Issues influencing development of the Canadian Cardiovascular Information Network

The 1995 Consensus Conference of the Canadian Cardiovascular Society on "Indications for and Access to Revascularization" recommended that Canadian centres with invasive cardiovascular facilities should participate in a national observational database that monitors the selection of patients, as well as evaluate outcomes. The Canadian Cardiovascular Society, the Heart and Stroke Foundation of Canada, and Health Canada with IBM as a partner, initiated a process to identify factors influencing the development of the Canadian Cardiovascular Information Network. IBM's "Business Discovery Methodology" was adapted for health care. Structured interviews with representatives of health organizations, cardiovascular databases and research institutes were conducted across Canada, followed by a workshop to identify goals, issues and challenges. Participants identified goals for a cardiovascular database (eg, evidence-based decision-making), project related issues (eg, respecting the integrity of existing databases) and health care related issues (eg, cardiac waiting lists). Challenges included initial mistrust between representatives of provincial cardiovascular databases and national agencies, and a lack of sustained funding. A Project Team was formed to address 'cardiac waiting lists'. Analysis of Alberta and Ontario data identified differences in definitions, such as when the waiting time for bypass surgery began, that impeded detailed comparisons. Development of a centralized national database was not feasible at this time for political, technical and financial reasons. However, provincial cardiovascular database representatives agreed to work together and to share aggregate data and analyses. A first step toward developing a national surveillance system for cardiovascular services will be achieving consensus about standardizing data definitions. This process will require sustained funding.     

Pan-canadian cardiovascular data definitions and quality indicators: a status update

After the 2009 publication of Building a Heart Healthy Canada, the Canadian Cardiovascular Society was commissioned to address a long-standing information gap related to the compatibility and comparability of data on the quality of cardiovascular care in Canada. Through collaboration between the Canadian Institute for Health Information, the Institute for Clinical Evaluative Sciences, the Public Health Agency of Canada, and 5 regional cardiovascular registries, 2 committees were tasked with developing standardized cardiovascular data definitions and quality indicators. The work culminated in national consensus on the definitions of 55 patient, disease, and therapeutic variables (core and optional) to facilitate cardiovascular care comparisons within and across Canada. Supplemental data definition chapters were then developed on acute coronary syndrome and coronary angiography/revascularization, with chapters on heart failure and atrial fibrillation electrophysiology to follow. This foundational work led to a critical appraisal of cardiac quality indicator development initiatives via the Appraisal of Guidelines for Research and Evaluation II (AGREE II) Quality Indicator tool, followed by the development of quality indicator catalogues on heart failure and atrial fibrillation. These indicators will be embedded within the clinical practice guidelines of the Canadian Cardiovascular Society, facilitating national comparisons across Canada on cardiovascular disease incidence, prevalence, patterns and quality of care, and clinical outcomes. This methodology-achieving national stakeholder consensus on a standardized process for the development and selection of cardiovascular quality indicators-illustrates the capacity to reach agreement by drawing on expertise and research across diverse organizational mandates and agendas, potentially contributing to improved cardiovascular care and outcomes for patients.     

Canadian Cardiovascular Society and Canadian Thoracic Society position statement on pulmonary arterial hypertension

The Canadian Cardiovascular Society and the Canadian Thoracic Society requested a position statement on pulmonary arterial hypertension from leading Canadian experts. The present document is intended to act as an update for the clinician, to provide a template for the initial evaluation of patients, to enable understanding of current therapeutic paradigms based on approved indications for Canada, to highlight new therapies on the horizon, and to state the positions of the Canadian Cardiovascular Society and the Canadian Thoracic Society on resource management for pulmonary arterial hypertension in Canada.     

2010 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiologists Guidelines for Training and Maintenance of Competency in Adult Interventional Cardiology

Interventional cardiology is a subspecialty of adult cardiology dedicated to the use and application of imaging-based diagnostic techniques and minimally invasive modalities for the treatment of cardiovascular disease. Currently, interventional cardiologists must demonstrate expert knowledge of cardiac imaging, along with cardiovascular anatomy and the pathophysiology of cardiovascular disease. In addition, they must possess the technical skills required for the practice of interventional cardiology and be knowledgeable about new antiplatelet and antithrombotic drugs mandated for optimal patient care. The 2010 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiologists Guidelines for Training and Maintenance of Competency in Adult Interventional Cardiology are the first such guidelines to be published in Canada. These guidelines should allow for more-fluid provision of high-quality interventional cardiology education, along with less geographic variation, resulting in more-widespread high-level services to the population.     

Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes

Sudden cardiac death (SCD), especially in a young seemingly healthy individual, is a tragic and highly publicized event, which is often followed by a strong emotional reaction from the public and medical community.” Although rare, SCD in the young is devastating to families and communities, underpinning our society’s desire to avoid any circumstances predisposing to the loss of human life during exertion. The Canadian Cardiovascular Society Position Statement on the cardiovascular screening of athletes provides evidence-based recommendations for Canadian sporting organizations and institutions with a focus on the role of routine electrocardiogram (ECG) screening in preventing SCD. We recommend that the cardiac screening and care of athletes within the Canadian health care model comprise a sequential (tiered) approach to the identification of cardiac risk, emphasizing the limitations of screening, the importance of shared decision-making when cardiac conditions are diagnosed, and the creation of policies and procedures for the management of emergencies in sport settings. Thus, we recommend against the routine (first-line or blanket mass performance of ECG) performance of a 12-lead ECG for the initial cardiovascular screening of competitive athletes. Organization/athlete-centred cardiovascular screening and care of athletes program is recommended. Such screening should occur in the context of a consistent, systematic approach to cardiovascular screening and care that provides: assessment, appropriate investigations, interpretation, management, counselling, and follow-up. The recommendations presented comprise a tiered framework that allows institutions some choice as to program creation.     

Canadian Society of Clinical Chemists Harmonized Clinical Laboratory Lipid Reporting Recommendations on the Basis of the 2021 Canadian Cardiovascular Society Lipid Guidelines

There is limited guidance on laboratory reporting and interpretation of lipids and lipoproteins used in cardiovascular risk stratification. This contributes to inconsistencies in lipid reporting across clinical laboratories. Recently, the Canadian Cardiovascular Society (CCS) published the 2021 CCS guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in the adult. A subcommittee of the Working Group on Reference Interval Harmonization of the Canadian Society of Clinical Chemists has developed harmonized lipid reporting recommendations that are aligned with the 2021 CCS guidelines, to improve the standardization of lipid assessment and clinical decision-making. The proposed harmonized lipid reporting recommendations were critically reviewed by a broad range of laboratory and clinical experts across Canada. Feedback from approximately 30 expert reviewers was reviewed by the Working Group on Reference Interval Harmonization lipid subcommittee, and consensus decisions were incorporated into the 2021 harmonized lipid reporting recommendations. In this position statement, we provide 6 recommendations for laboratory reporting of lipid parameters. These recommendations include implementing the new National Institutes of Health equation to replace the Friedewald equation for calculating low-density lipoprotein cholesterol, offering lipoprotein (a), either as an in-house or send-out test, and using assays that report lipoprotein (a) in molar units (nmol/L). We also developed a harmonized lipid reporting format with interpretive comments that includes flagging results based on screening patients using treatment decision thresholds in a primary prevention setting. Overall, harmonized lipid reporting will help bridge the gap between clinical guideline recommendations and clinical laboratory reporting and interpretation, and will improve cardiovascular risk assessment across Canada.     

The burden of blood pressure: where are we and where should we go?

Hypertension and related diseases are a global burden of cardiovascular disorders. Ischemic heart disease and cardiovascular disease rank fourth and fifth among the 10 leading causes of mortality worldwide. A generation from now, these diseases will be an epidemic for which we should be ready and against which we should attempt to find the best preventive measures. In Canada, the percentage of cardiovascular deaths increases with age. After the age of 50 years, these deaths actually exceed 50% of total mortality. Cardiovascular diseases also have the highest financial health care costs. The newest guidelines from national and international societies have a unifying goal of controlling cardiovascular burden. Guidelines of the international societies are written for a worldwide audience, including countries with very variable health care systems. However, the supreme goal is universal - to lower blood pressure and other risk factors to reduce the risk of cardiovascular disease with its fatal consequences.     

