Guideline Alignment in Related Areas

Clinical practice guidelines serve an important role in the primary and secondary prevention of cardiovascular disease. There is variability among guideline groups in the methods used to assess and grade clinical evidence, resulting in discrepancies in various guidelines. Multiple guidelines focused on different aspects of cardiovascular care can lead to recommendations that are out of sync. Discrepancies between a practice recommendation from 2 different Canadian guideline groups can lead to confusion among clinicians and patients, reducing the likelihood that the practice recommendation will be carried out. Assisting cardiovascular-focused guideline groups to align, to harmonize, and to score highly on appraisal has been a main function of the Canadian Cardiovascular Harmonized National Guidelines Endeavour (C-CHANGE). Validated appraisal tools, harmonized guideline initiatives, and continuous evaluation of the impact of guidelines on quality indicators and practice outcomes are crucial for improving cardiovascular care for all Canadians.     

Canadian Cardiovascular Society 2022 Guidelines for Peripheral Arterial Disease

Patients with widespread atherosclerosis such as peripheral artery disease (PAD) have a high risk of cardiovascular and limb symptoms and complications, which affects their quality of life and longevity. Over the past 2 decades there have been substantial advances in diagnostics, pharmacotherapy, and interventions including endovascular and open surgical to aid in the management of PAD patients. To summarize the evidence regarding approaches to diagnosis, risk stratification, medical and intervention treatments for patients with PAD, guided by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework, evidence was synthesized, and assessed for quality, and recommendations provided—categorized as weak or strong for each prespecified research question. Fifty-six recommendations were made, with 27% (15/56) graded as strong recommendations with high-quality evidence, 14% (8/56) were designated as strong recommendations with moderate-quality evidence, and 20% (11/56) were strong recommendations with low quality of evidence. Conversely 39% (22/56) were classified as weak recommendations. For PAD patients, strong recommendations on the basis of high-quality evidence, include smoking cessation interventions, structured exercise programs for claudication, lipid-modifying therapy, antithrombotic therapy with a single antiplatelet agent or dual pathway inhibition with low-dose rivaroxaban and aspirin; treatment of hypertension with an angiotensin converting enzyme or angiotensin receptor blocker; and for those with diabetes, a sodium-glucose cotransporter 2 inhibitor should be considered. Furthermore, autogenous grafts are more effective than prosthetic grafts for surgical bypasses for claudication or chronic limb-threatening ischemia involving the popliteal or distal arteries. Other recommendations indicated that new endovascular techniques and hybrid procedures be considered in patients with favourable anatomy and patient factors, and finally, the evidence for perioperative risk stratification for PAD patients who undergo surgery remains weak.     

Development of the International Cardiac Rehabilitation Registry Including Variable Selection and Definition Process

Introduction:The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) is developing a registry (ICRR) specifically for low-resource settings, where the burden of cardiovascular diseases is greatest and the need for program development highest. Herein we describe the development process, including the variable selection process.Method:Following a literature search on registry best practices, a stepwise model for ICRR development was identified. Then, based on recommendations by Core Outcome Set-STAndards for Development (COS-STAD), we underwent a process to identify variables. All available CR registries were contacted to request their data dictionaries, reviewed CR quality indicators and guideline recommendations, and searched for common data elements and core outcome sets; 35 unique variables (including patient-reported outcomes) were selected for potential inclusion. Twenty-one purposively-identified stakeholders and experts agreed to serve on a Delphi panel. Panelists rated the variables in an online survey, and suggested potential additional variables; A webcall was held to reach consensus on which to include/exclude. Next, panelists provided input to finalize each variable definition, and rated which associated indicators should be used for benchmarking in registry dashboards and a patient lay summary; a second consensus call was held. A 1-month public comment period ensued.Results:First, registry objectives and governance were approved by ICCPR, including data quality and access policies. The protocol was developed, for public posting. For variable selection, the overall mean rating was 6.1 ± 0.3/7; 12 were excluded, some of which were moved to a program survey, and others were revised. Two variables were added in an annual follow-up, resulting in 13 program and 16 patient-reported variables. Legal advice was sought to finalize ICRR agreements. Ethics approvals were obtained. Usability testing is now being initiated.Conclusion:It is hoped this will serve to harmonize CR assessment internationally and enable quality improvement in CR delivery in low-resource settings.     

