Upload
piers-baker
View
225
Download
0
Tags:
Embed Size (px)
Citation preview
Surgical Coronary RevascularizationWho, What, When
Speaker - Jonathan G. Howlett, MD FRCPCChairperson – Gordon W. Moe, MD, MSc, FRCPC
WELCOME!
Heart Failure Guidelines
This event is an Accredited Group Learning Activity (Section 1) as defined by the Maintenance of Certification program of The Royal College of Physicians and Surgeons of Canada, and approved by the Canadian Cardiovascular Society for 1 Royal Credit MOC Section 1 Credit.
Accreditation
Heart Failure Guidelines
Learning ObjectivesAt the conclusion of this webinar, participants will be able to:
•Review the potential role of surgical intervention as a heart failure management and treatment option
•Discuss opportunities and challenges of surgery for heart failure patients – where to begin, where to end
•Develop patient specific treatment plans that take into account the benefits, risks and limitations of surgery as a treatment option
•Integrate CCS guidelines into best clinical practices
Heart Failure Guidelines
Disclosures- J. Howlett
• Speaker and/or Consultant Fees:– AstraZeneca, Bayer, CVRx, Medtronic, Novartis,
Servier, Pfizer, Otsuka, Merck
• Research and/or Funding for Research:– AstraZeneca, Bayer, CVRx, Medtronic, Novartis,
Servier– NGOs: AIHS, NIH, Canada Health Infoway
Heart Failure Guidelines
Disclosures- Dr. Moe
• No disclosures
Heart Failure Guidelines
Case 1 • 75 year old female presenting with a diagnosis of HF
• Progressive SOBOE and orthopnea– Atypical chest discomfort with variable exertion, emotional stress
• Past history– HTN – Former smoker– Negative workup for atypical chest pain 10 years ago
• Initial assessment: – BP 130/82, HR 84 bpm (regular), obvious volume overload– NT-BNP 3800 pg/mL, troponin I negative– ECG: sinus rhythm, Q waves leads II,III, AVF, QRS duration 110 msec
Heart Failure Guidelines
Case 1
• Echocardiogram performed:– LVEF ~25%, global hypokinesis– LVIDd 5.8cm; LVIDs 5.1cm, EF 29%– 2+MR– RVSP ~ 45 mmHg
• Course in hospital over 7 days– Diuresed 4 kg with IV furosemide, at “dry weight”– Started on ramipril 5mg/d, and carvedilol 6.25 mg bid and MRA
Ambulatory, wondering what we are going to do??
Heart Failure Guidelines
……prepare to provide your answers!prepare to provide your answers!
Heart Failure Guidelines
Case 1 - What would you like to do next?
1. Coronary angiogram
2. Myocardial perfusion imaging (persantine sestamibi)
3. Cardiac MRI
4. Referral to EP for ICD and or CRT
Heart Failure Guidelines
Case 1 - What would you like to do next?
1. Coronary angiogram
2. Myocardial perfusion imaging (persantine sestamibi)
3. Cardiac MRI
4. Referral to EP for ICD and or CRT
Heart Failure Guidelines
Back to Case 1
• Angiogram reveals multivessel coronary disease– Occluded RCA– 80% mid LAD lesion– 90% mid LAD lesion– 70% OM1 and 90% OM2 lesions (medium size)
• Surgical colleague reviews the films:– Technically graftable with good distal target vessels
– Serum creatinine stable at 120 mmol/L, GFR 51 ml/min
Heart Failure Guidelines
……prepare to provide your answers!prepare to provide your answers!
Heart Failure Guidelines
Case 1- Your recommended course of action ?
1. Discharge w/a plan for titrated medical tx until angina occurs
2. Present the patient to CV surgical colleagues to consider CABG
3. Refer to interventional colleague for multivessel PCI
4. Referral for ICD/CRT
Heart Failure Guidelines
Case 1 - Your recommended course of action ?
