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Heart failure is a clinical syndrome that normally requires health care to be provided by both specialists and nonspecialists. This is advantageous because patients benefit from complementary skill sets and experience, but can present challenges in the development of a common, shared treatment plan. The Canadian Cardiovascular Society published a comprehensive set of recommendations on the diagnosis and management of heart failure in January 2006, and on the prevention, management during intercurrent illness or acute decompensation, and use of biomarkers in January 2007. The present update builds on those core recommendations. Based on feedback obtained through a national program of heart failure workshops during 2006 and 2007, 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 that was adopted and previously described by the Society. Specific recommendations and practical tips were written for best practices during the transition of care of heart failure patients, and the recognition, investigation and treatment of some specific cardiomyopathies. Specific clinical questions that are addressed include: What information should a referring physician provide for a specialist consultation? What instructions should a consultant provide to the referring physician? What processes should be in place to ensure that the expectations and needs of each physician are met? When a cardiomyopathy is suspected, how can it be recognized, how should it be investigated and diagnosed, how should it be treated, when should the patient be referred, and what special tests are available to assist in the diagnosis and treatment? The goals of the present update are to translate best evidence into practice, apply clinical wisdom where evidence for specific strategies is weaker, and 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.

Background: The incidence of congestive heart failure (CHF) has increased due, in part, to an aging population and improvements in the diagnosis and treatment of myocardial infarction. This has been reported internationally but no systematic epidemiological assessment of CHF has been conducted for Canada nationally., Objectives: To estimate length of stay, mortality and readmission rates and projected number of future CHF hospital patients., Methods: Health insurance numbers were used to link all hospital visits for 1996/97 CHF patients who had no CHF discharges within the previous two years. All patients were followed up for one year from the date of their initial visit., Results: The numbers of males and females in the study were similar: 40,958 males and 42,255 females. Within the first year, CHF patients used an average of 26.9 hospital days and nearly 50% were readmitted to hospital. Within the index episode, 16.5% of the CHF patients died in hospital. Under the age of 70, female patients had higher mortality than males, while after the age of 70, males were more likely to die. The number of CHF incident hospital cases per year is projected to more than double by the year 2025. To keep the current number of incident patients the same as in 1996/97, the incidence of would have to decrease by 2.6% per year., Conclusions: Patients admitted with CHF have high rates of mortality and prolonged and recurrent hospitalization. If the current rates are not reduced, health care costs related to CHF could increase substantially.

Background: Quality indicators are measurement tools for assessing the structure, processes and outcomes of care. Although quality indicators have been developed in other countries, Canadian cardiovascular disease indicators do not exist., Objective: To develop quality indicators for measuring and improving congestive heart failure (CHF) care in Canada., Methods: An 11-member multidisciplinary national expert panel was selected from nominees from national medical organizations. Potential quality indicators were identified by a detailed search of published guidelines, randomized trials and outcomes studies. A two-step modified Delphi process was employed with an initial screening round of indicator ratings, followed by a national quality indicator panel meeting, where definitions of the indicators were developed using consensus methods. Indicators were designed to be measurable, using retrospective chart review and linking existing administrative databases., Results: The case definition criterion was developed based on a discharge diagnosis of CHF (International Classification of Diseases, 9th revision [ICD-9] code 428.x), with diagnostic confirmation using clinical criteria. In total, 29 indicators and five test indicators were recommended. Process indicators included prescription for angiotensin-converting enzyme inhibitors, beta-blockers or warfarin (for atrial fibrillation) at hospital discharge. Nonpharmacological in hospital process indicators included evaluation of left ventricular function, weight measurement and selected patient education counselling instructions. Process indicators in the ambulatory setting included prescription and adherence to drug therapies and physician follow-up. Outcome indicators included mortality, readmissions and emergency visits., Conclusions: A set of Canadian quality indicators for CHF care encompassing organizational attributes, pharmacotherapy, investigations, counselling, continuity of care and disease outcomes has been developed. These quality indicators will serve as a foundation for future studies evaluating the quality of CHF care in Canada.

Background: It has been cited that the management of congestive heart failure (CHF) requires a multidisciplinary approach; however, the role of the pharmacist has not been extensively studied. The roles for pharmacists are changing to meet the long term needs of patients in the community setting, including patients with CHF., Objectives: To evaluate the effect of a pharmacist on the appropriateness of medications taken by patients in the heart function clinic using the Medication Appropriateness Index (MAI) and to measure the effect of a pharmacist on the patients' response to the pharmacist's interventions using the Purdue Directive Guidance (DG) scale., Methods: Eighty patients attending the heart function clinic at The University Health Network, Toronto General Hospital Toronto, Ontario were randomly assigned to an intervention group that received pharmacist services or a nonintervention group that received usual care from the clinic staff. Patients were assessed at baseline and at one-month follow-up., Results: The change in MAI score from baseline was 0.74 and 0.49 for the intervention and nonintervention groups, respectively (P=0.605). The change in DG survey results was 9.97 and 1.00 for the intervention and nonintervention groups, respectively (P<0.001). The intervention group improved significantly in all components of the DG survey, especially those pertaining to feedback and goal setting., Conclusions: A benefit was demonstrated for 'directive guidance' of patients, in the form of education and goal setting as shown by positive survey results.