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The 2010 Canadian Cardiovascular Society guidelines

for the diagnosis and management of heart failure
update: Heart failure in ethnic minority populations,
heart failure and pregnancy, disease management,
and quality improvement/assurance programs
Primary panelists: Jonathan G Howlett MD FRCPC (Chair)1, Robert S McKelvie MD PhD FRCPC (Co-Chair)2,
Jeannine Costigan RN MScN APN3, Anique Ducharme MD FRCPC4, Estrellita Estrella-Holder RN BN MScA CCNC5,
Justin A Ezekowitz MB BCh MSc FRCPC6, Nadia Giannetti MD FRCPC7, Haissam Haddad MD FRCPC8,
George A Heckman MD MSc FRCPC2,9, Anthony M Herd MD CCFP CCFP(EM)10, Debra Isaac MD FRCPC1,
Simon Kouz MD FACC11, Kori Leblanc BScPhm ACPR PharmD12, Peter Liu MD FRCPC12, Elizabeth Mann MD FRCPC13,
Gordon W Moe MD FRCPC14, Eileen O’Meara MD FRCPC4, Miroslav Rajda MD FRCPC13, Samuel Siu MD SM FRCPC FACC FASE15,
Paul Stolee BA MPA MSc PhD9, Elizabeth Swiggum MD FRCPC16, Shelley Zeiroth MD FRCPC10
JG Howlett, RS McKelvie, J Costigan, et al. The 2010 Canadian Mise à jour 2010 des Lignes directrices de la
Cardiovascular Society guidelines for the diagnosis and
management of heart failure update: Heart failure in ethnic
Société canadienne de cardiologie sur le diagnostic
minority populations, heart failure and pregnancy, disease et la prise en charge de l’insuffisance cardiaque :
management, and quality improvement/assurance programs. Insuffisance cardiaque dans les populations des
Can J Cardiol 2010;26(4):185-202. minorités ethniques, insuffisance cardiaque et
Since 2006, the Canadian Cardiovascular Society heart failure (HF)
grossesse, prise en charge de la maladie et
guidelines have published annual focused updates for cardiovascular care programmes d’amélioration et d’assurance de la
providers. The 2010 Canadian Cardiovascular Society HF guidelines qualité
update focuses on an increasing issue in the western world – HF in ethnic
minorities – and in an uncommon but important setting – the pregnant
Depuis 2006, la Société canadienne de cardiologie publie chaque année
patient. Additionally, due to increasing attention recently given to the
une mise à jour de ses Lignes directrices sur l’insuffisance cardiaque (IC)
assessment of how care is delivered and measured, two critically important
ciblées, à l’intention des professionnels de la santé cardiovasculaire. La
topics – disease management programs in HF and quality assurance – have
mise à jour 2010 des Lignes directrices de la Société canadienne de
been included. Both of these topics were written from a clinical perspec-
cardiologie sur l’IC porte sur un problème croissant en Occident,
tive. It is hoped that the present update will become a useful tool for
l’insuffisance cardiaque chez les minorités ethniques, et sur un tableau rare
health care providers and planners in the ongoing evolution of care for HF
mais important, l’insuffisance cardiaque chez la femme enceinte. En outre,
patients in Canada. comme on accorde depuis peu une plus grande attention à l’évaluation de
la façon dont les soins sont prodigués et évalués, deux autres sujets d’une
Key Words: Cardiomyopathy; Disease management; Ethnicity; HF; Heart grande importance sont abordés : les programmes de prise en charge de l’IC
failure clinic; Minority; Outcomes; Performance indicator; Peripartum; et l’assurance de la qualité. Ces deux derniers volets ont été rédigés d’un
Pregnancy; Quality assurance; Quality of care point de vue clinique. Il est à espérer que la présente mise à jour deviendra
un outil pratique pour les professionnels de la santé et les planificateurs,
compte tenu de l’évolution constante des soins prodigués aux patients
atteints d’IC au Canada.
S ince 2006, the Canadian Cardiovascular Society (CCS) has been

publishing heart failure (HF) guidelines as part of a commitment to
a multiyear, closed-loop initiative to provide support for the best prac-
Individuals from all relevant professional groups are represented
and include the Canadian Pharmacists Association, the Canadian
Council of Cardiovascular Nurses, the Canadian Geriatrics Society,
tice of HF management. The systematic review strategy and methods the Canadian Society of Internal Medicine, the College of Family
for formulating the recommendations are described in more detail on Physicians of Canada, and the Canadian Association of Advanced
the CCS HF Consensus Program Web site in the Terms of Reference Practice Nurses. In response to needs assessments of cardiovascular
section (www.hfcc.ca, navigate to www.hfcc.ca/downloads/stage3/ care providers, the objective of the 2010 CCS HF consensus update is
Terms_of_Reference_CDT.pdf). to provide Canadian practitioners with recommendations and advice
1University of Calgary, Calgary, Alberta; 2Hamilton Health Sciences, McMaster University, Hamilton; 3St Mary’s General Hospital, Kitchener, Ontario;
4Institut de Cardiologie de Montréal, Montreal, Quebec; 5St Boniface General Hospital, Cardiac Sciences Program, Winnipeg, Manitoba; 6University
of Alberta, Edmonton, Alberta; 7McGill University, Montreal, Quebec; 8Ottawa Heart Institute, Ottawa; 9University of Waterloo, Waterloo,
Ontario; 10University of Manitoba, Winnipeg, Manitoba; 11Centre Hospitalier Régional de Lanaudière, Joliette, Quebec; 12University of Toronto,
Toronto, Ontario; 13Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia; 14St Michael’s Hospital, Toronto, Ontario; 15University of
Western Ontario, London, Ontario; 16University of British Columbia, Vancouver, British Columbia
Correspondence: Dr Jonathan G Howlett, University of Calgary, Room 812 South Tower, 3031 Hospital Drive, Calgary, Alberta T2N 2T8.
Telephone 403-457-4338, fax 403-944-3262, e-mail howlettjonathan@gmail.com
Additionally, comments may be directed to www.hfcc.ca
Received and accepted for publication February 16, 2010
Can J Cardiol Vol 26 No 4 April 2010 ©2010 Pulsus Group Inc. All rights reserved 185
Howlett et al
Table 1 Table 2
Classes of recommendations and levels of evidence basic overview of the four most common ethnic minority
Class Definition populations in Canada
I Evidence or general agreement that a given procedure or Population,
treatment is beneficial, useful and effective % of Important risk language and
II Conflicting evidence or a divergence of opinion about the minorities factors for HF ethnocultural
usefulness or efficacy of the procedure or treatment in Canada prevention considerations Treatment
IIa Weight of evidence is in favour of usefulness or efficacy South Asian, Diabetes, Mostly speak English Evidence-based
IIb Usefulness or efficacy is less well established by evidence or 25% obesity and Family involvement in therapy from HF
opinion the metabolic health care behaviour is guidelines
III Evidence or general agreement that the procedure or treatment is syndrome common
not useful or effective and in some cases may be harmful Chinese, Hypertension* Mostly speak Cantonese Follow HF
level Definition 24% and Mandarin guidelines
A Data derived from multiple randomized clinical trials or Family involvement in Be aware of the
meta-analyses health care behaviour is use of traditional
common Chinese
B Data derived from a single randomized clinical trial or
medicines
nonrandomized studies
Black, Hypertension Almost all speak English, Follow HF
C Consensus of opinion of experts and/or small studies
15.8% apart from Quebec, guidelines
where French is Consider adding
in four emerging areas – HF in ethnic minority populations, HF and prominent nitrate/
pregnancy, disease management of HF clinic care, and HF quality hydralazine
improvement and assurance. Each of these topics is approached from a combination in
clinical perspective with recommendations and practical tips designed those with
for relevancy to the practicing clinician. severe HF
An extensive dissemination and implementation program has been Aboriginal, Diabetes, Cree and Ojibwe are the Follow general HF
developed for the CCS HF Consensus Program. In addition to the 24% obesity main spoken languages guidelines
CCS National HF Workshop Initiative, bilingual versions of a handy Frequently need to
‘pocket card’ and slide kit have been developed based on the recom- involve family and
mendations from 2006 to 2009 and are available online. Details community
regarding these and other initiatives can be found on the CCS HF representatives in health
Consensus Program Web site (http://hfcc.ca/index.aspx). care initiatives
The class of recommendation and the grade of evidence were *Coronary artery disease, diabetes and obesity are rapidly emerging risk factors.
determined according to Table 1. HF Heart failure
HF In ETHnIC MInoRITY { Work as multidisciplinary teams.

