Treating cardiogenic shock and cardiac arrest: The right place,the right time,the right equipment

• The use of VA‐ECMO for patients with cardiac arrest or cardiogenic shock in the cardiac catheterization laboratory may be associated with improved survival.
• Clinicians should be aware of a high complication rate of this therapy.
• Further data is needed to best select the appropriate form of mechanical circulatory support in this clinical context.

     

Special report: club drugs & HIV. Drug treatment best hope for meth-using MSMs. Researchers want to get word out about problem

New unpublished and published research show that gay and bisexual men who use methamphetamine have a greater prevalence of HIV infection than men who have sex with men who do not use the drug. This finding has led some researchers to speculate that methamphetamine use could result in a resurgence of the virus among gay men. And it highlights the need for targeted substance abuse programs directed toward MSM who use methamphetamine.     

Treating the right patient at the right time: access to cardiovascular nuclear imaging

Cardiovascular nuclear medicine uses agents labelled with radioisotopes that can be imaged with cameras (single-photon emission tomography [SPECT] or positron emission tomography [PET]) capable of detecting gamma photons to show physiological parameters such as myocardial perfusion, myocardial viability or ventricular function. There is a growing body of literature providing guidelines for the appropriate use of these techniques, but there are little data regarding the appropriate timeframe during which the procedures should be accessed. An expert working group composed of cardiologists and nuclear medicine specialists conducted an Internet search to identify current wait times and recommendations for wait times for a number of cardiac diagnostic tools and procedures, including cardiac catheterization and angioplasty, bypass grafting and vascular surgery. These data were used to estimate appropriate wait times for cardiovascular nuclear medicine procedures. The estimated times were compared with current wait times in each province. Wait time benchmarks were developed for the following: myocardial perfusion with either exercise or pharmacological stress and SPECT or PET imaging; myocardial viability assessment with either fluorodeoxyglucose SPECT or PET imaging, or thallium-201 SPECT imaging; and radionuclide angiography. Emergent, urgent and nonurgent indications were defined for each clinical examination. In each case, appropriate wait time benchmarks were defined as within 24 h for emergent indications, within three days for urgent indications and within 14 days for nonurgent indications. Substantial variability was noted from province to province with respect to access for these procedures. For myocardial perfusion imaging, mean emergent/urgent wait times varied from four to 24 days, and mean nonurgent wait times varied from 15 to 158 days. Only Ontario provided limited access to viability assessment, with fluorodeoxyglucose available in one centre. Mean emergent/urgent wait times for access to viability assessment with thallium-201 SPECT imaging varied from three to eight days, with the exception of Newfoundland, where an emergent/urgent assessment was not available; mean nonurgent wait times varied from seven to 85 days. Finally, for radionuclide angiography, mean emergent/urgent wait times varied from two to 20 days, and nonurgent wait times varied from eight to 36 days. Again, Newfoundland centres were unable to provide emergent/urgent access. The publication of these data and proposed wait times as national targets is a step toward the validation of these recommendations through consultation with clinicians caring for cardiac patients across Canada.     

Treating the right patient at the right time: Access to echocardiography in Canada

The Canadian Cardiovascular Society is the national professional society for cardiovascular specialists and researchers in Canada. In the spring of 2004, the Canadian Cardiovascular Society Council formed the Access to Care Working Group ('Working Group') to use the best science and information available to establish reasonable triage categories and safe wait times for access to common cardiovascular procedures. The Working Group decided to publish a series of commentaries to initiate a structured national discussion on this important issue, and the present commentary proposes recommended wait times for access to echocardiography. 'Emergent' echocardiograms should be performed within 24 h, 'urgent' within seven days and 'scheduled' (elective) within 30 days. A framework for a solution-oriented approach to improve access is presented.     