1. Discharge w/ a plan for titrated medical tx until angina occurs
2. Present the patient to CV surgical colleagues to consider for CABG
3. Refer to interventional colleague for multivessel PCI
4. Referral for ICD/CRT
Heart Failure Guidelines
Prognostic significance of ischemic cardiomyopathy
Felker et al, N Engl J Med 2000
>1200 patients with invasive evaluation for cardiomyopathy over 15 years
Ischemic etiology is also an independent predictor of mortality in risk models: Seattle Heart Failure Model (SHFM) Heart Failure Survival Score (HFSS)
Ischemic etiology is also an independent predictor of mortality in risk models: Seattle Heart Failure Model (SHFM) Heart Failure Survival Score (HFSS)
Levy et al, Circulation 2006Aaronson et al, Circulation 1997Levy et al, Circulation 2006Aaronson et al, Circulation 1997
Heart Failure Guidelines
Yusuf et al, Lancet 2004Yusuf et al, Lancet 2004
Individual patient level meta-analysis of 7 trials•2600 patients enrolled 1972-84
•CABG associated with mortality reduction
•39% at 5 years, 17% at 10 years
•No interaction with LV dysfunction and mortality reduction but higher absolute benefits seen in high risk subgroups
Individual patient level meta-analysis of 7 trials•2600 patients enrolled 1972-84
•CABG associated with mortality reduction
•39% at 5 years, 17% at 10 years
•No interaction with LV dysfunction and mortality reduction but higher absolute benefits seen in high risk subgroups
Surgical Treatment for Ischemic Heart Failure – where’s the evidence?
Heart Failure Guidelines
• In these early studies:– 90% had angina– 80% had normal LVEF– 10% had arterial conduits– Medical therapy = digoxin and
diuretics
• In these early studies:– 90% had angina– 80% had normal LVEF– 10% had arterial conduits– Medical therapy = digoxin and
diuretics
Yusuf et al, Lancet 2004Yusuf et al, Lancet 2004
Surgical Treatment for Ischemic Heart Failure – where’s the evidence?
Need to assess the benefits of revascularization in contemporary patients with ischemic cardiomypathyNeed to assess the benefits of revascularization in
contemporary patients with ischemic cardiomypathy
Heart Failure Guidelines
Current Era: Surgical Treatment for Ischemic Heart failure (STICH)
Randomized non-blinded study of surgical revascularization:
Included patients with LVEF <35% and CAD suitable for revascularization
Hypothesis 1:CABG + medical rx superior to medical rx alone
Hypothesis 2: CABG + SVR superior to CABG alone in patients undergoing revascularization with anterior wall akinesis/dyskinesis
Randomized non-blinded study of surgical revascularization:
Included patients with LVEF <35% and CAD suitable for revascularization
Hypothesis 1:CABG + medical rx superior to medical rx alone
Hypothesis 2: CABG + SVR superior to CABG alone in patients undergoing revascularization with anterior wall akinesis/dyskinesis
Velazquez et al, J Thorac and Cardiovasc SurgVelazquez et al, J Thorac and Cardiovasc Surg
Heart Failure Guidelines
STICH Hypothesis 1: Primary outcome
1212 patients randomized to CABG vs medical therapy
Patients with recent MI, major illness, significant L Main disease and severe angina excluded
No difference in all cause mortalityseen at median 56 months follow-up
17% of patients in medical therapy arm crossed over to surgical arm
1212 patients randomized to CABG vs medical therapy
Patients with recent MI, major illness, significant L Main disease and severe angina excluded
No difference in all cause mortalityseen at median 56 months follow-up
17% of patients in medical therapy arm crossed over to surgical arm
Heart Failure Guidelines
STICH Hypothesis 1: secondary outcomes
CABG associated with reduction in cardiovascular death and combined outcome of death or cardiovascular hospitalizationCABG also associated with 30% relative reduction in mortality in “on-treatment”analysis (accounting for patients crossing over within 1st year of study)
CABG associated with reduction in cardiovascular death and combined outcome of death or cardiovascular hospitalizationCABG also associated with 30% relative reduction in mortality in “on-treatment”analysis (accounting for patients crossing over within 1st year of study)
Heart Failure Guidelines
We recommend that coronary angiography be:
a)Performed in patients with heart failure with ischemic symptoms, who are likely to be good candidates for revascularization.
b)Considered in patients with systolic heart failure (LVEF < 35%) at risk of coronary artery disease, irrespective of angina, who may be good candidates for revascularization.
Strong RecommendationModerate Quality Evidence
Strong RecommendationLow Quality Evidence
Recommendations - Revascularization Procedures
Assessment for Coronary Disease
Heart Failure Guidelines
We recommend that coronary angiography be:
c) Considered in patients with systolic heart failure and in whom non-invasive coronary perfusion testing yields features consistent with high risk.
Strong RecommendationModerate Quality Evidence
Recommendations - Revascularization Procedures
Assessment for Coronary Disease
Values and Preferences: These recommendations place value on the need of coronary angiography to identify coronary artery disease amenable to revascularization. Patients with systolic heart failure due to ischemic heart disease may derive clinical benefit from coronary revascularization even in the absence of angina or reversible ischemia.
Heart Failure Guidelines
We recommend consideration of coronary artery bypass surgery for patients with chronic ischemic cardiomyopathy, LVEF < 35%, graftable coronary arteries and who are otherwise suitable candidates for surgery, irrespective of the presence of angina in order to improve quality of life, cardiovascular death and hospitalization.