popuLaTIonS In Canada { Include community health representatives, where appropriate.
Recommendations • Health care workers and patients should be aware of the risk
• Health care providers should consider the prevalent etiological factors for the development of HF such as hypertension and
factors for HF, language, ethnoculture and social values, and obesity, which are more prevalent in certain ethnic groups, and
diagnostic patterns as well as the potential barriers to health care should work to prevent and treat these conditions.
that are specific to their patients with HF from an ethnic minority • During assessment, etiologies that are prevalent in a patient’s
group. (Class I, level C) home region must be considered in addition to common causes of
• In the management of black subjects with HF, the following are HF in Canada.
recommended: { Chagas disease and rheumatic heart disease, besides coronary
{ Angiotensin-converting enzyme (ACE) inhibitors as standard artery disease, should be considered in those who recently
therapy in patients with HF and a left ventricular ejection arrived from South America.
fraction (LVEF) of less than 40%. (Class I, level A) { Rheumatic heart disease should still be considered in a patient
{ Beta-blockers as standard therapy in patients with HF and an who recently immigrated from Africa.
LVEF of less than 40%. (Class I, level B) • Diastolic HF or HF with preserved systolic function is especially
{ A combination of hydralazine and isosorbide dinitrate as part common in patients of Chinese, black and Aboriginal descent.
of standard therapy in addition to beta-blockers and ACE • Treatment of a patient with HF from an ethnic minority group
inhibitors in patients with moderate to severe HF and an should follow the same treatment recommendations from current
LVEF of less than 35%. (Class I, level B) practice guidelines. However, consideration should be given to
Practical tips lower starting dosages for pharmacotherapy in certain ethnic
• Family and social values within the ethnocultural background groups (ie, Chinese and Japanese patients frequently are
underlie a patient’s attitudes and beliefs toward health and disease. administered a lower starting dose of ACE inhibitors or beta-
When managing patients from ethnic minority groups with HF, blockers). Target dosage remains identical to guideline
health care professionals, where possible, should do the following: recommendations.
{ Ensure proper language translation is available and include Recommendations and practical tips that pertain to specific ethnic
family members in the overall management plan. minority groups are summarized in Table 2.
{ Provide medical information or educational aids in a language General considerations
understood by patients or their caregivers. Few places in the world possess the racial diversity that is present in
{ Respect local traditions and be careful not to impose Canada. Based on the Statistics Canada 2006 Census (1), the visible
professionals’ own values. minority population surpassed five million, reaching 16.2% of the
186 Can J Cardiol Vol 26 No 4 April 2010

2010 heart failure guidelines
population. Of these, the four most common minorities in Canada a matched historical cohort study – also conducted in Leicestershire –
include Chinese, South Asian, black and Aboriginal groups. Together, of patients newly hospitalized for HF (15), the South Asian patients
these four groups comprise over 88% of visible minorities in Canada had rates of previous coronary artery disease that were similar to
and, as such, the focus of the present section will primarily be on them. Caucasian patients, but more often had previous hypertension and
In addition, most of the data currently published in this arena has been diabetes. At follow-up, South Asian patients had a lower mortality
observational in nature. However, apart from ethnocultural data, most rate than Caucasian patients. A retrospective sequential chart review
of the published data suggest that there are more similarities than dif- of South Asians and non-South Asian white individuals hospitalized
ferences among these populations and Caucasians with respect to diag- with a primary diagnosis of HF at two Toronto (Ontario)-area com-
nosis or treatment of HF. To understand and manage a person’s illness, it munity hospitals demonstrated that South Asians were younger, of
is necessary to appreciate the effects of the person’s culture, experiences lower body mass index and were more often diabetic, although they
and social environment. Hope and morale may be crucial to patients’ did not suffer increased mortality (16). These data suggest that South
adaptation and maintenance of involvement in the management of Asians suffer a higher risk factor burden for the development of coro-
their condition (2), and gaps in communications as a result of ethno- nary artery disease and subsequent HF, although their outcomes may
cultural differences between the patients and the health care workers not be different. Thus, to prevent HF in the South Asian population,
may have a detrimental effect on patients’ adaptation to their illness. health care professionals as well as the South Asian community should
To date, there have been very few published population-based epi- be made aware of their unique risk profile so that appropriate
demiological studies of HF in countries outside North America and ethnocultural-specific screening procedures and support programs can
western Europe. It is generally believed that rheumatic heart disease is be implemented.
a major cause of HF in sub-Saharan Africa, and certain parts of Asia
and South America. Hypertension is an important cause of HF in Asia The Chinese population
and in the African and African American populations, whereas The Chinese population represents the second largest visible minority
Chagas disease is a cause of HF in subjects from South America (3). group, comprising 24% of the minority population in Canada (1).
However, because these regions constantly undergo epidemiological Chinese is the third most commonly spoken language in Canada and
and economic transitions, the epidemiology of HF is likely to increas- many Chinese people do not understand English well. Modern
ingly resemble that of the western world. The large international case- Chinese people continue to emphasize family values and maintain
controlled INTERHEART study (4) has demonstrated that the impact close family links, which play a prominent role in health behaviours
of conventional and potentially preventable risk factors on the risk of and medical decision making. Evidence from a large survey (17) of a
myocardial infarctions is consistent across different geographical cohort of Chinese people in two large Canadian cities indicated a lack
regions and different ethnic groups. This implies that similar preven- of awareness of symptoms of stroke and myocardial infarction and risk
tive measures for myocardial infarction and the subsequent develop- factors for heart disease. This lack of knowledge, combined with social
ment of HF may be applicable to different ethnic populations in and ethnocultural factors, may confound the management of Chinese
different geographical locations. There is little evidence to indicate patients with HF or at risk of developing HF. One strategy that helps
that the criteria used to diagnose HF substantially differs among ethnic to break the language barrier is to provide health information designed
populations. For example, a recent study from the United States (US) specifically for Chinese patients, exemplified by the Chinese language
(5) demonstrated that the diagnostic performance of N-terminal pro- brochure entitled “Living with HF”, produced recently by the Heart
B-type natriuretic peptide is similar in African Americans and non- and Stroke Foundation of Ontario (www.heartandstroke.on.ca/site/c.
African Americans. With respect to the treatment of patients with HF, pvI3IeNWJwE/b.3581609/k.90B3/Multicultural_Resources.htm).
relatively few large-scale randomized controlled intervention trials in Available data, which are not definitive, point to hypertension
HF have included regions outside Europe and the US. Smaller clinical being the most important identifiable risk factor in Chinese people
trials (6,7) have shown the effectiveness of ACE inhibitors and beta- with HF (18,19). In a prospective study (20) of 730 consecutive
blockers in HF patients from Africa and Asia. Given the fundamental Hong Kong Chinese patients admitted to the hospital with HF, the
nature of the derangements in HF, our current approach, including main identifiable risk factors were hypertension (37%), coronary artery
neurohormonal blockade and the appropriate use of devices, will likely disease (31%), diabetes (21%), valvular heart disease (15%), cor pul-
be effective, although dosages and responses may differ slightly among monale (27%), idiopathic dilated cardiomyopathy (4%) and miscella-
ethnic groups. neous (10%). In women, hypertension was the most common cause of
HF at all ages but in men younger than 70 years of age, coronary artery
The South asian population disease was equal in frequency to hypertension (36% and 35%, respec-
The South Asian population, representing those from India, Pakistan, tively) (20). A subsequent study reported by the same group (21) evalu-
Bangladesh and surrounding countries, is currently the largest and fast- ated 200 consecutive patients with the typical features of HF using
est growing visible minority group, comprising 25% of all visible two-dimensional Doppler echocardiography. The results showed 66%
minorities (4% of Canadians) (1). South Asian Canadians have vary- of patients had an LVEF of greater than 45% (which was more common
ing backgrounds, which limits generalities that can be made about in those older than 70 years of age) and an additional 12.5% had sig-
their social and community life. The majority of South Asians who nificant valvular heart disease. These investigators concluded that HF
seek medical care speak or are accompanied by family members who with a normal LVEF is more common than systolic HF in Chinese
speak English. It is common for South Asian patient populations to patients and that this may be related to an older age at presentation and
involve or depend on extended families and/or community figures or the high prevalence of hypertension. These results are supported by
relations in their medical decision making. those of a case-mix study (22) from an urban tertiary care centre in
South Asians have increased susceptibility to premature morbidity Toronto, where Chinese patients with HF were older and were more
and mortality from coronary artery disease (8-11). Hypertension (as likely to have an ejection fraction of greater than 40% (and a higher
well as diabetes and dyslipidemia) is a major problem in Asia Pacific median ejection fraction) than their Caucasian counterparts (Figure 1).
regions, including China, and high blood pressure is poorly controlled The metabolic syndrome has been identified in an increasingly large
(12,13). In a study conducted in Leicestershire, United Kingdom (14), proportion of Chinese adults; obesity has become an important public
involving 5789 consecutive patients admitted with HF, admission health concern in China (23). Investigations conducted by the
rates for HF were higher among South Asian patients than white Shanghai Investigation Group of HF in 1980, 1990 and 2000 (24),
patients. At the first admission, South Asian patients were younger based on 2178 hospitalized patients with HF, found that the etiology of
and more frequently had concomitant diabetes or acute coronary syn- HF had shifted from mainly rheumatic valvular disease to coronary
drome than white patients, although clinical outcomes were similar. In artery disease during the previous 20 years (24). It is anticipated that
Can J Cardiol Vol 26 No 4 April 2010 187