Canadian Cardiovascular Society Consensus Conference: peripheral arterial disease - executive summary

This Consensus Conference has been supported by the Canadian Cardiovascular Society. The process is dynamic, with intentional structure that requires peer review and feedback from cardiovascular specialists across Canada. The writing and review panel encompassed a broad range of specialists caring for the patient with peripheral arterial disease (PAD). PAD is an often asymptomatic, underdiagnosed, under-recognized and undertreated condition. It is associated with significant morbidity and cardiac mortality. Until recently, little attention has focused on the evaluation and treatment of the disease process itself. The goal of the present paper is to ensure better treatment, to reduce both morbidity and mortality in the patient with vascular disease and, importantly, to serve as a guide to the busy clinician. Although the focus is PAD, there are chapters on thoracic and abdominal aortic disease, renal arterial disease and the evidence supporting management. Screening and diagnostic techniques including history and physical examination as well as noninvasive imaging techniques are reviewed. Medical management for patients with vascular disease including prevention and risk reduction is graded based on evidence, including both pharmacological and nonpharmacological management strategies, followed by an introduction to newer percutaneous techniques. Finally, surgical treatment for claudication including new concepts on the perioperative risk assessment for patients undergoing major vascular surgery is discussed.     

The Canadian Cardiovascular Society and knowledge translation: turning best evidence into best practice

Care gaps, the discrepancy between processes of care recognized as best practice and care provided in usual clinical practice, exist in cardiovascular disease. Knowledge translation, the process of turning best evidence into best practices, has the potential to reduce care gaps. As the national voice for cardiovascular physicians and scientists, the Canadian Cardiovascular Society is committed to knowledge translation. The present article describes how knowledge translation builds on the constructs of continuing medical education and continuing professional development; what can be done to improve knowledge translation; and what the Canadian Cardiovascular Society is currently doing about this.     

Atherosclerosis Imaging and the Canadian Atherosclerosis Imaging Network

Atherosclerosis exacts a large toll on society in the form of cardiovascular morbidity, mortality, and resource use and is exacerbated by the epidemics of obesity and diabetes. Consequently, there is a critical need for more-effective methods of diagnosis, treatment, and prevention of the complications of atherosclerosis. Careful and well-conducted large population studies are needed in order to truly understand the natural history of the disease, its imaging biomarkers, and their links to patient outcomes. The Canadian Atherosclerosis Imaging Network (CAIN) is a unique research network funded by the Canadian Institutes of Health Research and the Canada Foundation for Innovation and designed to address these needs and to enable large population-based imaging studies. The central objective of CAIN is to move innovations in imaging toward their broad application in clinical research and clinical practice for the improved evaluation of cardiac and neurologic vascular disease. CAIN is established as an international resource for studying the natural history, progression, and regression of atherosclerosis, as well as novel therapeutic interventions aimed at atherosclerosis. The network represents Canada's leading atherosclerosis imaging experts, embodying both basic imaging science and clinical imaging research. The network is improving methods of detection and treatment of atherosclerosis and, through a better understanding of the underlying disease itself, improving strategies for disease prevention. The benefits are expected to appear in the next 2 to 3 years. CAIN will drive innovation in imaging technology within the field of cardiology and neurology and improve health outcomes in Canada and worldwide.     

2010 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Training Standards and Maintenance of Competency in Adult Clinical Cardiac Electrophysiology

The last guidelines on training for adult cardiac electrophysiology (EP) were published by the Canadian Cardiovascular Society in 1996.¹ Since then, substantial changes in the knowledge and practice of EP have mandated a review of the previous guidelines by the Canadian Heart Rhythm Society, an affiliate of the Canadian Cardiovascular Society. Novel tools and techniques also now allow electrophysiologists to map and ablate increasingly complex arrhythmias previously managed with pharmacologic or device therapy. Furthermore, no formal attempt had previously been made to standardize EP training across the country. The 2010 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Training Standards and Maintenance of Competency in Adult Clinical Cardiac Electrophysiology represent a consensus arrived at by panel members from both societies, as well as EP program directors across Canada and other select contributors. In describing program requirements, the technical and cognitive skills that must be acquired to meet training standards, as well as the minimum number of procedures needed in order to acquire these skills, the new guidelines provide EP program directors and committee members with a template to develop an appropriate curriculum for EP training for cardiology fellows here in Canada.     