Treating the right patient at the right time: access to heart failure care

Heart failure affects over 500,000 Canadians, and 50,000 new patients are diagnosed each year. The mortality remains staggering, with a five-year age-adjusted rate of 45%. Disease management programs for heart failure patients have been associated with improved outcomes, the use of evidence-based therapies, improved quality of care, and reduced costs, mortality and hospitalizations. Currently, national benchmarks and targets for access to care for cardiovascular procedures or office consultations do not exist. The present paper summarizes the currently available data, particularly focusing on the risk of adverse events as a function of waiting time, as well as on the identification of gaps in existing data on heart failure. Using best evidence and expert consensus, the present article also focuses on timely access to care for acute and chronic heart failure, including timely access to heart failure disease management programs and physician care (heart failure specialists, cardiologists, internists and general practitioners).     

Treating the right patient at the right time: access to specialist consultation and non-invasive testing

The Council of the Canadian Cardiovascular Society commissioned working groups to examine issues of access to, and wait times for, various aspects of cardiovascular care. The present article summarizes the deliberations on targets for medically acceptable wait times for access to cardiovascular specialist evaluation and on the performance of noninvasive testing needed to complete this evaluation. Three categories of referral indications were identified: those requiring hospitalization due to substantial ongoing risk of mortality and morbidity; those requiring an expedited early review in an ambulatory setting; and, finally, a larger category in which delays of two to six weeks can be justified. The proposed wait time targets will provide guidance on the timeliness of care to busy clinicians charged with the care of patients with cardiovascular disease, help policy makers appreciate the clinical challenges in providing access to high quality care, and highlight the critical need for a thoughtful review of cardiology human resource requirements. Wait time implementation suggestions are also included, such as the innovative use of disease management and special need clinics. The times proposed assume that available clinical practice guidelines are followed for clinical coronary syndrome management and for treatment of associated conditions such as hypertension, diabetes, renal disease, smoking cessation and lipid disorders. Although media attention tends to focus on wait times for higher profile surgical procedures and high technology imaging, it is likely that patients face the greatest wait-related risk at the earlier phases of care, before the disease has been adequately characterized.     

Treating the right patient at the right time: an innovative approach to the management of atrial fibrillation

The Canadian Cardiovascular Society Access to Care Working Group recently published a series of commentaries on access to cardiovascular care in Canada. These commentaries included proposed minimally acceptable wait times for patients with atrial fibrillation (AF) to be assessed by a cardiologist or an electrophysiologist. To improve access to medical care for the patient with AF, a nurse clinician-based AF clinic was established in the Calgary Health Region (Alberta) in 2005. More than 330 patients had been referred at the time of writing. The time from referral to initial nurse assessment was 38+/-31 days, to physician review and establishment of a management plan was 66+/-49 days and to in-person specialist physician assessment was 80+/-55 days. These wait times are markedly shorter than historical wait times to see an arrhythmia specialist in the Calgary Region. As experience increased, wait times continued to shorten significantly. Preliminary data suggest that early assessment and patient education may reduce emergency department visits and hospitalizations for AF. This experience suggests that a nurse clinician-based AF clinic may provide earlier access to medical care and may improve health outcomes in the long term.     

Treating the right patient at the right time: Access to cardiac catheterization, percutaneous coronary intervention and cardiac surgery

The Canadian Cardiovascular Society Access to Care Working Group was formed with a mandate to use the best science and information available to establish reasonable triage categories and safe wait times for common cardiovascular services and procedures through a series of commentaries. The present commentary discusses the rationale for access benchmarks for cardiac catheterization and revascularization procedures for patients with stable angina, and access benchmarks for cardiac catheterization and surgery for patients with valvular heart disease. Literature on standards of care, wait times and wait list management was reviewed. A survey of cardiac centres in Canada was performed to develop an inventory of current practices in identifying and triaging patients. The Working Group recommends the following medically acceptable wait times for access to cardiac catheterization: 14 days for symptomatic aortic stenosis and six weeks for patients with stable angina and other valvular disease. For percutaneous coronary intervention in stable patients with high-risk anatomy, immediate revascularization or a wait time of 14 days is recommended; six weeks is recommended for all other patients. The target for bypass surgery in those with high-risk anatomy or valve surgery in patients with symptomatic aortic stenosis is 14 days; for all others, the target is six weeks. All stakeholders must affirm the appropriateness of these standards and work continuously to achieve them. There is an ongoing need to continually reassess current risk stratification methods to limit adverse events in patients on waiting lists and assist clinicians in triaging patients for invasive therapies.