Howlett et al
symptoms of HF at younger ages, which are less likely to be due to

coronary artery disease than in Caucasians (33-35). Recently pub-
lished data from the Coronary Artery Risk Development in Young
Adults (CARDIA) study (36) indicated that one in 100 African
American men and women develop HF at an average age of 39 years,
which is 20 times the rate in Caucasians. Incident HF in African
Americans before 50 years of age was associated with antecedent
hypertension, obesity, chronic kidney disease and systolic dysfunc-
tion that were already present before 35 years of age (36). These data
imply that relatively young black subjects with risk factors should be
a target of more aggressive intervention for HF prevention. Data
from the Studies of Left Ventricular Dysfunction (SOLVD) trials
(37-39) suggest poorer outcomes for black HF patients, while other
reports suggest that clinical characteristics independent of HF may
contribute to these outcomes.
Figure 1) Distribution of left ventricular ejection fraction values in Caucasian
Longstanding clinical observations suggest that black individuals
and Chinese patients with heart failure. Data from reference 22
with hypertension respond less well than Caucasians to ACE inhibi-
tors (40). Retrospective subgroup analyses of data from randomized
antecedent factors for incident HF in the Chinese population will trials (41) suggest the response of black individuals and Caucasians
increasingly mirror those of the western world. with HF and left ventricular systolic dysfunction to ACE inhibition
There are no large-scale randomized controlled trials of pharma- may differ. However, these post hoc analyses do not provide sufficient
cological and device therapy conducted specifically among Chinese evidence to support a strategy other than routine use of ACE inhibi-
patients with HF. The recently published Hong Kong diastolic HF tors in black individuals with HF and systolic dysfunction. Although
study (25) investigated 150 Chinese patients with HF and preserved the Beta-Blocker Evaluation of Survival Trial (BEST) (42) with
systolic function, and reported no significant additional benefit by bucindolol did not find a beneficial effect of beta blockade in black
adding irbesartan or ramipril to diuretic treatment. It has been stated individuals with HF, a subgroup analysis of data from the US Carvedilol
that Chinese subjects experience a high incidence of cough when Trials (43-45), as well as other trials, suggests that the beneficial effect
treated with ACE inhibitors (26,27). However, most of the studies of beta-blockers on outcomes in black individuals with HF with sys-
that reported a high incidence of ACE inhibitor-induced cough in tolic dysfunction is similar to the effects in the overall population. The
Chinese patients involved a very small number of patients and did total data to date therefore support the use of ACE inhibitors and
not compare Chinese patients with Caucasian patients simultane- beta-blockers in black patients with HF and systolic dysfunction.
ously. In the Perindopril Protection Against Recurrent Stroke Study Data from the earlier Vasodilator-HF Trial (VHeFT) I and II (46)
(PROGRESS) (28,29), there were no differences in cough among suggested black patients with HF and an LVEF of less than 35% were
the Asian and non-Asian participants. Given the compelling data in particularly responsive to hydralazine-isosorbide dinitrate. The
support of the benefit of ACE inhibition in HF with systolic dysfunc- African-American Heart Failure Trial (A-HeFT) (47) enrolled
tion, a Chinese patient with HF should not be denied the initiation 1050 black patients who had New York Heart Association class III or
of an ACE inhibitor based on anticipated intolerance. The doses of IV symptoms of HF with dilated ventricles and systolic dysfunction. In
antihypertensive agents prescribed in Asian patients are frequently this randomized trial, subjects were assigned to receive a fixed combi-
lower than in Caucasian patients, due in part to a perception of nation of isosorbide dinitrate plus hydralazine or placebo in addition to
greater sensitivity (30) and, therefore, a higher risk of hypotension in standard therapy for HF. The primary end point was a composite score
Asian patients. Although this is by no means a uniform finding, it is made up of weighted values for death from any cause, a first hospital-
a common practice to start vasodilator medications at lower doses ization for HF, and change in the quality of life. The study was termi-
and to titrate the dose slower than in a Caucasian patient, but with nated early because of a significantly higher mortality rate in the
a goal of eventually reaching the same target dose. As such, current placebo group than in the group given the fixed combination of isosor-
recommendations from the Chinese guidelines on the diagnosis and bide dinitrate plus hydralazine. The mean primary composite score was
treatment of chronic HF closely resemble those contained in guide- significantly better in the group given isosorbide dinitrate plus hydral-
lines in the western world (31). azine than in the placebo group, as well as its components: 43% reduc-
It is quite common for Chinese patients to consume traditional tion in the rate of death from any cause, 33% relative reduction in first
Chinese medicines in which herbal medicines form the key compo- hospitalization for HF, and an improvement in the quality of life.
nent in combination with their prescribed western medicines. In These data support the addition of the combination of isosorbide dini-
Canada, the use of these combinations is largely incidental rather than trate and hydralazine to the standard medical regimen for black
intentional; this means that patients typically do not advise their cli- patients with moderately severe HF due to low ejection fraction.
nicians of concomitant use, which may expose the patients to poten-
tially undesirable drug-drug or herb-drug interactions. Examples of The aboriginal population
many such interactions that may be relevant when managing a patient Data from the 2006 Census on Canada’s Aboriginal population
with HF include a change in the effect of warfarin with the use of dong counted 1,172,790 First Nations, Métis and Inuit people (the three
quai, or an attenuation of the effect of diuretics and vasodilators with political groupings), representing 3.8% of Canada’s total population.
the use of fu ling and ma huang (32). More than one-half of the country’s 1.2 million Aboriginal people
are living off reserve. The First Nations population has a growth rate
The black population that is three times the Canadian rate (see the “Assembly of First
Black Canadians constitute 2.5% of the Canadian population (1). Nations Royal Commission on Aboriginal People at 10 years: A
While many black individuals in Quebec are of Haitian (as well as Report Card 2006”, available at www.afn.ca). Aboriginal people
Central African) descent and speak French, the majority of black were almost four times as likely as non-Aboriginal people to live in a
individuals living elsewhere in Canada speak English. Most of the crowded dwelling and were three times as likely to live in a dwelling
population and randomized controlled data have been derived from in need of major repairs. The life expectancy is 7.4 years less and
the US. In the US, African Americans have a higher prevalence 5.2 years less for First Nations men and women compared with
of HF than persons of other ethnicities. They also present with Canadian men and women, respectively. Furthermore, there is also

evidence to indicate that geographical location, compared with Table 3

Aboriginal identity, appears to have a large impact on health status Predictors and the rate of maternal cardiac complications
and the use of physician services, with on-reserve Aboriginals report- Number of maternal estimated/expected risk Observed event
ing a lower likelihood of having seen a physician and ranking their conditions (primarily hospitalization), % rate, %
health as poor (48). 0 5 3
The Study of Health Assessment and Risk Evaluation in Aboriginal
1 27 30
Peoples (SHARE-AP) (49) reported a higher frequency of cardiovas-
>1 75 66
cular disease (CVD) among Aboriginal people and a greater burden of
Data from references 81 and 82
atherosclerosis compared with Canadians of European ancestry. These
were accompanied by social, economic and cultural changes in the
past decades, which might have had an impact on the observed • Cardiac testing of women with worsening or suspected new-onset
increase in hospitalization for coronary artery disease (50). With the HF during pregnancy should include echocardiography; radiation
increasing incidence of diabetes that accompanies the transition from should be avoided where possible. (Class I, level C)
traditional to urban lifestyles (51,52), it is anticipated that the inci- • Women with a history of HF should have a complete
dence of CVD and HF will also increase. preconception evaluation and counselling by an individual with
There are no Canadian data available that can directly guide the expertise and experience in HF and pregnancy before becoming
management of HF in the Aboriginal population. In patients who pregnant or as early as possible once pregnancy is known. Risk of
commenced dialysis in Alberta, Saskatchewan or Manitoba, the risk of transmission of inheritable cardiac disease should be addressed
death from HF was higher in Aboriginals than in Caucasians (hazard where appropriate. (Class I, level C)
ratio [HR] 1.66, 95% CI 1.51 to 1.83) (53). A report from the
• Women with mechanical heart valves, Eisenmenger’s syndrome,
Australian Institute of Health and Welfare (54) has indicated that HF
Marfan syndrome with aortopathy, and cardiomyopathy/peripartum
is a major cause of illness and death among Aboriginal and Torres
cardiomyopathy (PPCM) with reduced LVEF should be referred to
Strait Islander people. The prevalence of HF in Australian Aboriginals
a regional centre with expertise in management of HF in pregnancy
was nearly twice as high as in non-Aboriginal Australians.
for evaluation, ongoing care and discussion of the health
When managing Aboriginal patients with HF, non-Aboriginal
consequences of continuing the pregnancy. (Class I, level C)
health care professionals should understand the logic and rationale of
another system of thought in which health is perceived as a harmoni- • A risk score used to identify predictors associated with the
ous order. There is a need to understand that health encompasses development of unfavourable cardiac events in women with heart
physical, emotional, intellectual and spiritual well-being; to recognize disease (Table 3) may be used to allow for establishment of a plan
the multigenerational legacies of colonization and importance of local of management for the antepartum, peripartum and postpartum
history; to respect traditional beliefs and healing practices; and to periods. (Class I, level C)
acknowledge the role of the social determinants of health and, in • Where possible, cardiac medications of a certain class (such as
many communities, inadequate resources. Health care professionals beta-blockers) should be switched to a member of that class where
may need to additionally adapt their treatment plans and education safety in pregnancy has been accepted. (Class IIa, level C)
programs for communities that are geographically remote. Non- • Women with HF during pregnancy should be closely followed
Aboriginal health care workers caring for Aboriginal patients with HF during their pregnancy and monitored at the time of delivery and
may adopt a holistic approach in offering advice and care for their the early postpartum period. (Class I, level C)
patients, respecting local traditions and by being careful not to impose • Anticoagulation during pregnancy should be undertaken
their own values (55). Health care workers should work in multidisci- according to the American College of Chest Physicians Evidence-
plinary teams and include community health representatives. Based Clinical Practice Guidelines (8th Edition) 2008 (84).
Aboriginal patients might be operating in a second language, might (Class I, level C)
need an interpreter, and might not be comfortable questioning some- • In most instances, the decision regarding timing and mode of
one who is perceived to have greater power and knowledge. A chronic delivery is based on obstetrical factors. Caesarean deliveries are
disease management program (DMP), such as the Chronic Disease not routinely necessary. Delivery before term for cardiac
Outreach Program (56), designed to improve awareness and manage- decompensation is rarely required. (Class IIa, level C)
ment of hypertension, renal disease and diabetes in remote Australian • Patients with PPCM who do not recover normal left ventricular
Aboriginal communities may be adopted for the prevention and treat- function should be advised against future pregnancies due to the
ment of HF in Canadian Aboriginals. high risk of worsening HF and death. (Class I, level B)
In summary, an appreciation of the ethnocultural diversity of • Patients with PPCM who recover normal left ventricular function
Canada is essential to successful prevention and treatment of HF should be advised regarding the potential for recurrent left
among the multiethnic groups. Strong ongoing efforts to increase the ventricular dysfunction in subsequent pregnancies. (Class I,
awareness of risk factors for the development of HF and inclusion of level B)
ethnic populations in randomized controlled trials are required to • Pregnant women (or those in the peripartum period) with acute
improve the outcome of HF in patients from ethnic minority groups decompensated HF should be managed according to the CCS
(22). guidelines for acute decompensated HF and should be referred to
a tertiary centre with expertise in advanced HF management,
HF and pREGnanCY including mechanical circulatory support and cardiac
definition transplantation. (Class I, level C)
Evidence of inadequate cardiac output despite elevated or normal • Several commonly used cardiac medications, such as ACE
cardiac filling pressure secondary to cardiac dysfunction occurring dur- inhibitors, angiotensin receptor blockers (ARBs), aldosterone
ing pregnancy, labour and delivery, or in the early postpartum period. antagonists and warfarin, are teratogenic. Their use should be
avoided or, in the case of warfarin, restricted to certain portions of
Recommendations the pregnancy. (Class I, level C)
• Health care professionals should be aware of the cardiovascular
changes associated with normal pregnancy because those changes Practical tips
may unmask pre-existing heart conditions or precipitate • The possibility of HF and/or PPCM should be considered in
decompensation in established or new-onset HF. (Class I, level C) patients with new-onset dyspnea or hemodynamic

