CCC OPENING CEREMONIES

Monday Edition

13th Anniversary of the Official Newspaper of theAnnual Canadian Cardiovascular Congress

October 27, 2008 / Toronto, Ontario

Canadian Cardiovascular Congress

Co-hosted by the Canadian Cardiovascular Society and the Heart and Stroke Foundation of Canada

13th Anniversary of the Official Newspaper of theAnnual Canadian Cardiovascular Congress

Veuillez prendre note que la version française des suppléments cliniques d’Info-Cardio est accessible

sur le site www.cardiocongress.org.

L essons learned from the venerablescience of electrocardiography(ECG) will be the focus of the

CIHR/ICRH distinguished lecture incardiovascular sciences, given this year byProf. Hein Wellens, Professor Emeritus,University Hospital, Maastricht, TheNetherlands, on Tuesday, October 28.In his lecture called “Electrocardio-graphy, a Vital Centenarian,” Prof.Wellens, himself a major contributor tothe knowledge derived from the 12-leadECG, will remind delegates that after over100 years of use, the 12-lead ECGcontinues to be the most widely available,non-invasive, reproducible, patient-friendly and inexpensive “work horse” incardiology. As he explained to INFO-Cardio, the ECG provides instantaneous information onthe diagnosis, treatment effect and prognosis of patientswith a spectrum of cardiac abnormalities including cardiacischemia, arrhythmias and conduction disturbances,structural changes of the cardiac chambers, drug effectson the heart, electrolyte and metabolic disturbances andmonogenic arrhythmology.

Indeed, knowledge on how to use the valuableinformation contained in an ECG keeps evolving and itsdiagnostic value is constantly improving because ofinsights provided by other techniques: programmedstimulation of the heart, coronary angiography,intracardiac mapping, echocardiography, MRI, CT,nuclear and genetic data, among others.

In his lecture, Prof. Wellens will focus on four areasin which new ECG information has recently becomeavailable: acute coronary syndromes, cardiacarrhythmias, heart failure and monogenic diseases. “Thereal challenge in acute chest pain is to identify the sizeof the ventricular area at risk, as this knowledgedetermines how aggressive cardiologists must be withreperfusion strategies to restore blood flow to the area,”he indicated. By using the deviation vector of the STsegment during acute cardiac ischemia, the location ofthe occlusion in the coronary artery can bedetermined—critical information, as Prof. Wellens

noted, “because the closer the occlusionsite to the origin of the coronary artery,the larger the ventricular area that isthreatened.”

Another area in which the ECGprovides extremely helpful insight is inpatients with heart failure. About one-fifth of heart failure patients have leftbundle branch block and the ECG cantell cardiologists about the width, axisand voltage of the QRS complex, as wellas the length of the PR interval. TheECG also provides information on theprognosis of these patients and dictatesmanagement strategies; for example, ifright ventricular disease is detected inpatients with left bundle branch block,“you are dealing with a different patient,

among whom our current intervention withresynchronization therapy is less beneficial,” notes Prof.Wellens.

The 12-lead ECG similarly allows cardiologists todiagnose not only the type of tachycardia that may bepresent, but its site of origin as well, a clear dictate in anyattempt to ablate the arrhythmia by modern cathetertechniques. For example, young patients with aprolonged QT interval are at risk for sudden cardiacdeath. This and other monogenic cardiac diseases may beidentified by timely ECG readings in patients with afamily history of premature death or who present withsymptoms of dizziness, dyspnea or palpitations, as Prof.Wellens suggests.

Yet he added that increasing specialization incardiology is threatening the implementation of newECG knowledge in daily cardiology practice.

Perhaps somewhat dazzled by the newer bells andwhistles now available for imaging and treatment,cardiologists are losing touch with the importantinformation they could glean from a simple 12-lead ECG.