2012 Update of the Canadian Cardiovascular Society Guidelines for the Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult

Many developments have occurred since the publication of the widely-used 2009 Canadian Cardiovascular Society (CCS) Dyslipidemia guidelines. Here, we present an updated version of the guidelines, incorporating new recommendations based on recent findings and harmonizing CCS guidelines with those from other Societies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used, per present standards of the CCS. The total cardiovascular disease Framingham Risk Score (FRS), modified for a family history of premature coronary disease, is recommended for risk assessment. Low-density lipoprotein cholesterol remains the primary target of therapy. However, non-high density lipoprotein cholesterol has been added to apolipoprotein B as an alternate target. There is an increased emphasis on treatment of higher risk patients, including those with chronic kidney disease and high risk hypertension. The primary panel has recommended a judicious use of secondary testing for subjects in whom the need for statin therapy is unclear. Expanded information on health behaviours is presented and is the backbone of risk reduction in all subjects. Finally, a systematic approach to statin intolerance is advocated to maximize appropriate use of lipid-lowering therapy. This document presents the recommendations and principal conclusions of this process. Along with associated Supplementary Material that can be accessed online, this document will be part of a program of knowledge translation. The goal is to increase the appropriate use of evidence-based cardiovascular disease event risk assessment in the management of dyslipidemia as a fundamental means of reducing global risk in the Canadian population.     

Cardiac Rehabilitation Programs for Chronic Heart Disease: A Bayesian Network Meta-analysis

BackgroundCardiac rehabilitation is a medically supervised program after coronary events that involves exercise and dietary modification. We evaluated the comparative benefits and harms of cardiac rehabilitation strategies via a network meta-analysis.MethodsWe followed a pre-specified protocol (PROSPERO: CRD42018094998). We searched Embase, MEDLINE, and Cochrane Central Register of Randomized Trials databases for randomized controlled trials that evaluated cardiac rehabilitation vs a second form of rehabilitation or standard/usual care in adults after myocardial infarction, coronary artery bypass grafting, percutaneous coronary intervention, or angiography. Risk of bias and evidence quality was evaluated using the Cochrane tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE), respectively. Pairwise and Bayesian network meta-analyses were performed for 11 clinical outcomes.ResultsWe included 134 randomized controlled trials involving 62,322 participants. Compared with standard care, exercise-only cardiac rehabilitation reduced the odds of cardiovascular mortality (odds ratio [OR], 0.70; 95% credibility interval [CrI], 0.51-0.96; moderate-quality evidence), major adverse cardiovascular events (OR, 0.57; 95% CrI, 0.40-0.78; low-quality evidence), nonfatal myocardial infarction (OR, 0.71; 95% CrI, 0.54-0.93; moderate-quality evidence), all-cause hospitalization (OR, 0.74; 95% CrI, 0.54-0.98; moderate-quality evidence), and cardiovascular hospitalization (OR, 0.69; 95% CrI, 0.51-0.88; moderate-quality evidence). Exercise-only cardiac rehabilitation was associated with lower cardiovascular hospitalization risk relative to cardiac rehabilitation without exercise (OR, 0.68; 95% CrI, 0.48-0.97; moderate-quality evidence).ConclusionsCardiac rehabilitation programs containing exercise might provide broader cardiovascular benefits compared with those without exercise.     