Howlett et al
Table 4 • Medications that may be used for pregnant women with HF are
Medications that may be useful for pregnant women with shown in Table 4. A more comprehensive list of medications is
heart failure (HF) available at www.motherisk.org.
Medication Use in pregnancy
Hemodynamic changes of normal pregnancy and precipitation of HF
Beta- Should be continued or initiated during pregnancy
During the course of pregnancy, there are a large number of pregnancy-
blockers Requires close fetal monitoring for growth retardation induced hemodynamic changes in the cardiovascular system, which
Beta-1 selective antagonists preferred to avoid potential are summarized in Table 5 (57-64). During the peripartum period,
increased uterine tone and decreased uterine perfusion further changes are noted as well (65-68). Maternal position can have
Digoxin May be used if volume overload symptoms persist despite a significant effect on cardiac output. In the supine position, the gravid
vasodilator and diuretic therapy uterus can cause vena cava compression resulting in decreased venous
Diuretics May be used, but with caution regarding excessive volume return and decreased cardiac output by as much as 25% (69). There is
contraction leading to reduced placental perfusion a further increase in cardiac output due to sympathetic stimulation,
Hydralazine May be used for management of HF symptoms or elevated pain and the autotransfusion of blood from the placenta, while sys-
blood pressure temic resistance may increase due to these changes and the loss of the
Nitrates May be used to treat decompensated HF in pregnancy low-resistance placenta circuit. Within 1 h of delivery, cardiac output
returns to third trimester values. Hemodynamic changes do not fully
return to baseline until six months postpartum.
While these changes are well tolerated by healthy women, those
decompensation late in pregnancy, during labour and delivery, or with heart disease can decompensate. It is essential to be familiar with
in the postpartum period. these cardiovascular adaptations because women with a new-onset or
• Dyspnea of normal pregnancy is often described as an inability to pre-existing left ventricle dysfunction may exhibit marked clinical
get enough air in, to get a deep breath, or both. Mild dyspnea on deterioration during the course of pregnancy (Table 5).
exertion alone does not suggest HF.
• The diagnosis of HF may be a challenge because many women in Common causes of HF in women of childbearing age
their final month of pregnancy experience symptoms identical to • Congenital heart disease;
early HF. Progressive dyspnea on exertion, paroxysmal nocturnal • Valvular heart disease;
dyspnea, orthopnea and recumbent cough are likely to be • Idiopathic dilated cardiomyopathy;
indicative of HF. • Familial cardiomyopathies;
• On physical examination, healthy pregnant women may • Drug-induced (ie, adriamycin) cardiomyopathy;
hyperventilate but the rate of respiration should be normal. • PPCM;
Pulmonary crackles are rarely observed in normal pregnancy and • Ischemic cardiomyopathy; and
their presence suggests HF. The jugular venous pulsation may be • Hypertension-related cardiomyopathy.
mildly distended with an exaggerated X and Y descent in normal
pregnancy. During pregnancy, women with new or pre-existing left ventricular
dysfunction are at risk for developing pulmonary edema as well as
• With echocardiography, cardiac chambers are normal or slightly
supraventricular or ventricular arrhythmias. Rarely, cardiac transplants
enlarged, and atrioventricular valve regurgitation increases mildly
may be necessary and deaths can occur (70,71). Cardiac decompensa-
during pregnancy. Diastolic dysfunction may be observed in
tion can occur anytime during pregnancy; however, there are specific
patients with severe pre-eclampsia, although this is an uncommon
periods when the risk is increased. Clinical deterioration can occur
cause of HF in pregnant women. Normal cardiac structures and
late in the second trimester, during the third trimester or in the peri-
preserved LVEF suggests a noncardiac cause for symptoms.
partum period, which is high risk due to rapid hemodynamic changes
• Clear diagnostic criteria for B-type natriuretic peptide/N-terminal that take place.
pro-B-type natriuretic peptide levels and HF in the pregnant
patient are not yet available; however, normal levels make HF
Evaluation of HF in pregnancy
very unlikely.
The diagnosis and evaluation of HF in pregnancy is more challenging
• Noncardiac conditions that may mimic decompensated HF
than in nonpregnant patients. Such changes may result in symptoms
include pneumonia, pulmonary embolus, amniotic fluid embolus,
and signs that can mimic HF. A high index of suspicion for cardiac
renal failure with volume overload and acute lung injury, while
diseases is essential to identify those at risk (Table 6).
cardiac failure may be secondary to myocardial infarction or
Distinguishing the symptoms and signs of a normal pregnancy from
severe pre-eclampsia.
those of HF requires careful clinical assessment (72,73). The principal
• The risk of thromboembolism associated with PPCM is increased findings are noted in Table 6. The 12-lead electrocardiogram in nor-
due to the hypercoagulable state of pregnancy, and is highest mal pregnancy frequently shows sinus tachycardia and nonspecific
during the first four weeks postpartum. ST-T wave changes, and may show atrial and/or ventricular ectopy.
• To optimize outcome in high-risk populations, tertiary regional Changes of left atrial enlargement or left ventricular hypertrophy may
centres should have a multidisciplinary team with expertise in be related to heart position (74).
management of HF in pregnancy, which should include The initial assessment of suspected HF in the pregnant patient
obstetrical, anesthesia and neonatology specialists, as well as should include a detailed history to document functional status, physi-
cardiology expertise in HF. cal examination, electrocardiography and echocardiography to assess
• Pain control during delivery is very important in patients with whether pregnancy-related cardiovascular changes are likely to be
limited cardiac reserve because pain results in tachycardia and tolerated. Echocardiography is the noninvasive investigation of choice
may precipitate cardiac decompensation. in pregnancy because it provides important cardiac structural and
• Patients should be monitored carefully throughout labour, but also functional information and does not involve exposure to radiation
in the early postpartum period, when decompensation may also (75,76). It should be arranged urgently in the setting of suspected HF
occur. In women at highest risk, close monitoring in an intensive in the pregnant patient. Measurement of plasma B-type natriuretic
care unit or cardiac care unit for the first 24 h to 48 h may be peptide may be useful in confirming a diagnosis of HF when the diag-
useful. nosis is not clear (77-79). Bloodwork should include complete blood