“The ECG is more than 100 years old,” Prof. Wellens stated, “but it is continuously improvingand cardiologists need to keep ECG continuously ontheir menu and be educated in the new developments inthe area.”q

Prof. Hein Wellens

Delegates packed the CCC opening ceremonies to hear HSFC keynote speaker Dr. Susan Bennett. (From top:) Dr. Malcolm Arnold,Dr. Beth Abramson, Dr. Anthony Graham, Dr. Lyall Higginson and Sally Brown welcomed delegates to this year’s meeting.

PLEASE PLAN TO ATTEND

MONDAY, October 27

“Improving Outcomes with Antiplatelet Therapy: PracticalApplications from New Research”7:00-9:00, Room 701 AB

State-of-the-Art Lecture: “Challenges in the 21st Century: FromTreatment to Promotion of Cardiovascular Health”Presenter: Dr. Valentin Fuster9:00-10:00, Hall F (Level 800)

CCS Research Achievement Award PresentationRecipient: Dr. Jean-Claude Tardif10:00-10:30, Hall F (Level 800)

Workshop: “The Heart Truth: Cardiovascular Disease Is a Woman’sDisease (Too)”14:00-15:30, Room 713 AB

TUESDAY, October 28

Health Promotion Educational Session: “Smoking Cessation: ThePrimary Task in CVD Prevention!”8:00-9:00, Room 801 AB

Workshop: “Clinical Conundrums in Heart Failure—CCS HeartFailure Guidelines 2008”9:00-10:30, Room 717 AB

John Keith Lecture: “Integrated Approach to Prevention ofCardiovascular Disease in Childhood”Presenter: Dr. Stephen Daniels9:00-9:45, Hall F (Level 800)

Wilfred G. Bigelow Lecture: “Cardiac Surgery—Retrospective andProspective Views”Presenter: Dr. Neil McKenzie9:45-10:30, Hall F (Level 800)

Workshop: “Canadian Approaches in Facilitating Patient Access toCare”10:00-11:30, Session Theatre (Community Forum)

CIHR/ICRH Distinguished Lecture in Cardiovascular Sciences:“Electrocardiography, A Vital Centenarian”Presenter: Dr. Hein Wellens11:00-12:30, Hall F (Level 800)

CCCN Closing Plenary Session: “Aboriginal Heart Health”Presenter: Denise Newton-Mathur12:00-13:00, Room 801 AB

CCS Guidelines and Position Statements14:00-15:00, Hall F (Level 800)

Meet-the-Experts Session: “Ablation Therapy for Atrial Fibrillation—Who Should We Be Referring? Recommendations from CCS andCHRS Position Paper 2008”16:00-17:30, Room 714 A

WEDNESDAY, October 29

“Expert Opinions: Current Issues in Cardiology”7:00-9:00, Room 701 AB

Late Breaking and Featured Clinical Trials Session9:00-10:30, Room 717 AB

Oral Session: PCI Outcomes9:00-10:30, Room 714 A

Also available on www.ccs.ca

Thank you to this year’s supporters!

AstraZeneca Canada Inc. Boehringer Ingelheim (Canada) Ltd.

Eli Lilly Canada Inc. Johnson & Johnson Medical Products

Merck Frosst Canada Ltd.Merck Frosst / Schering Pharmaceuticals

sanofi-aventissanofi-aventis / Bristol-Myers Squibb

INFO-Cardio, the official newspaper of the CCC, is made possible through collaboration

of industry partners.

CIHR/ICRH Distinguished Lecture in Cardiovascular Sciences: One Hundred Years of Electrocardiography

CCS Research Achievement Award goes to top Montreal investigator

2

D r. Jean-Claude Tardif, investigatorextraordinaire and the Pfizer and CanadianInstitutes of Health Research Chair in

Atherosclerosis, Université de Montréal, as well asDirector, Montreal Heart Institute Research Centre,has been awarded the prestigious CCS ResearchAchievement prize given each year to a Canadiansuperstar in recognition of their commitment toscience. The award presentation is chaired by Dr. John Cairns, University of British Columbia, andtakes place today.