Impacts of the COVID-19 Pandemic on Cardiac Rehabilitation Delivery around the World

Background:We investigated impacts of COVID-19 on cardiac rehabilitation (CR) delivery around the globe, including virtual delivery, as well as effects on providers and patients.Methods:In this cross-sectional study, a piloted survey was administered to CR programs globally via REDCap from April to June 2020. The 50 members of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) and personal contacts facilitated program identification.Results:Overall, 1062 (18.3% program response rate) responses were received from 70/111 (63.1% country response rate) countries in the world with existent CR programs. Of these, 367 (49.1%) programs reported they had stopped CR delivery, and 203 (27.1%) stopped temporarily (mean = 8.3 ± 2.8 weeks). Alternative models were delivered in 322 (39.7%) programs, primarily through low-tech modes (n = 226,19.3%). Furthermore, 353 (30.2%) respondents were re-deployed, and 276 (37.3%) felt the need to work due to fear of losing their job, despite the perceived risk of contracting COVID-19 (mean = 30.0% ± 27.4/100). Also, 266 (22.5%) reported anxiety, 241(20.4%) were concerned about exposing their family, 113 (9.7%) reported increased workload to transition to remote delivery, and 105 (9.0%) were juggling caregiving responsibilities during business hours. Patients were often contacting staff regarding grocery shopping for heart-healthy foods (n = 333, 28.4%), how to use technology to interact with the program (n = 329, 27.9%), having to stop their exercise because they have no place to exercise (n = 303, 25.7%), and their risk of death from COVID-19 due to pre-existing cardiovascular disease (n = 249, 21.2%). Respondents perceived staff (n = 488, 41.3%) and patient (n = 453, 38.6%) personal protective equipment, as well as COVID-19 screening (n = 414, 35.2%), and testing (n = 411, 35.0%) as paramount to in-person service resumption.Conclusion:Given the estimated number of CR programs globally, these results suggest approximately 4400 CR programs globally have ceased or temporarily stopped service delivery. Those that remain open are implementing new technologies to ensure their patients receive CR safely, despite the challenges.Highlights:

• – COVID-19 has impacted cardiac rehabilitation (CR) delivery around the globe.
• – In this cross-sectional study, a survey was completed by 1062 (18.3%) CR programs from 70 (63.1%) countries.
• – The pandemic has resulted in at least temporary cessation of ~75% of CR programs, with others ceasing initiation of new patients, reducing components delivered, and/or changing of mode delivery with little opportunity for planning and training.
• – There is also significant psychosocial and economic impact on CR providers.
• – Alternative CR model (e.g., home-based, virtual) reimbursement advocacy is needed, to ensure safe, accessible secondary prevention delivery.

     

Barriers to implementing the “2008 Mexican Clinical Practice Guideline recommendations for the management of hip and knee osteoarthritis” in primary healthcare practice

ObjectiveTo evaluate the implementability of the “2008 Mexican Clinical Practice Guideline for the management of hip and knee osteoarthritis at the primary level of care” within primary healthcare of three Mexican regions using the Guideline Implementability Appraisal methodology version 2 (GLIA.v2).MethodsSix family physicians, representing the South, North, and Central Mexico, and one Mexican physiatrist evaluated the 45 recommendations stated by the Mexican guideline. The GLIA.v2 methodology includes the execution of qualitative and semi-quantitative techniques.ResultsReviewers’ agreement was between moderate to near complete in most cases. Sixty-nine percent of the recommendations were considered difficult to implement within clinical practice. Eight recommendations did not have an appropriate format. Only 6 recommendations were judged as able to be consistently applied to clinical practice. Barriers related to the context of one or more institutions/regions were identified in 25 recommendations. These barriers are related to health providers/patients’ beliefs, processes of care within each institution, and availability of some treatments recommended by the guideline.ConclusionsThe guideline presented problems of conciseness and clarity that negatively affect its application within the Mexican primary healthcare context. We identified individual, organizational and system characteristics, which are common to the 3 institutions/regions studied and constitute barriers for implementing the guideline to clinical practice. It is recommended that the 2008-Mexican-CPG-OA be thoroughly revised and restructured to improve the clarity of the actions implied by each recommendation. We propose some strategies to accomplish this and to overcome some of the identified regional/institutional barriers.     

