guidelines. There should be an explicit statement that the views or interests of the funding body have not influenced the final recommendations. Please note: If it is stated that a guideline was developed without external funding, then you should answer ‘Strongly Agree’. 22. There are circumstances when members of the development group may have conflicts of interest. For example, this would apply to a member of the development group whose research on the topic covered by the guideline is also funded by a pharmaceutical company. There should be an explicit statement that all group members have declared whether they have any conflict of interest. 23. USER GUIDE EDITORIAL INDEPENDENCE20 AGREE APPRAISAL INSTRUMENT Strongly recommend Comments Recommend (with provisos or alterations) Would not recommend Unsure Would you recommend these guidelines for use in practice? OVERALL ASSESSMENT NOTESThe AGREE Collaboration. Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument. www.agreecollaboration.org||http:\/\/www.hfcc.ca/downloads/stage5/AGREE_Instrument_AGREE_Collaboration_2001.pdf", "Microsoft Word - CCS HF CC AGREE Assessment 2006 _V3.0_04282006.doc|- 1 – CCS HF CC AGREE Assessment 2006_V3.0_04282006 CCS AGREE ASSESSMENT 2006 The CCS Heart Failure Consensus Recommendations recently underwent assessment using the Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument (http:\/\/www.agreetrust.org/ ). The AGREE instrument consists of 23 key items organized in six domains which, together, reflect guideline quality: Scope and purpose are concerned with the overall aim of the guideline, the specific clinical questions and the target patient population. Stakeholder involvement focuses on the extent to which the guideline represents the views of its intended users. Rigor of development relates to the process used to gather and synthesize the evidence, the methods to formulate the recommendations and to update them. Clarity and presentation deal with the language and format of the guideline. Applicability pertains to the likely organizational, behavioral and cost implications of applying the guideline. Editorial independence is concerned with the independence of the recommendations and acknowledgement of possible conflict of interest from the guideline development group. CCS Agree Review 2006 - Process CCS recruited the participation of six volunteers (five physicians and one registered nurse) from the University of Ottawa Heart Institute. These volunteers were provided a brief introduction to the AGREE Assessment process along with a description of where information might be found to complete the review. They were provided two weeks to complete the review and submitted their results directly to CCS. CSS wishes to express its genuine gratitude to Dr. Ian Graham, University of Ottawa, Ottawa, Ontario, who provided very generous direction and counsel throughout this firstever review.- 2 – CCS HF CC AGREE Assessment 2006_V3.0_04282006 The results of the CCS AGREE Assessment for 2006 demonstrate that the CCS performs many activities within its guidelines development process extremely well. These activities include: Proficiencies Identified Within the CCS Consensus Development Process • Clear presentation and definitions of the guidelines objective, clinical questions(s) and relevant patient populations • Significant consideration is given to health benefits, side effects and risks in formulating recommendations • Explicit link between recommendations and supporting evidence • External review process is considered excellent • Recommendations are clearly presented and include welcomed options for management • Both editorial independence and conflicts of interest are transparent Based on the results of the CCS AGREE Assessment for 2006, CCS has identified the following priorities which will be addressed prior to publication of the next update of the Heart Failure Consensus Conference in the Canadian Journal of Cardiology, January 2007. Improvements Identified for Update 2007 Document • Extend current multi-disciplinary, patient population and end user participation during the Update 2007 process (e.g. broaden Primary Panel representation, end-user and patient focus groups) • Pilot the beta version of the guidelines within the program’s three pilot sites prior to publication of the Update 2007 document • Provide more detailed descriptions of evidence search and selection methods, formulation and linking of recommendations with supporting evidence and the process for updating the guidelines within the Update 2007 document • Continue efforts to enhance dissemination of recommendations • Clarify and state the degree to which the guidelines address organizational barriers to implementation, cost implications and monitoring/auditing within the Update 2007 document A formal AGREE review will be undertaken for the 2007 update of the CCS Heart Failure Consensus Recommendations.||http:\/\/www.hfcc.ca/downloads/stage5/CCSHFCC_AGREE_Assessment_2006.pdf", "HFCC - Stage 5: 2006 CCC Heartfailure Workshop Initiative|Home About Us Contact Us What's New! Important Notices Search Stage 5: Evaluation & Recommendations Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation HFCC Newsletter Sign-Up Enter your email address: Stage 5: 2006 CCC Heartfailure Workshop Initiative The CCS National Heart Failure Workshop Initiative continued to gather momentum at the recent International Heart Failure Summit, June 16, 2006 in Toronto , Ontario . The CCS delivered the second in its series of regional heart failure workshops as part of its multi-year CCS Heart Failure Consensus Program. CCS continues to gather feedback, comments and insights from workshop participants. Both pre- and post-feedback was gathered during the Toronto workshop. With a 60% return rate and 91% of respondents rating the workshop as either very good or excellent, CCS continues to better understand the needs of end-users of its Consensus Recommendations. Further, the ongoing evaluation of these workshops enables CCS to fulfill its commitment to eliciting the help of the entire multi-disciplinary community in shaping the future of evidence-based cardiovascular care in Canada . Complete results of the pre-workshop questionnaire can be found here . Complete results of the post-workshop evaluations can be found here . Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage5/cc_workshop_initiative.aspx", "HFCC - Stage 5: Impact Working Group|Home About Us Contact Us What's New! Important Notices Search Stage 5: Evaluation & Recommendations Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation HFCC Newsletter Sign-Up Enter your email address: Stage 5: Impact Working Group The Impact Working Group (IWG) was recently formed by CCS to establish and execute a five year impact analysis and communication strategy for the Heart Failure Consensus Conference Recommendations Program. This strategy focuses on quantifying potential impact of these evidence-based recommendations on both clinical practice patterns and health outcomes. The first meeting of this group took place in Toronto on January 4, 2006 followed by a teleconference on February 10, 2006. A second face-to-face meeting is scheduled for March 2006. Representation on the IWG includes CCS, Heart and Stroke Foundation of Canada, Canadian Institutes of Health Research, Canadian Institute of Health Information, Canadian Cardiovascular Outcomes Research Team, Canadian Congestive Heart Failure Clinics Network and others. The IWG represents recent and significant growth of the CCS Heart Failure Consensus Conference Recommendations Program and the potential of this initiative to quantify impact of these evidence-based recommendations on both clinical practice patterns and health outcomes. Terms of Reference and membership for the IWG can be found here. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage5/impact_working_group.aspx", "HFCC - Stage 5: Impact Working Group - Members|Home About Us Contact Us What's New! Important Notices Search Stage 5: Evaluation & Recommendations Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation HFCC Newsletter Sign-Up Enter your email address: Stage 5: Impact Working Group - Members Dr. Malcolm Arnold London Health Sciences Centre University Hospital London, ON Dr. Heather J. Ross TorontoGeneral Hospital NCSB11-1203 Toronto, ON Dr. Andrew Ignazewski St. Paul’s Hospital Vancouver, BC Dr. Ian Graham University of Ottawa Ottawa Hospital, Civic Campus Ottawa, ON Dr. Jonathan Howlett Queen Elizabeth II Health Sciences Centre Halifax, NS Dr. Jack V. Tu Institute for Clinical Evaluative Sciences Toronto, ON Dr. Peter Liu TorontoGeneral Hospital Toronto, ON Dr. Greg Webster Canadian Institute of Health Information Research and Indicator Development Toronto, ON Dr. Anique Ducharme Institut de Cardiologie de Montréal Montréal, QC Ms. Elizabeth Stirling Canadian Institutes of Health Research Ottawa, ON Mr. Mark Healy Mezzanine Business Consulting Toronto, ON Ms. Sally Brown The Heart and Stroke Foundation of Canada Ottawa, ON Dr. Vaska Micevski The TorontoGeneral Hospital Cardiology North Building 4-499 Toronto, ON Ms. Francine Duquette The TorontoGeneral Hospital Toronto, ON Ms. Wendy Lecompte The Heart and Stroke Foundation of Canada Ottawa, ON Ms. Marie-Josée Martin Sunergia Management Montréal, QC Mr. John Parker Canadian Cardiovascular Society Knowledge Translation Ottawa, ON Ms. Fiona Webster Institute of Circulatory & Respiratory Health/CIHR Toronto, ON Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/stage5/iwg_members.aspx", "Microsoft Word - TOR Impact Working Group_V4 0_04252006 _2_.doc|- 1 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 2006 Heart Failure Consensus Conference Recommendations Program Terms of Reference for Clinical Practice and Health Outcomes Impact Working Group (IWG)- 2 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 Table of Contents Letter of Introduction…………………………………………………………...…...3 CCS HF CC Impact Working Group- Terms of Reference….………………….4 CCS IWG Meeting Agenda/Minutes- 01/04/2006……..……….………………..9 CCS IWG Meeting Agenda/Minutes-02/10/2006………………………………..20 CCS IWG Meeting Agenda/Minutes-03/16/2006………………………………..27- 3 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 Letter of Introduction RE: CCS Heart Failure Consensus Conference – Impact Working Group Terms of Reference We are pleased to offer the enclosed document which outlines the Terms of Reference for the Impact Working Group including a project summary and descriptions of roles, responsibilities, benefits and commitment. As you know, CCS has made a substantial and long-term commitment to identifying best practices in Knowledge Translation. Since beginning this initiative in 2005, The CCS Heart Failure Consensus Recommendations Program has experienced significant growth during this time and now includes participation of organizations and individuals who represent Canada’s cardiovascular care community. Over the past year, our ‘closed-loop’ approach to guidelines development has resulted in a number of innovative achievements including: • CCS’ first formal multi-disciplinary Primary Panel • Establishment of the CCS Heart Failure Consensus Conference Advisory Roundtable • Completion of CCS’ first-ever end-user needs assessment • Detailed program specifications for dissemination, implementation and evaluation • Deployment of Core Development Teams • Completion and publication of 2006 Heart Failure Consensus Recommendations in CJC January 2006 • Publication of 2006 Consensus Recommendations in four professional journals March 2006 • National program of regional workshops for the 2006 Consensus Recommendations scheduled for Lake Louise, Toronto, St. John and Montreal • Creation of the multi-disciplinary and –organization Impact Working Group Please feel free to contact John Parker (parker@ccs.ca) who will be happy to address your questions and comments on any aspect of this initiative. We are genuinely grateful for your continued support and interest and look forward to completing this important next stage of this project with you. Kindest regards, Heather Ross MD Chair CCS Consensus Conference Committee John Parker MN Director Knowledge Translation Malcolm Arnold MD Chair CCS Heart Failure Consensus Conference Jonathan Howlett MD Co-Chair CCS Heart Failure Consensus Conference- 4 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 Impact Working Group – Terms of Reference Purpose: The CCS Heart Failure Consensus Conference Clinical Practice and Health Outcomes Impact Working Group (IWG), which involves the highly collaborative efforts of CCS and a number of national health care organizations, has been struck to: 1. Develop a five-year strategic impact research plan for quantifying potential impact of the CCS Heart Failure Consensus Conference Program (includes the consensus and a number of dissemination and implementation strategies) on clinical practice patterns and health outcomes 2. Develop a five-year academic publishing/communication plan whereby the results of CCS’ long-term commitment to identifying best