Table 5
Hemodynamic changes in normal pregnancy
Trimester
Parameter First Second Third Peripartum
Blood volume Rises Rises Maximum at 45%–50% early Potential rapid autotransfusion from
on, additional 33% increase placenta due to sympathetic stimulation
in twin gestation and uterine contraction
Peripheral vascular Gradual drop, diastolic At lowest point in mid Gradual reversion to normal Variable changes depending on stage
resistance and blood more such that pulse pregnancy and sympathetic stimulation
pressure pressure increases
Heart rate Increases Peaks at 20% increase late 20% increase Further increase
Cardiac output Increases Increases Maximal 30%–50% increase Further increase up to 31% in labour,
early 49% in second stage. Return to 3rd
trimester values within 1 h of delivery
Table 6
Cardiovascular symptoms and signs, and the pregnant state
Findings Noted in normal pregnancy Not seen in normal pregnancy
Dizziness, palpitations Common Syncope on exertion
Dyspnea Common (75%) if mild, not progressive Progressive or New York Heart Association functional class IV
Orthopnea Common, especially late in term
Decreased exercise capacity Mild, not progressive New York Heart Association functional class IV symptoms
Chest pain Common, may be musculoskeletal in origin, not Typical angina pain, severe or tearing pain may be dissection, especially
progressive. Not typically anginal late in term/peripartum
Pulse Increased volume, rate Decreased volume or upstroke
Peripheral edema Mild, common Severe or progressive edema
Apical beat Mildly displaced laterally, hyperdynamic Double or triple apex beat, thrill
Heart rate Sinus tachycardia common Atrial fibrillation, persistent supraventricular tachycardia, symptomatic
ventricular arrhythmias
Neck veins May be mildly distended Progressively distended with dominant V wave
Heart sounds Increased S1, S2, S3 common Opening snap, pericardial rub, S4
Systolic ejection murmur common; continuous murmur Late peaking systolic murmur, diastolic murnur, other continuous
(venous hum, mammary souffle) not common murmurs
count, electrolytes, renal function and thyroid-stimulating hormone. of these conditions should be referred early to a cardiac specialist in
The use of x-ray in pregnant women (with fetal shielding in place) maternal cardiology. Paradoxically, pregnant patients with a cardiovas-
should be used only if judged clinically essential. Coronary angiogra- cular condition may also be prescribed unnecessary therapies (activity
phy is rarely required. limitation, caesarean section). As such, these patients may benefit from
Noncardiac conditions that may mimic decompensated HF include consultation by physicians with expertise in maternal cardiology (83).
pneumonia, pulmonary embolus, amniotic fluid embolus, renal failure In addition, maternal conditions associated with unfavourable
with volume overload and acute lung injury, while cardiac failure may neonatal events following pregnancy include anticoagulation, an
be secondary to myocardial infarction or severe pre-eclampsia. NYHA class of greater than II or cyanosis before pregnancy, left ven-
tricular inflow or outflow tract obstruction, smoking and multiple
pregnancy and chronic cardiovascular disease gestations (81,84).
In addition to this, four major maternal cardiac conditions are associated Women with HF during pregnancy should be followed closely. To
with a very high (up to 50%) maternal risk for mortality during or after optimize pregnancy outcome in this population, a multidisciplinary
pregnancy – ongoing HF with an LVEF of less than 35%, pulmonary management team should be established, including obstetrical, cardiac,
hypertension, Eisenmenger’s syndrome and Marfan syndrome with an anesthesia and neonatology specialists. Pregnant women with underly-
enlarged aortic root. Most experts consider pregnancy to be contraindi- ing cardiac disease will tend to initially develop worsening HF symptoms
cated in these settings. Patients with cardiac conditions and prepreg- during the second trimester of pregnancy, although symptoms may occur
nancy New York Heart Association (NYHA) class I or II symptoms or worsen at any time, including postpartum. Once HF is diagnosed,
tolerate pregnancy well with a mortality rate of less than 1%, while efforts to treat volume overload should be undertaken, but with judi-
those in classes III and IV have a mortality rate of 5% to 15% (80). A cious care to avoid rapid volume removal or depletion.
prospective, observational study (81,82) examining maternal cardiac
events in patients with pre-existing cardiac disease was undertaken. In anesthetic considerations
this study, four conditions were shown to be predictors of adverse mater- Pregnant women with chronic or new-onset HF require specialized
nal events (primarily HF or hospitalization) – maternal NYHA func- anesthetic management during labour and delivery. Prepartum anes-
tional class III or IV, or cyanosis before pregnancy; history of transient thetic evaluation is recommended for planning of optimal monitoring
ischemic attack, HF or arrhythmia; left heart obstructive lesions; and and the anesthetic approach. The goals of management of anesthesia in
left ventricular dysfunction (LVEF of less than 40%). A score outlining these patients are avoidance of excessive anesthetic-induced myocardial
a risk of events based on the number of predictors was generated and depression, maintenance of normovolemia, attenuation of increases in
validated in their dataset (Table 3). Given the increased rate of mater- systemic vascular resistance, and minimization of myocardial wall stress
nal events, we recommend that the pregnant patient with one or more and sympathetic stimulation associated with pain (85).

Howlett et al
The decision regarding timing and mode of delivery should be The treatment and goals of therapy for PPCM are similar to the
made for obstetrical reasons: early delivery is not required unless medi- management of chronic systolic HF in pregnant women. Case reports
cal management is unsuccessful and the patient is hemodynamically have indicated improvement in patients with PPCM treated with bro-
deteriorating. Induction of labour is not contraindicated and vaginal mocriptine (110), but no high-quality data exist for this therapy or for
delivery is preferable to caesarean delivery unless necessary for obstet- immunomodulatory (ie, intravenous immunoglobulin) agents. Patients
rical reasons. Early administration of labour anesthesia is very impor- who deteriorate or who fail to respond to standard antifailure therapy
tant in patients with limited cardiac reserve because pain results in should be considered early on for transfer to a centre of excellence in
tachycardia and may precipitate cardiac decompensation. advanced HF for consideration of mechanical circulatory support or
Patients should be monitored carefully with noninvasive blood other therapies such as cardiac transplantation (111).
pressure, continuous maternal electrocardiography, tocodynamometry
with fetal heart rate monitoring throughout labour and the early post- prognosis
partum period when decompensation is most likely to occur. Maternal With appropriate medical therapy, approximately 50% of patients with
pulse oximetry is reserved for those at highest risk. More invasive PPCM will recover cardiac function, usually within six months
monitoring with central venous, pulmonary artery and systemic pres- (112,113). If symptoms persist longer than this, myocardial damage is
sure is indicated in the setting of the hemodynamically compromised more likely irreversible, although recovery can occur with optimal
or unstable patient, or when fluid volume monitoring is critical. medical therapy up to and beyond 12 months (114,115). However,
There is no consensus as to the optimal technique of labour anes- even in women with echocardiographically recovered ventricular
thesia. Epidural anesthesia, if introduced slowly and carefully, produces function, contractile reserve may be impaired (116). Mortality rates
changes in preload and afterload that may be advantageous in the set- range between 10% and 23%, with death being attributed to pump
ting of reduced ventricular function (86,87). Caution must be taken to failure, sudden cardiac death and thromboembolic events (117).
avoid sudden sympathetic blockade. Spinal or combined spinal- Recovery is less likely in women with increased left ventricular dimen-
epidural anesthesia (with or without caesarean section) with the use of sion (larger than 5.6 cm) and those with left ventricular thrombus
spinal opioids rather than spinal local anesthetics, has been suggested (112). The outcome of PPCM requiring cardiac transplantation (4%
to provide adequate analgesia with less hemodynamic instability to 7% of patients) is good, with survival similar to patients undergoing
(88-90). Other anesthetic or obstetrical issues are discussed in detail transplantation for idiopathic dilated cardiomyopathy. The risk of
elsewhere (91,92). worsening cardiac function in subsequent pregnancies is largely depen-
dent on the extent of subsequent left ventricular recovery. The risk of
ppCM poor outcome of subsequent pregnancy is high in patients with incom-
definition plete left ventricular recovery. Even in patients with recovered left
PPCM is defined as a dilated cardiomyopathy (LVEF of less than 45%) ventricular function, there is an increased risk of complications
with the development of HF in the last month of pregnancy or within including recurrent HF and reduced LVEF with subsequent pregnancy
five months after delivery, in the absence of a demonstrable cause for (118,119).
HF and in the absence of documented heart disease before the last
month of pregnancy (93,94). HF presenting earlier than the last aCuTE dECoMpEnSaTEd HF duRInG
month of pregnancy may be part of the same spectrum of disease, pREGnanCY
despite not meeting traditional criteria, and these patients tend to In general, patients presenting with acute decompensated HF in preg-
have the same demographics, degree of cardiac dysfunction and prog- nancy should be managed according to the CCS acute decompensated
nosis (95). The incidence of PPCM varies widely geographically, rang- HF management algorithm (77). In patients with worsening HF or
ing from an incidence of one per 2289 to one per 4000 live births in difficult-to-manage pulmonary edema in the setting of preserved blood
the United States (96,97), to an incidence of one per 300 live births pressure, intravenous vasodilators such as nitrates can be used with
in Haiti (96). Risk factors for the development of PPCM include the close monitoring. The use of nesiritide in this setting has not been
following (85,93): studied, and should only be considered if believed to be essential to
• Multiparity; management. Nitroprusside is not recommended except in the setting
• Multiple fetus gestations; of an acute need for significant afterload reduction where all other
interventions have been insufficient, due to the risk of fetal cyanide
• Older maternal age (older than 30 years);
toxicity. When decompensation is associated with hypotension, unre-
• History of gestational hypertension;
solved pulmonary edema and/or evidence of organ hypoperfusion,
• African descent; inotropic support with dopamine, dobutamine or milrinone should be
• Maternal cocaine use; and considered depending on the clinical scenario. In the setting of severe
• Long-term oral tocolytic therapy. hypotension requiring vasopressor support, dopamine may be less del-
The cause of PPCM is unknown but certain etiologies have been eterious to uterine blood flow than phenylephrine or noradrenaline. In
considered including nutritional deficiencies, various viral infections the setting of cardiogenic shock, an intra-aortic balloon pump may be
(98-100), myocarditis (101-104), myocyte apoptosis (105,106), devel- considered; however, these patients are best managed by urgent trans-
opment of maternal cardiac autoantibodies (107,108) and oxidative fer to a centre with expertise and capability to provide mechanical
stress linked to proteolysis’ cleavage of prolactin into a potent cardio- circulatory support and/or cardiac transplantation. Because many
toxic subfragment (109). women will recover cardiac function in the setting of PPCM, listing
In a pregnant woman presenting with new-onset HF, the diagnosis for cardiac transplantation is usually delayed until absolutely necessary
of PPCM is made by documenting reduced LVEF and by ruling out to allow for cardiac recovery.
other potential causes of cardiac dysfunction. It is particularly impor-
tant to assess for the presence of pre-eclampsia, infections, thyroid dMps
dysfunction and toxins (eg, ethanol or cocaine). In some cases, coro- Recommendations
nary artery disease needs to be excluded. While stress echocardiogra- • Specialized hospital-based clinics or DMPs staffed by physicians,
phy may be the safest test to assess for coronary artery disease during nurses, pharmacists, dieticians and other health care
pregnancy, in the setting of acute cardiac decompensation and evi- professionals with expertise in HF management should be
dence of potential ischemic etiology, coronary angiography with view developed and used for assessment and management of
to revascularization may be performed with the use of abdominal higher-risk (eg, two or more HF admissions in six months) HF
shielding. patients. (Class I, level A)

