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Objectives The aim of this study was to determine the impact of the 2016 Canadian cardiovascular society guidelines for the management of dyslipidemia. More specifically, we assessed the use of 1) alternate lipid targets when triglyceride (TG) levels are high; and 2) nonfasting lipid testing. Methods Lipid profiles and pharmacy data were obtained from patients with a history of myocardial infarction and from patients ≥40 years of age with a diagnosis of diabetes. Results As TG increased to >1.5 mmol/L, percent within target for non–high-density lipoprotein cholesterol and apolipoprotein B 18 months after guideline release remained low in both patients with atherosclerotic cardiovascular disease (40%) and patients with diabetes in primary prevention (30%). Approximately 50% of patients were fasting when presenting for lipid testing. Use of high-intensity statin was suboptimal in both groups. Conclusions The concept of alternate lipid targets may not be well understood by many physicians, leading to undertreatment of patients. Progress was made in the promotion of routine nonfasting lipid testing.

Aim of this retrospective, multicenter study was to evaluate early and mid-term clinical and hemodynamic results of patients who underwent surgical aortic valve replacement (SAVR) with Intuity rapid-deployment bioprostheses (RDB) (Edwards Lifesciences, Irvine, CA). We analyzed data from the Italian Registry of Intuity Valve (INTU-ITA registry) that is a national, real-world and independent from the industry registry. Preoperative variables were defined according to EuroSCORE and postoperative outcomes according to Valve Academic Research Consortium (VARC). Survival distribution was evaluated using the Kaplan-Meier approach. A Cox-Proportional Hazard Model was employed to assess the effect of the covariates on patients’ survival. The registry included 1687 patients from 23 centers (June 2012-September 2019). Aortic cross clamp time for isolated SAVR was 55 minutes (IQR: 45–70 minute). Postoperative pace-maker rate was 6.3%. At discharge transaortic peak and mean gradients were: 18 mm Hg (IQR: 14–23 mm Hg) and 10 mmHg (IQR: 8–13 mm Hg), respectively. Indexed effective orifice area was 1.10 cm2/m2 (IQR: 0.91–1.31 cm2/m2) and the incidence of severe patient-prosthesis mismatch was 0.6%. Hemodynamic data for all valve sizes remained stable during follow-up. Thirty-day overall mortality was 1.8% (30 patients), and at follow-up it was 5.3% (89 patients). Kaplan-Meier overall survival was 95.5% (94.3–96.7%); 90.7% (88.3–93.1%); 86.4% (82.6–90.4%) at 1, 3, and 5 years, respectively. Serum creatinine (HR: 1.36; 95%CI: 1.04–1.81; p = 0.0397) and cross-clamp time (HR: 1.01; 95%CI: 1.002–1.017; p = 0.0077) were identified as independent predictors of mortality. According to our data from the INTU-ITA registry, SAVR with RDB provides good early clinical and hemodynamic results that are confirmed at follow-up.

An 81-year-old female presented with chronic coronary disease (Canadian Cardiovascular Society angina severity grading III). The patient underwent coronary computed tomography angiography (CCTA) that revealed three-vessel coronary artery disease (3VD). This case illustrates that in a patient with 3VD, planning and execution of coronary artery bypass grafting (CABG) were successfully performed based solely on CCTA combined with fractional flow reserve derived from computed tomography angiography (FFRCT). Coronary artery bypass grafting (CABG) was planned and executed as follows: left internal mammary artery grafted to the left anterior descending artery (LAD), saphenous vein graft (SVG) to the right coronary artery (RCA), and SVG to the obtuse marginal artery (OM). Repeat imaging assessment with non-invasive CCTA and FFRCT at 30-day follow-up confirmed the safety of this approach. The FFRCT values of the RCA and LAD were normalized, whereas a borderline pressure drop was observed in the distal run-off of the OM (FFRCT=0.79). Notably, this is the first case in which post-CABG FFRCT assessment was performed. Post-CABG FFRCT is an investigational novel non-invasive tool for assessing the functional improvement of the epicardial conductance vessels following surgical revascularization.

Background Patients with refractory angina (RA) have poor quality of life and new therapies are needed. XC001 is a novel adenoviral vector expressing multiple isoforms of vascular endothelial growth factor (VEGF) promoting an enhanced local angiogenic effect. Methods The E picardial Delivery of X C001 Gene Therapy for Refractory A ngina C oronary T reatment (EXACT) trial is a 6-month (with 6-month extension) phase 1/2, first-in-human, multicenter, open-label, single-arm, dose-escalation study to evaluate the safety, tolerability, and preliminary efficacy of XC001 in patients with RA. The trial will enroll 33 patients in an initial (n = 12) ascending dose-escalation phase (1 × 109, 1 × 1010, 4 × 1010, and 1 × 1011 viral particles), followed by phase 2 (n = 21) assessing the highest tolerated dose. Patients must have stable Canadian Cardiovascular Society (CCS) class II–IV angina on maximally tolerated medical therapy without options for conventional revascularization, demonstrable ischemia on stress testing, and angina limiting exercise tolerance. XC001 will be delivered directly to ischemic myocardium via surgical transthoracic epi c ardial access. The primary outcome is safety via adverse event monitoring through 6 months. Efficacy assessments include difference from baseline to month 6 in time to 1 mm of ST segment depression, time to angina, and total exercise duration; myocardial blood flow at rest, and stress and coronary flow reserve by positron emission tomography; quality of life; CCS functional class; and angina frequency. Conclusions The EXACT trial will determine whether direct intramyocardial administration of XC001 in patients with RA is safe and evaluate its effect on exercise tolerance, myocardial perfusion, angina and physical activity, informing future clinical investigation. Clinical trial registration NCT04125732

Background: Mediated by outcomes such as improved exercise capacity, cardiac rehabilitation (CR) reduces morbidity and mortality. For accuracy, an individual CR patient's change must be measured reliably, an issue not typically considered in practice. Drawing from psychometric theory, we calculated reliable change indices (RCIs), to measure individual CR patients’ true clinical change, apart from that from error and test practice/exposure, in exercise capacity, anxiety, and depression. Methods: Indirectly calculated exercise capacity (peak metabolic equivalents [METs]) and psychological symptoms were each measured twice, 1 week apart, by administering treadmill tests or the Hospital Anxiety and Depression Scale (HADS) to separate samples of 35 (mean age: 59.0 years; 6 women) and 96 (mean age: 64.4 years; 32 women) CR patients, respectively. Using test-retest reliability and mean difference scores from these samples to estimate error and practice/exposure effects, we calculated RCIs for a separate cohort (n = 2066; mean age: 62.0 years; 533 women) who completed 6-month CR, and compared change distributions (worsened/unchanged/improved) based on critical RCIs, mean and percent changes, cut-off scores, and standard deviations. Results: Practice/exposure effects were nonsignificant, except the mean HADS anxiety score decreased significantly (P ≤ 0.013; d = 0.17, small effect). Test-retest reliabilities were high (METs r = 0.934; HADS anxiety score r = 0.912; HADS depression score r = 0.90; P < 0.001). Among 2066 CR patients, RCI distributions differed (P < 0.001) from those of most other change criteria. Conclusions: Change ascertainment depends on criterion choice. A Canadian Cardiovascular Society CR quality indicator of increase by 0.5 MET may be too small to assess individuals’ functional capacity change. RCIs offer a pragmatic approach to benchmarking reliable change frequency, and pending further validation, could be used for feedback to individual patients. Résumé: Contexte: Grâce à des résultats tels que l'amélioration de la capacité d'exercice, la réadaptation cardiaque (RC) réduit la morbidité et la mortalité. Pour être précis, le changement de RC d'un patient doit être mesuré de manière fiable, un aspect qui n'est généralement pas pris en compte dans la pratique. En nous inspirant de la théorie psychométrique, nous avons déterminé des indices de changement fiables afin de mesurer le véritable changement clinique individuel des patients en RC en lien avec la capacité d'entraînement, l'anxiété et la dépression et indépendamment des erreurs et de la pratique du test/l'exposition au test. Méthodologie: La capacité d'entraînement calculée indirectement (l’équivalent métabolique maximum [MET]) et les symptômes psychologiques ont été mesurés deux fois, à une semaine d'intervalle, par le biais de tests sur tapis roulant ou de l’échelle de l’évaluation de l'anxiété et de la dépression en milieu hospitalier (HADS), auxquels ont respectivement été soumis des échantillons de 35 personnes en RC (âge moyen : 59,0 ans; 6 femmes) et de 96 personnes en RC (âge moyen : 64,4 ans; 32 femmes). En recourant à la fiabilité test-retest et aux écarts moyens dans les scores de ces échantillons pour faire une approximation des effets d'erreur et de pratique/exposition, nous avons déterminé des indices de changement fiables pour une cohorte distincte (n = 2 066; âge moyen : 62,0 ans; 533 femmes) qui a terminé une RC de six mois, et comparé la répartition des changements (aggravé/inchangé/amélioré) sur la base des indices de changement fiables critiques, des changements moyens et en pourcentage, des scores-seuils et des écarts types. Résultats: Les effets de la pratique/exposition étaient peu significatifs, sauf une diminution du score moyen de l'anxiété sur l’échelle HADS (p ≤ 0,013; d = 0,17, petit effet). La fiabilité test-retest était élevée (MET, r = 0,934; score de l'anxiété sur l’échelle HADS, r = 0,912; score de la dépression sur l’échelle HADS, r = 0,90; p < 0,001). Parmi les 2 066 patients en RC, la répartition des indices de changement fiables différait (p < 0,001) de celle de la plupart des autres critères de changement. Conclusions: Le constat du changement dépend du choix du critère. Une augmentation de 0,5 MET selon l'indicateur de qualité en RC de la Société canadienne de cardiologie est peut-être trop faible pour évaluer le changement de capacité fonctionnelle des individus. Les indices de changement fiables offrent une approche pragmatique pour comparer la fréquence du changement fiable et, en attendant une vérification plus poussée, ils pourraient être utilisés comme rétroaction fournie individuellement aux patients.

