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Introduction: Congestive heart failure (CHF) is responsible for significant morbidity, mortality and health resource consumption. There have been major advances in the treatment of this condition over the past two decades, yet little information is currently available regarding the current status of CHF management in Canada., Objective: To describe the pharmacological management of patients hospitalized with CHF in five provinces: Alberta, British Columbia, Nova Scotia, Ontario and Quebec., Design and Methods: Administrative data sources were used to identify all consecutive patients hospitalized with a principal diagnosis of CHF and discharged alive in the provinces of Alberta, British Columbia, Quebec and Ontario. Rates of use of prespecified medications at 30 days after hospital discharge were obtained for patients 65 years of age and older by linkage of their hospital records with drug benefit plans in these provinces. For Nova Scotia, the disease-specific registry of the Improving Cardiovascular Outcomes in Nova Scotia (ICONS) study was used to obtain discharge medications of individuals consecutively hospitalized with a diagnosis of CHF. Where available, data were acquired from 1997 to 2002., Results: Data were obtained for a total of 115,037 patients in the five provinces over the five-year period. Overall, 54.9% of patients received an angiotensin-converting enzyme inhibitor at or 30 days after hospital discharge, with minimal change in prescription rates over the five-year period. Beta-blocker prescription rates increased steadily during the study, more than doubling from 15.0% in 1997/1998 to 32.0% in 2001/2002. Spironolactone use increased dramatically, with only 2.2% of patients receiving this medication in 1997/1998 compared with 18.7% in 2001/2002. The rates of digoxin prescription decreased each year, while the use of angiotensin receptor blockers increased slightly throughout the observation period., Conclusions: While the use of evidence-based treatment for CHF in Canada is increasing and is currently at levels similar to those reported in other developed countries, there is still the potential in every province for further improvement.

Background: Oral anticoagulation is an effective therapy for the prevention of cardioembolic complications in patients with atrial fibrillation. However, previous practice reviews have indicated that oral anticoagulants are often underused in this setting. Most of those reports have focused on reviews of hospitalized and institutionalized patients, or small geographical areas., Objectives: To determine the use of antithrombotic therapy for the treatment of atrial fibrillation in Nova Scotia and to survey the knowledge of antithrombotic therapy for atrial fibrillation among a concurrent cohort of primary care and specialist physicians involved in the management of patients with atrial fibrillation., Patients and Methods: Patients with atrial fibrillation were identified through outpatient electrocardiography clinics held throughout Nova Scotia. Following consent of the primary care physicians, patients were contacted and completed a survey about their current management. Family physicians and specialists in Nova Scotia were also surveyed about the management of atrial fibrillation with antithrombotic therapy through the receipt of one of four case scenarios., Results: Four hundred twenty-five patients participated in the cross-sectional survey. The mean patient age was 70.6 years, 255 (60%) were male and 398 (93.6%) had at least one risk factor for stroke in addition to atrial fibrillation. Two hundred ninety-four patients (69.2%) were receiving oral anticoagulants either alone (61.9%) or in combination with acetylsalicylic acid (ASA) (7.3%). An additional 85 patients (20%) received ASA alone. There was no difference in the rates of prescription of oral anticoagulants between elderly patients (75 years of age and older) and those younger than 75 years (71.7% versus 67.3%, 95% CI -13.1% to 4.5%; P=0.34). Overall, 72.0% of patients were receiving antithrombotic therapy in accordance with the 2001 guidelines of the American College of Chest Physicians, with no difference in the rates between individuals younger than 75 years (72.2%) and those over 75 years of age (71.7%) (absolute difference -0.5%, 95% CI -9.2% to 8.1%). Physician responses to case scenarios indicated that knowledge was high among both general practitioners and specialists regarding the appropriate use of oral anticoagulants for the prevention of thrombotic complications associated with atrial fibrillation., Conclusions: The appropriate use of oral antithrombotic therapy for the prevention of thrombotic complications of atrial fibrillation occurs in approximately 72% of patients studied in Nova Scotia, and physician knowledge about this indication is high. There was no bias against prescribing oral anticoagulants to elderly patients. The findings suggest that with time, education and evidence have positively impacted the use of antithrombotic therapy in these patients.