• Multidisciplinary care should include close follow-up, and Since these meta-analyses were published, more recent data have
patient and caregiver education in an outpatient HF clinic been reported from a variety of sources. Data from smaller (single- and
and/or through telemanagement or telemonitoring, or home two-centre) studies (128-131) demonstrated a significant reduction in
visits by specialized HF health care professionals where resources hospitalization and a trend toward a reduction in mortality. A larger
are available. (Class I, level A) study (428 patients) by Cleland et al (132) examining home telemoni-
• Patients with recurrent HF hospitalization should be referred to toring (HTM) compared with either nurse telephone support (NTS)
a DMP by family physicians, emergency room physicians, or usual care found that there was no statistically significant difference
internists or cardiologists for follow-up within four weeks of between groups for the number of days lost as a result of death or hos-
hospital or emergency department discharge, or sooner where pitalization. There was a trend for fewer days lost to death or hospital-
feasible. (Class I, level A) ization for those in the HTM group (12.7%) compared with the NTS
(15.9%) or usual care (19.5%) groups, and significantly lower one-year
Practical tips mortality for NTS (27%) or HTM (29%) compared with usual care
• The optimal care model should reflect local circumstances, (45%).
current resources and available health care personnel. In some There have been three studies with more than 1000 patients in
situations, it may be beneficial to include HF care in an integrated each study published over the past few years (133-135). In a study by
model of care with other chronic diseases such as diabetes Galbreath et al (133), 1069 NYHA class I to IV patients (mainly
mellitus, which is related to the development of cardiovascular NYHA class II to IV) with systolic or diastolic dysfunction were ran-
disease. domly assigned to receive DMP or usual care for 18 months. The DMP
• Integration of a DMP into a primary care setting with adequate consisted of telephone monitoring by disease managers with recom-
specialist support may be the most feasible solution in certain mendations made to the patient’s primary care physician. Patients in
health care settings. this group also received bathroom scales to monitor weight and a toll-
• Practical resources to aid in HF diagnosis and management should free number they could call 24 h/day, seven days/week. Telephonic
be made available across the continuum of community health DMP was found to reduce mortality (P=0.037) with a trend toward
care delivery. improvement in cardiac event-free survival (P=0.074). When the
analysis was restricted to the group of patients with systolic dysfunc-
• Teaching patients to control their sodium and fluid intake, to
tion, there was a reduction (P=0.012) in both mortality and improve-
weigh themselves daily and to recognize symptoms of worsening
ment in cardiac event-free survival. This benefit in systolic HF
HF as well as providing an algorithm to adjust a patient’s diuretics
patients was greatest in those most severely ill (mortality for treatment
are key strategies to clinical stability in patients with recurrent
group for NYHA class I HR 1.32, P value nonsignificant; NYHA
fluid retention.
class II HR 0.76, P value nonsignificant; NYHA class III/IV HR 0.54,
• HF (function) clinics may also provide a full range of treatment
P=0.048). In patients with preserved LVEF, there was no significant
options including pharmacological, interventional,
benefit found for mortality or cardiac event-free survival. There was an
electrophysiological and surgical therapeutic options. Repeat
improvement (P<0.001) in the NYHA score in the DMP. For those
contacts, including by telephone or Internet calls, by experienced
with systolic HF, there were significantly more patients (P=0.002) in
health care professionals to HF patients, appears to be an
the treatment group (54.4%) on guideline-recommended treatment
important intervention in preventing recurrent HF
compared with the control group (43.3%).
hospitalizations.
The randomized trial of telephone intervention in chronic HF
• Communication among relevant care providers for HF patients is (DIAL) (134) recruited 1518 mainly NYHA class II to III HF patients,
essential to realize the benefits of DMPs. with 20% having preserved LVEF (LVEF of greater than 40%) HF and
• In Canada, suggestions on how to set up a multidisciplinary HF 80% having reduced LVEF (LVEF of 40% or less) HF. All patients
(function) clinic are available at www.chfn.org. Routine follow-up received usual care by an attending cardiologist with the intervention
and protocols are available at www.qhfs.org and www.sqic.ca. group also receiving education, counselling and monitoring by nurses
HF mortality and morbidity remain high despite the available through frequent telephone follow-up delivered from a single centre. The
therapies, and management of these patients can be challenging. A mean length of follow-up was 16 months (range seven to 27 months). In
DMP typically refers to multidisciplinary efforts to improve the quality the treatment group, there was a significant reduction in the primary
and cost-effectiveness of care for selected patients suffering from outcome of any cause death or HF admission (RR 0.80, 95% CI 0.66 to
chronic conditions. These programs involve interventions designed to 0.97; P=0.025), HF hospitalizations (RR 0.71, 95% CI 0.56 to 0.91;
improve adherence to scientific guidelines and treatment plans (120). P=0.003) and all-cause admissions (RR 0.85, 95% CI 0.72 to 0.99;
HF DMPs can be grouped into three overlapping categories – HF clin- P=0.049), but not for mortality (RR 0.95, 95% CI 0.73 to 1.23; P=0.69).
ics, home-based care and telemonitoring. There have been a number In contrast to the Galbreath et al study, similar point estimates for HF
of studies over the past 15 years examining the effects of DMPs for HF hospitalization, adherence to HF therapy and quality of life were not dif-
patients (121). The majority of these studies have been small single- ferent for the preserved and reduced LVEF groups of patients.
centre studies. During the past few years, a number of systematic The Coordinating Study Evaluating Outcomes of Advising
reviews and larger randomized controlled trials (122-127) have been Counseling in HF (COACH) (135) was a multicentre randomized
performed to better estimate the effects of DMPs for HF patients on controlled trial in which 1023 patients were enrolled after hospitaliza-
mortality and morbidity. These reviews generally found that DMPs tion because of HF. Patients were assigned to one of three groups: a
reduce both all-cause and HF hospitalizations (122,123,125-127). One control group consisting of follow-up by a cardiologist; a basic support
review (124) reported a trend to reduce hospitalization rather than a group with cardiologist and HF nurse follow-up that included educa-
significant reduction. This may be due to a limited number of studies tion as well as strategies to improve adherence and the ability to con-
included in the analysis. tact the nurse if necessary; and an intensive support group that
Pooled data from several meta-analyses (122,123,127) have dem- included every component of the basic support group plus monthly
onstrated a significant reduction in mortality of 25%. Other studies contact by the HF nurse – this group also received advice from a phys-
have either not examined mortality (126) or examined it in a com- iotherapist, a dietician and a social worker. There were two primary
bined outcome of hospital readmission or death, showing an 18% outcomes – one was a composite of HF hospitalization or death from
decrease (125). One meta-analysis (124) demonstrated a nonsignifi- any cause, and the other was the number of unfavourable days, defined
cant 20% reduction in mortality (P=0.15), although this finding may as the number of days lost because of death or hospitalization during
be underpowered. the 18 months of follow-up. There was no significant benefit for either

Howlett et al
primary outcome for the basic or intensive support groups compared { Use evidence-based performance indicators to identify care
with controls. However, the control group had unusually close gaps in the management of HF in a particular population.
follow-up throughout the study. This may have accounted to some { Provide intervention supports such as clinical tools or practice
extent for the lack of difference in the primary outcome in the inter- change to facilitate best practices.
vention group compared with the control group. For the two interven- { Provide feedback and education to assist HF care professionals
tion groups combined, there was a trend toward a reduction in meet these performance indicators.
mortality (HR 0.85, 95% CI 0.66 to 1.08; P=0.18).
The long-term benefits of a DMP are not as well established Practical tips
because the studies to date have not examined whether the benefits of • Selection of performance indicators that have been associated
these programs continue after the patient is referred back to their pri- with improved patient outcomes in randomized clinical trials is
mary care physician. A recent study by Nguyen et al (136) examined preferred.
the long-term benefit of a six-month DMP. In this study, patients were • Quality improvement initiatives that combine practice audits
randomly assigned to DMP or usual care for six months and then at the with multifaceted, proscriptive education strategies are preferred.
end of this time, followed for a mean of 2.8 years. At the end of • Recent reviews also suggest the greatest gain in terms of quality of
2.8 years of follow-up, there were no differences between the DMP and care is system change with an emphasis on the multidisciplinary
usual care with regard to the primary outcome of all-cause death, hos- team approach.
pital admissions and emergency room visits (HR 1.01, 95% CI 0.75 to
• Strategies shown to result in improved care processes and/or
1.37). These findings suggest the possibility that long-term follow-up
outcomes usually have included administrative support, change
is required after the initial exposure to a DMP and that it may not be
management support, resource support and a physician champion.
possible to discharge these patients from the DMP without first
• Broader regional, provincial and national frameworks are required
enhancing the capacity of primary care physicians to manage HF.
to promote and facilitate quality assurance initiatives at all levels
Another important area that has not been well explored is whether
of HF care.
men and women are equally enrolled in DMPs and whether they
derive the same benefits. A recent study has addressed this question Quality assurance: What is it?
and examined the records of 765 patients referred to one of three The Institute of Medicine (144) defines quality of care as “the degree
DMPs in Montreal, Quebec (137). The LVEF and NYHA functional to which health services for individuals and populations increase the
class at entry were similar among men and women with a reduced likelihood of desired health outcomes and are consistent with cur-
LVEF. Among patients with preserved LVEF, women were more symp- rent professional knowledge”. In addition to whether care for a par-
tomatic, with a greater NYHA class at entry into the DMP (OR 2.52, ticular condition achieves desired health outcomes, other
95% CI 1.18 to 5.38). The prescription profiles were similar between considerations in gauging quality of care include accessibility, the
men and women. These findings suggest that for reduced LVEF HF, quality of the patient experience when receiving care, and how the
there is no difference with regard to referral. However, when HF is processes of care delivery are structured in a manner to constrain
associated with preserved LVEF, there may be a delay in referring health care costs (145-147).
women to a DMP. Quality assurance is a process whereby a health care organization
The DMPs assessed have had variable structures, the studies for the can ensure that the care it delivers for a particular illness meets
most part have involved only a single centre and the sample sizes have accepted quality standards (144,145). Inherent characteristics of this
been relatively small. Because of this, it has been difficult to define the process include the following:
best type of DMP for HF patients. However, the published overview • Existence of evidence-based clinical guidelines for the illness of
analyses have been able to provide some direction with regard to the interest, and from which quality of care performance indicators
most effective type of DMP. Multidisciplinary programs involving both can be derived. These indicators can refer to structures, processes
a doctor and a nurse specializing in HF management appear to be a or outcomes of care (148,149).
consistent requirement for these programs, with the potential for fur-
• Development and maintenance of a health information database
ther benefit from the addition of other allied health professionals such
representative of the patients served by the health care
as a pharmacist (122,123,126,127,138). Combinations of in-clinic and
organization and pertinent to the illness of interest. The database
telephone follow-ups would appear to be important with entry into the
can be audited and benchmarked against the performance
DMP as soon as possible after discharge (122,124,125). The DMP
indicators to assess the quality of care.
should involve education, exercise and psychosocial counselling, self-
care supportive strategy, optimization of the medication regimen and • Development of mechanisms to address care deficiencies
medical referrals for deterioration (122,124,125,127). identified in the database audit and improve the quality of care.
The majority of data suggest a DMP is of benefit for HF patients. More in-depth evaluative work may be required to understand
Whether a DMP is a cost-effective way to manage these patients is not causes of these deficiencies and to inform potential care
well established. The studies suggest a DMP may be cost effective or improvement strategies.
the extra cost associated with a DMP is acceptable (131,139-142). In • Repeated database audits to assess the effectiveness of measures
a recent analysis by Whellan et al (143), an interesting concept based taken to improve care delivery, and to ensure the ongoing delivery
on the American system of reimbursement is presented. This paper of quality care.
suggested that although DMPs may provide patients with improved Quality assurance considerations for HF care
clinical outcomes and decreased hospitalizations that save third-party Chronic HF is a common health condition associated with a signifi-
payers money, limited financial incentives are currently in place for cant clinical and economic burden of illness, and has been identified
health care providers and hospitals to initiate these programs. as a priority condition for quality assurance (144). While recent evi-
dence suggests modest improvements in HF-related outcomes (150),
QuaLITY aSSuRanCE and HF the care provided to many HF patients, particularly those who are
Recommendations elderly, still fails to meet the standards set out in the CCS recommen-
• Health care systems should provide for quality assurance in both dations on HF (151-155).
the process and content of care provision. (Class I, level C) Applying quality assurance methods to chronic HF requires consid-
• Quality assurance programs should ensure the following to eration of the often unpredictable illness trajectory, characterized by
improve adherence to HF guidelines and improve patient periods of relative stability that are punctuated by episodes of acute
outcomes (Class I, level B): decompensation (156). This may be conceptualized as in Figure 2,