Dr. Tardif has been the lead and contributingauthor for a wide variety of publications, many ofthem seminal in the field. In 2008 alone, He andcolleagues published a wide range of findings, amongthem an examination of the effects of a newantioxidant, succinobucol, in patients with acute

coronary syndromes (Lancet 2008;371:1761-8). Treatment actually had no effecton the primary end point of time to first occurrence of cardiovascular disease (CVD)death, resuscitated cardiac arrest, myocardial infarction (MI), stroke, unstable anginaor coronary revascularization. However, the secondary end point of CV death,cardiac arrest, MI or stroke occurred in fewer patients receiving active therapy, andfewer patients developed new-onset diabetes in the succinobucol group comparedwith controls.

In a basic science study (Br J Pharmacol 2008;154:765-73), Tardif andcolleagues fed rabbits a cholesterol-enriched diet along with vitamin D2 untilsignificant aortic valve stenosis was detected on echocardiography. Animals werethen allocated to either saline or an ApoA-1 mimetic peptide three times per weekfor two weeks. On post-mortem histology, aortic valve areas had increasedsignificantly in animals receiving active treatment while aortic valve thicknessdecreased significantly vs. controls, where it was unchanged. Investigatorsconcluded that infusions of ApoA-1 mimetic peptide could lead to regression ofexperimental aortic valve stenosis, suggesting that HDL-based therapies mightlead to regression of the disease.

Dr. Tardif was also involved in an evaluation of heart rate reduction withivabradine in an animal model of dyslipidemia (Br J Pharmacol2008;154(4):749-57). Results showed that selective heart rate reduction withthe If inhibitor limited cardiac dysfunction in dyslipidemic mice and preventedboth renovascular and cerebrovascular endothelial dysfunction associated withdyslipidemia.

He was again active in the evaluation of torcetrapib, a cholesteryl estertransfer protein inhibitor that increased HDL-C but which was prematurelydiscontinued because of adverse clinical outcomes. The Montreal-basedresearcher was also among investigators who assessed the effects of reconstitutedHDL on plaque burden (JAMA 2007;297:1675-82). Findings from this studysuggested that short-term infusions of reconstituted HDL did not significantlyreduce atheroma or plaque volume but did significantly improve both plaquecharacterization index as well as coronary score on coronary angiography. q

Dr. Jean-Claude Tardif

CCS Heart Failure Consensus Conference highlights: transitional care, cardiomyopathy diagnosis and management

A n update of the CCS Heart Failure Consensus Conference has selected twoprincipal areas of clinical practice as it affects heart failure patients: transitionalcare between referring physicians and specialists and the diagnosis and

management of cardiomyopathies. Both will be discussed in a workshop at this year’s CCC chaired by Dr. Robert McKelvie, McMaster University, on Tuesday, October 28. In the interest of brevity, only highlights from the diagnosis andmanagement of cardiomyopathies have been excerpted here.

As published in the January 2008 issue of the Canadian Journal of Cardiology,cardiomyopathy with diabetes mellitus should be suspected in patients with both heartfailure and diabetes when other causes such as CAD, hypertension and valvular diseasedo not seem to explain the occurrence or severity of heart failure. “Patients withdiabetes mellitus are more likely to have concomitant renal dysfunction,” the authorsnote, “and renal function and serum electrolytes should be followed more closely.”Thiazolidinediones can cause fluid retention and thus may exacerbate heart failure,and patients on these agents should be monitored for signs of it.

Obesity-related cardiomyopathy should be suspected in heart failure patients whoweigh 125% or more than their ideal body weight, whose BMI is 40 kg/m2 or greaterand especially in patients who have been obese for 10 years or longer. Among thepractical tips offered by the guidelines, physicians should assess patients with obesity-related cardiomyopathy for the presence of obstructive sleep apnea and, if confirmedby a sleep study, treated with CPAP. The authors do not recommend routine weightloss medications at this time; bariatric surgery may be considered in selected severelyobese patients with mild cardiac dysfunction.