Translation of the Canadian Cardiovascular Society/Canadian Heart Rhythm Society Cardiovascular Screening and Care of Athletes Program Into Practice

In the absence of systematic cardiovascular preparticipation screening (PPS) practices in Canada, the Canadian Cardiovascular Society and Canadian Heart Rhythm Society published a joint position statement outlining PPS recommendations for competitive athletes in an effort to standardize screening. The Queen’s University Cardiovascular Screening and Care of Athletes Program aimed to translate these recommendations into practice. Screening packages were administered to athletes in 2017 and 2018. Each package required completion of a medical/history questionnaire, a physician’s examination, and 12-lead electrocardiogram performed by the athlete’s primary care physician. A tiered approach to screening, as recommended by the position statement, was implemented. A multidisciplinary team flagged at-risk athletes and determined the need for follow-up testing and participation eligibility. Over a 2-year period, 517 varsity athletes were screened, with 438 (84.7%) completing all recommended screening components. Analysis of completed packages resulted in 114 (26.0%) athletes flagged for initial review. After subsequent review by an emergency care physician, only 12 (2.7%) athletes required further referral to cardiology for assessment or further testing. All athletes referred for cardiology assessment were cleared for participation, except for one, who was eventually cleared after a shared decision-making process and cardiovascular intervention. The Queen’s University Cardiovascular Screening and Care of Athletes Program shows the successful implementation of a cardiovascular PPS program that used shared decision-making and a multidisciplinary approach to screening, allowing for efficiency and effective resource utilization.     

《心肺血管病杂志》

《心肺血管病杂志》由吴英恺和翁心植院士于1982年2月创刊。《心肺血管病杂志》是以心肺血管疾病的预防、医疗、科研和国际学术交流为主题的专业性学术月刊。杂志主要刊登国内外心肺血管疾病相关临床研究、基础研究以及综合国内外最新进展。1992年被北京高校图书馆期刊工作研究会\北京大学图书馆评为中文核心期刊,2001年入选中国核心期刊,同年入选中国期刊方阵,被评为双效期刊,并被《中国核心期刊(遴选)数据库》和中国生物医学文献数据库(SinoMed)收录。     

《心肺血管病杂志》

《心肺血管病杂志》由吴英恺和翁心植院士于1982年2月创刊。《心肺血管病杂志》是以心肺血管疾病的预防、医疗、科研和国际学术交流为主题的专业性学术月刊。杂志主要刊登国内外心肺血管疾病相关临床研究、基础研究以及综合国内外最新进展。1992年被北京高校图书馆期刊工作研究会\北京大学图书馆评为中文核心期刊,2001年入选中国核心期刊,同年入选中国期刊方阵,被评为双效期刊,并被《中国核心期刊(遴选)数据库》和中国生物医学文献数据库(SinoMed)收录。     

Guidelines for the provision of echocardiography in Canada: recommendations of a joint Canadian Cardiovascular Society/Canadian Society of Echocardiography Consensus Panel

Recognizing the central role of echocardiographic examinations in the assessment of most cardiac disorders and the need to ensure the provision of these services in a highly reliable, timely, economical and safe manner, the Canadian Cardiovascular Society and Canadian Society of Echocardiography undertook a comprehensive review of all aspects influencing the provision of echocardiographic services in Canada. Five regional panels were established to develop preliminary recommendations in the five component areas, which included the echocardiographic examination, the echocardiographic laboratory and report, the physician, the sonographer and indications for examinations. Membership in the panels was structured to recognize the regional professional diversity of individuals involved in the provision of echocardiography. In addition, a focus group of cardiac sonograhers was recruited to review aspects of the document impacting on sonographer responsibilities and qualification. The document is intended to be used as a comprehensive and practical reference for all of those involved in the provision of echocardiography in Canada.     

The 2004 ACC/AHA Guidelines: a perspective and adaptation for Canada by the Canadian Cardiovascular Society Working Group

Major changes in acute ST elevation myocardial infarction (STEMI) management prompted a comprehensive rewriting of the American College of Cardiology/American Heart Association Guidelines. The Canadian Cardiovascular Society (CCS) participated in both the writing process and the external review. Subsequently, a Canadian Working Group (CWG), formed under the auspices of the CCS, developed a perspective and adaptation for Canada. Herein, accounting for specific realities of the Canadian cardiovascular health system, is a discussion of the implications for prehospital care and transport, optimal reperfusion therapy and an approach to decision making regarding reperfusion options and invasive therapy following fibrinolytic therapy. Major recent developments regarding indications for implantable cardioverter defibrillator(s) (ICDs) also prompted a review of indications for ICDs and the optimal timing of implantation given the potential for recovery of left ventricular function. At least a 40-day, preferably a 12-week, waiting period was judged to be optimal to evaluate left ventricular function post-STEMI. A recommended algorithm for the insertion of an ICD is provided. Implementation of the new STEMI guidelines has substantial implications for resources, organization and priorities of the Canadian health care system. While on the one hand, the necessary incremental funding to provide tertiary and quaternary care and to support revascularization and device implantation capability is desirable, it is equally or more important to develop enhanced prehospital care, including the capacity for early recognition, risk assessment, fibrinolytic therapy and/or triage to a tertiary care centre as part of an enlightened approach to improving cardiac care.     