Objectives This study sought to determine if percutaneous coronary intervention (PCI) prior to transcatheter aortic valve replacement (TAVR) in patients with significant coronary artery disease would produce noninferior clinical results when compared with no PCI (control arm). Background PCI in patients undergoing TAVR is not without risk, and there are no randomized data to inform clinical practice. Methods Patients with severe symptomatic aortic stenosis and significant coronary artery disease with Canadian Cardiovascular Society class ≤2 angina were randomly assigned to receive PCI or no PCI prior to TAVR. The primary endpoint was a composite of all-cause death or rehospitalization at 1 year. Noninferiority testing (prespecified margin of 7.5%) was performed in the intention-to-treat population. Results At 17 centers, 235 patients underwent randomization. At 1 year, the primary composite endpoint occurred in 48 (41.5%) of the PCI arm and 47 (44.0%) of the no-PCI arm. The requirement for noninferiority was not met (difference: -2.5%; 1-sided upper 95% confidence limit: 8.5%; 1-sided noninferiority test P = 0.067). On analysis of the as-treated population, the difference was -3.7% (1-sided upper 95% confidence limit: 7.5%; P = 0.050). Mortality was 16 (13.4%) in the PCI arm and 14 (12.1%) in the no-PCI arm. At 1 year, there was no evidence of a difference in the rates of stroke, myocardial infarction, or acute kidney injury, with higher rates of any bleed in the PCI arm (P = 0.021). Conclusions Observed rates of death and rehospitalization at 1 year were similar between PCI and no PCI prior to TAVR; however, the noninferiority margin was not met, and PCI resulted in a higher incidence of bleeding. (Assessing the Effects of Stenting in Significant Coronary Artery Disease Prior to Transcatheter Aortic Valve Implantation; ISRCTN75836930 )

Introduction Refractory angina (RA) is considered the end-stage of coronary artery disease, and often has no interventional treatment options. Coronary sinus Reducer (CSR) is a recent addition to the therapeutic arsenal, but its efficacy has only been evaluated on small populations. The RESOURCE registry provides further insights into this therapy. Methods The RESOURCE is an observational, retrospective registry that includes 658 patients with RA from 20 centers in Europe, United Kingdom and Israel. Prespecified endpoints were the amelioration of anginal symptoms evaluated with the Canadian Cardiovascular Society (CCS) score, the rates of procedural success and complications, and MACEs as composite of all-cause mortality, acute coronary syndromes, and stroke. Results At a median follow-up of 502 days (IQR 225–1091) after CSR implantation, 39.7% of patients improved by ≥2 CCS classes (primary endpoint), and 76% by ≥1 class. Procedural success was achieved in 96.7% of attempts, with 3% of procedures aborted mostly for unsuitable coronary sinus anatomy. Any complication occurred in 5.7% of procedures, but never required bailout surgery nor resulted in intra- or periprocedural death or myocardial infarction. One patient developed periprocedural stroke after inadvertent carotid artery puncture. At the last available follow-up, overall mortality and MACE were 10.4% and 14.6% respectively. At one, three and five years, mortality rate at Kaplan-Meier analysis was 4%, 13.7%, and 23.4% respectively. Conclusions CSR implantation is safe and reduces angina in patients with refractory angina.

Background: Documentation of quality of life (QOL) of patients after transcatheter aortic valve implantation (TAVI) is a Canadian Cardiovascular Society quality indicator. National results have not been reported to date. Methods: We conducted an observational cohort study including all TAVI patients, irrespective of surgical risk, treated between January 2016 and June 2019 as documented in the British Columbia TAVI Registry. QOL was measured at baseline, 30 days, and 1 year, using the Kansas City Cardiomyopathy Questionnaire overall score (KCCQ-OS). We used linear regression modelling to examine factors associated with 30-day changes in QOL, logistic regression modelling to identify predictors of sustaining a poor outcome, and Cox regression modelling to ascertain risk estimates of the effect of QOL on 1-year mortality. Results: The cohort included 1706 patients (742 women [43.5%]); median age 83 years (interquartile range [IQR]: 77, 86). Median (IQR) baseline KCCQ-OS was 45 (28.2, 67), indicating severe impairment. Patients alive at 1 year (91.3%) reported a mean improvement of 24.1 (95% confidence interval [CI], 22.7-25.6) points in the KCCQ-OS at 30 days, which was sustained at 1 year (25.3; 95% CI, 23.8, 26.8). Older age, lower baseline health status, lower aortic valve gradient, lower hemoglobin, atrial fibrillation, and non-transfemoral access were associated with worse 30-day QOL. At 1 year, 65% of patients had a favorable outcome; additional risk factors for 1-year mortality (8.7%) were male sex, New York Heart Association Class IV, severe pulmonary and renal disease, diabetes, and in-patient status. Conclusions: TAVI is associated with significant early improvement in QOL, which is sustained at 1 year. The inclusion of QOL can support treatment decisions and patient-centred evaluation. Résumé: Introduction: Les données sur la qualité de vie (QdV) des patients après l'implantation valvulaire aortique par cathéter (IVAC) sont un indicateur de qualité de la Société canadienne de cardiologie. Jusqu’à ce jour, les résultats nationaux n'ont pas été présentés. Méthodes: Nous avons mené une étude de cohorte observationnelle portant sur tous les patients ayant subi une IVAC, sans tenir compte du risque lié à l'intervention chirurgicale, qui ont été traités entre janvier 2016 et juin 2019 selon le registre d'IVAC de la Colombie-Britannique. L’évaluation de la QdV a été établie au début, 30 jours après et 1 an après au moyen du score global au Kansas City Cardiomyopathy Questionnaire (SG-KCCQ). Nous avons utilisé le modèle de régression linéaire pour examiner 30 jours après les facteurs associés aux changements dans la QdV, le modèle de régression logistique pour déterminer les prédicteurs du maintien d'issues médiocres et le modèle de régression de Cox pour établir les estimations du risque en fonction des effets de la QdV sur la mortalité 1 un après. Résultats: La cohorte regroupait 1 706 patients (742 femmes [43,5 %]); l’âge médian était de 83 ans (écart interquartile [ÉI] : 77; 86). Le SG-KCCQ médian (ÉI) au début était de 45 (28,2; 67), soit une détérioration importante. Les patients en vie un an après (91,3 %) ont signalé une amélioration moyenne de 24,1 (intervalle de confiance [IC] à 95 %, 22,7-25,6) points au SG-KCCQ 30 jours après, qui a été maintenue jusqu’à un an (25,3; IC à 95 %; 23,8; 26,8). L’âge avancé, l’état de santé initial inférieur, le gradient de la valve aortique plus faible, l'hémoglobine plus faible, la fibrillation auriculaire et l'accès non transfémoral ont été associés à une plus mauvaise qualité de vie 30 jours après. Un an après, 65 % des patients avaient des issues favorables; les facteurs additionnels de risque de mortalité un an après (8,7 %) étaient le sexe masculin, la classe IV selon la New York Heart Association, la pneumopathie et la néphropathie graves, le diabète et l’état du patient hospitalisé. Conclusions: L'IVAC est associée à une amélioration précoce significative de la QdV, qui est maintenue un an après. L'inclusion de la QdV peut contribuer aux décisions de traitement et à l’évaluation axée sur le patient.