which illustrates the HF cycle, components of which are potential

objects for quality assurance, and which include the following:
• Periods of acute decompensation that may last from days to
weeks, and may culminate in resolution, hospitalization or death.
• Hospitalization phase, from admission to either death or
discharge.
• Transition period, from hospital discharge to the resumption of
outpatient care.
• Chronic, apparently stable outpatient phase.
At all stages of the HF cycle, there is continuing reference to
end-of-life planning and care.
What performance indicators have been developed for HF?

It is neither feasible nor necessary to adapt all recommendations in
HF guidelines as performance indicators. Accordingly, several orga- Figure 2) The heart failure cycle
nizations have developed through consensus processes restricted sets
of performance indicators deemed sufficiently representative of the
guidelines to be considered indicators of quality HF care. These orga- ventricular systolic dysfunction) were only marginally associated with
nizations include the Canadian Cardiovascular Outcomes Research improvements in mortality rates at 30 days and one year.
Team (CCORT)/CCS (157), the American College of Cardiology/ The Organized Program to Initiate Lifesaving Treatment in
American Heart Association (158), the Joint Commission on Hospitalized Patients with Heart Failure (OPTIMIZE-HF) (176) was a
Accreditation of Healthcare Organizations (JCAHO) (159), and the large prospective registry targeting hospitalized patients admitted with
Assessing the Care of Vulnerable Elders (ACOVE) project (160), HF or who develop HF during hospitalization. Data were collected
and are summarized in Table 7. It is unclear which, if any, set of per- regarding the JCAHO and American College of Cardiology/American
formance measures is superior in gauging the quality of HF care. All Heart Association performance indicators for HF, as well as for perfor-
have the drawback of focusing on the hospital and transition phases mance indicators developed specifically for the registry, which include
of HF, and do not address the processes of health care delivery. They the use of 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibi-
do, however, share several core performance indicators including the tors (statins), aldosterone antagonists and beta-blockers for eligible
use of ACE inhibitors in eligible patients, the importance of appro- patients without contraindications (Table 7). Health care providers
priate patient education and the assessment of left ventricular were encouraged to attend workshops and rounds. Evidence-based
function. pathways, algorithms and standardized orders were provided to guide
patient care, and an Internet-based tool provided participating institu-
What care improvement mechanisms should be considered? tions with real-time quality-of-care reports and benchmark compari-
Numerous initiatives to improve the management of HF have been sons with other institutions.
developed and evaluated in different care settings, and have met with During a two-year period from January 2003 to December 2004,
varying degrees of success. Strategies used in these initiatives have the OPTIMIZE-HF program was associated with increased use of
included passive dissemination of educational information to health evidence-based beta-blockers, aldosterone antagonists, statins and
care providers and patients, computerized order sets, automatically anticoagulants in eligible patients, and continued high prescription
generated suggestions for care interventions, automated reminders rates for ACE inhibitors and ARBs (176,177). The program was also
attached to echocardiography results, as well as intensive education, associated with an increase in the use of discharge education, smoking
direct feedback and care support from expert clinicians (161-171). cessation counselling and assessment of left ventricular function
Strategies that rely on passive dissemination of information to health (176,177). The use of computerized tools was associated with lower
care providers are, at best, modestly effective (162,167,168). More inpatient mortality (4.1% versus 2.5%, P<0.001), postdischarge mor-
proscriptive strategies, either through computerized order sets or direct tality and readmissions (34.8% versus 38.2%, P=0.02; which was no
feedback and support from specialists, may be more successful. longer significant after propensity risk adjustment) (177). Further data
Involvement of end users in the development of strategies for improv- from OPTIMIZE-HF (178) suggested that of all indicators, only beta-
ing HF care may increase their likelihood of success (164,172). A sys- blocker prescription was associated with a 52% reduction in mortality
tematic review (173) of computerized decision support for prescribing (95% CI 0.21 to 0.70) at 90 days. Only the use of ACE inhibitors for
suggested that most studies resulted in improved prescribing, although patients with left ventricular systolic dysfunction was associated with
few reported on patient-relevant outcomes. Another systematic review reduced combined mortality and rehospitalization at three months.
(174) suggested that strategies that combine practice audits with feed- The Registry to Improve the Use of Evidence-Based Heart Failure
back regarding gaps between the care provided for a particular condi- Therapies in the Outpatient Setting (IMPROVE HF) (179,180)
tion and clinical practice guidelines have small to moderate effects on addressed quality assurance for patients with HF or myocardial infarc-
improving care quality. However, the effects may be larger when base- tion with impaired left ventricular function in participating outpatient
line adherence to clinical guidelines is low and intensity of audit and cardiology clinics (chronic, stable outpatient phase). Performance
feedback is high. Multifaceted interventions may also be more likely to indicators included the use of ACE inhibitors, beta-blockers, aldoster-
succeed (174). Recent reviews also suggest that the greatest gain in one antagonists, anticoagulants, implantable cardioverter defibrilla-
terms of quality of care is system change with an emphasis on the mul- tors and cardiac resynchronization therapy in eligible patients, as well
tidisciplinary team approach. as the provision of appropriate HF education to patients (179).
Change tools included mandatory educational programs, development
Quality assurance in HF: What is the evidence? of practice-specific clinical pathways and periodic chart reviews cou-
A number of large prospective registry-based programs aiming to pled with Internet-based feedback and comparison with regional and
improve the quality of HF care are underway in the United States. national benchmarks (179). To date, no data have been published
Results from a study of 3657 US hospitals (175), in which hospital- regarding the impact of the program on adherence to performance
reported performance measures were linked to Medicare claims data, indicators.
suggested that two HF care quality indicators (assessment of left ven- Finally, the Acute Decompensated HF National Registry (ADHERE)
tricular function and use of ACE inhibitors in patients with left (181,182) was a prospective observational study enrolling adult patients