practices in knowledge translation, as they apply to evidence-informed recommendations for heart failure care, are shared with CCS stakeholders and the broader national and international health care communities 3. Mobilize resources necessary to execute strategic research plan Membership: The IWG currently consists of the following formally represented individuals and organizations (see Table next page):- 5 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 Current CCS IWG Representation (February 2006) Canadian Cardiovascular Society M Arnold P Liu H Ross J Parker Heart and Stroke Foundation of Canada Sally Brown/Designate Canadian Institute for Health Information G Webster Canadian Institutes of Health Research Elizabeth Stirling Canadian Cardiovascular Outcomes Research Team J Tu Canadian Congestive Heart Failure Clinics Network J Howlett A Ignaszewski Quebec Heart Failure Society N. Racine Guidelines Standards and Evaluation (AGREE) Expertise I Graham Acute Care Nurse Practitioner V Micevski Mezzanine Business Consulting M Healy Membership will expand to include Health Canada and appropriate representation from the province of Quebec Term: Given CCS has secured funding to evaluate three cycles of its closed-loop model of guidelines development, the term for membership on the IWG is similarly three years. At the- 6 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 conclusion of the three year commitment, extending membership for additional three year intervals is possible. The current Chair of the CCS Consensus Conference Committee serves as Co-Leader of the CCS IWG for a period of three years. The second Co-Leader of the CCS IWG will be chosen at the discretion of individual members of the IWG. IWG Co-leaders will be nominated thereafter and approved by CCS Executive. Timeline: The IWG will focus on three parallel streams of activities: Strategic Impact Research & Publication Plans Jan ‘06 Jan ‘07 Jan ‘08 Jan ‘09 Jan ‘10 Jan ‘11 Impact Research Impact Publishing/Communication The primary focus of the strategic research plan is quantitative data that relate to clinical practice patterns and health outcomes. These data could, for example, reflect diagnostic, treatment or hospital usage patterns or incidence, prevalence or mortality patterns. In addition, the strategic research plan will include detailed resource (human, financial, infrastructure) requirements. The primary focus of the academic publishing and communication plan is sharing of findings which identify and quantify impact with project stakeholders as well as the broader national and international health care communities. In addition, the strategic academic publishing/communication plan will include detailed resource (human, financial, infrastructure) requirements.- 7 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 Time Requirements: The IWG is a ‘virtual’ working group with the balance of communication conducted by electronic means, teleconference and surface mail. The inaugural meeting of the IWG is a face-to-face meeting to review proposed terms of reference, overall objectives and timelines. The need for future face-to-face meetings will be determined by the IWG on an as needed basis. Participation on the IWG will require an estimated 20 hours per year. The balance of this commitment will involve ongoing correspondence and dialogue with the IWG’s members. Resources: The IWG has access to CCS resources provided in the form of support staff and funding required to deliver both strategic research and publishing/communication plans. This includes as-needed access to the CCS Director Knowledge Translation and CCS Manager Knowledge Translation in addition to funds necessary to cover reasonable expenses incurred by individual IWG members during the strategic planning phase due to travel, accommodation, meals, communication and office supplies. Once completed, both strategic research and publishing/communications plans will be used to secure funding and resources necessary to realize the third objective of the IWG – execution of both strategic plans. Concurrent Evaluation: As a concurrent evaluation activity, the Core Development Teams responsible for implementation and evaluation stages of the project are conducting and reporting results of annual evaluations of qualitative variables known to affect end-user acceptance, uptake, allegiance and recurrent use of evidence-based recommendations including:- 8 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 Value as Perceived by Target Users • Relative advantage of new CC • Complexity of CC implementation into day to day care • Feedback integrated into CC development process • Magnitude of change in clinical practice of new CC • Representation of stakeholders during development • Does the CC save time and improve patient satisfaction Development Process as Perceived by Target Users • Transparency of development, dissemination and implementation processes • Quality of recommendations • Development involves systematic computerized review a grading of evidence • Rationale is provided for revising existing recommendations • Inclusively of development Known Dissemination & Implementation Barriers Posed by Target Users • Awareness and familiarity • Practicality of recommendations • Passive means of dissemination and implementation • Education/training requirements and implications of CC • Cost/equipment implications of CC • Potential liability/malpractice implications • Barriers in practice setting (i.e. policies, processes, social factors) • Means of evaluation and integration of feedback (quality improvement)- 9 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 CCS IWG Meeting Agenda & Minutes 01/04/2006 CCS Heart Failure Consensus Conference Clinical Practice Patterns and Health Outcomes Impact Working Group Toronto, Ontario January 4, 2006 Participants H Ross, Co-Chair M Arnold, Co-Chair P Liu, Co-Chair I Graham G Webster Regrets A Ignaszewski J Tu V Micevski J Howlett VA Singh M Healy 1300 – Welcome & Introductions H Ross/M Arnold 1315 – Summary of CCS Heart Failure Consensus Conference Project – J Parker 1345 – CCS Objectives of Impact Evaluation – H Ross, M Arnold 1400 – Open Discussion 1430 – Review Working Group Draft Terms of Reference – H Ross/M Arnold 1500 – Break 1530 – Summary of Professional/Institutional Interest (15 minutes/Participant) • VA Singh – Canadian Institutes of Health Research (CIHR) • I Graham – Guidelines Standards and Evaluation (AGREE) • A Ignaszewski/J Howlett – Canadian Heart Failure Clinics Network (CCHFCN) • G Webster – Canadian Institute for Health Information (CIHI) • J Tu – Canadian Cardiovascular outcomes Research Team (CCORT) • V Micevski – Acute Care Nurse Practitioner • H Ross/M Arnold/P Liu – CCS- 10 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 1700 – Dinner 1800 – Definition of Working Group Goal – H Ross/M Arnold/P Liu 1815 – Inventory of Available/Required Resources – M Arnold/J Parker 1830 – Identify Short- & Long-term Timeline – H Ross/M Arnold 1930 – Future Meeting Dates/Format – H Ross/ M Arnold 1945 – Close- 11 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 CCS Heart Failure Consensus Conference - Minutes Clinical Practice Patterns and Health Outcomes Impact Working Group Renaissance Toronto Hotel Blue Jays Room Toronto, Ontario January 4, 2006 Attendees H Ross, Co-Chair M Arnold, Co-Chair P Liu, Co-Chair I Graham G Webster J Tu Regrets A Ignaszewski V Micevski J Howlett VA Singh M Healy K Harrison 1. Welcome & Introductions H Ross/M Arnold M Arnold welcomed everyone to the meeting. M Arnold also thanked everyone for agreeing to be part of this important working group. 2. CCS Objectives of Impact Evaluation – H Ross, M Arnold Summary of Presentation by H Ross Consensus Conference Guidelines – 2004 Member Needs Assessment The Canadian Cardiovascular Society represents over 750 physicians and researchers in Canada. It is the national voice for cardiovascular physicians and scientists. The mission of the CCS is to promote cardiovascular health and care through: – Knowledge translation, including dissemination of research and encouragement of best practices through dissemination. – Professional development and leadership in health policy. In 2004, CCS members identified Consensus Conference (CC) Guidelines as the second most important offering of the Society. To strengthen this offering, CCS has undertaken an innovative initiative to improve its Consensus Conference Guidelines development and dissemination process.- 12 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 History of CCS Consensus Conferences • Long history of excellence with CCS Consensus documents • Of critical importance to CCS membership • Decision made at Council level to redress the purpose of Consensus documents – Do we want to be one more guideline? – Same old same old – OR - do we want to change uptake, practice and potentially patient outcomes Decision Regarding CCS Consensus Conferences • Re-evaluate the consensus process • Long term changes - controversial • Iterative • Based on holes/gaps/reasons why health care providers do not use/uptake guidelines • Based on needs assessment/reassessment • Look at impact of changing the consensus process CCS Heart Failure Guidelines - Results of a Multi-disciplinary Needs Assessment- Patient Related Findings – 15% are aware of heart failure guidelines. – 30% have heard of CCS. – 0% are aware of CCS HF CC Guidelines. – 95% desire a copy of the CCS HF CC Guidelines. – 85% would like to have a copy of the CCS HF CC Guidelines in a simple, patient-friendly (e.g. Explaining why a doctor has prescribed beta blockers) one page summary format. Recommendations Development • CCS should consider further expanding its representation of the Primary Health Model on the CCS HF CC Guidelines Primary Panel.- 13 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 Dissemination • CCS must coordinate dissemination of Guidelines to a much broader series of populations, through the heads of their respective organizations, including: GPs, Internists, Nurses, and Patients. • CCS must increase the frequency with which the availability of the CCS HF CC Guidelines are communicated. • CCS must improve its marketing of the CCS HF CC Guidelines. • CCS should incorporate more process transparency into its communications with the five target populations. Implementation • The CCS HF CC Guidelines should prepared and distributed by these societies in the most appropriate format. – Cardiologists, GPs, internists, and nurses – a one-page, laminated, folding pocket card summary of the CCS HF CC Guidelines. – Patients – a simple one-page, patient-friendly summary, and access to a full text hardcopy version on the CCS website. • CCS should support the written versions of the Guidelines with a training “road show” across Canada. Evaluation • CCS should consider conducting clinical practice audits at pilot sites starting in Cycle 2 • CCS should establish a Clinical Impact and Health Outcomes Working Group Actions taken by CCS based on Recommendations .. CCS Core Development Teams for Dissemination, Implementation and End-User Satisfaction – Knowledge Translation Office – Microsoft Canada – Nova Networks – H3 Communications – Project Management .. End-User Identified Implementation Tools Development – Pocket Card – Practice Audit – Regional Interactive Workshops – Lake Louise, Toronto, Quebec, St. John- 14 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 .. CCS Guidelines Impact and Outcomes Working Group – Canadian Cardiovascular Society – Canadian Cardiovascular Outcomes Research Team – Canadian Institute for Health Information – Canadian Institutes of Health Research – Canadian Congestive Heart Failure Clinics Network – Guidelines Quality and Standards Expertise (AGREE) – Advanced Practice Nursing Expertise – Business Management Expertise Additional IWG membership was discussed, including Heart and Stroke Foundation of Canada, Health Canada and Quebec-based representation. J Parker will follow through with formal invitations .. Publishing – Canadian Journal of Cardiology – Canadian Cardiovascular Society – Canadian Family Physician – College of Family Physicians of Canada – Canadian Pharmacists Journal – Canadian Pharmacists Association – Geriatrics Today – Canadian Geriatrics Society – Canadian Nurse – Canadian Nurses Association .. Commitment – Three complete cycles of ‘closed loop’ guidelines development model Discussion: M Arnold brought up the issue that CCS does not use the term “guidelines”. Will try and have key words and linkage with the word “guidelines”. However the term Consensus Conferences Recommendation(s) will be used. I Graham discussed the fact that Consensus Conference is not thought of as evidence based, just best practices as identified by consensus of a group. So, regardless of what it is called and how it is branded, it must be clearly promoted as evidence-informed. M Arnold circulated the Canadian CC recommendations on heart failure diagnosis and management 2006. J Howlett suggested that the title should be shortened to say CCS heart failure diagnosis and management 2006. In addition, I Graham will review this document using the AGREE guidelines. 