2010 Canadian Cardiovascular Society/Canadian Society of Echocardiography Guidelines for Training and Maintenance of Competency in Adult Echocardiography

Guidelines for the provision of echocardiography in Canada were jointly developed and published by the Canadian Cardiovascular Society and the Canadian Society of Echocardiography in 2005. Since their publication, recognition of the importance of echocardiography to patient care has increased, along with the use of focused, point-of-care echocardiography by physicians of diverse clinical backgrounds and variable training. New guidelines for physician training and maintenance of competence in adult echocardiography were required to ensure that physicians providing either focused, point-of-care echocardiography or comprehensive echocardiography are appropriately trained and proficient in their use of echocardiography. In addition, revision of the guidelines was required to address technological advances and the desire to standardize echocardiography training across the country to facilitate the national recognition of a phy sician's expertise in echocardiography. This paper summarizes the new Guidelines for Physician Training and Maintenance of Competency in Adult Echocardiography, which are considerably more comprehensive than earlier guidelines and address many important issues not previously covered. These guidelines provide a blueprint for physician training despite different clinical backgrounds and help standardize physician training and training programs across the country. Adherence to the guidelines will ensure that physicians providing echocardiography have acquired sufficient expertise required for their specific practice. The document will also provide a framework for other national societies to standardize their training programs in echocardiography and will provide a benchmark by which competency in adult echocardiography may be measured.     

Smoking cessation and the cardiovascular specialist: Canadian Cardiovascular Society position paper

Tobacco addiction is the leading cause of preventable disease, disability, and death in Canada and is the most significant of the modifiable cardiovascular risk factors. Tobacco addiction is a principal contributor to the development of coronary artery disease (CAD) and its consequences, including sudden cardiac death, acute myocardial infarction, and heart failure. Its prevention and treatment should be accorded high priority. In fact, 30% of all CAD deaths are attributable to smoking. The identification and documentation of the smoking status of all patients, and the provision of cessation assistance, should be a priority in every cardiovascular setting. Systematic approaches to the identification and treatment of smokers can dramatically enhance the likelihood of cessation—the most cost-effective of all the interventions to prevent the development or progression of CAD. It is the view of the Canadian Cardiovascular Society that all patients in every medical setting—private office, outpatient clinic, or hospital—should have their smoking status systematically identified and documented and be offered specific assistance in initiating a cessation attempt. The provision of unambiguous, nonjudgemental advice regarding the importance of cessation and assistance with the initiation of a smoking cessation attempt should be seen as a fundamental responsibility of any cardiovascular clinician who encounters smokers in any setting. All cardiovascular specialists should be familiar with the principles and practice of smoking cessation. It is important for cardiovascular specialists to be as familiar with the initiation of smoking-cessation pharmacotherapy as they are with the pharmacological management of hypertension and hyperlipidemia.     

Canadian Cardiovascular Society Consensus Conference guidelines on heart failure, update 2009: Diagnosis and management of right-sided heart failure, myocarditis, device therapy and recent important clinical trials

The Canadian Cardiovascular Society published a comprehensive set of recommendations on the diagnosis and management of heart failure in January 2006. Based on feedback obtained through a national program of heart failure workshops and through active solicitation of stakeholders, several topics were identified because of their importance to the practicing clinician. Topics chosen for the present update include best practices for the diagnosis and management of right-sided heart failure, myocarditis and device therapy, and a review of recent important or landmark clinical trials. These recommendations were developed using the structured approach for the review and assessment of evidence adopted and previously described by the Society. The present update has been written from a clinical perspective to provide a user-friendly and practical approach. Specific clinical questions that are addressed include: What is right-sided heart failure and how should one approach the diagnostic work-up? What other clinical entities may masquerade as this nebulous condition and how can we tell them apart? When should we be concerned about the presence of myocarditis and how quickly should patients with this condition be referred to an experienced centre? Among the myriad of recently published landmark clinical trials, which ones will impact our standards of clinical care? The goals are to aid physicians and other health care providers to optimally treat heart failure patients, resulting in a measurable impact on patient health and clinical outcomes in Canada.