Canadian Cardiovascular Society Consensus Conference guidelines on heart failure, update 2009: Diagnosis and management of right-sided heart failure, myocarditis, device therapy and recent important clinical trials

Abstract

The Canadian Cardiovascular Society published a comprehensive set of recommendations on the diagnosis and management of heart failure in January 2006. Based on feedback obtained through a national program of heart failure workshops and through active solicitation of stakeholders, several topics were identified because of their importance to the practicing clinician. Topics chosen for the present update include best practices for the diagnosis and management of right-sided heart failure, myocarditis and device therapy, and a review of recent important or landmark clinical trials. These recommendations were developed using the structured approach for the review and assessment of evidence adopted and previously described by the Society. The present update has been written from a clinical perspective to provide a user-friendly and practical approach. Specific clinical questions that are addressed include: What is right-sided heart failure and how should one approach the diagnostic work-up? What other clinical entities may masquerade as this nebulous condition and how can we tell them apart? When should we be concerned about the presence of myocarditis and how quickly should patients with this condition be referred to an experienced centre? Among the myriad of recently published landmark clinical trials, which ones will impact our standards of clinical care? The goals are to aid physicians and other health care providers to optimally treat heart failure patients, resulting in a measurable impact on patient health and clinical outcomes in Canada.

Global Variation in Quality of Care Among Patients Hospitalized With Acute Heart Failure in an International Trial

“…8,9,[25][26][27] It is important to recognize that these measures are applied only to patients with clear qualifying indications for therapy; furthermore, they are excluded from consideration if there is documentation of a contraindication or intolerance to the therapy in question, a reason the most responsible physician does not believe the therapy should be applied or if there are plans for application in the future. Thus, apart from incomplete documentation, the quality measure would ideally be satisfied in 100% of eligible patients.…”

Drug-Refractory Ventricular Tachycardias After Myocarditis

“…Even in chronic myocarditis, therapy is largely confined to antiarrhythmic drugs, with limited efficacy, and to implantable cardioverter-defibrillator (ICD) for higher-risk cases, such as those with hemodynamically unstable ventricular tachycardia (VT) and aborted sudden cardiac death. 2,3,10 Radiofrequency catheter ablation (RFCA) has been demonstrated to be effective in reducing VT occurrence in patients with Chagas cardiomyopathy. 11 In nonchagasic myocarditis, isolated reports suggest that RFCA of VT may be effective, [12][13][14] but its safety and long-term efficacy in this setting is unclear.…”

“…RFCA is not mentioned at all in this context and is not contemplated in more specific guidelines on myocarditis. 2,3 This absence reflects the lack of specific evidence on RFCA of VT in myocarditis, as most of the published evidence consists of case reports. [12][13][14]29 A significantly larger body of published evidence is available on RFCA of VTs in patients with Chagas disease, a dilated cardiomyopathy caused by infestation by the protozoan Trypanosoma cruzi.…”

“…M yocarditis is simply defined as an inflammatory condition mainly located in the heart muscle, [1][2][3] although considerable uncertainties still persist as to its etiologic, pathological, and clinical subclassifications. 4,5 In addition to the possibility of an aspecific flu-like prodrome, possible presentations include different degrees of heart failure (ranging from cardiogenic shock to subtly progressive chronic heart failure), chest pain, conduction anomalies, bradyarrhythmias, and tachyarrhythmias (including sudden cardiac death).…”

Noninvasive risk stratification after myocardial infarction: Rationale, current evidence and the need for definitive trials

“…Thus, this population accounts for a significant proportion of all sudden deaths. However, most sudden deaths occur in patients who are not recommended to receive a prophylactic ICD based on current guidelines (9,10). Establishing a risk stratification approach that incorporates sufficient positive accuracy, ie, patients identified are at sufficient risk to justify long-term ICD therapy, plus has reasonable Despite advances in therapies for myocardial infarction (MI), death attributed to a cardiac arrest from ventricular tachycardia (VT) or ventricular fibrillation (VF) remains an important problem.…”