Background The current Canadian Cardiovascular Society antiplatelet therapy guidelines recommend the use of ticagrelor or prasugrel over clopidogrel as first-line platelet P2Y12 receptor antagonists for treatment of moderate- to high-risk acute coronary syndromes. Recently, Effient (prasugrel [Eli Lilly Canada Inc, Toronto, Canada]) was discontinued by its distributor in Canada. Methods Five members of the Canadian Cardiovascular Society antiplatelet therapy 2018 guidelines committee undertook an independent, evidence-based review to outline patients for whom prasugrel should be the optimal P2Y12 agent and discuss alternative strategies to consider without prasugrel. Results Several clinical scenarios where prasugrel should be indicated are identified and discussed. Considerations to be undertaken for alternative therapies are summarized, including a review of national and international guidelines for de-escalation of P2Y12 receptor antagonists. Conclusions The discontinuation of prasugrel poses a challenge for clinicians. Clinicians must consider key factors in determining the best alternate therapy., Introduction Dans ses lignes directrices actuelles sur la thérapie antiplaquettaire, la Société canadienne de cardiologie recommande l’utilisation du ticagrélor ou du prasugrel plutôt que l’utilisation du clopidogrel comme antagonistes des récepteurs plaquettaires P2Y12 de première intention dans le traitement des patients qui présentent un risque modéré à élevé de syndromes coronariens aigus. Depuis peu, le distributeur a cessé la distribution d’Effient (prasugrel) au Canada. Méthodes Cinq membres du comité des lignes directrices 2018 sur la thérapie antiplaquettaire de la Société canadienne de cardiologie ont entrepris une revue indépendante fondée sur les données probantes pour dresser le profil des patients pour lesquels le prasugrel devrait être la meilleure option parmi les antagonistes des récepteurs P2Y12 et se pencher sur les traitements alternatifs en l'absence de prasugrel. Résultats Plusieurs scénarios cliniques où le prasugrel devrait être indiqué sont recensés et abordés. Les réflexions sur les solutions de rechange au traitement, notamment une revue des lignes directrices nationales et internationales en matière de désescalade des antagonistes des récepteurs P2Y12, sont présentées. Conclusions La cessation de la distribution du prasugrel pose problème aux cliniciens. Les cliniciens doivent tenir compte des facteurs clés pour déterminer le meilleur traitement de remplacement.

To effectively implement the Canadian Cardiovascular Society (CCS) guidelines for dyslipidemia management into clinical laboratories, clear recommendations for lipid reporting are essential. In this study, the Canadian Society of Clinical Chemists Working Group on Reference Interval Harmonisation surveyed Canadian laboratories on adult lipid reporting practices to set a foundation for the development and implementation of harmonised lipid reporting across Canada. Key aspects of the survey asked laboratories: what reporting parameters were in place to assess lipid results; what interpretative comments were provided; whether nonfasting lipids were permitted and, if so, what strategy was used to document fasting status; and whether there was interest in implementing a harmonised lipid report. A total of 101 laboratories were represented by 24 respondents, as many responses were submitted by laboratory networks that included more than 1 laboratory. There was at least 1 response from 9 Canadian provinces and representation across 5 testing platforms. Upper and lower limits for lipid parameters and referenced source of limits varied substantially across laboratories, with only 56% of laboratories (9 respondents) referencing the 2016 CCS guidelines. Eighty-six percent of laboratories (19 respondents) report nonfasting lipids, although the method of documenting nonfasting status varied. Overall, 36% of laboratories (8 respondents) reported interest in implementing a harmonised lipid report. Assessment of current lipid-reporting practices supports the need for harmonised lipid reporting across Canada. Development of a harmonised lipid report for the adult population, consistent with up-to-date Canadian guidelines, will improve continuity of lipid test interpretation across Canada and improve clinical decision making.

Magnetic resonance imaging (MRI) is often considered the gold-standard test for characterizing cardiac as well as noncardiac structure and function. However, many patients with cardiac implantable electronic devices (CIEDs) and/or severe renal dysfunction are unable to undergo this test because of safety concerns. In the past 10 years, newer-generation CIEDs and gadolinium-based contrast agents (GBCAs) as well as coordinated care between imaging and heart rhythm device teams have mitigated risk to patients and improved access to MRI at many hospitals. The purpose of this statement is to review published data on safety of MRI in patients with conditional and nonconditional CIEDs in addition to patient risks from older and newer GBCAs. This statement was developed through multidisciplinary collaboration of pan-Canadian experts after a relevant and independent literature search by the Canadian Agency for Drugs and Technologies in Health. All recommendations align with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Key recommendations include: (1) the development of standardized protocols for patients with a CIED undergoing MRI; (2) patients with MRI nonconditional pacemakers and pacemaker dependency should be programmed to asynchronous mode and those with MRI nonconditional transvenous defibrillators should have tachycardia therapies turned off during the scan; and (3) macrocyclic or newer linear GBCAs should be used in preference to older GBCAs because of their better safety profile in patients at higher risk of nephrogenic systemic fibrosis.

Background Increased arterial stiffness (AS) has been described as a predictor of atrial fibrillation (AF). This study was performed to assess whether increased AS leads to a higher symptom burden in patients with AF. Methods One hundred sixty-two consecutive patients (104 male, 58 female) with diagnosed AF (paroxysmal or persistent) were enrolled. Symptoms most likely attributable to AF were quantified according to the Canadian Cardiovascular Society Severity of Atrial Fibrillation (SAF) scale. AS indices (aortic distensibility, cyclic circumferential strain, and aortic compliance) were characterized using transoesophageal echocardiography. Results The cohort was divided into asymptomatic to oligosymptomatic (SAF scale 0-1, n = 78 [48.1%]) and symptomatic (SAF scale ≥ 2, n = 84 [51.9%]) patients. Symptomatic patients tended to be younger (median, 75 [interquartile range (IQR) 67-80] vs 71 [65-79]; P = 0.047) and were more likely to be female (22 [28.2%] vs 36 [42.9%]; P = 0.052). Hypertension was more frequent in symptomatic patients. Aortic compliance indices each were reduced in symptomatic patients, most pronounced for aortic compliance (median, 0.05 [IQR 0.03-0.06] vs 0.04 [0.03-0.05] cm/mm Hg; P = 0.01) followed by cyclic circumferential strain (median, 0.09 [IQR 0.07-0.11] vs 0.07 [0.04-0.10]; P = 0.02) and aortic distensibility (10−3 mm Hg−1, median, 1.74 [IQR 1.34-2.24] vs 1.54 [1.12-2.08]; P = 0.03). Multivariable analysis revealed aortic compliance as an independent predictor for symptoms in patients with AF with an odds ratio of 2.6 (95% confidence interval, 1.2-3.4; P = 0.003). Conclusions AS contributes to a high symptom burden in patients with AF, emphasizing the prognostic role of AS in the early detection and prevention in patients with AF.

Lipid-lowering medication can considerably lessen the risk for cardiovascular events in patients with atherosclerotic cardiovascular disease (ASCVD). Despite well-publicized guidelines and the accessibility of effective therapies, many patients do not attain their lipid goals and remain at high cardiovascular risk. Guidelines recommend statins as first-line therapy to reduce cardiovascular morbidity and mortality in ASCVD. We aimed to analyze admission lipid levels in a broad contemporary population of patients with ASCVD attending a vascular clinic or admitted to an inpatient vascular unit.Patients with known ASCVD, current cholesterol levels, and lipid-lowering medications were documented and compared with published current Canadian Cardiovascular Society Guidelines recommendations for achieving2.0 mmol/L or50% reduction in low-density lipoprotein cholesterol (LDL-C). Cholesterol levels (current and previous), demographic characteristics, cardiovascular risk factors, and medical therapy were assessed from available patient records.Two hundred eight adult patients were identified. The mean age of the patients was 72 (±10) years, and 76% were men. About half had peripheral arterial disease (n = 118, 56.7%), one-third had coronary artery disease (n = 78, 37.5%), and one-third had diabetes (n = 76, 36.5%). Most were hypertensive (n = 140, 67.3%) and half gave a history of dyslipidemia (n = 103, 49.5%). Most patients (n = 183, 88%) were taking a statin and the majority at a moderate-intensity dose (n = 79, 43.2%) or high-intensity dose (n = 101, 55.2%). However, 32.7% of patients (n = 68) did not reach target of LDL-C level of2.0 mmol/L or had ≤50% reduction from the baseline level. Of the patients who did not reach goals, 7 (10.3%) did not fill their statin prescriptions in the last 3 months. Only 26 patients (12.5%) were also on ezetimibe, a guideline-recommended second-line therapy if targets are not reached with maximally tolerated statin therapy. One patient, who was able to reach target LDL-C, was on evolocumab monotherapy, a PCSK9 inhibitor, a contemporary nonstatin therapy that could be considered in ASCVD in those not at LDL-C goal. Of the 16 patients who were not prescribed any lipid-lowering therapy and did not reach target, 8 (50%) did not have any identified or documented reasons. Of the remaining 8 patients, 7 (87.5%) reported intolerance or side effects to statins only, and could benefit from nonstatin LDL-lowering therapy.In this observational study, we established suboptimal adherence to guideline recommendations for statin therapy and hesitancy to use nonstatin LDL-lowering agents in high-risk patients with ASCVD. These treatment gaps have an enormous effect on achieving improved cardiovascular clinical outcomes and must be tackled.