Tachycardia-induced cardiomyopathy is caused by persistent supraventricular orventricular arrhythmias, the most common being atrial fibrillation, atrial flutter, atrialtachycardia, junctional tachycardia and ventricular tachycardia. Unlike other formsof heart failure, tachycardia-induced cardiomyopathy is considered to be potentiallyreversible and, with appropriate heart rate or rhythm control or both, clinical,hemodynamic and structural parameters may normalize in as early as four weeks. Asthe guidelines also point out, alcohol has long been recognized as a major risk factorfor the development of dilated cardiomyopathy, alcohol having many negative effectson myocardial function.

Patients who develop alcohol-induced cardiomyopathy have a history of heavydrinking (at least 10 years): abstinence is critical for treatment and most patients willlikely require professional help to stop drinking.

Permanent abstinence must also be counselled for patients who developcocaine-induced cardiomyopathy, the result of long-term cocaine use which canlead to dilated cardiomyopathy, as can alcohol.

Chemotherapy-induced heart failure occurs in susceptible patients who receivecardiotoxic agents and left ventricular function should be monitored during andafter chemotherapy. If left ventricular function deteriorates, patients undergoingchemotherapy should receive beta-blockers along with other heart failuretherapies, and different treatment options should be considered.

A “high index of suspicion and early intervention” are also important in thediagnosis of other causes of cardiomyopathy, especially since the population inCanada is changing rapidly and international travel can expose patients to a varietyof factors that contribute to the development of cardiomyopathy.

Lastly, hypertrophic cardiomyopathy (HCM) is a genetic disease of themyocardium characterized by pathological and disproportionate hypertrophy ofthe left ventricle and, occasionally, the right ventricle. It should be suspected inthe setting of known familial HCM, sudden death or if there is significant leftventricular hypertrophy without a known cause, or when the cause is not thoughtto be adequate to explain left ventricular hypertrophy. First-degree family membersof those suspected should be screened for this condition if possible. Patient withHCM should be treated for both symptoms and prevention of sudden cardiacdeath. Beta-blockers should be used as first-line therapy while patients who survivea cardiac arrest should be considered for an implantable cardioverter defibrillator(ICD), as should those who have sustained ventricular tachycardia, as well as thosewith multiple high-risk factors for sudden death. Athletes with this particular formof cardiomyopathy should avoid strenuous competitive activities.

Restrictive cardiomyopathy is the least common cardiomyopathy and ischaracterized by a myocardium with markedly stiff ventricular walls, restrictiveventricular filling and reduced diastolic volume of either or both ventricles butnormal or near-normal systolic function. “Patients usually exhibit typicalsymptoms and signs of heart failure, including Kussmaul’s sign that may bedisproportionate to the degree of systolic or valvular dysfunction,” as guidelineauthors indicate. Therapy for patients with restrictive cardiomyopathy should focuson symptom control but digitalis, vasodilators, calcium channel blockers andnitrates are not highly effective in restrictive cardiomyopathy and should bemonitored if used.q

Maintenance of sinus rhythm does not improve survival in patientswith atrial fibrillation and heart failure. Talajic et al. performed atime-dependent efficacy analysis in an atrial fibrillation-congestive heartfailure (AF-CHF) cohort based on the presence or absence of AF duringfollow-up. Patients were followed every four months for four years, andevery six months thereafter. After a mean follow-up of 37 months, 32%of the cohort had died while 31% had NYHA class III to IV heart failure.The mean proportion of time spent in AF was 39% for the cohort overall,but AF was not predictive of cardiovascular or all-cause mortality, furthersupporting the lack of additional benefit of sinus rhythm maintenancein this population of patients.

sFas improves diagnostic accuracy for acute coronary syndromes in patients presentingwith chest pain. Cardinal et al. assessed whether measuring sFas—a soluble marker ofapoptosis—improves diagnostic accuracy or timeliness of the diagnosis of ACS in patientspresenting with chest pain. sFas was measured in 488 patients whose chest pain was feltto be due to ACS, 388 of whom were diagnosed with ACS. Results showed that sFas wasindependently associated with a diagnosis of ACS, with an odds ratio (OR) of 15.20 forthe second vs. the first tertile and an OR of 24.51 for the third vs. the first tertile.Investigators also found that sFas was strongly associated with ACS and improveddiagnostic accuracy in patients with no ischemic changes on the ECG and negative necrosismarkers. sFas levels appear to rise rapidly after onset of myocardial ischemia, suggesting apotential marker for early diagnosis or discharge in patients presenting with chest pain.