Long-term Enrollment in Cardiac Rehabilitation Benefits Cardiorespiratory Fitness and Skeletal Muscle Strength in Men With Cardiovascular Disease

BackgroundDespite known associations between fitness and recurrent cardiovascular events, changes in cardiorespiratory fitness (CRF) and muscle strength with long-term cardiac rehabilitation (CR) have not been extensively examined. The objectives of this study were to (1) examine changes in CRF and muscle strength associated with long-term CR program enrollment in men, and (2) compare these changes to previously published rates of decline (2.0% per year for CRF and 2.36% per year for muscle strength in healthy age-matched individuals).MethodsData were extracted from the program charts of 160 men (64 ± 9 years) who were enrolled ≥ 1 year in a maintenance-phase CR program and who completed ≥ 2 exercise tests. CRF was represented by peak oxygen consumption (VO_2peak, mL/min/kg). The skeletal muscle strength was assessed using 1-repetition maximum tests for chest press, seated row, and knee extension. Mixed model analyses with polynomial functions were used to determine changes in CRF (up to 5.5 years) and muscle strength (up to 10 years).ResultsCRF increased nonlinearly up to 3 years (range, 0.33%-3.23% per year) and then declined nonlinearly to the 5.5-year endpoint (range, 1.03%-2.59% per year). Chest press and seated row strength declined at < 1% per year over 10 years, whereas knee extension increased nonlinearly by 0.18%-1.40% per year from baseline until 4 years and then declined nonlinearly at 1.00%-3.58% per year until the 10-year endpoint. All declines were similar to literature rates.ConclusionsThe results indicate that significant health benefits are associated with maintenance-phase CR programs for men. Enrollment was associated with preserved CRF and lower body muscle strength for 3-4 years.     

What Information Do Clinicians Use in Recommending Oral versus Nonoral Feeding in Oropharyngeal Dysphagic Patients?

There is little evidence regarding the type(s) of information clinicians use to make the recommendation for oral or nonoral feeding in patients with oropharyngeal dysphagia. This study represents a first step toward identifying data used by clinicians to make this recommendation and how clinical experience may affect the recommendation. Thirteen variables were considered critical in making the oral vs. nonoral decision by the 23 clinicians working in dysphagia. These variables were then used by the clinicians to independently recommend oral vs. nonoral feeding or partial oral with nonoral feeding for the 20 anonymous patients whose modified barium swallows were sent on a videotape to each clinician. Clinicians also received data on the 13 variables for each patient. Results of clinician agreement on the recommendation of full oral and nonoral only were quite high, as measured by Kappa statistics. In an analysis of which of the 13 criteria clinicians used in making their recommendations, amount of aspiration was the criterion with the highest frequency. Recommendations for use of postures and maneuvers and the effect of clinician experience on these choices were also analyzed.

The Effect of Cardiac Rehabilitation Attendance on Sexual Activity Outcomes in Cardiovascular Disease Patients: A Systematic Review

Background

Decreased sexual activity (SA) is a common problem in patients with cardiovascular disease (CVD). Although there is evidence that cardiac rehabilitation (CR) is effective in improving physical outcomes and overall quality of life, its effects on SA remain unclear. In this systematic review we assessed the association between CR attendance and SA outcomes in adults with CVD.

The PrEDICT-DGE score as a simple preoperative screening tool identifies patients at increased risk for delayed gastric emptying after pancreaticoduodenectomy

BackgroundMorbidity after Pancreaticoduodenectomy (PD) has remained unchanged over the past decade. Delayed Gastric Emptying (DGE) is a major contributor with significant impact on healthcare-costs, quality of life and, for malignancies, even survival. We sought to develop a scoring system to aid in easy preoperative identification of patients at risk for DGE.MethodsThe ACS-NSQIP dataset from 2014 to 2018 was queried for patients undergoing PD with Whipple or pylorus preserving reconstruction. 15,154 patients were analyzed using multivariable logistic regression to identify risk factors for DGE, which were incorporated into a prediction model. Subgroup analysis of patients without SSI or fistula (primary DGE) was performed.ResultsWe identified 9 factors independently associated with DGE to compile the PrEDICT-DGE score: Procedures (Concurrent adhesiolysis, feeding jejunostomy, vascular reconstruction with vein graft), Elderly (Age>70), Ductal stent (Lack of biliary stent), Invagination (Pancreatic reconstruction technique), COPD, Tobacco use, Disease, systemic (ASA>2), Gender (Male) and Erythrocytes (preoperative RBC-transfusion). PrEDICT-DGE scoring strongly correlated with actual DGE rates (R² = 0.95) and predicted patients at low, intermediate, and high risk.Subgroup analysis of patients with primary DGE, retained all predictive factors, except for age>70 (p = 0.07) and ASA(p = 0.30).ConclusionPrEDICT-DGE scoring accurately identifies patients at high risk for DGE and can help guide perioperative management.     