Ranolazine is approved for patients with chronic stable angina but has not been formally studied in patients with refractory angina pectoris (RAP). Patients with RAP have limited therapeutic options and significant limitations in their quality of life. The Ranolazine Refractory Angina Registry was designed to evaluate the safety, tolerability, and effectiveness of ranolazine in RAP patients in order to expand treatment options for this challenging patient population. Using an extensive prospective database, we enrolled 158 consecutive patients evaluated in a dedicated RAP clinic. Angina class, medications, major adverse cardiac events including death, myocardial infarction, and revascularization were obtained at 12, 24, and 36 months. At 3 years, 95 (60%) patients remained on ranolazine. A ≥2 class improvement in angina was seen in 48% (38 of 80 patients with known Canadian Cardiovascular Society class) of those who remained on ranolazine. Discontinuation due to side effects, ineffectiveness, cost, and progression of disease were the principle reasons for discontinuation, but primarily occurred within the first year. In conclusion, ranolazine is an effective antianginal therapy at 3-year follow-up in patients with RAP and may reduce cardiac readmission.

The landscape of pulmonary hypertension (PH) has changed significantly since the last Canadian Cardiovascular Society/Canadian Thoracic Society position statement in 2005. Since then, advances in our understanding of the pathophysiology of PH and improvements in diagnostic and therapeutic options have transformed the care of patients with PH. Globally, PH has an estimated prevalence of 1%, increasing to 10% in those aged 65 years and older, most commonly due to left heart or lung disease. Although pulmonary arterial hypertension (PAH) is less common, the morbidity and mortality is significant and early diagnosis and treatment are essential. This document is targeted at clinicians and describes a framework for screening and diagnosis of PH, with recommendations for performance and interpretation of echocardiography, cardiac magnetic resonance imaging, and right heart catheterization. In addition, the current approach to PAH management in Canada including risk stratification and pharmacologic therapy aimed at achieving a low-risk profile is discussed. The rationale to avoid specific PAH therapy in patients with left heart disease and lung disease-related PH is emphasized, along with special considerations for the diagnosis and management of chronic thromboembolic PH. Future advancements in the identification of novel pathways and therapies, personalized approaches to direct therapy, as well as interventional approaches such as balloon pulmonary angioplasty for chronic thromboembolic PH promise to continue the rapid evolution of this field.

Prevention of sudden cardiac arrest/death and disease progression has traditionally been the primary basis for determining exercise recommendations for those with underlying cardiovascular disease. Potential harms of exercise restriction, including physical inactivity's impact on obesity, chronic disease, and negative psychological and emotional consequences, have been considered ancillary, if considered at all. Accumulating evidence suggests the relative safety of continued sport and exercise participation in the vast majority of those with a variety of cardiac conditions that were previously considered to be criteria for exclusion. Despite ongoing clinical uncertainty however, respect for patient autonomy and the inclusion of patient values and preferences is now required in the decision-making process. The shared decision-making construct, a cornerstone of patient-centred care, should be applied for determining exercise and participation recommendations for those with cardiovascular disease. Safe exercise principles should be employed in all cases, regardless of whether athletes chose to follow recommendations, following a harm-reduction model. This approach is recommended by the 2019 Canadian Cardiovascular Society and Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes, and other contemporary societal guidelines, for all aspects of cardiovascular care of athletes.

On March 11, 2020, the World Health Organization declared that COVID-19 was a pandemic.1 At that time, only 118,000 cases had been reported globally, 90% of which had occurred in 4 countries.1 Since then, the world landscape has changed dramatically. As of March 31, 2020, there are now nearly 800,000 cases, with truly global involvement.2 Countries that were previously unaffected are currently experiencing mounting rates of the novel coronavirus infection with associated increases in COVID-19–related deaths. At present, Canada has more than 8000 cases of COVID-19, with considerable variation in rates of infection among provinces and territories.3 Amid concerns over growing resource constraints, cardiac surgeons from across Canada have been forced to make drastic changes to their clinical practices. From prioritizing and delaying elective cases to altering therapeutic strategies in high-risk patients, cardiac surgeons, along with their heart teams, are having to reconsider how best to manage their patients. It is with this in mind that the Canadian Society of Cardiac Surgeons (CSCS) and its Board of Directors have come together to formulate a series of guiding statements. With strong representation from across the country and the support of the Canadian Cardiovascular Society, the authors have attempted to provide guidance to their colleagues on the subjects of leadership roles that cardiac surgeons may assume during this pandemic: patient assessment and triage, risk reduction, and real-time sharing of expertise and experiences. A visual abstract of the main principles underlying our recommended approach is provided in Figure 1.

This Canadian Cardiovascular Society position statement is focused on the management of sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) that occurs in patients with structural heart disease (SHD), including previous myocardial infarction, dilated cardiomyopathy, and other forms of nonischemic cardiomyopathy. This patient population is rapidly increasing because of advances in care and improved overall survival of patients with all forms of SHD. In this position statement, the acute and long-term management of VT/VF are outlined, and the many unique aspects of care in this population are emphasized. The initial evaluation, acute therapy, indications for chronic suppressive therapy, choices of chronic suppressive therapy, implantable cardioverter-defibrillator programming, alternative therapies, and psychosocial care are reviewed and recommendations for optimal care are provided. The target audience for this statement includes all health professionals involved in the continuum of care of patients with SHD and VT/VF.

Significant practice-changing developments have occurred in the care of heart transplantation candidates and recipients over the past decade. This Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement provides evidence-based, expert panel recommendations with values and preferences, and practical tips on: (1) patient selection criteria; (2) selected patient populations; and (3) post transplantation surveillance. The recommendations were developed through systematic review of the literature and using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The evolving areas of importance addressed include transplant recipient age, frailty assessment, pulmonary hypertension evaluation, cannabis use, combined heart and other solid organ transplantation, adult congenital heart disease, cardiac amyloidosis, high sensitization, and post-transplantation management of antibodies to human leukocyte antigen, rejection, cardiac allograft vasculopathy, and long-term noncardiac care. Attention is also given to Canadian-specific management strategies including the prioritization of highly sensitized transplant candidates (status 4S) and heart organ allocation algorithms. The focus topics in this position statement highlight the increased complexity of patients who undergo evaluation for heart transplantation as well as improved patient selection, and advances in post-transplantation management and surveillance that have led to better long-term outcomes for heart transplant recipients.

The current definition of postural orthostatic tachycardia syndrome (POTS) dates back to a small case series of patients with a subacute illness who presented with excessive orthostatic tachycardia and orthostatic intolerance, in the absence of another recognized disease. Conventional POTS criteria require an excessive orthostatic tachycardia in the absence of substantial orthostatic hypotension, and predominant symptoms of orthostatic intolerance, worse with upright posture and better with recumbence. POTS is a heterogeneous syndrome with likely several underlying pathophysiological processes, and not a specific disease. The primary panel for this Canadian Cardiovascular Society position statement sought to provide a contemporary update of the best evidence for the evaluation and treatment of POTS. We performed a systemic review of evidence for the evaluation of treatment of POTS using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology, and developed recommendations on the basis of the Canadian Cardiovascular Society approach to position statements. One identified problem was that numerous patients who did not meet criteria for POTS would still be given that diagnoses by providers to validate the illness even though this diagnosis is incorrect. This includes patients with postural symptoms without tachycardia, orthostatic tachycardia without symptoms, and those with orthostatic tachycardia but another overt cause for excessive tachycardia. We developed a novel nomenclature ecosystem for orthostatic intolerance syndromes to increase clarity. We also provide more clarity on how to interpret the orthostatic vital signs. These concepts will need to be prospectively assessed.