Background: Therapy for management of acute myocardial infarction (AMI) varies according to patient, prescriber and geographical characteristics., Objectives: To describe the in-hospital use of reperfusion therapy for ST elevation MI (STEMI) and discharge use of acetylsalicylic acid, beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs) and statins in patients presenting with either STEMI or non-STEMI in Canada from 1999 to 2002., Methods: Four Canadian registries (FASTRAK II, Canadian Acute Coronary Syndromes, Enhanced Feedback for Effective Cardiac Treatment and Improving Cardiovascular Outcomes in Nova Scotia) were used to identify patients with AMI in Canada and to measure in-hospital reperfusion and medication use. Use rates were compared by age, sex, time period and geographical area, according to available data., Results: Use rates for reperfusion in STEMI patients ranged from 60% to 70%, primarily representing fibrinolytic therapy. A delay in presentation to hospital after symptom onset represented an impediment to timely therapy, which was particularly pronounced for women and elderly patients. Overall, less than 50% of patients met the door-to-needle target of less than 30 min. Medication use rates at discharge increased from 1999/2000 to 2000/2001 across the different data sources: acetylsalicylic acid, 83% to 88%; beta-blockers, 74% to 89%; ACEIs, 54% to 67%; statins, 41% to 53%; and calcium antagonists, 21% to 32%., Conclusions: Canadian and provincial rates of use of evidence-based medications for the treatment of AMI have increased over time, although there remains room for improvement. A single, comprehensive data source would supply better insights into the management of AMI in Canada.

Hyperglycemia on admission to the coronary care unit is associated with poor outcome. It has now been reasonably well established that intravenous insulin infusion during acute myocardial infarction has a protective role and reduces mortality. The present article reviews the current understanding of the cardioprotective effect of insulin and the recent advances in this area.

Background: Atrial fibrillation (AF) is the most prevalent sustained cardiac dysrhythmia and constitutes a major public health problem. AF significantly increases the risk of stroke, and anticoagulation has been shown to reduce this risk. However, Canadian data on the prevalence of AF and the use of warfarin in these patients are lacking., Methods: International Classification of Diseases, ninth revision, codes for admissions to acute care hospitals in Canada were used to estimate the prevalence of hospitalization for AF between 1997/1998 and 1999/2000, and subsequent readmissions for stroke in all 10 provinces and overall in Canada. Warfarin use was obtained by linkage with drug benefit plans in Alberta, British Columbia, Nova Scotia and Ontario, for patients 65 years and older., Results: The overall rate of hospitalization with AF between April 1, 1997, and March 31, 2000, was 582.7 per 100,000 population. The age- and sex-standardized rate rose from 513.4 to 555.3 during the three-year period of observation. The mean age was 74.4 years and 51.8% of patients were male. Of those discharged alive, 2.7% were readmitted for stroke within one year. Overall, less than one-half of the patients with AF filled a prescription for warfarin within 90 days of discharge, with only a small increase in warfarin use over the study time period., Conclusions: The rate of hospitalization with AF is increasing in Canada and is more frequent in men than in women across all age groups. Consistent with reports from other countries, warfarin use was lower than one might expect given its efficacy, with only a small increase in use over time.

Background: Fibrinolytic therapy has become the standard therapy for acute myocardial infarction with ST segment elevation. Many clinical trials have established that early administration of therapy correlates with improved outcomes. However, there are very few published data analyzing time to treatment in Canadian hospitals., Objectives: To examine all time intervals from onset of symptoms to treatment with fibrinolytic therapy in patients in Canada., Methods: Using the FASTRAK II database, time intervals in 11,574 patients treated with fibrinolytic therapy in 106 contributing institutions across Canada from 1998 to 2000 were studied. Variables contributing to long delays in starting fibrinolytic therapy were analyzed., Results: The mean time from onset of symptoms to arrival at hospital was 162 min (2.7 h). Only 6.3% of patients received fibrinolytic therapy within 1 h of symptom onset. Time from hospital arrival to acquisition of first 12 lead electrocardiogram was 14 min. Mean time from diagnostic electrocardiogram to decision to treat was 29.7 min, and time from decision to treat to administration of fibrinolytic therapy was 11 min. The overall average time from arrival at hospital to administration of fibrinolytic therapy was 69 min., Conclusion: In Canada, time from onset of symptoms to hospital presentation precludes early fibrinolytic therapy administration in the majority of cases. Time intervals from arrival in the emergency department to administration of fibrinolytic therapy are longer than the published and accepted standards. Strategies to alter health care seeking behaviour and to minimize in-hospital delays are needed.