Yoga-Based Cardiac Rehabilitation After Acute Myocardial Infarction: A Randomized Trial

BackgroundGiven the shortage of cardiac rehabilitation (CR) programs in India and poor uptake worldwide, there is an urgent need to find alternative models of CR that are inexpensive and may offer choice to subgroups with poor uptake (e.g., women and elderly).ObjectivesThis study sought to evaluate the effects of yoga-based CR (Yoga-CaRe) on major cardiovascular events and self-rated health in a multicenter randomized controlled trial.MethodsThe trial was conducted in 24 medical centers across India. This study recruited 3,959 patients with acute myocardial infarction with a median and minimum follow-up of 22 and 6 months. Patients were individually randomized to receive either a Yoga-CaRe program (n = 1,970) or enhanced standard care involving educational advice (n = 1,989). The co-primary outcomes were: 1) first occurrence of major adverse cardiovascular events (MACE) (composite of all-cause mortality, myocardial infarction, stroke, or emergency cardiovascular hospitalization); and 2) self-rated health on the European Quality of Life–5 Dimensions–5 Level visual analogue scale at 12 weeks.ResultsMACE occurred in 131 (6.7%) patients in the Yoga-CaRe group and 146 (7.4%) patients in the enhanced standard care group (hazard ratio with Yoga-CaRe: 0.90; 95% confidence interval [CI]: 0.71 to 1.15; p = 0.41). Self-rated health was 77 in Yoga-CaRe and 75.7 in the enhanced standard care group (baseline-adjusted mean difference in favor of Yoga-CaRe: 1.5; 95% CI: 0.5 to 2.5; p = 0.002). The Yoga-CaRe group had greater return to pre-infarct activities, but there was no difference in tobacco cessation or medication adherence between the treatment groups (secondary outcomes).ConclusionsYoga-CaRe improved self-rated health and return to pre-infarct activities after acute myocardial infarction, but the trial lacked statistical power to show a difference in MACE. Yoga-CaRe may be an option when conventional CR is unavailable or unacceptable to individuals. (A study on effectiveness of YOGA based cardiac rehabilitation programme in India and United Kingdom; CTRI/2012/02/002408).     

Therapeutic guidelines on ulcerative colitis: A GRADE methodology based effort of GETECCU

Background and aim

Evidence-based clinical guidelines on Ulcerative colitis (UC) have been developed through a consensus, while GRADE methodology is the current standard for guideline development. This is the first one based on GRADE methodology on UC.

Methods

Following GRADE methodology, the Spanish Group of Ulcerative Colitis and Crohn's disease (GETECCU) have developed a guideline on UC treatment. After selection of relevant clinical scenarios, 32 clinical questions were chosen and recommendations were established.

Results

In 2 questions no recommendation was possible. Twenty-two actions were recommended for, 14 strongly and 8 weakly. However, in 8 questions a recommendation against doing something was obtained, weak in 5 and strong in 3. The majority of recommendations were based on moderate quality evidence, and only 5 on high-quality evidence.

Conclusions

With GRADE methodology we find a clear recommendation on possible actions in most clinical decisions in UC treatment, but much more clinical high-quality research is needed.     

Factors Associated With Cardiorespiratory Fitness at Completion of Cardiac Rehabilitation: Identification of Specific Patient Features Requiring Attention

Background

We aimed to determine and compare predictors of postcardiac rehabilitation (CR) cardiorespiratory fitness (CRF), improvements in a large cohort of subjects with varying baseline CRF levels completing CR for ischemic heart disease and to refine prediction models further by baseline CRF.