Background There is no systematic evidence review of the long-term results of surgical pulmonary valve replacement (PVR) dedicated to adults with repaired tetralogy of Fallot (rTOF) and pulmonary regurgitation. Methods Our primary objective was to determine whether PVR reduced long-term mortality in adults with rTOF compared with conservative therapy. Secondary objectives were to determine the postoperative incidence rate of death, the changes in functional capacity and in right ventricular (RV) volumes and ejection fraction after PVR, and the postoperative incidence rate of sustained ventricular arrhythmias. A systematic search of multiple databases for studies was conducted without limits. Results No eligible randomized controlled trial or cohort study compared outcomes of PVR and conservative therapy in adults with rTOF. We selected 10 cohort studies (total 657 patients) reporting secondary outcomes. After PVR, the pooled incidence rate of death was 1% per year (95% confidence interval [CI] 0-1% per year) and the pooled incidence rate of sustained ventricular arrhythmias was 1% per year (95% CI 1%-2% per year). PVR improved symptoms (odds ratio for postoperative New York Heart Association functional class > II 0.08, 95% CI 0.03-0.24). Indexed RV end-diastolic (−61.29 mL/m2, −43.64 to −78.94 mL/m2) and end-systolic (−37.20 mL/m2, −25.58 to −48.82 mL/m2) volumes decreased after PVR, but RV ejection fraction did not change (0.19%, −2.36% to 2.74%). The effect of PVR on RV volumes remained constant regardless of functional status. Conclusion Studies comparing PVR and conservative therapy exclusively in adults with rTOF are lacking. After PVR, the incidence rates of death and ventricular tachycardia are both 1 per 100 patient-years. Pooled analyses demonstrated an improved functional status and a reduction in RV volumes.

Introduction Coronary Sinus Reducer emerged as promising therapeutic option for patients with refractory angina. While recent literature reports short-term benefits of Reducer implantation, there is paucity of evidence regarding its safety and efficacy at longer follow-up. Methods In the original cohort of 50 refractory angina patients treated with Reducer at San Raffaele Hospital (Milan, Italy) between March 2015 and August 2016, we reassessed angina symptoms, quality of life and recorded adverse events at 2-year (mean ± SD: 748 ± 84 days) follow-up. Results Canadian Cardiovascular Society (CCS) score improved of ≥1 class in 34 patients (75.6%), and of ≥2 classes in 16 patients (35.6%), translating into a significant mean CCS score reduction at 2-year follow-up (1.74 ± 0.86 vs. 2.98 ± 0.52; p Conclusions Safety and efficacy observed in the short follow-up period after Reducer implantation are maintained at two years. Ten patients underwent PCI during follow-up, underlining that Reducer does not affect coronary artery disease progression.

In this Viewpoint concerns raised by Canadian emergency physicians regarding recommendations 2 and 6 from the recent Canadian Cardiovascular Society 2018 update for atrial fibrillation are discussed. These recommendations narrow the window for safe cardioversion and suggest 4 weeks of anticoagulation for all patients who undergo urgent cardioversion regardless of their CHADS-65 status. We discuss the implications of Grading of Recommendations, Assessment, Development, and Evaluation weak recommendations on the basis of low-quality evidence.

The practice of electrical or pharmacological cardioversion (CV) to restore sinus rhythm in patents with symptomatic atrial fibrillation (AF) or atrial flutter has been a part of clinical practice for more than 100 years. For almost as long as CV has been performed, it has been recognized that the act of restoring sinus rhythm is associated with an increased risk of stroke and systemic embolism, and that oral anticoagulant (OAC) therapy can be used to prevent peri-CV thromboembolism. Although it has been widely accepted that OAC therapy is necessary to prevent thromboembolism in patients with chronic AF/atrial flutter who undergo CV, previous clinical practice recommendations have suggested that OAC therapy may be omitted in patients at low risk of stroke. However, in recent years, evidence has emerged from several sources challenging these historical conventions. In 2018 the Canadian Cardiovascular Society AF guidelines updated the previous recommendations regarding CV of acute onset AF, and the use of peri-CV anticoagulation. In this article we present an extensive review of the evidence informing the previous recommendations, as well as the novel evidence that informed the change in recommendations. In addition, the current Canadian Cardiovascular Society AF guideline recommendations are examined within the context of contemporary international major society guidelines.

Background: In 2010, the Canadian Cardiovascular Society Atrial Fibrillation/Atrial Flutter (AF/AFL) quality indicator (QI) working group was established to develop QIs and assess feasibility of measurement. After extensive review, 3 priority QIs were selected. However, none were measurable at a national level. Methods: The working group reconvened in 2017 to review the relevance of previously proposed QIs, identify opportunities to develop new QIs, and propose an initial strategy for measuring and reporting. Results: Two additional priority QIs were added to the previous 3: proportion of patients with nonvalvular (NV) AF/AFL sorted by stroke risk stratum and annual rate of hospitalization for a new heart failure diagnosis. An environmental scan was undertaken to determine the potential of existing databases to provide national and provincial estimates. On the basis of validated administrative codes, the Canadian Institute for Health Information discharge abstract database can be used for inpatients. In collaboration with the Canadian Primary Care Sentinel Surveillance Network, 2 of the 5 QIs can be assessed in outpatients (patients with NVAF/AFL sorted by stroke risk stratum and high risk for stroke NVAF/AFL receiving oral anticoagulation). Stroke prevention therapy can be further measured in selected provinces with linked databases including prescriptions. Conclusions: This first step could provide a better initial understanding of the quality of AF/AFL care in Canada, but important gaps in the meaningful measurement of QIs remain. The AF/AFL QI working group has limited capacity to make progress without national level leadership and the resources to support data aggregation, data analysis, and pan-Canadian reporting. Résumé: Contexte: En 2010, le groupe de travail des indicateurs de qualité (IQ) de la Société canadienne de cardiologie sur la fibrillation auriculaire (FA) et le flutter auriculaire (FLA) a été mis sur pied pour élaborer des IQ et évaluer la faisabilité d’utiliser ces IQ comme outils de mesure. Après un examen approfondi, trois IQ prioritaires ont été sélectionnés, mais aucun n’a pu être mesuré à l’échelle nationale. Méthodologie: Le groupe de travail s’est réuni à nouveau en 2017 afin d’examiner la pertinence des IQ proposés au départ, de recenser des occasions d’élaborer de nouveau IQ et de proposer une stratégie initiale de mesure et de production de rapports à cet égard. Résultats: Deux IQ prioritaires supplémentaires ont été ajoutés aux trois premiers : la proportion de patients atteints de FA non valvulaire (FANV) ou de FLA ayant fait l’objet d’un tri selon la strate de risque d’AVC et le taux annuel d’hospitalisations attribuables à un nouveau diagnostic d’insuffisance cardiaque. Une analyse de l’environnement a été réalisée afin de déterminer si les bases de données existantes pouvaient fournir des estimations nationales et provinciales. Dans le cas de patients hospitalisés, on peut utiliser la Base de données sur les congés des patients de l’Institut canadien d’information sur la santé en se servant de codes administratifs validés. Dans le cas de patients non hospitalisés (patients atteints de FANV/FLA, triés par strate de risque, exposés à un risque élevé d’AVC en raison d’une FANV ou d’un FLA et recevant une anticoagulation orale), on peut mesurer deux des cinq IQ, en collaboration avec le Réseau canadien de surveillance sentinelle en soins primaires. Le traitement préventif de l’AVC peut continuer à faire l’objet de mesures dans certaines provinces grâce aux bases de données interreliées, comme les bases de données sur les ordonnances. Conclusions: Cette première étape a permis d’obtenir une meilleure compréhension initiale de la qualité de la prise en charge de la FA et du FLA au Canada, mais d’importantes lacunes restent à combler pour rendre pertinente la mesure des IQ. Le groupe de travail des IQ sur de la FA et le FLA n’a pas toutes les capacités requises pour réaliser des progrès en l’absence de leadership national et de ressources permettant de soutenir le regroupement et l’analyse des données, ainsi que la production de rapports à l’échelle pancanadienne.

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.

The SARS-Coronavirus-2 (COVID-19) related pandemic has resulted in profound health, financial and societal impacts. Organized sporting events, from the recreational to Olympic levels, have been cancelled to both mitigate the spread of COVID-19 and protect athletes and highly active individuals from potential acute and long-term infection associated harms. COVID-19 infection has been associated with increased cardiac morbidity and mortality. Myocarditis and late gadolinium enhancement (LGE) as a result of COVID-19 infection has been confirmed. Correspondingly, myocarditis has been implicated in sudden cardiac death (SCD) of athletes. A pragmatic approach is required to guide those who care for athletes and highly active persons with COVID-19 infection. Members of the Community and Athletic Cardiovascular Health Network (CATCHNet) and writing group for the Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes recommend that highly active persons with suspected or confirmed COVID-19 infection refrain from exercise for 7 days after resolution of viral symptoms before gradual return to exercise. We do not recommend routine troponin testing, resting 12-lead electrocardiogram (ECG), echocardiography, or cardiac magnetic resonance imaging before return-to-play. However, medical assessment including history and physical examination with consideration of resting ECG and troponin can be considered in the athlete manifesting new active cardiac symptoms or a marked reduction in fitness. If concerning abnormalities on the initial medical assessment are encountered then referral to a cardiologist who cares for athletes is recommended., COVID-19 infection has been associated with myocarditis and late gadolinium enhancement on cardiac MRI. Myocarditis has been implicated in sudden cardiac death of athletes. Return-to-play recommendations after COVID-19 infection for athletes and active persons are presented herein. In athletes with previous COVID-19 infection, return-to-play is recommended 7 days following viral resolution. Routine cardiac investigations (troponin, 12-lead ECG, and imaging) of these athletes are recommended only with the occurrence of cardiovascular symptoms.