T he rapid evolution of techniques now used for atrial fibrillation ablation hasnecessitated the development of a new position paper to reflect currenthospital practice, according to Canadian Heart Rhythm Society (CHRS)

incoming president Dr. Peter Guerra, Montreal Heart Institute. To that end, CHRSmembers are working together with the Canadian Cardiovascular Society to replacejoint recommendations made in 2004, key elements of which will be debated duringa dedicated CCS/CHRS workshop on the joint position statement Tuesday,October 28.

As Dr. Guerra told INFO-Cardio, the ablation field has moved forward sincethe last guidelines were crafted in 2004. “Previously, we were doing only patientswith completely normal hearts who had failed a number of medications and whowere paroxysmal,” he related. Now, techniques are being applied to more patients,both earlier on in their disease before they have failed a number of antiarrhythmics,as well as in patients with more persistent forms of atrial fibrillation. The evolutionof catheter ablation has come about because of a number of changes in the field.

Electrophysiologists now have different types of catheters and energy sourcesthat have made treatment more efficient to begin with. They also have betterimaging technology to visualize the delinquent structures of the heart that need

to be silenced and there is increased use of navigational assessment such ascomputerized magnets to help direct the catheter within the heart. “It’s a bit likewe approached coronary artery disease 30 years ago, when we only operated onsingle-vessel disease in 50-year-olds,” Dr. Guerra explains. In the same way,indications for atrial fibrillation have broadened, especially given that inappropriately selected candidates, the success rate of ablation at approximately80% is higher than the success rate of 60% to 70% with various antiarrhythmicagents.

There are trade-offs: there exists a 1% to 3% risk of complications with ablation,as with any catheter-based technique vs. the known arrhythmogenic risk with someantiarrhythmic agents. Still, the higher success rate with the ablation approachusually justifies the small risk of complications from the procedure, as he suggests.

“Even by my standards, we were very conservative back in 2004 when we wrotethe guidelines, but since the field has changed so much, the CCS felt that an updatewas not only warranted but that it needed to better reflect current hospitalpractices,” Dr. Guerra confirmed, “and judging from the referrals we now get, Ithink many cardiologists have already embraced these expanding indications so wereally do have to get our position paper in line with current practice.” q

3

The Annual Achievement Award: Dr. George Wyse,University of Calgary. Dr. Wyse joined the University’sFaculty of Medicine in 1978. He served as AssociateDean (Clinical Affairs) from 1993-99 and is nowProfessor Emeritus. Dr. Wyse stayed close to the latestresearch by spending his sabbatical leaves working onclinical trials and by his editorial involvement in fiveprofessional journals. His own research has resulted in240 peer-reviewed publications, another 100 bookchapters and invited publications. “I think strategically,organize and get people working together for acommon goal,” he reveals. “Making those multicentrestudies work has been something I brought to theprofession.”

Distinguished Teacher Award: Dr. Ernest LeonFallen, McMaster University. Dr. Fallen has taught atMcMaster University since 1975. Now EmeritusProfessor, Dr. Fallen is semi-retired but maintains anoutpatient cardiology clinic where he supervisesspecialty residents in cardiology. “My method ofteaching is primarily Socratic,” he tells INFO-Cardio.“The residents are bright, innovative and querulous. Ienjoy the odour of the wood burning when they arethinking. They teach me a lot more than I teach them.”