3. Review Working Group Draft Terms of Reference – H Ross/M Arnold Objective • Charged with determining how to evaluate……..and then to evaluate if there is an impact of the new consensus process/efforts on healthcare provider practice/patient outcome- 15 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 Purpose • Develop a five-year strategic research plan for quantifying potential impact of the CCS Heart Failure Consensus Conference Program (includes the consensus and a number of dissemination and implementation strategies) on clinical practice patterns and health outcomes • Develop a five-year academic publishing/communication plan whereby the results of CCS’ long-term commitment to identifying best practices in knowledge translation, as they apply to evidence-informed recommendations for heart failure care, are shared with CCS stakeholders and the broader national and international health care communities • Mobilize resources necessary to execute strategic research plan Membership • CCS – J. Parker, M. Arnold, P. Liu, H. Ross • CIHI – G. Webster • CIHR – A. Leury, VA. Singh • CCORT – J. Tu • Canadian Standards and Evaluation – I. Graham • Canadian Congestive Heart Failure Clinics Network - J Howlett, A Ignaszewski • ACNP – V. Micevski • Mezzanine Business Consulting – M. Healy Term • CCS has secured funding to evaluate three cycles of its closed-loop model of guidelines development • Hence the proposed term for membership is three years • At the conclusion of the term a three year extension is possible Co-Chairs • One Co-Chair of the IWG is the current CCS Consensus Conference Committee Chair • The second IWG Co-Chair will be chosen at the discretion of the IWG members • IWG Co-leaders will be nominated thereafter and approved by CCS Executive- 16 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 Timelines: IWG focus - three parallel streams of activities Plan .. Jack Tu: – Focus on one or two of the recommendations as opposed to all of them – Ensure dissemination, and media to help in dissemination (medical post/star, globe etc) Key issue: That people are not aware – Include use of the HF awareness week Feb 14th – Get message out multiple times – Aim at GP in terms of target and measured outcomes audience – note most difficult to reach – Measurable and changeable within the target audience and time – Create incentives for change - audit data, feedback and potentially make it public (as a way to change practice) – KOL’s from industry/hospital involved in knowledge translation – Target pharmaceutical: BBL, spironolactone, including monitoring of therapy – Target non-pharmaceutical options as well – Comments/Suggestions from the committee members: • I Graham o Prioritize these important messages while being very clear who is the target audience o Communicate with the knowledge translation group o System issues e.g. – short visits, may not be because they don’t know or believe in recommendations but what are the system issues that may be blocking implementation of guidelines. Take the recommendations to small group/AGREE reviewed o Tailor the recommendations to fit local context – includes involvement of key opinion leaders – hence try to facilitate the adaptation process at local level Strategic Impact Research & Publication Plans Jan ‘06 Jan ‘07 Jan ‘08 Jan ‘09 Jan ‘10 Jan ‘11 Impact Research Impact Publishing/Communication- 17 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 - Innovation decision process: 1) awareness is first step, 2) persuasive (change) 3) Use (intention – do you intend to use them) 4) Sustainability (on going use – three types a) Use it, doesn’t work, abandon it b) Use it, works, implements it c) Use it, partially works, adapt it • M Healy o Dissemination – uptake –implementation o Must measure at discrete points in time .. J Howlett: o Morbidity and mortality, o hospitalization and death o what is the penetrance of heart failure clinical usage o ACEI/ARB (though Jack’s point well taken – may well be saturated o EOL o Lifestyle o device therapy o BNP • V Micevski o Indicators of self-care practice – daily weights, adherence to their prescribed therapy • M Arnold o Symptoms of HF- awareness at GP and public level • J Tu o Ontario laboratory data bases to be ‘linked’ in the near future o 2004 calendar year, approx. 9000 patient hospitalizations for HF audit 1) Will review – recommendation and case report form to ensure that issues that we have are included on their case report form Specific Variables .. Beta Blockers – most promise 1) prescription rates, hospital BBL use discharge rate, hospital/clinical BBL use at admission rate, long term compliance prescribing, pharmacy fills 2) Provincial databases – ICES, ICONS and the Heart Failure Clinic Network 3) Target doses or % of target dose 4) Compare between different health care providers- 18 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 a) Potential need for focus groups, survey to find out why they aren’t using it (part of knowledge translation group) .. Disease Management Program 1) Get hospital to report if patients will be enrolled into or are currently in DMP program – longer term goal – are hospitals paying attention to the importance of DMP (number needed to treat 5), and increasing the number of programs/access 2) Use HF clinic network – enrollment rates pre and post CCS recommendations – specifically are the high risk patients getting referred to established DMP (shorter term) 3) Attitudes toward DMP – GP – diagnosis, management and timely referral - can also use as a method of dissemination 4) Patients Self knowledge and awareness, post discharge or HFC visit mailed questionnaire 5) Public Awareness – Health Promotion and prevention general awareness, prevention 6) CIHI – special project fields – have specific centers enter data into the specific fields and then you can get the data at the end 7) have clinical team develop a basic check list, get health records to enter that minor data, then can access later 8) Need info in by fall to get info back by next year. a) Variables: o have they been discharged to a disease management program o Discharge education o Where they on BBL before admission to hospital o Are they on BBL at discharge .. Review of discharge summaries/strategies to assess patient education effectiveness- 19 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 CIHI ICONS, ICES (BBL) Hospitals (BBL) HF Clinics (BBL) Clinical Studies (Targeted Sampling) GP Offices (BBL) – HF Patients (Survey) (nested study with knowledge translation, survey then implantation different between groups, focus group) Population ACTION: Minutes to be sent out ASAP. Members are to send J Parker a half page/proposal outlining what they would like to be involved in along with any additional ideas they may have. Will create a small executive group and get individuals together. Need to start very quickly and getting some names tied to get some broad objectives together. J Parker proposes to outline a business plan that will outline the necessary resources that is required, including a full time project manager. Face to face meeting in another 2 months. If no dates feasible at the beginning of March, then Lake Louise at the end of March might be an option – L Hodgson to arrange Teleconference call in 3 weeks – L Hodgson to arrange Meeting adjourned at 7:30pm.- 20 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 CCS IWG Meeting Agenda & Minutes 02/10/2006 PARTICIPANTS Malcolm Arnold-Co-Chair Heather Ross- Co-Chair John Parker Mark Healy Greg Webster Peter Liu Jonathan Howlett Andrew Ignaszewski André Leury Normand Racine Regrets: Jack Tu Sally Brown Vaska Micevski Welcome: Heather welcomed everyone to the call. Malcolm and Heather will co chair. Review of past minutes: Malcolm moved them to go forward. Hearing no opposition and no changes, Heather accepted the minutes. John noted that this teleconference is being recorded and notes will be created based on the recording. Review/Approval IWG Business Plan: John circulated draft of the business plan; Peter, Heather, Malcolm and Jonathan have reviewed it. Their feedback has been incorporated into the version that the group has received.- 21 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 John tested the model and proposal with two industry partners who are currently part of the investor pool for the Heart Failure project, Sanofi and Boehringer Ingelheim. The feedback that we have received is essentially positive. Based on the feedback, we learned that the information that is needed for the investors to make the decision internally to support this project is contained in this document, the amount we are asking for are perceived to be reasonable, that there is a clear return on investment and they said that if this document was on their table formally the would have no problem supporting this project for 3 years. This proposal is an extension and a mirror of original business proposal. It is a multi investor, pooled, 3-year commitment. The money comes directly to CCS, CCS pools the money and allocates based on need over the duration of the project. We are seeking $750,000 unevenly spread over 3 years. There is some upfront one time investment costs for year 1. One of those proposed is money that is directed to upgrading and stabilizing the current database within the Heart Failure Clinics Network and the second is that money goes towards the development of a Heart Failure specific Website. There are reoccurring costs from one year to the next including a full time Program Manager, it is suggested that recruiting begin as soon as possible. We are looking for a minimum of 6 investors; we are offering the original 6 investors first right of refusal, they are aware of this and they know this is coming. John would like to get the information to them by Monday with the group’s input and approval. The expectations per investor for the first year (Fiscal 06/07) investment is $45,100 and for year two and three $38,500 for a total of $ 122,100 for the 3 year investment. The investors will sign a commitment of investment form to be submitted by March 17th, which is two weeks prior to our fiscal year.- 22 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 All companies that we have spoken to are in the position where they are planning and allocating funds for the coming fiscal year and feel the timing is right for investing in this project. John requested comments and feedback. Heather felt it was a great document. One of the people who comes to mind as a project manager is Marcella Shouldice. She is great at organizing people and holding them to timelines. Malcolm felt she was also a good suggestion. Some of her projects are winding down so it might be a good time to approach her. John agreed that Marcella was worth every penny and that they have had positive experiences working with her. Heather noted from an administrative point she has the history, experience and track record with us and we know what we would be getting. It was agreed that John should approach her and make an offer. Mark mentioned that they should look for an individual who has health care experience, good with long term planning, deadline management and strong communication skills. Heather agreed and confirmed that from working with Marcella on the Access to Care that she is confident that Marcella would be an excellent candidate. Mark asked if the candidate would be involved with the financials. John said the financials would most likely remain in his scope. The candidate would look after execution. Ian noted that he didn’t see a budget line for an analyst, so who is actually going to analyse the databases. John said that each organization at the table represents significant infrastructure; part of our strategy is how we could economically tap into those infrastructures with the meat of this project. If that is not possible then we need to allocate the money for an analyst would likely be full time. Ian noted Jack Tu has a number of analysts but in order to shift their priorities money does magic. In the business case, there is money allocated to database usage, John thought that the $65,000 could be used towards the salary for an analyst.