BACKGROUND The Coordinated National Network to Engage Cardiologists in the antithrombotic Treatment of patients with Atrial Fibrillation undergoing Percutaneous Coronary Intervention (CONNECT AF+PCI-I) program provided a snapshot (Nov 2015-Jul 2018) of the antithrombotic management of 467 non-valvular atrial fibrillation (NVAF) patients undergoing PCI in Canada (Bagai et al Can J Cardiol 2018;34:S16). Since then, further randomized clinical trials have supported updated Canadian Cardiovascular Society (CCS) AF and Antiplatelet guideline recommendations for antithrombotic strategies for NVAF and coronary artery disease (CAD) patients undergoing PCI and/or medical management. Thus, an updated quality enhancement assessment in Canadian practice (CONNECT AF+PCI-II) was undertaken. METHODS AND RESULTS By retrospective chart audit (Aug 2018-Dec 2020), 68 cardiologists from 8 provinces identified 626 patients with NVAF. 37% had stable CAD, 56% had an acute coronary syndrome (ACS) and PCI, and 7% had an ACS and were medically managed. Median age was 76 (25th,75th percentiles 69, 83; 87% ≥65 years); 29% female; 38% diabetes; median CHADS2 score 2 (1, 3); median CHA2DS2-VASc score 4 (3, 5); median HAS-BLED score 3 (2, 3). 73% were receiving oral anticoagulation (OAC) before the index ACS/PCI (apixaban 31%, rivaroxaban 24%, dabigatran 6%, edoxaban 2%, warfarin 10%). Initial antithrombotic therapy after the index ACS/PCI was: 53% triple therapy (OAC+dual antiplatelet therapy [DAPT=ASA+P2Y12 receptor inhibitor], 31% OAC+P2Y12 inhibitor, 9% DAPT, 4% OAC+ASA, 2% OAC alone, and CONCLUSION While triple therapy remains the most common initial antithrombotic strategy used in AF patients undergoing PCI and/or admitted with ACS in Canada, treatment duration has shortened over time. Further, more patients are receiving CCS guideline-recommended OAC+ P2Y12 receptor inhibitor post-PCI compared to previously, and OAC monotherapy 1 year post-ACS/PCI.

Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.

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.

Studies evaluating physician adherence to guideline recommendations for implantable cardioverter defibrillator (ICD) therapy are sparse, and none exist for the application of appropriate-use criteria (AUC) in clinical practice. As part of a quality improvement initiative, a review of all ICD procedures was performed from January 1, 2015 to December 31, 2016 in Alberta, Canada, to evaluate the proportion of patients receiving appropriate ICD therapy and to identify reasons for nonadherence. Our device-implant process involves an electrophysiologist or implanting cardiologist evaluation, reminders of ICD eligibility criteria on the device requisition, and peer-review consensus. Implants were classified according to the 2008 American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) ICD guidelines, 2013 Canadian Cardiovascular Society (CCS) Cardiac Resynchronization Therapy (CRT) guidelines, and 2013 AUC. There were 1,300 ICD procedures performed, and the mean age was 63.8 ± 12.9 years; 79% were male; the mean ejection fraction was 0.32 ± 0.13, and 69% were for primary prevention. Among all implants,1% were discordant with American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) recommendations. Among CRT implants, 10% were inconsistent with Canadian Cardiovascular Society (CCS) recommendations. According to AUC, 92% of implants were appropriate. Reasons for nonadherence to ACC/AHA/HRS recommendations included QRS width120 msec (n = 3), LVEF0.35 (n = 2) and recent myocardial infarction (MI) (n = 1). The most common reason for nonadherence to AUC was the absence of criteria for classification (n = 57, 4%). In this population-based study, we found that a process of specialist evaluation, eligibility reminders on device forms, and peer-review consensus may improve adherence to guideline recommendations and AUC for ICD therapy.

Familial hypercholesterolemia (FH) is the most common monogenic disorder causing premature atherosclerotic cardiovascular disease. It affects 1 in 250 individuals worldwide, and of the approximately 145,000 Canadians estimated to have FH, most are undiagnosed. Herein, we provide an update of the 2014 Canadian Cardiovascular Society position statement on FH addressing the need for case identification, prompt recognition, and treatment with statins and ezetimibe, and cascade family screening. We provide a new Canadian definition for FH and tools for clinicians to make a diagnosis. The risk of atherosclerotic cardiovascular disease in patients with "definite" FH is 10- to 20-fold that of a normolipidemic individual and initiating treatment in youth or young adulthood can normalize life expectancy. Target levels for low-density lipoprotein cholesterol are proposed and are aligned with the Canadian Cardiovascular Society guidelines on dyslipidemia. Recommendation for the use of inhibitors of proprotein convertase kexin/subtilisin type 9 are made in patients who cannot achieve therapeutic low-density lipoprotein cholesterol targets on maximally tolerated statins and ezetimibe. The writing committee used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology in the preparation of the present document, which offers guidance for practical evaluation and management of patients with FH. This position statement also aims to raise awareness of FH nationally, and to mobilize patient support, promote knowledge translation, and availability of treatment and health care resources for this under-recognized, but important medical condition.

The Canadian Cardiovascular Society (CCS) Atrial Fibrillation Guidelines Committee provides periodic reviews of new data to produce focused updates that address clinically important advances in atrial fibrillation (AF) management. This 2018 Focused Update addresses: (1) anticoagulation in the context of cardioversion of AF; (2) the management of antithrombotic therapy for patients with AF in the context of coronary artery disease; (3) investigation and management of subclinical AF; (4) the use of antidotes for the reversal of non-vitamin K antagonist oral anticoagulants; (5) acute pharmacological cardioversion of AF; (6) catheter ablation for AF, including patients with concomitant AF and heart failure; and (7) an integrated approach to the patient with AF and modifiable cardiovascular risk factors. The recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards. Individual studies and literature were reviewed for quality and bias; the literature review process and evidence tables are included as Supplementary Material and are available on the CCS Web site. Details of the updated recommendations are presented, along with their background and rationale. This document is linked to an updated summary of all CCS AF guidelines recommendations, from 2010 to the present 2018 Focused Update, which is provided in the Supplementary Material.

Background Although the Seattle Angina Questionnaire (SAQ) has been widely used to assess disease-specific health status in patients with ischemic heart disease, it was originally developed in a predominantly male population and its validity in women has been questioned. Methods Using data from 8892 men and 4013 women across 2 multicenter trials and 5 registries, we assessed the construct validity, test–retest reliability, responsiveness to clinical change, and predictive validity of the SAQ Summary Score (SS) and its 5 subdomains (Physical Limitation (PL), Anginal Stability (AS), Angina Frequency (AF), Treatment Satisfaction (TS), and Quality of Life (QoL)) separately in men and women. Results Comparable correlations of the SAQ SS with Canadian Cardiovascular Society class was demonstrated in both men and women (−0.48 for men, −0.46 for women). Similar correlations between the SAQ PL scale with treadmill exercise duration and Short Form-12 (SF-12) Physical Component Summary were observed in women and men (0.34–0.63 and 0.40–0.63, respectively). SAQ AS scores were significantly lower for both men and women with acute syndromes compared with 1 month later. The SAQ AF scale was strongly correlated with daily angina diaries (0.62 for men and 0.66 for women). The SAQ QoL scores were moderately correlated with the EQ5D visual analog scale and SF-12 general health question in men (0.43–0.50) and women (0.33–0.39). All SAQ scales demonstrated excellent reliability (intraclass correlation ≥0.78) in both men and women with stable CAD and were very sensitive to change after percutaneous coronary intervention (≥15-point difference in scores, standardized response mean ≥ 0.67). The SAQ SS was similarly predictive of 1-year mortality and cardiac re-hospitalizations for both men and women. Conclusion The SAQ demonstrates similar psychometric properties in men and women with CAD. These findings provide evidence for validity of the SAQ in assessing women with IHD.

