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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.

Congestive heart failure (CHF) is the most common cause of cardiovascular hospital admission. A significant proportion of the costs of CHF is due to hospitalizations. The present study evaluated the economic impact of a modest increase in the use of angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, spironolactone and digoxin on CHF hospitalizations. Patients with CHF were identified through the Canadian Institute for Health Information (CIHI) database. The efficacy of ACE inhibitors, beta-blockers, spironolactone and digoxin in the first year of treatment were retrieved from the Survival and Ventricular Enlargement (SAVE) trial, a meta-analysis, the Randomized Aldactone Evaluation Study (RALES) and the Digitalis Investigation Group (DIG) trial, respectively. Cost of CHF hospitalization was based on the National List of Provincial Costs. Costs of drug treatment were based on the 2002 Alberta Health and Wellness Drug Benefit list. Physician visits for drug titration were also included in the model. A total of 85,679 patients with CHF were identified with a total of 106,130 hospital discharges. A 10% increase in use of ACE inhibitors, beta-blockers, spironolactone and digoxin would incur in a total cost due to avoidable hospital admissions of 0.4 million dollars, 1.3 million dollars, 3.7 million dollars and 1.2 million dollars, respectively. Similarly, the costs of drug treatment would be 2.2 million dollars, 1.3 million dollars, 0.3 million dollars and 0.5 million dollars, respectively. An increase in the use of the above medications would save 6.6 million dollars due to avoidable hospital admissions. The total cost of drug treatment was 4.3 million dollars, giving a net savings of 2.3 million dollars in the first year. The implementation of evidence-based therapy for CHF treatment is not only clinically efficacious, but also economically attractive.

Background: Congestive heart failure (CHF) is associated with high morbidity and mortality; however, there is little contemporary Canadian data to quantify the burden of this illness., Objective: To report the impact of CHF in Canada, as measured by hospitalizations., Methods: Data were obtained from the Canadian Institute for Health Information on patients hospitalized with CHF as a most responsible, primary or complication diagnosis during fiscal year 2000/01., Results: There were a total of 106,130 discharges for 85,679 CHF patients in the fiscal year 2000/01. Total in-hospital mortality was 15.8%. In terms of total discharges for CHF, 32.7% were readmissions. On an individual patient basis, 19.9% of patients were rehospitalized once or more during 2000. In terms of burden of illness of CHF compared with other major illnesses, CHF is associated with the second highest total number of hospital days and third highest number of patients affected., Conclusions: Hospitalization for CHF occurs frequently and accounts for a large number of hospital bed-days in Canada. These figures should signal a call to action for researchers, administrators and health care providers regarding the need for more efficacious therapies, better application of already-proven therapies and patient education.

Background and Purpose: Despite the publication of a number of randomized, controlled trials demonstrating a substantial reduction in stroke with anticoagulation in patients with nonvalvular atrial fibrillation, the 'real world' use of warfarin is sub-optimal. Previous surveys have attempted to explain this problem but have significant limitations. The purpose of this study was to assess the relative importance of various barriers that may influence the prescription of warfarin in patients with nonvalvular atrial fibrillation., Methods: This cross-sectional survey was mailed to all practising cardiologists, neurologists and internists, as well as a random sample of family physicians within Alberta. Physicians caring for patients with NVAF rated the relative importance of potential barriers using a Likert scale., Results: Sixty-seven per cent of all physicians returned the survey. Overall, barriers pertaining to the patient's clinical characteristics were rated to be more important than those pertaining to the physician or to the organization required when prescribing these therapies. Specifically, an ongoing history of falls, a history of bleeding within the previous year and an inability to comply with therapy were rated as important barriers by 64%, 55% and 53% of physicians, respectively. Most physicians strongly believed that patients should receive information on the benefits and risks of warfarin (96%) and that patients should have a say in whether warfarin is prescribed (86%)., Implications: This study suggests that most of the barriers to warfarin use pertain to patient clinical characteristics and the need for patients to be involved in the decision to initiate therapy. The use of decision support technologies would facilitate involvement of the patient and serve to educate both the patient and physician on the risks and benefits of warfarin therapy.

Background: Access to new therapies in hospitals depends upon both clinical trial evidence and local Pharmacy and Therapeutics (P&T) committee approval. The process of formulary evaluation by P&T committees is not well-understood., Objectives: To describe the formulary decision-making process in Canadian hospitals for cardiovascular medications recently made available on the Canadian market., Methods: Postal survey of hospital pharmacy directors in all Canadian hospitals with more than 50 beds. Target drugs included abciximab, enoxaparin, dalteparin, clopidogrel, eptifibatide and tirofiban., Results: Of 428 surveys mailed, responses were received from 164 P&T committees representing 350 hospitals for an effective response rate of 82%. While physicians make up the largest proportion of committee membership, pharmacists play an influential role. Information most commonly cited as influencing formulary decisions included published clinical trials (97%), regional guidelines (90%), pharmacoeconomic data (84%), decisions at peer hospitals (73%) and local opinion leaders (60%). However, this information was often not required on formulary applications. Approval timelines varied widely for target medications but there were no regional, hospital or P&T committee characteristics that were independent predictors of early formulary application or approval., Conclusions: There is wide variability in the time taken for Canadian institutions to adopt new cardiovascular therapies, which is not explained by regional, hospital or P&T committee characteristics. Standardization of the formulary application and evaluation processes, including sharing of information amongst institutions, would lead to broader understanding of the applicable issues, more objectivity and improved efficiency.

Background: In 1994, the Canadian Cardiovascular Society (CCS) issued practice guidelines for the management of congestive heart failure (CHF), which strongly recommended the use of angiotensin-converting enzyme (ACE) inhibitors., Objective: To compare a strategy of active implementation of the CCS guidelines for CHF with the usual passive approach on the use of ACE inhibitors in hospitalized patients with CHF., Patients and Methods: The study was conducted in eight Canadian hospitals close to the time of release of the CCS guidelines for CHF in the summer of 1994. The patients comprised those who were admitted to the participating hospitals with a diagnosis of CHF during the study period. Active dissemination included stakeholder development of pocket cards outlining an algorithm for the management of CHF based on the CCS guidelines and was conducted at the two Edmonton, Alberta hospitals. The cards were widely disseminated in conjunction with a series of workshops and presentations. Passive dissemination occurred at six other hospitals, and involved only the distribution of the CCS guidelines in the usual fashion (with no structured dissemination program). The primary outcome measured was the use of ACE inhibitors in the six- to 12-month period before the release of the CCS guidelines, compared with after the release in the active and passive groups., Results: In the active group, hospital records of 1170 patients with CHF were reviewed before, and 1279 were reviewed after, the release of the CCS guidelines. In the passive group, 3436 were reviewed before, and 1912 were reviewed after the release of the guidelines. ACE inhibitor use did not change significantly in the active group (52.4% before versus 50.9% after) or in the passive group (53.4% before versus 56.5% after)., Conclusions: Neither the active nor passive approaches to the dissemination of the CCS guidelines for CHF had any impact on the use of ACE inhibitors in hospitalized patients with CHF. Further efforts to package, deliver and evaluate guidelines are needed.