Howlett et al
Table 7
Summary of performance indicators for heart failure (HF) by development group
CCORT CCORT Canadian aHa/aCC aHa/aCC IMPROVe
inpatient outpatient primary inpatient outpatient JCaHO OPTIMIZe-HF aCOVe HF
Indicator (157) (157) care (196) (158) (158) (159) (176) (160) (179,180)
Therapeutics
ACEi and/or ARB if LV systolic dysfunction in eligible x x x x x x x x x
patients
Use of beta-blockers (evidence based or not) in eligible x x x x x x x x
patients
Use of statins in eligible patients if underlying CAD, x
PVD, CVD or diabetes
Aldosterone antagonists for eligible patients x x x
Anticoagulants for atrial fibrillation x x x x x x
Use of ICD in eligible patients x
Use of CRT in eligible patients x
Avoid 1st and 2nd generation CCBs if LV systolic x
dysfunction
Avoid type 1 antiarrhythmic agents if LV systolic x
dysfunction (unless ICD in place)
Investigations
Outpatient assessment including one or more of regular x x x x
volume assessment, weight, blood pressure, activity
level
Appropriate baseline blood/urine tests, ECG, CXR x x
Appropriate biochemical monitoring of renal function x x x
and electrolytes
Assessment of LV function x x x x x x x x x
Measure digoxin levels if toxicity suspected x
Education and follow-up
HF patient education/discharge instructions x x x x x x x
Outpatient follow-up within 4 weeks x
Advice on smoking cessation x x x
Please refer to primary references for specific details regarding inclusion and exclusion criteria, and implantation requirements for each quality indicator. ACEi
Angiotensin-converting enzyme inhibitor; ACOVE Assessing the Care of Vulnerable Elders Project; AHA/ACC American Heart Association/American College of
Cardiology; ARB Angiotensin Receptor Blocker; CAD Coronary artery disease; CCB Calcium channel blocker; CCORT Canadian Cardiovascular Outcomes
Research Team; CRT Cardiac resynchronization therapy; CVD Cerebrovascular disease; CXR Chest x-ray; ECG Electrocardiogram; ICD Implantable cardioverter
defibrillator; IMPROVE HF Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting; JCAHO Joint Commission on
Accreditation of Healthcare Organizations; LV Left ventricle; OPTIMIZE-HF Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart
Failure; PVD Peripheral vascular disease
hospitalized with HF. The study used JCAHO performance indicators, ACE inhibitors, ARBs and beta-blockers were high. The interven-
which, through Internet-based quarterly audits, were then fed back to tion failed to show any improvement in overall adherence to HF
participating centres with comparison to national benchmarks (181). quality indicators, except for a small and statistically significant
Results suggest that the program was associated over 18 months with improvement in the use of ACE inhibitors and ARBs. HF mortality
substantial increases in compliance with the provision of appropriate rates at one year were modestly improved, although the risk reduc-
discharge instructions for HF and counselling on smoking cessation, as tion did not achieve statistical significance.
well as modest increases in the assessment of left ventricular function
but not ACE inhibitor use (183). Inpatient mortality in participating Can quality assurance initiatives produce meaningful
sites fell from 4.5% to 3.1% from 2002 to 2004 (184). improvements in HF patient outcomes?
Few randomized controlled trials evaluated the impact of an The relationship between specific performance measures and patient
intervention targeting health care providers and aiming to educate outcomes remains unclear. Methodological limitations of the studies
them on how to conduct quality assurance programs for HF (185). reviewed above, such as nonrandomized designs and limited follow-up,
Participation in the educational session by health care providers was may have impeded their ability to detect improvements in patient
poor, and few participating hospitals completed the program; thus, outcomes in relation to specific HF performance measures. Many of
the trial failed to demonstrate improvement in the use of ACE the commonly assessed performance indicators have not been shown
inhibitors and ARBs in eligible patients, and on rates of assessment in clinical trials to reduce mortality and prevent hospitalization in HF
of left ventricular function. A recently published cluster randomized patients (187). In addition, while some performance indicators, such
controlled study assessed the value of a publicly released report card as smoking cessation counselling, may have been met, the manner in
on the quality of care provided to patients with acute myocardial which they were delivered may have been suboptimal (187). Finally,
infarction and HF in 86 hospital corporations in Ontario (186). The in several projects, baseline adherence to proven performance indica-
CCORT quality indicators were used to gauge care quality. The tors, such as the use of ACE inhibitors in eligible patients, was already
development and nature of quality improvement initiatives was left high, making further improvements in patient outcomes more difficult
to the participating hospital corporations. At baseline, usage rates for to demonstrate.

The failure to demonstrate meaningful improvements in HF Table 8

patient outcomes may reflect an approach to quality assurance that Summary of critical performance objectives that may be
to date has not taken a comprehensive approach to the HF cycle. used to guide the development of performance indicators
Current performance indicators only provide guidance on care qual- in all phases of the heart failure (HF) life cycle
ity in two of the four phases of the HF cycle – the stable outpatient Discharge/transitional care phase
phase and the hospitalization phase. Furthermore, outpatient phase Assessment of cognition in hospitalized older patients before discharge
performance indicators have only been evaluated in the context of Assessment of frailty in hospitalized older patients in view of identifying those
specialist cardiology practices (180). For example, the benefits of requiring development of a multidisciplinary care plan
better in-hospital care may be undone by suboptimal transitional Provision of HF education initiation before discharge, and continuing after
care or outpatient disease management. Previous updates of the CCS discharge, with a focus on the following:
HF guidelines (188-190) have addressed disease management, transi- • Home visits
tional care and end-of-life planning and care, formulating recom- • Medication reconciliation
mendations that could form the basis for new performance indicators • Self-management skills
(Table 8). Whatever their source, performance indicators are more • Health system navigation
Provision of a written discharge summary to the primary care physician within
likely to be effective if stakeholders are actively involved in their
48 h of discharge including the following:
development and application, and if they are sensitive to the organi-
• Plan of care and follow-up
zational context in which they are used (191). • Inclusion of relevant care settings (HF clinic, other clinics, specialist,
Potentially one of the most important systemic considerations primary care)
toward improved HF care and outcomes pertains to care coordina- Outpatient phase
tion. The US Agency for Healthcare Research and Quality (192) Percentage of eligible patients receiving implantable cardiac defibrillators
defines care coordination as “the deliberate organization of patient Percentage of eligible patients receiving biventricular pacing (CRT)
care activities between two or more participants (including the Percentage of eligible patients receiving beta-blocker therapy
patient) involved in a patient’s care to facilitate the appropriate Percentage of eligible patients receiving ACE/ARB therapy
delivery of health care services. Organizing care involves the mar- Percentage of eligible patients receiving spironolactone
shalling of personnel and other resources needed to carry out all Percentage of newly diagnosed HF patients who see an HF specialist
required patient care activities, and is often managed by the within 6 weeks
exchange of information among participants responsible for different Referral of higher risk HF patients to disease management programs
including those with the following:
aspects of care”. Although the evidence regarding the effectiveness
• Multiple comorbidities
of individual aspects of care coordination, such as multidisciplinary
• Multiple recent hospitalizations
care teams, case management or interprofessional educational activi-
Percentage of HF patients admitted to an outpatient clinic within
ties, is lacking, care coordination programs appear to be highly effec- recommended benchmarks:
tive in improving the care of HF patients (192). Strong transitional • <24 h if NYHA IV or progressive HF
care that includes home visits appears to be an important component • <4 weeks if NYHA III
of successful care coordination (193). Care coordination is integral • <6 weeks if NYHA II
to the chronic disease management model, which has been recom- Medication review to identify potential drug interactions
mended as the preferred model for care delivery for cardiovascular Ensure appropriate immunizations (influenza, pneumococcal)
disease by the Canadian Heart Health Strategy and Action Plan Percentage of HF patients referred to cardiac rehabilitation
(www.chhs-scsc.ca/web). Ensure appropriate communication between referring physician and HF clinic/
specialist including the following:
Who should participate in quality assurance? • Results of pertinent investigations
Quality assurance principles could be applied at any level of health • Pertinent medical history and consultant notes
care delivery – from the individual practitioner to group family or • Recommendations regarding clinical and laboratory monitoring
specialty practices and clinics, hospitals, and regional or provincial • Recommendations regarding medication dose titration
health authorities. However, the costs of quality assurance programs acute HF
can be substantial barriers to their implementation (187). Time to diagnosis of HF in acute decompensated setting
Paradoxically, providers and institutions with low baseline adher- Accuracy of provisional HF diagnosis compared with final discharge diagnosis
ence to the guidelines, and who are thus most likely to benefit from Time to initiation of appropriate therapy specific to HF:
• Diuretics
quality assurance initiatives, may be the least likely to willingly pay
• Nitrates as appropriate
for and implement such programs. In the US, financial incentives
Time of transfer to tertiary care centre for eligible patients with persistent
have been used to promote quality assurance, including linking full cardiogenic shock
Medicare reimbursements with the collection and submission of end-of-life planning and care – indicators
performance indicators (187). In Canada, professional agencies, such Percentage of HF patients who have a documented advanced care directive
as the Royal College of Physicians and Surgeons of Canada, recog- Percentage of HF patients who have a proxy decision maker identified
nize Personal Practice Reviews as valid continuing professional Percentage of HF patients who have a documented discussion on
development activities (www.rcpsc.medical.org). While health care resuscitation preferences
services will continue to be delivered by individual practitioners, Number of reviews and revisions to a patient’s advanced care directive
provincial and national organizations and governments should col- Measures of quality end-of-life planning and care
laborate to provide the broader framework and incentives to facili- • Patient- and family-centred decision making
tate the implementation of quality assurance initiatives that • Communication about disease course and care plan
encompass the entire HF cycle, in a manner consistent with the • Continuity of care
recommendations that the Canadian Heart Health Strategy and • Emotional and practical support
Action Plan provide (194,195). • Symptom management and comfort care
• Spiritual support
• Caregiver well-being
ConCLuSIon Percentage of HF patients who die in their place of preference
HF is a complex, progressive disorder that carries a high health care ACE Angiotensin-converting enzyme; ARB Angiotensin receptor blocker; CRT
burden to patients and their families, care providers and society as a Cardiac resynchronization therapy; NYHA New York Heart Association func-
whole. The present CCS HF guidelines update follows four previous tional classification

Howlett et al
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SPeCial arTiCle

The 2010 Canadian Cardiovascular Society guidelines

S ince 2006, the Canadian Cardiovascular Society (CCS) has been

HF In ETHnIC MInoRITY { Work as multidisciplinary teams.

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symptoms of HF at younger ages, which are less likely to be due to

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evidence to indicate that geographical location, compared with Table 3

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192 Can J Cardiol Vol 26 No 4 April 2010

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which illustrates the HF cycle, components of which are potential

What performance indicators have been developed for HF?

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The failure to demonstrate meaningful improvements in HF Table 8

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