Dr. Harold N. Segall Award of Merit: Dr. MilanGupta, University of Toronto. Dr. Gupta has madesignificant contributions to both the prevention ofcardiovascular disease and the promotion of

cardiovascular health in Canada. Dr. Gupta is incommunity practice where he has focused his attentionon improving access to care for thousands of patientstreated in the community setting.

Research Achievement Award: Dr. Jean-ClaudeTardif, Montreal Heart Institute. Over the past decadehe has been the most prolific and collaborativecardiovascular researcher working in Canada. He hashad major roles in the design and execution of large clinical outcome trials—ASTEROID, ARISE, BEAUTIFUL, EAGER, GUARDIAN,ILLUMINATE, ILLUSTRATE, MEND-CABG andWAVE—all within the past eight years. In addition, hehas been involved in trials of endothelial dysfunction,coronary irradiation for the prevention of stentrestenosis, and cardiovascular genetics. Dr. Tardif haspublished over 200 manuscripts during his career.

Trainee Excellence in Education Award: Dr. KapilBhagirath, University of Manitoba. Ideally,Dr. Bhagirath would like to combine academia—surrounded by research and residents—andphilanthropy, travelling to developing countries andcontributing to their knowledge of medicine. “To strikethat balance would be the most rewarding to meprofessionally,” he avers. “I love my job. All these yearsof work are finally paying off. It’s quite a charge to wakeup and help somebody with a problem that’s affectingtheir life.”

Young Investigator Award: Dr. Alexander Kulik,University of Ottawa Heart Institute. Dr. Kulik has adegree in medicine, has completed his training incardiac surgery (where he was the 2005 chiefresident), and has gone on to secure a Masters ofPublic Health in Clinical Effectiveness from HarvardUniversity. As author or co-author of over 30publications, Dr. Kulik has presented research at theCanadian Cardiovascular Congress and at theAmerican Heart Association Scientific Sessions onseveral occasions.

Young Investigator Award Runner-Up:Dr. Davinder Jassal, St. Boniface Research Centre.After an internal medicine residency at the Universityof Manitoba and a cardiology residency at DalhousieUniversity, he went on to complete a fellowship incardiac imaging at Massachusetts General Hospital.As principal investigator in CV imaging at the researchcentre’s Institute of Cardiovascular Sciences, Dr. Jassal has studied women with HER2-positivebreast cancer who received trastuzumab. Results ofhis research showed that women treated with themonoclonal antibody likely have a 25% risk ofdeveloping heart failure, not a 10% risk as clinical trialssuggest. Women who smoke, who are hypertensive,take diuretics or have a family history of heart diseaseare more likely to develop heart failure than others.q

R ecipients of the 2008 CCS Awards were given their day in the sun yesterday evening at the Fairmont Royal York Hotel in recognition of their many varied contributionsto cardiovascular medicine.

Joint CCS/CHRS Position Statement: new elements of atrial fibrillation ablation reflect current hospital practice

2008 CCS Award recipients step up to the podium

Clinical Snapshots from CCC 2008Is beta blockade associated with a mortality reductionin heart failure with preserved ejection fraction?Howlett et al. used a population-based, disease-specific registry to identify all patients hospitalizedin Nova Scotia with a diagnosis of heart failurebetween 1997 and 2003. Over 12,000 records wereidentified, among which 4200 had a documentedejection fraction (EF), half of them 40% or greater.Discharge prescription of a beta blocker wasassociated with a 13% lower mortality rate overall aswell as in the subgroup with reduced EF (hazardratio 0.80) but not in those with EF of 40% orgreater. Thus, beta blockers may reduce mortality inheart failure patients with lower EF but notapparently in those with preserved EF. (Abstract865) Long-term benefit of statin treatment has a greaterimpact on 10-year survival than the use of doubleinternal thoracic artery grafts. Carrier et al. examined

the effect of statin therapy on long-term resultsfollowing coronary artery bypass graft (CABG)surgery. All 6660 patients who underwent CABGsurgery between 1995 and 2005 at the authors’institution were included in the analysis. Patientswho received a single internal thoracic artery (ITA)graft had an average 10-year survival rate of 67% vs.83% in patients who received double ITA grafts.Indeed, the latter decreased mortality risk by overhalf (HR 0.47), while the use of statins within 30days of surgery decreased mortality risk by 32% (HR0.68). Rates of death, redo CABG and PCI averaged41% at 10 years in single ITA patients vs. 27% indouble ITA graft patients. Investigators concludedthat not only does double ITA grafting improve 10-year survival rates but the initiation of statin therapywithin 30 days of CABG had a greater impact on therisk of death and of coronary re-intervention at 10years than the use of multiple ITAs. (Abstract 108)