Cardiac Rehabilitation: Current Review of the Literature and Its Role in Patients with Heart Failure

Purpose of review

Cardiovascular (CV) disease remains the leading cause of death in the USA despite major advances in its treatment. With time, cardiac rehabilitation (CR) programs have gathered interest to help increase CV health and improve functional status after a CV event. Patients with heart failure have also been shown to benefit. In this review, we will evaluate the current literature showcasing the benefits of CR, particularly in patients with heart failure, discuss current limitations, and avenues for future investigation.

Recent findings

Studies have shown that CR is beneficial in reducing morbidity, mortality, hospitalizations, activity-related symptoms, and increasing quality of life. Similar findings have also been observed in patients with heart failure who underwent CR in addition to optimal medical management.

Summary

The positive effects of CR are well established in patients with coronary disease. Recent literature is also showing a trend to benefit in patients with heart failure, though much of the evidence is limited to patients with systolic dysfunction. Despite recommendations by professional societies, the use of CR remains underutilized. Further investigation is needed to better understand the impact of CR in heart failure. Moreover, strategies to increase CR utilization must be explored.

     

A Randomized Controlled Trial of an Exercise Maintenance Intervention in Men and Women After Cardiac Rehabilitation (ECO-PCR Trial)

BackgroundExercise maintenance interventions are needed for cardiac rehabilitation (CR) graduates to maintain moderate and vigorous-intensity physical activity (MVPA). We tested an exercise facilitator intervention (EFI) to promote exercise maintenance compared with usual care (UC) separately in men and women.MethodsThis was a 3-site, randomized (1:1), parallel-group, superiority trial (ECO-PCR). CR graduates were stratified by site and sex and randomly allocated (concealed). EFI participants received a face-to-face introductory session, 5 small-group counseling teleconferences, and 3 personal calls from a trained facilitator over 50 weeks. In-person assessments were undertaken at baseline and 26 and 52 weeks after randomization. The primary outcome was weekly minutes of MVPA, measured by accelerometer. Secondary outcomes were exercise capacity, risk factors, quality of life, and enrollment in community-based exercise programs. Effects were tested with the use of linear mixed models.ResultsA total of 449 CR graduates (135 women, 314 men) were randomised (n = 226 EFI, n = 223 UC). In the intention-to-treat analysis for men and for women, there were no significant effects for treatment or time on MVPA. In a planned secondary analysis that considered only those adherent to EFI (completed ≥ 66% of sessions; per-protocol), bouted MVPA (ie, in sustained bouts of ≥ 10 min) was higher in women in the EFI group (mean = 132.6 ± 135.2 min/wk at 52 weeks) compared with UC (111.8 ± 113.1; P = 0.013). Regarding secondary outcomes, in women, a treatment group main effect was observed for blood pressure (P = 0.011) and exercise capacity (P = 0.019; both per-protocol) favouring EFI; no other differences were observed.ConclusionsIn this trial of CR completers, an EFI showed promise for women, but was ineffective in men.     

Poststroke Dysphagia Rehabilitation by Repetitive Transcranial Magnetic Stimulation: A Noncontrolled Pilot Study

Poststroke dysphagia is frequent and significantly increases patient mortality. In two thirds of cases there is a spontaneous improvement in a few weeks, but in the other third, oropharyngeal dysphagia persists. Repetitive transcranial magnetic stimulation (rTMS) is known to excite or inhibit cortical neurons, depending on stimulation frequency. The aim of this noncontrolled pilot study was to assess the feasibility and the effects of 1-Hz rTMS, known to have an inhibitory effect, on poststroke dysphagia. Seven patients (3 females, age = 65 ± 10 years), with poststroke dysphagia due to hemispheric or subhemispheric stroke more than 6 months earlier (56 ± 50 months) diagnosed by videofluoroscopy, participated in the study. rTMS at 1 Hz was applied for 20 min per day every day for 5 days to the healthy hemisphere to decrease transcallosal inhibition. The evaluation was performed using the dysphagia handicap index and videofluoroscopy. The dysphagia handicap index demonstrated that the patients had mild oropharyngeal dysphagia. Initially, the score was 43 ± 9 of a possible 120 which decreased to 30 ± 7 (p < 0.05) after rTMS. After rTMS, there was an improvement of swallowing coordination, with a decrease in swallow reaction time for liquids (p = 0.0506) and paste (p < 0.01), although oral transit time, pharyngeal transit time, and laryngeal closure duration were not modified. Aspiration score significantly decreased for liquids (p < 0.05) and residue score decreased for paste (p < 0.05). This pilot study demonstrated that rTMS is feasible in poststroke dysphagia and improves swallowing coordination. Our results now need to be confirmed by a randomized controlled study with a larger patient population.