- 23 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 Ian mentioned that getting the analyst to get the data into the formats that we can use and then we have to pay them to do the analysis. As long as we have the resources it is will be ok. Peter noted that as the project moves we will have a better idea of the financial allocations needed. John agreed and that there would be some play with the financials for allocating to areas that need it. The total fiscal requirement for fiscal 06/07 is $45,000, which is just under the $50,000 mark, and our experience has been once you meet that threshold it becomes a different conversation with the Pharma companies and involves higher-level approval. By staying under it or around it we reduce the number of people involved in the decision of supporting the project. Heather mentioned that having Peter around the table should help provide some guidance as he is currently in control of a large budget. Mark questioned whether Marcella would come for $75,000 per year? Heather wasn’t sure but John thought that was reasonable and that he felt it was within a range she would consider. John would like to finalize the document and with the group’s approval send it to our potential investors and would ask that once this document is released that we (the group) take this back to our contacts through our networks, create some excitement and buzz regarding this work group and the importance of the work we are achieving. Peter suggested that we look at what is required and who is accessible and who are yet the potential accessible candidates and divide it up as we may each have preferred candidates that we are more individually affective at communicating with.- 24 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 John has put together a web site for this project and we will be testing it with the primary panel and working group at the beginning of next week. The intent is for this to become a focus of activity and information sharing for this project. The website will be very rich with information and will become an important centrepiece of this project. Heather requested group agreement on making a formal pitch to securing Marcella as a project manager. The group agreed. John will put forward an offer to her on Monday. Finalization of Research/ Publication Projects Heather noted that at the last meeting, all the members were to send John a half page proposal outline what they would like to be involved in and outlining any other comments or ideas. We have not received any to date. We really need to move this piece forward. This is meant for open discussion. Everyone has received the minutes and Malcolm has done a really nice diagram looking at it in it’s entirety. She mentioned that it all falls under the title “Who is going to take what and what time frame?” Identification of Project Champions/Roles & Responsibilities Malcolm noted that the project champions and identification of them would probably help to drive the outlines required and specifics also the projects and the type of research that needs to be done. The problem with items 4,5 & 6 is we haven’t finalized what our research question is. We have identified potential resources to address a question that we haven’t formalized. We have identified a number of research questions and outcomes that we think would like to measure, the flip side of that is the feasibility and cost and timeframe of measurement and the energy and expertise of enthusiasts and project champions.- 25 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 Malcolm suggested Heather and himself prepare a draft of a document that might beginning to identify things we missed or better practices. Heather agreed. There has been excellent discussion around the table since the meeting but there has been no follow thru from there to today’s call on what the specific research projects should be. Heather felt that the suggestion was an excellent one. Malcolm noted that the group would have to commit to the time to critically reviewing the document with criticism and suggestions that we would build on. It will not be final or comprehensive. It would represent our discussions to date. Over the next two or three weeks we might be able to identify our current plan of action and have a clear objectives, hypothesis, initial timelines and champions. The champions identified would then be responsible for taking each project and plan and outline for their particular project providing objectives, measurement outcomes, strategies and timeframes. The group agreed to this. Milestones and Timelines: It is going to be hard other than to put a timeline for the end of February, to identify the research projects and identify the champions for these projects. We need a strong working document that would be the platform for project champions to build on. Then the project champions can come back with more detailed documents and ideas that can be integrated into a subsequent document by the end of March early April. • Strong document commitment by February 28th 2006-02-20 • Feedback from call by February 24th. • Lise to organize Teleconference for March • Lise to organize Face to Face late April early Ma Face to Face: John suggested an alternative to the initial March recommendation.- 26 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 Heather suggested a teleconference in March. Once we have the project champions identified and a project manager in place a lot of this can be managed electronically and then follow up with a Face to Face in April-May. Other Business: Normand Racine committed to the 3 year project officially. John asked Normand how we should designate him, Normand is a member of the CCS and a representative of the Quebec Heart Failure Society Normand suggested a monthly recurring call in order to block off the individuals schedules. Summary/Close: • The group accepted the minutes • Normand Racine officially committed to the 3 year commitment • John presented the Business plan • John will approach Marcella as a project manager • ‘Straw dog’ document by end of February • Group will send comments and feedback to Heather and Malcolm by end of week • By March we will identify projects and project champions • Face to Face late April or early May • John will send a summary (to do list) to all those not available for today’s call.- 27 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 CCS IWG Meeting Agenda & Minutes 03/16/2006 CCS Impact Working Group Teleconference Thursday March 16th 2006 11:am EST Participants: Malcolm Arnold, Chair Jonathan Howlett Sally Brown Malcolm Arnold Vaska Micevski Normand Racine Peter Liu Greg Webster Regrets: Ian Graham Heather Ross Andrew Ignaszewski Jack Tu 1. Welcome- M. Arnold 2. Review of Minutes – M. Arnold Malcolm suggested the minutes from the last meeting be accepted. John agreed. The minutes were accepted. 3. Summary of Research Questions – M. Arnold Jonathan is leading the Heart Failure workshops, there are four across the country aimed at high-level internists/specialists and is hoping to determine some degree of impact, outcomes and change of practice - the details are yet to be defined. In principal the work that will take place at the workshops will target people who can learn from the opinion leaders themselves.- 28 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 Heather and Vaska, are interested in taking a look at clinicians both academic and in community institutions. It would include specialists as well as trainees and nurse practitioners. The emphasis is on education and adherence to guidelines. Vaska noted that the purpose of our study was to take a look at how the educational intervention would be affected. One thing that we were looking at implementing was expert clinicians or opinion leaders presenting at rounds. As we are having more discussions around methods, she wondered if there was an opportunity to do two different things, her group could take a look at using webbased learning. Malcolm has spent time developing a slide kit, and is interested in the continuity of care - the care gap or breakdown of care that exists when a patient comes to emerge with Heart Failure and then is sent home, looking at what happens in the emerge, what information they are sent home with, what follow up happens in the GP’s office and how the emerge doctors communicate with the GP’s. Peter will look at the broad base community cluster randomization that would involve GPs and the change in care and the impact of incentives on that. Academic and industrial detailing. Randomization will be based on clusters or groups as it is hard to randomize individuals. John to draft minutes and send to Malcolm. Malcolm will summarize what accurately reflects each proposal and see where we can have some degree of separation between the projects. Then look to see where each project overlaps or complements the other projects then identify specific interventions, hypotheses and outcomes that would be unique to each project but would complement what the other projects are looking at. Determine at the next conference call based on the feedback, prioritizing what needs to be done first or can they be done in parallel and what data is required for each project and what may be useful for one or two projects so that duplicate data is not being collected.- 29 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 If the minutes can be turned around relatively quickly then each of the group members should still have a memory of our discussions and each of the group can fine tune and have another conference call and move this forward. If we have a project manager to help in the near future then this would work extremely well. Sally asked Normand to expand on his comment “that family practice physicians are not interested in following congestive heart failure patients because they are too sick” and asked if others on the call share this view. Sally noted that if that holds true then that is a huge barrier to knowledge translation. Normand noted that in Quebec they are currently working on trying to desensitize physicians to not be intimidated and to understand that these patients are not that sick. In Quebec, about 20% of GP’s do hospitalization and will also follow up outside of hospital, Many do just hospitalization and do very little clinic follow-ups. So the physicians who are sensitized to the hospital follow ups are not the same physicians receiving the patients for follow up care. Normand went on to describe how we can get physicians excited about heart failure; we are holding two workshops one on the April 7th and one on the 28th. One in Montreal one in Quebec. The afternoon session will be on Heart Failure and in the morning we will be looking at the global cardiovascular risk factors ramifications. We hope to attract more physicians. Peter noted that while we are putting the projects together we should submit to the CIHR knowledge translation program for funding. They won’t fund the entire project but certain aspects of the project would meet the qualifying criteria. Peter will look into the deadline and process for submitting to CIHR for funding and whether there is a cap on budgets for anyone individual project. The average grant size is approximately $120,000 per year. Malcolm asked that Peter provide this information to be included into the minutes.- 30 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 4. Open Discussion/Additional Suggestion – M. Arnold 5. Priority Ranking of Questions – M. Arnold 6. Business Plan Update – J. Parker John gave an updated on the business plan. The plan was finalized and distributed to the six investors. John has heard responses from two of the original six, Biovail and Merke. They wish to continue their support of phase I of this project (meaning identification of best practices and knowledge translation) but they are both unable to support the activities of the Impact Group. Informally John has heard from both Sanofi and AstroZenica and both are extremely interested in supporting the work of the impact group but John has not received a formal signed off commitment. John is following up with them. John remains positive and optimistic in receiving the support needed to get the project going for the first year and starting to develop some momentum and then continuing to raise funds for year two and three. Malcolm asked what resources are needed to move forward. Most pressing right now is to get a project manager on board on a near full or full time basis. The project requires a project management skill at this time. Malcolm asked if there has been any progress with the individuals whose names have been brought forward as project managers. Marie Josie Martin has been approached and the CCS knows her. Marie Josie is here on the call today in Ottawa, to discuss her interest in joining the team. Marie Josie stepped out of the office so that the group could openly discuss her candidacy. Malcolm asked John what type of position he would like to offer Marie Josie and how that would be funded. John said he would like to engage Marie Josie full time for the term of one year with the possibility of extension for two to three years.- 31 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 This project needs a lot of work in terms of establishing a detailed process and that will require someone’s full time concentration and attention. John will continue to broaden the search for funding and support to ensure the resources are there to fund this position. Malcolm asked if the group was in favor of using the funds to hire a good project manager even though that would take from funds that could have been put towards the individual projects. The group all agreed that this was a good idea John will start expanding the search from the original six investors. He was in Atlanta where he met with different Pharma representatives around this project and there was a huge interest and excitement surrounding this project. CCS has submitted an abstract for the family medicine forum that takes place in Montreal in November. The abstract is a jointly presented workshop (CCS and the College of Physicians) around the Heart Failure Consensus Recommendations. That might be an opportunity for that aspect of Knowledge Translation to be investigated further. 