Diagnostic yield of formal clinical screening processfor inherited heart diseases. Romeo et al. evaluatedthe diagnostic yield of systematic clinical screeningof asymptomatic patients referred to theirInherited Heart Disease Clinic in Halifax. Of the293 referred patients, 251 were asymptomatic butpotentially had a genetic cardiac disorder due to adiagnosis of a genetic cardiac disorder in a familymember. Based on disease-specific protocols,patients underwent systematic screening with anumber of modalities. Slightly over 30% of thegroup were identified as having clinical findings oftheir family’s diagnosed condition. The mean ageat diagnosis was 24.9 years, and some two-thirdsof the affected patients received a prophylacticICD. Thus, a systematic and consistent approachto diagnosis of patients with a potentially inheritable cardiac disorder may be life-saving.(Abstract 131)

4

INFO-Cardio is published by Medical Education Network Canada Inc. for the annual meeting of the Canadian Cardiovascular Congress. The purpose of INFO-Cardio is to promote events organized by the CCC, and to bring delegates closer together by fostering a sense of community spirit at the meeting. Your comments/suggestions are welcome. Contact us at mednet@mednet.ca or www.mednet.ca

CCS Guidelines and Position Statements: Persistent pain and refractory angina

P ain specialists and cardiovascular disease experts will be developing aposition statement on refractory angina that will bring the issue ofpersistent pain to the fore in CVD management, on Tuesday,

October 28. Dr. Heather Ross, University of Toronto, is chair.As defined by the European Society of Cardiology, refractory angina is a

chronic condition characterized by the presence of angina caused by coronaryinsufficiency which cannot be controlled by a combination of medical therapy,angioplasty or coronary artery bypass surgery. But as pain specialist MichaelMcGillion, PhD, Assistant Professor, Lawrence S. Bloomberg Faculty ofNursing, University of Toronto, indicates, “Right now, we don’t even have ahandle on the number of patients in Canada with refractory angina and if weare talking about a persistent pain problem that is not responsive toconventional treatment, it is a real issue.”

Part of the problem lies in the paucity of specialists who are knowledgeableabout both chronic pain and CVD. “Refractory angina requires a multi-dimensional approach because you have to consider both CV mechanisms aswell as pain signalling mechanisms,” as McGillion explains. Refractory anginacan also arise or persist in the absence of myocardial ischemia, he added, “soit poses some unique management challenges.” Like all forms of chronic pain,the pain of refractory angina can be all-consuming. But because the pain iscardiac-related, it carries a heavy psychological burden and people live in fearbecause of the pain. Fear then prevents them from participating in physicalactivities which leads to a major decrease in functional status.

It is therefore important to address the cognitive aspect of their pain, asMcGillion pointed out, and techniques such as cognitive behaviour-basedself-management training is often necessary to assuage fear and improvefunction.

There are also several modalities that have proven to be particularlyeffective in refractory angina, one of which is spinal cord stimulation. Thisprocedure helps increase myocardial perfusion and decreases myocardialoxygen consumption, ameliorating coronary blood flow. “For optimal relief,it is one piece of the picture for a multi-dimensional problem like refractoryangina,” McGillion notes. Enhanced external counterpulsation is anothermodality that works well in refractory angina. It has been used in China forthe treatment of angina for decades but it has only recently gained attentionin North America. The overall hemodynamic effect of enhanced externalcounterpulsation is to augment diastolic blood flow, increase coronaryperfusion pressure and unload systolic cardiac workload, thereby decreasingmyocardial oxygen demand.