Background: Heart failure is a condition associated with significant mortality and morbidity. However, demographic features and outcomes following hospitalization for heart failure, and associated regional comparisons have not been performed in Canada., Methods: Anonymously rendered records of patients hospitalized for incident heart failure in Canada were selected from the Canadian Institute for Health Information discharge abstract and hospital morbidity databases from fiscal years 1997/1998 to 1999/2000. The demographics, in-hospital mortality rate and heart failure readmission rates were compared among provinces and health regions., Results: A total of 83,406 patients were hospitalized for heart failure across Canada during the study period. The number of cases increased dramatically with each decade after age 50 years, with 85% of hospitalized patients being age 65 years and over. On average, in-hospital mortality per index admission in Canada was 9.5 deaths per 100 hospitalized cases. While the greatest burden of readmissions was among those 65 years of age and over, heart failure readmission rates were similar across age groups. Among all patients surviving the index admission, heart failure readmission rates were 8.7%, 14.1% and 23.6% at 30 days, 90 days and one year, respectively. The highest age- and sex-adjusted in-hospital mortality rates were 11.9% (95% CI 10.6 to 13.2) in Newfoundland/Labrador and 11.6% (95% CI 10.6 to 12.7) in Nova Scotia. The highest readmission rates at one year were 26.9% (95% CI 24.9 to 28.9) in Newfoundland/Labrador, 26.3% (95% CI 25.0 to 27.7) in Saskatchewan and 25.2% (95% CI 24.3 to 26.1) in British Columbia. There were significant regional variations in heart failure readmission rates and mortality., Conclusions: There is a great burden of heart failure in Canada, increasing significantly with age. The mortality and readmission rates for this condition are high and exhibit variation among health regions and provinces. Factors contributing to regional variations in these outcomes merit further study.

Background: Geographical variations in the use of invasive cardiac procedures have been documented. It remains unclear to what extent these variations exist across the Canadian provinces., Objective: To describe variation in the use of invasive cardiac procedures and waiting times for these procedures across nine Canadian provinces., Methods: Using longitudinal, de-identified patient data from the Canadian Institute for Health Information, records of patients who had suffered an acute myocardial infarction (AMI) in each of nine Canadian provinces between 1997/1998 and 1999/2000 were selected. Rates and median waiting times for percutaneous coronary intervention and coronary artery bypass graft surgery were calculated by age, sex and health region., Results: There was a large variation in the use of and waiting times for invasive cardiac procedures across the Canadian provinces studied. In general, cardiac procedure rates in Western provinces were higher than in Eastern provinces, most notably higher than in the Maritime provinces and Ontario. In addition to interprovincial variation, there was also significant regional variation in the rates of revascularization and waiting times. Rates of percutaneous coronary intervention increased over the study period, whereas rates of bypass surgery remained relatively stable., Conclusions: Significant variation in the use of cardiac procedures after AMI exists across Canada and this April represent potential inequalities in the treatment of AMI across Canada.

Background: Publication of population-based analyses of medication use after acute myocardial infarction (AMI) could encourage the use of effective secondary prevention medications., Objective: To describe outpatient use of beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, statins, calcium channel blockers and nitrates in elderly survivors of AMI over the fiscal years from 1997/98 to 1999/2000 in Nova Scotia, Quebec, Ontario and British Columbia., Methods: Linked administrative databases were used to identify all AMI patients 65 years of age or older admitted in Quebec (n=14,880), Ontario (n=28,647) and British Columbia (n=7549) over the study period, and to measure 90-day postdischarge utilization rates of cardiac medications for these patients. A population-based clinical registry was used to measure rates of prescription at discharge for elderly patients in Nova Scotia admitted to an acute care hospital from 1997 to 2000 (n=1997)., Results: Utilization rates for beta-blockers, ACE inhibitors and statins increased over time, while rates for calcium channel blockers and nitrates decreased only slightly. The largest increases were for statins (Nova Scotia: 26% to 42%, Quebec: 27% to 43%; Ontario: 28% to 40%; British Columbia: 30% to 42%) and for ACE inhibitors in Ontario (55% to 65%) and Nova Scotia (46% to 68%). Of the three drugs recommended for secondary prevention, overall utilization rates for beta-blockers were highest in Nova Scotia, lowest in British Columbia, and similar in Quebec and Ontario. Rates for ACE inhibitors were highest in Ontario and similar in Quebec, Nova Scotia and British Columbia. Rates for statins were slightly higher in Quebec and British Columbia than in Ontario and Nova Scotia. The proportion of patients without a prescription for any of the recommended drugs was highest in British Columbia (20%), lowest in Nova Scotia (8%), and similar in Quebec and Ontario (Ontario: 12%; Quebec: 13%). There was marked regional variation in utilization rates within the four provinces., Conclusions: Although utilization rates for recommended cardiac medications are increasing over time, there remains room for improvement. Overall utilization rates and temporal trends are generally similar in all four provinces, but there are wide regional variations within provinces.