7. Next Steps/Face to Face Meeting – M. Arnold A date has been chosen. It is May 12th in Toronto. It was noted it would be beneficial to have a teleconference before the May 12th meeting. If John and Malcolm can work on the wording of the minutes and then get them out to you within a week and then give another week or two for feedback, then having a conference call the 3rd week of April would be beneficial. John noted that he would resend the meeting information with dates and time out to the group. 8. Conclusion Vaska just wanted to bring to everyone’s attention that the CIHR knowledge grant that Peter discussed; the full nomination package must be couriered out and received by May 15th. And the decision is November 2006. There appears to be one competition with three different levels of impact.- 32 - 2006 CCS HFCC – TOR IWG_V.4.0_04252006 Based on this information Malcolm suggested that we need to tighten the timelines for returning feedback and move up the conference call up sooner than a month. Some people might have more time, energy and experience to put such a grant together within a short timeframe but it would certainly require dedication for several weeks to make that happen. Malcolm thanked everyone for attending, and special thanks to Greg for attending because they will be looking to him for help with some of the outcomes and measurements that some of these projects would necessitate. Malcolm also thanked Sally noting we are excited to work with Heart and Stroke and see a lot of opportunities for drawing on your expertise.||http:\/\/www.hfcc.ca/downloads/stage5/Terms_of_Reference_IWG.pdf", "HFCC - What's New! -> 2006 Archives|Home About Us Contact Us What's New! Important Notices Search Whats New! Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: What's New: 2006 Archives The Canadian cardiovascular community comments on the CCS Heart Failure Consensus Conference Program - November 29, 2006 What's New? - We are!!!!!! CCS launches the redesigned HFCC website with a new look and feel! - October 20, 2006 Toronto Heart Failure Summit Highlights - Version française - September 27, 2006 CCS Launches Heart Failure Consensus Slide Kit! - Version française - September 22, 2006 CCS National Heart Failure Workshop Initiative 2006 – Join us in Saint John, NB! - September 11, 2006 CCS Undertaking Complete Redesign of the Heart Failure Consensus Website! - August 28, 2006 CCS Heart Failure Consensus Program Welcomes International Perspective! - August 21, 2006 CCS Publishes Benchmarks for Access to Heart Failure Care in Canada! - July 28, 2006 CCS Gathers Momentum Through Second Heart Failure Workshop! - July 7th, 2006 CCS and Canadian Pharmacists Association (CPhA) Collaborate on Guidelines! - June 22nd, 2006 The CCS Heart Failure Consensus Conference website is now live! - June 6th, 2006 CCS Heart Failure Primary Panel Gets 2007 Update Underway! - May 19th, 2006 CCS Heart Failure Consensus Primary Panel Welcomes Four New Members! - May 16th, 2006 CCS Heart Failure Consensus Impact Working Group Making Progress! - May 12th, 2006 CCS National Heart Failure Workshop Initiative 2006 - Lake Louise - May 1st, 2006 The Canadian Cardiovascular Society (CCS) and the Canadian Nurses Association (CNA) are very proud to announce the first-ever collaborative publication of CCS guidelines within Canadian Nurse, the official publication of CAN. - April 25th, 2006 CCS and Heart and Stroke Foundation of Canada Staff Complete Website Usability Testing - April 17th, 2006 CCS Heart Failure Consensus Workshop a Resounding Success! - April 04th, 2006 CCS Completes Establishes Critical Benchmark with its First-Ever AGREE Review! - April 04th, 2006 22nd Annual Cardiovascular Conference at Lake Louise - March 26-30, 2006 Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/whatsnew/2006.aspx", "HFCC - What's New! -> 2005 Archives|Home About Us Contact Us What's New! Important Notices Search Whats New! Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: What's New: 2005 Archives Dr. Denis Drouin, Quebec City, Quebec - Recorded at the Canadian Cardiovascular Congress, Montreal 2005 Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/whatsnew/2005.aspx", "HFCC - What's New! -> 2003 Archives|Home About Us Contact Us What's New! Important Notices Search Whats New! Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: What's New: 2003 Archives The 2002/3 Canadian Cardiovascular Society Consensus Guideline Update for the Diagnosis and Management of Heart Failure Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/whatsnew/2003.aspx", "HFCC - What's New! -> 2001 Archives|Home About Us Contact Us What's New! Important Notices Search Whats New! Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: What's New: 2001 Archives The 2001 Canadian Cardiovascular Society Guideline Update for the Management and Prevention of Congestive Heart Failure. Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/whatsnew/2001.aspx", "HFCC - What's New! -> 1994 Archives|Home About Us Contact Us What's New! Important Notices Search Whats New! Stage 1: End-User Needs Assessment Stage 2: Consensus Conference Update Stage 3: Program Specifications Stage 4: Dissemination & Implementation Stage 5: Evaluation & Recommendations HFCC Newsletter Sign-Up Enter your email address: What's New: 1994 Archives The 1994 Canadian Cardiovascular Society Guidelines for Diagnosis and Management of Heart Failure Canadian Cardiovascular Society Website Site Map Document Last Modified Friday, February 16, 2007||http:\/\/www.hfcc.ca/whatsnew/1994.aspx", "Microsoft PowerPoint - CCS_Consensus_Conference_Heart_Failure (1|Leadership. Knowledge. Community. Recommendations on Heart Failure 2006 Diagnosis and Management Faculty* • Malcolm O. Arnold, MD (Chair) • Haissam Haddad, MD, • David E. Johnstone, MD • Gordon W. Moe, MD • Michel White, MD *This faculty has reviewed the slide kit on behalf of the Primary and Secondary Consensus Conference Multidisciplinary Panels. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm2 unity. CCS HF Recommendations 2006 Slide List Content • Background on HF and CV disease • CCS Consensus Conference Process • Key Recommendations • Diagnosis, Causes and Risk factors for HF • Education, Non-drug Management, Referral and HF Clinics • Treatment of HF – ACE-I – BB – ARB – Combination therapies – Preserved systolic function – Acute HF – Device therapies – Surgical considerations • Care of Elderly and End of Life • Conclusion/Summary • Additional Reference slides • Case Studies Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm3 Heart and Stroke Foundation of Canada, 2003. unity. Cardiovascular Disease and Mortality in CanadaLeadership. Knowledge. Comm4 unity. The Heart Failure ContinuumLeadership. Knowledge. Comm5 unity. A normal heart pumps blood in a smooth and synchronized way. Used with the permission of Medtronic Canada Ltd. Normal Heartbeat Click on the heart to begin the animation.Leadership. Knowledge. Comm6 unity. Heart Failure Heart A heart failure heart has a reduced ability to pump blood. Used with the permission of Medtronic Canada Ltd. Heart Failure Heart Click on the heart to begin the animation.Leadership. Knowledge. Comm7 unity. • HF is a complex syndrome in which abnormal heart function results in, or increases the subsequent risk of, clinical symptoms and signs of low cardiac output and/or pulmonary or systemic congestion • HF is common and reduces quality of life, exercise tolerance and survival • New treatments have greatly improved prognosis and many patients can now hope for long periods of stable, improved symptoms and improved heart function • Evidence-based guidelines help in our ability to improve outcomes despite the challenges associated with the treatment and management of HF What is Heart Failure (HF)? Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm8 unity. HF Prevalence in Canada Chow C-M et al. Can J Cardiol 2005;21(14):1265-71.Leadership. Knowledge. Comm9 unity. Majority of HF Patients Treated by GPs/FPs Tu K et al. Can J Cardiol 2004;20:282-91.Leadership. Knowledge. Comm10 unity. Projected number of incident hospitalizations for CHF patients, using high, medium and low population growth projections in Canada 1996-2050 HF Cases on the Rise Johansen et al. Can J Cardiol 2003;19(4):430-5.Leadership. Knowledge. Comm11 unity. Heart Failure Mortality • Canada’s average annual in-hospital mortality rate is: – 9.5 deaths/100 hospitalized patients >65 years of age – 12.5 deaths/100 hospitalized patients >75 years of age • HF patients have a poor prognosis, with an average 1-year mortality rate of 33% Lee DS et al. Can J Cardiol 2004;20(6):599-607.Leadership. Knowledge. Comm12 unity. HF Readmissions • Hospital readmission rates are high, and mainly due to recurrent heart failure Lee DS et al. Can J Cardiol 2004;20(6):599-607.Leadership. Knowledge. Comm13 unity. • Higher LVEF decreases the risk of death Data derived from CHARM patients (n=7599). Median follow-up of 38 months. Solomon SD et al. Circulation 2005;112:3738-44. Mortality in HF Increases With Lower LVEFLeadership. Knowledge. Comm14 unity. • Higher LVEF decreases the risk of HF hospitalization HF Hospitalizations Increase With Lower LVEF Data derived from CHARM patients (n=7599). Median follow-up of 38 months. Solomon SD et al. Circulation 2005;112:3738-44.Leadership. Knowledge. Comm15 unity. P vs Class I HF. Data derived from DIG patients (n=988). Median follow-up of 38.5 months. Ahmed A et al. Am Heart J 2006;151:444-50. Mortality in HF Increases With Worsening NYHA Classification • Worse NYHA classification associated with an increased risk of deathLeadership. Knowledge. Comm16 unity. Hospitalization for HF Increases With Worsening NYHA Classification • Worse NYHA classification associated with an increased risk of all-cause hospitalization P vs Class I HF. Data derived from DIG patients (n=988). Median follow-up of 38.5 months. Ahmed A et al. Am Heart J 2006;151:444-50.Leadership. Knowledge. Comm17 unity. National Vital Statistics Report, 1999; Cohn JN et al. N Engl J Med 2001;345:1667-75; Pfeffer MA et al. Lancet 2003;363:759-66; MERIT-HF Study Group. Lancet 1999;353:2001-7; Packer M et al. Circulation 2002;106:2194-9; Pitt B et al. N Engl J Med 1999;341:709-17. Comparative Survival in HF Trials (Placebo Arm)Leadership. Knowledge. Comm18 www.ccs.ca unity. What Are CCS Consensus Conferences? • Represent current recommendations for the prevention, diagnosis, treatment and ongoing management of heart disease • Based upon detailed review of relevant published research and undertaken by healthcare professionals recognized for their expertise across Canada and around the world • Useful for establishing patient care standards and serving as a balanced and trustworthy reference for Canadian healthcare professionals • Each is developed independent of, and at arm's length from, third party interests which is considered essential to maintaining content objectivity and balanceLeadership. Knowledge. Comm19 unity. Who Are CCS Consensus Recommendations Developed For? www.ccs.ca • Developed for Canadian healthcare professionals involved in research, teaching and, especially, day-today delivery of patient care • Also available to patients and families who wish to acquaint themselves with evidence-based recommendations for patient care • Made broadly available to constantly improve the quality of cardiovascular patient care across CanadaLeadership. Knowledge. Comm20 unity. What is the CCS HF Consensus Program? www.ccs.ca • CCS has adopted an innovative ‘closed-loop’ model of CC development which accommodates end-user and stakeholder input and evaluation on an ongoing basis • The development processes identified will be of utility and interest to those dedicated to closing the gap ‘between what we know and what we do’ • CCS has elicited the support and active participation of 12 national health professional societies and organizations, patient support and advocacy groups, Federal, Provincial and Regional health governments, national health outcomes databases, international and national IT companies, national medical communications companies and pharmaceutical industries • To learn more about this important initiative, please visit the CCS HF Consensus Program Website (http:\/\/hfcc.ccs.ca) or contact John Parker, Director Knowledge Translation (parker@ccs.ca)Leadership. Knowledge. Comm21 unity. Process and Purpose of New CCS HF Recommendations 2006 • First CCS recommendations were published in 1994 with updates in 2001 and 2003 • New clinical trial evidence and meta-analyses were critically reviewed by a multidisciplinary primary panel whose recommendations and practical tips were reviewed by a secondary panel • Practical advice for specialists, family physicians, nurses, pharmacists and others involved in HF care • Goal is to translate best evidence-based therapies into clinical practice with a measurable impact on the health of HF patients in Canada Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm22 unity. Panelists Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45. Primary panelists: J Malcolm O Arnold, Peter Liu, Catherine Demers, Paul Dorion, Nadia Giannetti, Haissam Haddad, George A Heckman, Jonathan G Howlett, Andrew Ignaszewski, David E Johnstone, Philip Jong, Robert S McKelvie, Gordon W Moe, John D Parker, Vivek Rao, Heather J Ross, Errol J Sequeira, Anna M Svendsen, Koon Teo, Ross T Tsuyuki, Michel White Secondary panelists: Tom Ashton, Victor Huckell, Debra Isaac, Marie-Helene Leblanc, Gary E Newton, Joel Niznick, Sherryn N Roth, Denis Roy, Stuart Smith, Bruce A Sussex, Salim YusufLeadership. Knowledge. Comm23 unity. Class of Recommendation and Grade of Evidence Evidence or general agreement that a given procedure or treatment is beneficial, useful and effective. Conflicting evidence or a divergence of opinion about the usefulness or efficacy of a procedure or treatment. Weight of evidence in favour of usefulness or efficacy. Usefulness or efficacy is less well established by evidence or opinion. Evidence or general agreement that the procedure or treatment is not useful or effective and in some cases may be harmful. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm24 unity. Class of Recommendation and Grade of Evidence Data derived from multiple randomized trials or meta-analyses Data derived from a single randomized clinical trial or nonrandomized studies Consensus of opinion of experts and/or small studies Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm25 unity. Key Recommendations Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45. • Management of HF begins with an accurate diagnosis • Aggressive treatment of all known risk factors (e.g. hypertension, DM) • Treatment requires rational combination drug therapy • Care should be individualized for each patient based on: • Symptoms • Clinical presentation • Disease severity • Underlying cause • Patient and caregiver education should be tailored and repeated • Mechanical interventions (e.g. revasc. and devices) should be available • Collaboration is required among healthcare professionals • Accessibility to primary, emergency and specialist care must be timelyLeadership. Knowledge. Comm26 unity. Diagnosis and Investigation • Clinical history, physical examination and laboratory testing • Transthoracic echocardiography (ventricular size and function, valves, etc.) • Coronary angiography in patients with known/suspected CAD • NYHA classification should be used to document functional capacity in all patients (Class I, Level C) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm27 unity. What is BNP and How Does It Help? Strunk A et al. Am J Med 2006;119:69:e1-11. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45. • B-type natriuretic peptide (BNP) is a 32- amino-acid polypeptide secreted by the ventricles of the heart in response to excessive stretch of ventricular myocytes • Elevated blood levels of BNP are used as a diagnostic test for heart failure • Measurement of blood levels of BNP or the amino terminal fragment of pro-BNP (NT-pro-BNP) should be considered, where available, in patients with suspected heart failure when clinical uncertainty exists (Class I, Level C)Leadership. Knowledge. Comm28 unity. Practical Tips in HF Diagnosis • HF can be diagnosed without a history or current evidence of volume overload. Thus, the term ‘heart failure’ is generally preferred over ‘congestive heart failure’ • A normal LVEF does not exclude HF as a diagnosis (e.g., HF with preserved systolic function – PSF) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm29 unity. Clinical Presentations of Heart Failure Dyspnea Orthopnea Paroxysmal nocturnal dyspnea Fatigue Weakness Exercise intolerance Dependent edema Cough Weight gain Abdominal distension Nocturia Cool extremities Cognitive impairment* Altered mentation or delirium* Nausea Abdominal discomfort Oliguria Anorexia Cyanosis * May be more common presentation in elderly patients. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm30 unity. Diagnosis of HF Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm31 unity. Causes of Heart Failure • Coronary artery disease • Myocardial infarction • Hypertension • Diabetes • Valvular heart disease • Dilated or hypertrophic cardiomyopathy, myocarditis • Congenital heart disease • Severe lung disease www.americanheart.orgLeadership. Knowledge. Comm32 unity. Risk Factors for HF • Cardiovascular risk factors should be aggressively managed with appropriate drugs and lifestyle modifications to targets identified in current diseasespecific national guidelines (Class I, Level A) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm33 unity. What Should I Look For and Talk About? • Talk to patients about their priorities • Identify specific targets for therapy • Look for, and treat, depression • Discuss advance directives, living wills and substitute decision-makers • Follow patients closely and systematically Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm34 unity. What Should I Look For and Talk About? • Educate about early warning signs of decompensation and how to respond • Discuss salt and fluid intake • Use daily morning weights with a diary and tailored prn diuretic dosing • Measure supine and erect BP • Follow creatinine and K+ closely • Eliminate harmful drugs Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm35 unity. Non-Pharmacological Management • Regular physical activity is recommended for all patients with stable symptoms and impaired LV systolic function • Before starting a training program, all patients should have a graded exercise stress test to assess functional capacity, ischemia, and optimal heart rate (Class IIa, Level B) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm36 unity. Non-Pharmacological Management • All patients with symptomatic HF should not add salt to their diet and patients with advanced HF should reduce salt to <2 g/day • Daily morning weight should be monitored in HF patients with fluid retention or congestion not easily controlled with diuretics, or with significant renal dysfunction or hyponatremia (Class I, Level C) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm37 unity. Non-Pharmacological Management • Restriction of daily fluid intake to 1.5-2 L/day should be considered for patients with fluid retention or congestion not easily controlled with diuretics, or in patients with severe renal dysfunction or hyponatremia (Class I, Level C) • Forced fluid intake beyond normal needs to prevent thirst is not recommended (Class III, Level C) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm38 unity. Immunization • Physicians should immunize HF patients against influenza (annually) and pneumococcal pneumonia (if not done in last six years) to reduce the risk of respiratory infections that may seriously aggravate HF (Class I, Level C) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm39 unity. Which Patients Should be Referred to a Heart Failure Specialist? • New onset HF • Recent HF hospitalization • HF associated with ischemia, hypertension, valvular disease, syncope, renal dysfunction, other multiple comorbidities • HF of unknown etiology • Intolerance to recommended drug therapies • Poor compliance with treatment • First degree family members if family history of cardiomyopathy or sudden cardiac death (Class I, Level C) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm40 unity. HF Disease Management Programs • Specialized hospital-based clinics or disease management programs, staffed by physicians, nurses, pharmacists and other healthcare professionals with expertise in HF management should be developed and used for assessment and management of higher risk patients with HF (Class I, Level A) • The optimal care model should reflect local circumstances, present resources, and available healthcare personnel (Class I, Level C) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm41 unity. Follow-up: How soon? • Patients with recurrent HF hospitalizations should be referred to a specialized HF clinic by family physicians, internists, and cardiologists for follow-up within 4 weeks of hospital discharge, or sooner when feasible (Class I, Level A) • Care should include close follow-up, patient and caregiver education, telemanagement or monitoring, and home visits by specialized staff where resources are available (Class I, Level A) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm42 unity. Multidisciplinary Interventions – Mortality and Hospitalization Benefits Rich MW et al. N Engl J Med 1995;333:1190-5.Leadership. Knowledge. Comm43 unity. Multidisciplinary HF Management – Meta-Analysis Duration of interventions in the pooled studies ranged from one visit to 30 months. McAlister FA et al. J Am Coll Cardiol 2004;44:810-9.Leadership. Knowledge. Comm44 unity. Treatment of Heart Failure Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm45 unity. • Drugs proven in large-scale clinical trials are recommended as they have known effective target doses (Class I, Level A) • Large-scale clinical trial doses should be used, or a lesser but maximum tolerated dose (see table on next slide) (Class I, Level A) Principles of Drug Therapy Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm46 unity. What Dosages of Drugs Should Be Used? * The Healing and Early Afterload Reduced Therapy (HEART) trial showed that 10 mg od was effective for attenuating left ventricular remodeling. † Not available in Canada. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm47 unity. Principles of Drug Therapy • If a drug with proven mortality or morbidity benefits is not tolerated (e.g., low BP, low heart rate, or renal dysfunction), concomitant drugs with less proven benefit should be carefully re-evaluated to determine if their dose can be reduced or the drug discontinued to allow better tolerance of the proven drug (Class I, Level B) • Contraindications to the use of a drug in an individual patient should be carefully evaluated before prescribing and emergent new signs or symptoms should be assessed to determine whether they could be side-effects related to the drug (Class I, Level C) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm48 unity. Where to Start? • Evidence-based combination drug therapy is recommended in most patients with HF (Class I, Level A) • All HF patients with LVEF <40% should be treated with an ACE-I and a beta-blocker, unless a specific contraindication exists (Class I, Level A) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm49 unity. When to Use ACE Inhibitors? These trials form the basis of ACE-I use in HF with LVEF < 40% and/or post-MI with reduced LVEF and/or HF • All HF patients with LVEF <40% should be treated with an ACE-I and a beta-blocker, unless a specific contraindication exists (Class I, Level A) CONSENSUS Trial . N Engl J Med 1987;316:1429-35. SOLVD Investigators. N Engl J Med 1991;325:293-302. Flather MD et al. Lancet 2000;355:1575-81. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm50 unity. When to Use ACE Inhibitors? • ACE-Is prevent occurrence of HF in patients at risk Arnold JMO et al. Circulation 2003;107:1284-90. SOLVD Investigators. N Engl J Med 1992;327:685-91. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm51 unity. ACE Inhibitors – Reductions in HF Hospitalizations SOLVD Investigators. N Engl J Med 1991;325:293-302. SOLVD Investigators. N Engl J Med 1992;327:685-91. Flather MD et al. Lancet 2000;355:1575-81.Leadership. Knowledge. Comm52 unity. Treatment Ramipril Enalapril Enalapril Ramipril Follow-up 5-10 years 10 yrs 12 yrs 7.2 yrs Characteristic Clinical HF, NYHA class IV HF, LV High CV risk, post-MI HF dysfunction no LV dysfunction, no HF Results RRR 36% Overall survival Extended Reduced major in mortality prolonged survival CV events and by 50% by 9.4 mo new diabetes Summary Substantial long-term Beneficial effect Sustained Sustained CV and mortality reduction maintained for at improvement metabolic benefit in with ACE-I treatment least 4 years in survival vascular disease post-MI patients without HF or LV dysfunction Hall AS et al. Lancet 1997;349:1493-7. Swedberg K et al. Eur Heart J 1999;20:136-9. Jong P et al. Lancet 2003;361:1843-8. HOPE/HOPE-TOO Study Investigators. Circulation 2005;112:1339-46. Extension Studies Show Sustained Benefits with ACE InhibitorsLeadership. Knowledge. Comm53 unity. ACE Inhibitors – Long-Term Mortality Benefits Hall AS et al. Lancet 1997;349:1493-7. Jong P et al. Lancet 2003;361:1843-8.Leadership. Knowledge. Comm54 unity. ACE Inhibitors – Long-Term Mortality Benefits Swedberg K et al. Eur Heart J 1999;20:136-9. HOPE/HOPE-TOO Study Investigators. Circulation 005;112:1339-46.Leadership. Knowledge. Comm55 unity. • Check supine and erect BP for symptomatic hypotension • If symptomatic hypotension persists, separate timing of dose from other medications that could also lower BP • Reduce dose of diuretic if patient stable and reassess need for other vasodilators (e.g., long-acting nitrates) • An increase in creatinine of up to 30% is not unexpected after introduction of an ACE-I/ARB • Adding spironolactone to an ACE-I plus an ARB is discouraged, unless followed closely in a specialist HF clinic Practical Tips for ACE-I/ARB Use Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm56 unity. • All HF patients with LVEF =40% (use clinically proven beta-blocker) (Class I, Level A) • In stabilized HF patients with NYHA Class IV symptoms (Class I, Level C) When to Use Beta-blockers? MERIT-HF Study Group. Lancet 1999;353:2001-7. CIBIS II Investigators. Lancet 1999;353:9-13. Packer M et al. Circulation 2002;106:2194-9. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm57 unity. Beta-blockers – Reductions in HF Hospitalizations CIBIS II Investigators and Committee. Lancet 1999;353:9-13. Packer M et al. Circulation 2002;106:2194-9.Leadership. Knowledge. Comm58 unity. Practical Tips for BB Use • Non-specialist physicians can safely initiate and titrate BB in NYHA Class I or II patients • Dose of BB should be increased slowly, e.g., double dose every 2-4 weeks if stable • If reactive airways disease is present, use more selective BB, e.g., bisoprolol • If bradycardia or AV block is present, reduce or stop digoxin or amiodarone (where appropriate) • If hypotensive, consider reducing other medications or change timing of doses Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm59 unity. Practical Tips for BB Use • Objective improvement in LV function may not be apparent for 6-12 months or longer • Major reduction of BB dose or abrupt withdrawal should generally be avoided • In acute decompensated HF, BB dose down-titration may be required (including those on beta-agonist +ve inotrope support), but not necessarily discontinued unless patient is in cardiogenic shock • BB should be considered in patients where it has often been underutilized, e.g., the elderly and those with asymptomatic LV dysfunction Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm60 unity. Combination Use of ACE-Is plus BBs • All HF patients with LVEF <40% should be treated with an ACE-I and a beta-blocker, unless a specific contraindication exists (Class I, Level A) • All major BB HF trials recommended ACE-I therapy as background therapy • It is recommended to initiate ACE-I first, although CIBIS III showed that initiating therapy with BB alone might also be appropriate Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45. Willenheimer R et al. Circulation 2005;112:2426-35.Leadership. Knowledge. Comm61 unity. Combination Use of ACE-Is plus BBs Willenheimer R et al. Circulation 2005;112:2426-35. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm62 unity. Pfeffer MA et al. Lancet 2003;363:759-66. Cohn JN et al. N Engl J Med 2001;345:1667-75. • In patients with persistent HF symptoms, and who are at increased risk of HF hospitalization, despite optimal treatment with ACE inhibitors and beta-blockers (Class I, Level A) When to Use ARBs as Add-on Therapy? Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm63 unity. ARBs - Reductions in HF Hospitalizations Pfeffer MA et al. Lancet 2003;363:759-66. Cohn JN et al. N Engl J Med 2001;345:1667-75.Leadership. Knowledge. Comm64 unity. Pfeffer MA et al. N Engl J Med 2003;349:1893-906. Dickstein K et al. Lancet 2002;360:752-60. • May be considered as an alternative to an ACE inhibitor in patients with acute MI with acute HF or LVEF <40% (Class I, Level B) When to Use ARBs instead of ACE-I? Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm65 unity. ARBs – Reductions in HF Hospitalizations Median duration of follow-up 24.7 months. Mean duration of follow-up 23 months. Median duration of follow-up 37.7 months. Cohn JN et al. N Engl J Med 2001;345:1667-75. Pfeffer MA et al. N Engl J Med 2003;349:1893-906. Pfeffer MA et al. Lancet 2003;363:759-66.Leadership. Knowledge. Comm66 unity. Other Indications for ARBs • As adjunctive therapy to ACE-I when beta-blockers are either contraindicated or not tolerated after careful attempts at initiation (Class IIa, Level B) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45. Granger CB et al. Lancet 2003;362:772-6. • With ACE inhibition intolerance (renal dysfunction and hyperkalemia may recur) (Class I, Level A)Leadership. Knowledge. Comm67 unity. Improving CHF Outcomes With Combination Drug Therapy Mean duration of follow-up 41.4 months. Mean duration of follow-up 1.3 year s. Median duration of follow-up 40 months. SOLVD N Engl J Med 1991;325:293-30 CIBIS II. Lancet 1999;353:9-13 Young JB et al. Circulation 2004;110:2618-26.Leadership. Knowledge. Comm68 unity. When to Use Aldosterone Blockers? Pitt B et al. N Engl J Med 1999;341:709-17. Spironolactone: • Patients with LVEF =30% and severe symptoms despite optimized other therapies (Class I, Level B) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm69 unity. When and How to Use Diuretics? • A loop diuretic, such as furosemide, is recommended for most patients with HF and congestive symptoms. Once acute congestion is cleared, the lowest dose should be used that is compatible with stable signs and symptoms (Class I, Level C) • For patients with persistent volume overload despite optimal other medical therapy and increases in loop diuretics, cautious addition of a second diuretic (e.g., a thiazide or low-dose metolazone) may be considered as long as it is possible to closely monitor renal function, serum potassium and daily morning weight (Class IIb, Level B) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm70 unity. • To relieve symptoms and reduce hospitalizations in patients in sinus rhythm who have persistent moderate-to-severe symptoms despite optimized HF medical therapy (Class I, Level A) When To Use Digoxin? The Digitalis Investigation Group. N Engl J Med 1997;336:525-33. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm71 unity. When To Use Nitrates + Hydralazine? • Other HF patients unable to tolerate ACE inhibitors and ARBs (Class IIb, Level B) • African-Americans with systolic dysfunction in addition to standard therapy (Class IIa, Level A) Cohn et al. N Engl J Med 1986;314:1547-52. Taylor AL et al. N Engl J Med 2004;351:2049-57. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm72 unity. When to Anticoagulate? • Anticoagulant therapy (international normalized ratio of 2 to 3) should be given to all patients with HF and associated atrial fibrillation (Class I, Level A) • Anticoagulation is not recommended routinely for patients with sinus rhythm, but should be considered for patients with intracardiac thrombus, spontaneous echocardiographic contrast or severe reduction in left ventricular systolic function (Class IIa, Level C) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm73 unity. Drug Interactions and Additive Adverse Effects of Common Medications (Class I, Level B) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm74 unity. HF with Preserved Systolic Function • Diagnosis is generally based on typical signs and symptoms of HF in patient with normal LVEF and no valvular abnormalities • Important to control comorbidities, such as hypertension and diabetes, which are often associated with HF with PSF • Systolic and diastolic hypertension should be controlled according to published guidelines (Class I, Level A) • The ventricular rate should be controlled in patients with atrial fibrillation at rest and during exercise (Class I, Level C) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm75 unity. HF with Preserved Systolic Function • Diuretics should be used to control pulmonary congestion and peripheral edema (Class I, Level C) • ACE inhibitors, ARBs, and beta-blockers should be considered for most patients (Class IIa, Level B) • Coronary revascularization may be considered for patients with symptomatic or demonstrable ischemia that is judged to have an adverse effect on cardiac function (Class IIa, Level C) • Excessive diuresis should be avoided as this can easily lead to reduced CO and renal dysfunction Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm76 unity. Management of Acute HF • The diagnosis of AHF should be established in <2 hours of the initial contact in the emergency department (Class IIa, Level C) • Treatment for AHF should be initiated as soon as possible after diagnosis. Assessment of response to initial therapy and the need for additional therapy should be made <2 hours after treatment initiation. Plans for patient disposition should be determined <8 hours after the first medical contact. (Class IIb, Level C) • Measurement of plasma B-type natriuretic peptides should be considered, where available, in patients with suspected HF but when clinical uncertainty exists (Class IIa, Level A) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm77 unity. Quick Assessment of AHF Nohria A et al. J Am Coll Cardiol 2003;41:1797-804.Leadership. Knowledge. Comm78 unity. Treatment Algorithm for Acute HF Erratum. Can J Cardiol 2006;22(3):271.Leadership. Knowledge. Comm79 unity. Shock-only ICD Therapy – Mortality Benefits • The decision to implant an ICD in any given patient must be individualized as some patients may not benefit from an ICD • An ICD should be considered in patients with IHD with or without mild to mod. HF symptoms and LVEF =30%, measured >1 month post-MI and >3 months post-coronary revascularization (Class I, Level A) • An ICD may be considered in patients with nonischemic cardiomyopathy present for at least 9 months, NYHA functional class II-III HF, and LVEF =30% (Class IIa, Level B) or LVEF 31-35% (Class IIb, Level C) Bardy GH et al. N Engl J Med 2005;352:225-37. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45. Tang AS et al. Can J Cardiol 2005;21(Suppl A):11A-8A.Leadership. Knowledge. Comm80 unity. Cleland JGF et al. N Engl J Med 2005;352:1539-49. Bristow MR et al. N Engl J Med 2004;350:2140-50. • Patients with symptomatic (NYHA III-IV) HF despite optimal medical therapy, and who are in normal sinus rhythm with QRS duration =120 msec and LVEF =35%, should be considered for CRT-ICD (Class I, Level A) Cardiac Resynchronization Therapy Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45. Tang AS et al. Can J Cardiol 2005;21(Suppl A):11A-8A.Leadership. Knowledge. Comm81 unity. Other Arrhythmia Caveats • Addition of ICD should be considered in patient referred for CRT who meet ICD requirements (Class IIa, Level B) • An ICD should not be implanted in NYHA class IV HF patients who are not expected to improve with any further therapy and who are not candidates for cardiac transplantation (Class III, Level C) • Antiarryhthmic drug therapy is discouraged in HF patients unless symptomatic arrhythmias persist despite optimal medical therapy with ACE-I plus beta-blocker and correction of any ischemia or electrolyte and metabolic abnormalities (Class I, Level B) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45. Tang AS et al. Can J Cardiol 2005;21(Suppl A):11A-8A.Leadership. Knowledge. Comm82 unity. Practical Tips for Device Therapy • Patients being considered for ICD should have a reasonable quality of life and a life expectancy greater than one year • Patients with significant co-morbidities may not benefit from an ICD • LVEF in most trials of CRT was very low at around 20-25% • ECHO may become helpful in identifying patients and predicting response to CRT Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm83 unity. Surgical Considerations in HF • HF patients with severe refractory symptoms despite optimal medical therapy, and an otherwise good life expectancy, should be considered for heart transplant (Class I, Level A) • HF patients with persistent symptomatic ischemia or large areas of viability should be evaluated for revascularization, either percutaneous or surgical (Class I, Level C) • CABG in patients with severe LV dysfunction should be considered only by surgical teams with extensive surgical experience in these patients (Class I, Level B) • The role of surgical revascularization in patients with ischemic HF and no evidence of reversible ischemia or viable myocardium remains unknown Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm84 unity. Care of the Elderly • Primary focus of care on symptom reduction and quality of life, rather than mortality reduction in patients with high comorbid burden (Class I, Level C) • Elderly HF patients should be screened for cognitive impairment (Class I, Level C) • Elderly HF patients with chronic physical complaints despite optimal HF therapy should be screened for depression (Class I, Level C) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm85 unity. Atypical Clinical Features of HF in the Frail Elderly Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm86 unity. Causes of Orthostatic Hypotension Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm87 unity. Ethical and End-of-Life Issues • Patients with HF should be approached early in the disease process regarding their