“There are pockets of expertise in Canada, but refractory angina is notgenerally well understood,” McGillion remarked. “So the main purpose ofthis position statement is to bring attention to refractory angina as a persistentpain problem and we will be looking at issues such as its incidence andprevalence in Canada as well as improving access to expert care. Our ultimateaim is to develop joint CCS/Canadian Pain Society practice guidelines toimprove refractory angina assessment and management.”q

University of Ottawa Heart Institute: continuing excellence in care, education and research

W orld-class contributions to cardiovascular medicine are on the agendaat the CCC, among them close to 100 presentations from the Universityof Ottawa Heart Institute.

Dr. Robert Roberts, President and Chief Executive Officer of the Institute,notes that as the foremost centre for cardiovascular care, education and research,the University of Ottawa Heart Institute will again play a prominent role in thedissemination of information at the meeting. “We have advanced ourunderstanding of cardiovascular disease through a number of novel projects,” heobserves, “and we are continuing to reshape the practice of patient care throughextraordinary standards of treatment.”

He adds that the University of Ottawa Heart Institute will also continue tobroaden training programs for nurses, scientists and physicians, while investigatorswill be present to discuss research during both oral sessions and posterpresentations as well as participate in various panel discussions and debates.

The research itself will be featured across many learning tracks and duringdifferent society agendas. Meanwhile, Dr. Robert Beanlands, Chief of CardiacImaging and Director of the Heart Institute’s National Cardiac PET Centre,served as chair of the CCS scientific program committee this year. The committeeis responsible for judging all submitted research and identifying studies worthy ofdelegates’ attention. q

Q. What makes the CCS meeting special for you?

Dr. Paul Dorian, University of Toronto: First of all, we’re far away from each other and we don’t see each other as often as we’d like,and the meeting gives Canadian cardiologists an opportunity to learn from each other and to discuss our academic activities in a way thatis not possible by phone. I think there is huge value in face-to-face interaction—I’m a big believer in that—so the meeting gives us anopportunity to discuss topics of mutual interest face-to-face. It also gives us an opportunity to meet with like-minded individuals. Wehave many ancillary academic activities that require us to get together from time to time, whether it’s for CCS position papers or guidelines,and we can get together here easily. Less tangible but very important as well is the opportunity for networking and team-building andsocial interaction which should not be underestimated. I think Canadian cardiologists have an enviable reputation of being able to worktogether, of collaborating and building on the strength of our collaborative networks, and the CCC gives us an opportunity to reinforcethese networks.

Dr. Ian Paterson, University of Alberta: Over the years, the CCC has become a much more scientific meeting—a lot ofground-breaking research gets presented now and it’s also a good place for clinical people to update their knowledge whichthey can easily do here as well. It’s also become a great meeting point for people from across the country, so we can gettogether and discuss what our own practices are and share our knowledge. That’s what I get out of this meeting and whatmakes it special for me.

Dr. Pedram Kazemian, University of Alberta: A plus this year is that the CCC is in Toronto and I’m from Toronto originally, so it’salways good to come back here and see the city. But as well, it’s good to see all of our colleagues coming in from across Canada andpresenting interesting findings from their research and just networking with them. The fact that the meeting has a Canadian slant probablymakes it more relevant in some areas of practice although medicine is medicine. But I think what makes the meeting most relevant is tobe able to network with others and when we have something in common, to get together with them later on. So it’s great, actually.

Dr. Sarah Pinto, Queen’s University: I’m a third-year cardiology student going into electrophysiology so the focus on EPhere is really important for me. But so is the focus on general cardiology, and then you have leaders in the field taking aboutupdates and guidelines and current trials that have come out—having their point of view is valuable, too. I also like the smallgroup sessions as well as the larger group sessions, and then there are opportunities to meet with my own colleagues as wellas those I’m hoping to work with and collaborate with in future years.

DEL

EGA

TES’

CO

RN

ER