Objectives The aim of this study was to assess the safety and efficacy of the Reducer in a real-world cohort of patients presenting with refractory angina. Background The coronary sinus Reducer is a novel device to aid in the management of patients with severe angina symptoms refractory to optimal medical therapy and not amenable to further revascularization. Methods Fifty patients with refractory angina and objective evidence of myocardial ischemia who were judged unsuitable for revascularization were treated with coronary sinus Reducer implantation at a single center between March 2015 and August 2016. Safety endpoints were procedural success and the absence of device-related adverse events. Efficacy endpoints, assessed at 4- and 12-month follow-up, were a reduction in Canadian Cardiovascular Society angina class, improvement in quality of life assessed using the Seattle Angina Questionnaire, improvement in exercise tolerance assessed using the 6-min walk test, and reduction in pharmacological antianginal therapy. Results Procedural success was achieved in all patients, with no device-related adverse effects during the procedure or at follow-up. Regarding the efficacy endpoint, 40 patients (80%) had at least 1 reduction in Canadian Cardiovascular Society class, and 20 patients (40%) had at least 2 class reductions, with a mean class reduction to 1.67 ± 0.83 vs. 2.98 ± 0.52 (p Conclusions In this real-world, single-center experience, implantation of the coronary sinus Reducer appeared safe and was associated with reduction in anginal symptoms and improvement in quality of life in patients with refractory angina who were not candidates for further revascularization.

Lipid treatment guidelines have continued to evolve as new evidence emerges. We sought to review similarities and differences of 5 lipid treatment guidelines from the American College of Cardiology/American Heart Association, Canadian Cardiovascular Society, European Society for Cardiology/European Atherosclerosis Society, U.S. Preventive Services Task Force, and U.S. Veterans Affairs/Department of Defense. All guidelines utilize rigorous evidentiary review, highlight statin therapy for primary and secondary prevention of atherosclerotic cardiovascular disease, and emphasize a clinician-patient risk discussion. However, there are differences in statin intensities, use of risk estimators, treatment of specific patient subgroups, and consideration of safety concerns. Clinicians should understand these similarities and differences in current and future guideline recommendations when considering if and how to treat their patients with statin therapy.

BACKGROUND Recent landmark trials investigating the use of sodium glucose cotransporter 2 (SGLT2) inhibitors in patients with heart failure (HF) with reduced ejection fraction (HFrEF) have demonstrated significant reductions in cardiovascular mortality and heart failure hospitalization. As a result of these trials, the Canadian Cardiovascular Society (CCS) has recently published a guideline update strongly recommending the initiation of SGLT2 inhibitors in patients with HFrEF and HF symptoms. The routine initiation of SGLT2 inhibitors in eligible patients, however, has been limited by several factors including cost, increased pill burden, concomitant chronic kidney disease and adverse effects, among others. Canadian real-world data investigating the use of SGLT2 inhibitors and perceived barriers to their initiation in eligible heart failure patients are currently lacking. METHODS AND RESULTS This is a prospective, single center, observational study evaluating the use of SGLT2 inhibitors in a specialized heart function clinic. Patients seen in clinic from January 1, 2021 to Mar 31, 2021 were screened for eligibility of SGLT2 inhibitor initiation. Patient characteristics, background medical therapy and lab values of interest were recorded using paper charts and local electronic records. Providers were asked to record whether SGLT2 inhibitor therapy was successfully initiated and if not, the reason it was not prescribed. In total, 258 of 384 (67%) patients screened were eligible for SGLT2 inhibitor therapy. Among eligible patients, average age was 63.1 years (SD +/- 13.7); 197 patients were male (76.4%) and 61 female (23.6%); 14 (5.4%) were NYHA class 1, 200 (77.5%) were NYHA class 2, 42 (16.3%) were NYHA class 3 and 2 (0.8%) were NYHA class 4. In total 104/258 eligible patients were prescribed SGLT2 inhibitors (40.3%). The most common reasons for not prescribing SGLT2 inhibitor therapy included: up-titration or initiation of other medications/defer to future visit in 97 patients (63.0%), patient preference or refusal in 13 patients (8.4%) and inability to afford the cost of medication in 11 patients (7.1%). CONCLUSION A substantial proportion (67%) of HF patients are eligible for an SGLT2 inhibitor. However, SGLT2 inhibitors are currently underutilized in eligible patients seen in a specialized heart function clinic predominantly due to up-titration or initiation of other HF therapies. Strategies should be undertaken to increase utilization of this new class of therapy for HF to reduce cardiovascular events.

This companion article is intended to address common clinical scenarios in patients with implantable defibrillators that were not addressed in the 2016 Canadian Cardiovascular Society/Canadian Heart Rhythm Society implantable cardioverter defibrillator guidelines including recommendations for device programming to improve detection, to minimize shocks (appropriate and inappropriate), and to minimize ventricular pacing. Important issues at the time of replacement such as device prescription, technical aspects (vascular access, extraction), and management of components on advisories are also discussed. Finally, common clinical scenarios such as management of patients with terminal illnesses, recurrent ventricular tachycardia, electrical storms, catheter ablation for ventricular tachycardia, and system infection management are considered. The management of these patients requires a team approach and comprehensive knowledge surrounding these common clinical scenarios.

Sudden cardiac death is a major public health issue in Canada. However, despite the overwhelming evidence to support the use of implantable cardioverter defibrillators (ICDs) in the prevention of cardiac death there remains significant variability in implantation rates across Canada. Since the most recent Canadian Cardiovascular Society position statement on ICD use in Canada in 2005, there has been a plethora of new scientific information to assist physicians in their discussions with patients considered for ICD implantation to prevent sudden cardiac death due to ventricular arrhythmias. We have reviewed, critically appraised, and synthesized the pertinent evidence to develop recommendations regarding: (1) ICD implantation in the primary and secondary prevention of sudden cardiac death in patients with and without ischemic heart disease; (2) when it is reasonable to withhold ICD implantation on the basis of comorbidities; (3) ICD implantation in patients listed for heart transplantation; (4) implantation of a single- vs dual-chamber ICD; (5) implantation of single- vs dual-coil ICD leads; (6) the role of subcutaneous ICDs; and (7) ICD implantation infection prevention strategies. We expect that this document, in combination with the companion article that addresses the implementation of these guidelines, will assist all medical professionals with the care of patients who have had or at risk of sudden cardiac death.

Out of hospital cardiac arrest (OHCA) is associated with a low rate of survival to hospital discharge and high rates of neurological morbidity among survivors. Programmatic efforts to institute and integrate OHCA best care practices from the bystander response through to the in-hospital phase have been associated with improved patient outcomes. This Canadian Cardiovascular Society position statement was developed to provide comprehensive yet practical recommendations to guide the in-hospital care of OHCA patients. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system recommendations have been generated. Recommendations on initial care delivery on the basis of presenting rhythm, appropriate use of targeted temperature management, postarrest angiography, and revascularization in the initial phase of care of the OHCA patient are detailed within this statement. In addition, further description of best practices on sedation, use of neuromuscular blockade, oxygenation targets, hemodynamic monitoring, and blood product transfusion triggers in the critical care environment are contained in this document. Last, discussion of optimal care systems for the OHCA patient is provided. These guidelines aim to serve as a practical guide to optimize the in-hospital care of survivors of cardiac arrest and encourage the adoption of "best practice" protocols and treatment pathways. Emphasis is placed on integrating these aspects of in-hospital care as part of a postarrest "care bundle." It is hoped that this position statement can assist all medical professionals who treat survivors of cardiac arrest.

Since the publication of the 2012 guidelines new literature has emerged to inform decision-making. The 2016 guidelines primary panel selected a number of clinically relevant questions and has produced updated recommendations, on the basis of important new findings. In subjects with clinical atherosclerosis, abdominal aortic aneurysm, most subjects with diabetes or chronic kidney disease, and those with low-density lipoprotein cholesterol ≥ 5 mmol/L, statin therapy is recommended. For all others, there is an emphasis on risk assessment linked to lipid determination to optimize decision-making. We have recommended nonfasting lipid determination as a suitable alternative to fasting levels. Risk assessment and lipid determination should be considered in individuals older than 40 years of age or in those at increased risk regardless of age. Pharmacotherapy is generally not indicated for those at low Framingham Risk Score (FRS;10%). A wider range of patients are now eligible for statin therapy in the FRS intermediate risk category (10%-19%) and in those with a high FRS (20%). Despite the controversy, we continue to advocate for low-density lipoprotein cholesterol targets for subjects who start therapy. Detailed recommendations are also presented for health behaviour modification that is indicated in all subjects. Finally, recommendation for the use of nonstatin medications is provided. Shared decision-making is vital because there are many areas in which clinical trials do not fully inform practice. The guidelines are meant to be a platform for meaningful conversation between patient and care provider so that individual decisions can be made for risk screening, assessment, and treatment.