prognosis, advanced medical directives and wishes for resuscitative care. These decisions should be reviewed regularly and specifically after any change in the patient’s condition. (Class I, Level C) • A substitute decision maker (proxy) should be identified (Class I, Level C) • Where possible, a living will should be discussed with patients to clarify wishes for end-of-life care (Class I, Level C) • As patients near end-of-life, physicians should re-address goals of therapy, balancing quantity and quality of life, with shift of focus to quality of life. Palliative care consultation should be considered. (Class I, Level C) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm88 unity. Social Considerations • Psycho-social issues (e.g., depression, fear, isolation, home supports, need for respite care, etc.) should be routinely re-evaluated (Class I, Level C) • Caregivers of patients with advanced HF should be evaluated for coping and degree of caregiver burden (Class I, Level C) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm89 unity. Conclusions • Make an accurate and timely diagnosis • Initiate treatment to • Reduce HF risk factors • Reduce HF symptoms • Reduce hospitalizations • Improve quality of life • Prolong survival • Refer patients at higher risk to specialist or HF clinic • Continue to translate new knowledge into practice • Combine available healthcare resources to improve delivery of best care and practices to HF patients • Improve HF outcomes in Canada Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.Leadership. Knowledge. Comm90 unity. Background Slides • Epidemiology • Clinical Trials • HF prognosisLeadership. Knowledge. Comm91 unity. Number of Hospitalizations for CHF (actual and projected) in Canada 1980-2025 Heart and Stroke Foundation of Canada.Leadership. Knowledge. Comm92 unity. Number of CHF Deaths (actual and projected) in Canada, 1980-2025 Heart and Stroke Foundation of Canada.Leadership. Knowledge. Comm93 unity. Heart Failure Costs in the UK Stewart et al. Eur J Heart Fail 2002;4:361-7.Leadership. Knowledge. Comm94 unity. Post-MI Therapy – Mortality Benefits The AIRE Study Investigators. Lancet 1993;342:821-8. Hall AS et al. Lancet 1997;349:1493-7. Køber L et al. N Engl J Med 1995;333:1670-6. The CAPRICORN Investigators. Lancet 2001;357:1385-90.Leadership. Knowledge. Comm95 unity. Other Therapies Packer M et al. N Engl J Med 1996;335:1107-14.Leadership. Knowledge. Comm96 unity. Case Study OneLeadership. Knowledge. Comm97 unity. 65 year old male, long standing COPD, no history of HF, previously known normal LV systolic function, presented to emergency room with increasing dyspnea Physical examination revealed diffuse crackles and wheeze. Systolic BP = 145 mm Hg, RR = 25, HR = 105, no peripheral edema. JVP could not be assessed properly. Illustrative Case of the Appropriate Use of BiomarkersLeadership. Knowledge. Comm98 unity. Chest radiograph: hyperinflation and “prominent lung markings” EKG: sinus tachycardia Laboratory: SaO2, 93%; Hb, 120; WBC, 17,000 Na, 131; creatinine, 116 Troponin I, 0.13Leadership. Knowledge. Comm99 unity. Diagnostic possibilities in this case a) Exacerbation of COPD b) Acute MI c) Acute decompensated HF d) Infection e) Pulmonary embolism f) Combinations of above Patients with suspected HF often have co-morbid conditions with manifestations that mimic HF Timely Diagnosis and Institution of Appropriate Management Plan are MandatoryLeadership. Knowledge. Comm100 unity. Illustrative Case Blood NT-proBNP level = 12,500 ng/mL There is a very high probability that this patient has HF as one of the etiologies of his dyspneaLeadership. Knowledge. Comm101 unity. Case Study TwoLeadership. Knowledge. Comm102 unity. Case Study Two • 44 year-old male engineer with a familial cardiomyopathy evolving for 12 months Symptoms: • Stable NYHA class II symptoms • LVEF = 27% twelve months ago, and now at 18% Physical examination: • Heart rate: 68 bpm • BP: 104/64 • Soft S3Leadership. Knowledge. Comm103 unity. Case Study Two Medications: • Digoxin 0.25 mg od • Lasix 40 mg od • Carvedilol 6.25 mg po bid • Ramipril 10 mg po hsLeadership. Knowledge. Comm104 unity. • Would you suggest any change in the drug treatment? • Is this patient a candidate to receive an ARB in addition to an ACE inhibitor therapy? • Would you consider spironolactone? Case Study Two - QuestionsLeadership. Knowledge. Comm105 unity. Case Study ThreeLeadership. Knowledge. Comm106 unity. Case Study Three • 65 year-old woman presents with depressed LVEF = 30% on echo requested for LV hypertrophy on the EKG • She has minimal dyspnea but does little physical activity Past medical history: • Diabetes for 15 years • Systemic hypertension for 10 years • Metabolic syndromeLeadership. Knowledge. Comm107 unity. Physical examination: • BP 152/90 mm Hg, S4 • Chest clear • No peripheral edema Medications: • Metformin 850 mg bid • ASA 80 mg pod od Case Study ThreeLeadership. Knowledge. Comm108 unity. • What would be your initial pharmacologic approach at this point? More specifically, would you consider: a) ACE versus ARB b) ACE plus ARB c) ACE plus beta-blocker d) Beta-blocker alone e) Other Case Study Three - Questions||http:\/\/www.hfcc.ca/downloads/educational_tools/CCS_Consensus_Conference_Heart_Failure.pdf", "Microsoft PowerPoint - CCS_Conference_Insuffisance_Cardiaque_f.ppt|Communauté. Connaissance. Leadership. L’insuffisance cardiaque : recommandations 2006 Diagnostic et prise en charge Faculté*: • Malcolm O. Arnold, M.D. (Président) • Haissam Haddad, M.D. • David E. Johnstone, M.D. • Gordon W. Moe, M.D. • Michel White, M.D. *Ce groupe d’experts a examiné le jeu de diapositives au nom des comités pluridisciplinaires principal et secondaire de la conférence consensuelle. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.2 Communauté. Connaissance. Leadership. Recommandations 2006 de la SCC relatives à l’IC - Table des matières du diaporama • Historique de l’IC et des maladies cardiovasculaires (MCV) • Méthodologie de la conférence de consensus de la SCC • Recommandations clés • Diagnostic, causes et facteurs de risque de l’IC • Information, traitement non médicamenteux, orientation et cliniques d’insuffisance cardiaque Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.3 Communauté. Connaissance. Leadership. Recommandations 2006 de la SCC relatives à l’IC - Table des matières du diaporama (suite) • Traitement de l’IC – IECA – BB – ARA – Thérapies combinés – Fonction systolique préservée – IC aiguë – Thérapie avec dispositifs – Quand envisager une chirurgie Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.4 Communauté. Connaissance. Leadership. • Soins aux aînés et fin de vie • Conclusion/résumé • Diapositives de référence supplémentaires • Études de cas Recommandations 2006 de la SCC relatives à l’IC - Table des matières du diaporama (suite) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.5 Fondation des maladies du coeur du Canada, 2003. Communauté. Connaissance. Leadership. Maladies cardiovasculaires et mortalité au Canada6 Communauté. Connaissance. Leadership. Le continuum de l’insuffisance cardiaque7 Communauté. Connaissance. Leadership. En temps normal, le coeur envoie le sang vers les organes de manière régulière et synchronisée. Battement de coeur normal Utilisé avec la permission de Medtronic Canada Ltd. Double-cliquer sur le coeur pour activer l’animation8 Communauté. Connaissance. Leadership. Le coeur d’une personne souffrant d’IC a une capacité réduite à envoyer du sang vers les organes. Coeur d’une personne souffrant d’IC Utilisé avec la permission de Medtronic Canada Ltd. Double-cliquer sur le coeur pour activer l’animation9 Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45. Communauté. Connaissance. Leadership. Qu’est ce que l’insuffisance cardiaque (IC)? • L’IC est un syndrome complexe caractérisé par une anomalie de la fonction cardiaque, qui se traduit par des symptômes cliniques et des signes de débit cardiaque affaibli ou de congestion pulmonaire ou systémique, ou en augmente les risques d’apparition ultérieure • L’IC est fréquente et diminue la qualité de vie, la tolérance à l’effort et la survie10 Communauté. Connaissance. Leadership. Qu’est ce que l’insuffisance cardiaque (IC)? (suite) • Les nouveaux traitements ont beaucoup amélioré les pronostics et de nombreux patients peuvent à présent espérer avoir de longues périodes de stabilisation et d’amélioration des symptômes ainsi qu’une meilleure fonction cardiaque • Les directives fondées sur des preuves scientifiques nous permettent d’améliorer les résultats en dépit des difficultés liées au traitement et à la prise en charge de l’IC Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.11 Communauté. Connaissance. Leadership. Prévalence de l’IC au Canada Chow C-M et al. Can J Cardiol 2005;21(14):1265-71.12 Tu K et al. Can J Cardiol 2004;20:282-91. Communauté. Connaissance. Leadership. La majorité des patients sont traités par des médecins généralistes/de famille13 Johansen et al. Can J Cardiol 2003;19(4):430-5. Communauté. Connaissance. Leadership. Augmentation du nombre de cas d’IC • Projection du nombre de nouvelles hospitalisations pour ICC, sur la base de projections d’augmentation faible, moyenne et élevée de population au Canada entre 1996 et 205014 Lee DS et al. Can J Cardiol 2004;20(6):599-607. Communauté. Connaissance. Leadership. Mortalité par insuffisance cardiaque • Taux de mortalité annuel moyen à l’hôpital au Canada : – 9,5 décès/100 patients hospitalisés de plus de 65 ans – 12,5 décès/100 patients hospitalisés de plus de 75 ans • Les patients atteints d’IC ont un mauvais pronostic, avec un taux moyen de mortalité survenant en l’espace d’un an de 33 %15 Communauté. Connaissance. Leadership. Réadmissions pour IC • Les taux de réadmission à l’hôpital sont élevés et principalement attribuables à une IC récurrente Lee DS et al. Can J Cardiol 2004;20(6):599-607. TAUX POUR 100 CAS16 Communauté. Connaissance. Leadership. Données issues des patients de l’étude CHARM (n = 7599). Suivi médian de 38 mois. Solomon SD et al. Circulation 2005;112:3738-44. La mortalité par IC augmente avec une FEVG basse • Une FEVG élevée réduit le risque de décès17 Communauté. Connaissance. Leadership. Données issues des patients de l’étude CHARM (n = 7599). Suivi médian de 38 mois. Solomon SD et al. Circulation 2005;112:3738-44. Les hospitalisations pour IC augmentent avec une FEVG basse • Une FEVG élevée réduit le risque d’hospitalisation pour IC18 Communauté. Connaissance. Leadership. P vs IC de classe I. Données issues des patients de l’étude DIG (n = 988). Suivi médian de 38,5 mois. Ahmed A et al. Am Heart J 2006;151:444-50. La mortalité par IC augmente avec l’aggravation de la classification NYHA • La classification NYHA la plus grave est associée à un risque plus élevé de décès19 Communauté. Connaissance. Leadership. P vs IC de classe I. Données issues des patients de l’étude DIG (n = 988). Suivi médian de 38,5 mois. Ahmed A et al. Am Heart J 2006;151:444-50. Les hospitalisations pour IC augmentent d’un stade de classification NYHA à l’autre • Le risque d’hospitalisation pour toutes causes s’accroît d’un stade de classification NYHA à l’autre20 Communauté. Connaissance. Leadership. National Vital Statistics Report. 1999; Cohn JN et al. N Engl J Med 2001;345:1667-75; Pfeffer MA et al. Lancet 2003;363:759-66; MERIT-HF Study Group. Lancet 1999; 353:2001-7; Packer M et al. Circulation 2002;106:2194-9; Pitt B et al. N Engl J Med 1999;341:709-17. Comparaison du pourcentage de survie dans les essais d’IC (groupe placebo)21 www.ccs.ca Communauté. Connaissance. Leadership. En quoi consistent les conférences de consensus de la SCC? • Reflètent les recommandations actuelles en matière de prévention, de diagnostic, de traitement et de prise en charge continue des maladies cardiaques • Se fondent sur un examen détaillé des recherches publiées pertinentes et entreprises par des professionnels de la santé reconnus pour leur expertise au Canada et à l’échelle internationale22 Communauté. Connaissance. Leadership. • Servent à établir des normes de soins aux patients et une référence pondérée et fiable pour les professionnels de la santé canadiens • Chaque conférence est élaborée sans lien de dépendance avec des tierces parties; un aspect considéré comme essentiel pour maintenir l’objectivité et la pondération de son contenu En quoi consistent les conférences de consensus de la SCC? (suite) www.ccs.ca23 www.ccs.ca Communauté. Connaissance. Leadership. À qui s’adressent les recommandations de consensus de la SCC? • Élaborées pour les professionnels de la santé canadiens concernés par la recherche, par l’enseignement et – tout particulièrement – par l’administration quotidienne de soins aux patients • Sont également offertes aux patients et aux familles qui souhaitent connaître les recommandations de soins aux patients fondées sur des preuves scientifiques • Sont mises à la disposition d’un large public pour améliorer constamment la qualité des soins prodigués aux patients souffrant de maladies cardiovasculaires au Canada24 Communauté. Connaissance. Leadership. En quo