Introducing the Canadian Thoracic Society Framework for Guideline Dissemination and Implementation,with Concurrent Evaluation

The Canadian Thoracic Society (CTS) is leveraging its strengths in guideline production to enable respiratory guideline implementation in Canada. The authors describe the new CTS Framework for Guideline Dissemination and Implementation, with Concurrent Evaluation, which has three spheres of action: guideline production, implementation infrastructure and knowledge translation (KT) methodological support. The Canadian Institutes of Health Research ‘Knowledge-to-Action’ process was adopted as the model of choice for conceptualizing KT interventions. Within the framework, new evidence for formatting guideline recommendations to enhance the intrinsic implementability of future guidelines were applied. Clinical assemblies will consider implementability early in the guideline production cycle when selecting clinical questions, and new practice guidelines will include a section dedicated to KT. The framework describes the development of a web-based repository and communication forum to inventory existing KT resources and to facilitate collaboration and communication among implementation stakeholders through an online discussion board. A national forum for presentation and peer-review of proposed KT projects is described. The framework outlines expert methodological support for KT planning, development and evaluation including a practical guide for implementers and a novel ‘Clinical Assembly – KT Action Team’, and in-kind logistical support and assistance in securing peer-reviewed funding.     

Validating the Performance of 5 Risk Scores for Major Adverse Cardiac Events in Patients Who Achieved Complete Revascularization After Percutaneous Coronary Intervention

BackgroundRisk scores, like the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (SS), clinical SS, logistic SS (core model and extended model [LSS_extended]), Age, Creatinine, and Ejection Fraction (ACEF) score, and modified ACEF score, are predictive for major adverse cardiac events (MACE; including all-cause mortality, myocardial infarction [MI], and revascularization) in patients who have undergone percutaneous coronary intervention (PCI). However, few studies have validated the performance of these scores in complete revascularization (CR) patients. We aimed to compare the performance of previous risk scores in patients who achieved CR after PCI.MethodsAll patients (N = 10,724) who underwent PCI at Fuwai Hospital in 2013 were screened, and those who achieved CR after PCI were enrolled. Risk scores were calculated by experienced cardiologists blinded to the clinical outcomes. Discrimination of risk scores was assessed according to the area under the receiver operating characteristic curve (AUC).ResultsFifty-one percent (5375/10,724) of patients who underwent PCI achieved CR. At a mean follow-up of 2.4 years, the mortality, MI, revascularization, and MACE rates were 1.2%, 1.0%, 6.3%, and 7.7%, respectively. SS was not predictive for mortality (AUC, 0.51; 95% confidence interval [CI], 0.44-0.59). All scores involving clinical variables, especially modified ACEF score (AUC, 0.73; 95% CI, 0.66-0.79), could predict mortality. LSS_extended was the most accurate for MI (AUC, 0.68; 95% CI, 0.61-0.75). SS and LSS_extended were predictive for revascularization, with marginally significant AUCs (SS, 0.54; LSS_extended, 0.55). No score was particularly accurate for predicting MACE, with AUCs ranging from 0.51 (ACEF score) to 0.58 (LSS_extended).ConclusionsIn CR patients, risk scores involving clinical variables might help to predict mortality; however, no risk scores showed helpful discrimination for MACE.