The Canadian Cardiovascular Society (CCS) Atrial Fibrillation (AF) Guidelines Committee provides periodic reviews of new data to produce focused updates that address clinically important advances in AF management. This 2016 Focused Update deals with: (1) the management of antithrombotic therapy for AF patients in the context of the various clinical presentations of coronary artery disease; (2) real-life data with non-vitamin K antagonist oral anticoagulants; (3) the use of antidotes for the reversal of non-vitamin K antagonist oral anticoagulants; (4) digoxin as a rate control agent; (5) perioperative anticoagulation management; and (6) AF surgical therapy including the prevention and treatment of AF after cardiac surgery. The recommendations were developed with the same methodology used for the initial 2010 guidelines and the 2012 and 2014 Focused Updates. Using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards, individual studies and literature were reviewed for quality and bias; the literature review process and evidence tables are included in the Supplementary Material, and on the CCS Web site. The section on concomitant AF and coronary artery disease was developed in collaboration with the CCS Antiplatelet Guidelines Committee. Details of the updated recommendations are presented, along with their background and rationale. This document is linked to an updated summary of all CCS AF Guidelines recommendations, from 2010 to the present 2016 Focused Update.

Cardiac rehabilitation (CR) is a proven model of secondary prevention. Indicated cardiac conditions for CR are well established, and participation of these patients results in significantly lower mortality and morbidity when compared with usual care. There are approximately 170 CR programs in Canada, which varies widely by province. There is a grossly insufficient capacity to treat all patients with cardiac indications in Canada and beyond. The density of CR services is about half that in the United States, at 1 program per 208,823 inhabitants or 1 program per 7779 patients with cardiac disease. Despite the Canadian Cardiovascular Society's target of 85% referral for CR for cardiac inpatients with the appropriate indications, significantly fewer patients are referred for CR. Moreover, certain patient groups—such as women, ethnocultural minorities, and those of low socioeconomic status—are less likely to access CR, despite greater need because of poorer outcomes. CR appears to be reaching a healthier population that is perhaps more adherent to secondary prevention recommendations and hence in less need of the limited CR spots available. The reasons for CR underuse are well established and include factors at patient, referring provider, CR program, and health system levels. A Cochrane review has established some effective interventions to increase CR use, and these must be implemented more broadly. We must advocate for CR reimbursement. Finally, we must reallocate our CR resources to patients with the greatest need. This may involve risk stratification, with subsequent allocation of lower-risk patients to a more widely available, lower-cost, and effective alternative model of CR.

OBJECTIVE: To investigate the impact of postoperative acute kidney injury (AKI) on early health outcome and on long-term survival in patients undergoing redo coronary artery bypass grafting (CABG).METHODS: We performed a Cox analysis with 398 consecutive patients undergoing redo CABG over a median follow-up of 7 years (interquartile range, 4-12.2 years). Renal function was assessed using baseline and peak postoperative levels of serum creatinine. AKI was defined according to the risk, injury, failure, loss, and end-stage (RIFLE) criteria. Health outcome measures included the rate of in-hospital AKI and all-cause 30-day and long-term mortality, using data from the United Kingdom's Office of National Statistics. Propensity score matching, as well as logistic regression analyses, were used. The impact of postoperative AKI at different time points was related to survival.RESULTS: In patients with redo CABG, the occurrence of postoperative AKI was associated with in-hospital mortality (odds ratio [OR], 3.74; 95% confidence interval [CI], -1.3 to 10.5; P < .01], high Euroscore (OR, 1.27; 95% CI, 1.07-1.52; P < .01), use of IABP (OR, 6.9; 95% CI, 2.24-20.3; P < .01), and reduced long-term survival (hazard ratio [HR], 2.42; 95% CI, 1.63-3.6; P = .01). Overall survival at 5 and 10 years was lower in AKI patients with AKI compared with those without AKI (64% vs 85% at 5 years; 51% vs 68% at 10 years). On 1:1 propensity score matching analysis, postoperative AKI was independently associated with reduced long term survival (HR, 2.8; 95% CI, 1.15-6.7).CONCLUSIONS: In patients undergoing redo CABG, the occurrence of postoperative AKI is associated with increased 30-day mortality and major complications and with reduced long-term survival.

In 2014, the Canadian Cardiovascular Society (CCS) published a position statement on the management of thoracic aortic disease addressing size thresholds for surgery, imaging modalities, medical therapy, and genetics. It did not address issues related to surgical intervention. This joint Position Statement on behalf of the CCS, Canadian Society of Cardiac Surgeons, and the Canadian Society for Vascular Surgery provides recommendations about thoracic aortic disease interventions, including: aortic valve repair, perfusion strategies for arch repair, extended arch hybrid reconstruction for acute type A dissection, endovascular management of arch and descending aortic aneurysms, and type B dissection. The position statement is constructed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and has been approved by the primary panel, an international secondary panel, and the CCS Guidelines Committee. Advent of endovascular technology has improved aortic surgery safety and extended the indications of minimally invasive thoracic aortic surgery. The combination of safer open surgery with endovascular treatment has improved patient outcomes in this rapidly evolving subspecialty field of cardiovascular surgery.

Heart failure (HF) affects millions of Americans and causes financial burdens because of the need for rehospitalization. For this reason, health care systems and patients alike are seeking methods to decrease readmissions. We assessed the potential for reducing readmissions of patients with postacute care HF through an educational program combined with enhanced external counterpulsation (EECP). We examined 99 patients with HF who were referred to EECP centers and received heart failure education and EECP treatment within 90 days of hospital discharge from March 2013 to January 2015. We compared observed and predicted 90-day readmission rates and examined results of 6-minute walk tests, Duke Activity Status Index, New York Heart Association classification, and Canadian Cardiovascular Society classification before and after EECP. Patients were treated with EECP at a median augmentation pressure of 280 mm Hg (quartile 1 = 240, quartile 3 = 280), achieved as early as the first treatment. Augmentation ratios varied from 0.4 to 1.9, with a median of 1.0 (quartile 1 = 0.8, quartile 3 = 1.2). Only 6 patients (6.1%) had unplanned readmissions compared to the predicted 34%, p

A 74-year-old woman with prior coronary artery bypass grafting presented with CCS (Canadian Cardiovascular Society) class III angina and underwent disobliteration of a circumflex coronary artery occlusion ([Figure 1][1]). Seven months later, she developed a recurrence of effort angina. Repeat

Objectives: Despite advances in screening and prevention, rates of premature coronary artery disease (CAD) have been stagnant. The goals of this study were to investigate the barriers to early risk detection and preventive treatment in patients with premature CAD. In particular, we: 1) assessed the performance of the latest versions of major international guidelines in detection of risk of premature CAD and eligibility for preventive treatment; and, 2) investigated real-life utilization of primary prevention with lipid-lowering therapies in these patients. Methods: We included patients in the Study to Avoid cardioVascular Events in British Columbia (SAVE BC), an observational study of patients with premature (males ​≤ ​50 years, females ​≤ ​55 years) angiographically confirmed CAD. Eligibility for primary prevention and treatment received were assessed retrospectively based on information recorded prior to or at the index presentation with CAD. Results: Of 417 patients (28.1% females) who met the criteria, 94.3% had at least one major cardiovascular risk factor. In the retrospective risk assessment, 41.7%, 61.4%, and 34.3% (p ​

Background: Smartphone applications may enable interventions to increase physical activity but this has limited evidence in randomized trials. Objectives: The MyHeart Counts Cardiovascular Health study (MHC) is a smartphone-based longitudinal research study aimed at elucidating the determinants of cardiovascular health. Among MHC participants, we performed a randomized controlled trial to investigate the response to four different physical activity coaching interventions on the primary outcome of change in daily step count. Secondary outcomes included life satisfaction, 6-minute walk distance, and sleep quality. Methods: The trial was completed entirely using personal smartphones: participants were digitally consented, the interventions were delivered via the device, and measurements of the primary and secondary outcomes were collected from smartphone sensors. Participants were enrolled from December 12, 2016 to June 6, 2018 and followed for up to 5 weeks. Participants completed the trial through the MyHeart Counts phone app in a free-living setting. All adults over 18 years of age with access to a smartphone (Apple iPhone, version 5S or later) were eligible to participate. After one week of baseline measurements, participants (n=2783) were randomized to a sequence of four, week-long interventions delivered in random order. Interventions consisted of either daily prompts to complete 10,000 steps (completed by n=853); hourly prompts to stand following a full hour of sitting (completed by n=879); instructions to read the guidelines from the American Heart Association website (completed by n=868); and e-coaching based upon the individual's personal activity patterns from the baseline week of data collection (completed by n=896). Results: 2783 participants consented to enroll in the coaching study, of whom 1075 completed the baseline week of data collection and at least one of the four interventions. 493 individuals completed the full set of assigned interventions. All four interventions were found effective at modestly increasing daily step count by a mean of 266 ±75 steps from a baseline mean of 2958±69 steps (p=0.003). Intervention-specific step increases were: 319±74 steps (p