Strong RecommendationModerate Quality Evidence
Recommendations - Revascularization Procedures
Surgical Revascularization for Patients with IHD and HF
Heart Failure Guidelines
We recommend that performance of coronary revascularization procedures in patients with chronic heart failure and reduced LV ejection fraction should be undertaken with a medical-surgical team approach with experience and expertise in high risk interventions.
Strong RecommendationLow Quality Evidence
Recommendations - Revascularization Procedures
Disease Management, Referral and Peri-operative Care
Values and Preferences: This recommendation reflects the panel preferences that high risk revascularization is likely to
best occur in higher volume centres with significant experience, known outcomes, and similar to participating in clinical trials involving high-risk coronary revascularization.
Practical Tip:Assessment for advanced heart failure therapies by an appropriate team should be performed
prior to revascularization in any patient with advanced heart failure
Heart Failure Guidelines
Time-varying hazard ratios for all-cause mortality in patients
randomized to CABG or MED.
Heart Failure Guidelines
However, there is interaction with risk factors:
• LVEF < median value (28%)• LV end systolic index > 60 ml/M2• 3 vessel disease
Heart Failure Guidelines
Kaplan-Meier rate estimates of all-cause mortality among patients with 2-3 (top panel) and 0-1 (bottom panel) prognostic factors.
Heart Failure Guidelines
Case 2
• 65 year old male patient assessed in your office• Multiple admissions for heart failure, difficulty with
self management• Past history
– Prior lateral wall MI, 2001 (not revascularized)– Hypertension– Significant COPD with FEV1 < 750 ml– Type 2 DM. Right AKA due to severe PVD and ABI 0.22– CKD Atrial fibrillation, previous right sided CVA– Poor mobility, refuses walking aids, but able to perform
basic ADLs slowly
Heart Failure Guidelines
Case 2
• Currently NYHA class III, no angina• Medications
– Carvedilol 25 mg bid, amlodipine 10mg/d, furosemide 120mg bid, Nitro patch 1.2 mg/h, hydralazine 50mg tid, insulin, warfarin 4 mg OD, rosuvastatin 40mg/d, Slow K 2400 mg/day, several alternative agents and periodic metolazone
• Examination: BP 90/70, HR 80 bpm, AF, enlarged heart with normal JVP, 3+ edema and clear chest with poor pulses.
• ECG: Atrial fibrillation, Heart rate 76, Q waves lateral and QRS Duration 130 msec.
• Hemoglobin 95, Creat 250, GFR 19, K 5.0 and INR 2.8
Heart Failure Guidelines
Case 2
• Patient wishes to live as long as possible but most fearful becoming dialysis dependent
http://riskcalc.sts.orgwww.euroscore.orghttp://riskcalc.sts.orgwww.euroscore.org
Heart Failure Guidelines
……prepare to provide your answers!prepare to provide your answers!
Heart Failure Guidelines
Case 2 - Your recommended course of action ?
1. Angiogram and possible CABG
2. Angiogram and possible ad hoc PCI of flow-limiting lesions
3. Non-invasive perfusion/viability test
4. Referral for ICD/CRT
5. Ongoing medical optimization only
Heart Failure Guidelines
Case 2 - Your recommended course of action ?
1. Angiogram and possible CABG
2. Angiogram and possible ad hoc PCI of flow-limiting lesions
3. Non-invasive perfusion/viability test
4. Referral for ICD/CRT
5. Ongoing medical optimization only
Heart Failure Guidelines
The average heart failure patient
Age 75 years
Hypertension 72%
Diabetes 44%
Atrial fibrillation 31%
COPD 31%
Chronic kidney disease
30%
Gheorghiade, Eur Heart J, 2005Gheorghiade, Eur Heart J, 2005
Heart Failure Guidelines
• Prospective cohort, 4 sites, ≥ 70 yrs, for CABG ± valve– Non-emergent / urgent; no major psychiatric Dx
• 5 meter walk: if ≥6 seconds, classified as frail
• 131 pts, 75.8±4.4 yrs old– 46% frail (usually diabetic, IADL problems)– No correlation with STS risk score (i.e. different domains)
• Outcome: mortality, renal failure, stroke, reoperation, prolonged ventilation, deep sternal infection
Afilalo et al J Am Coll Cardiol 2010Afilalo et al J Am Coll Cardiol 2010
Frailty and cardiac surgery
Heart Failure Guidelines
Gait speed predicts mortality/major morbidity (OR 3.05, 95%CI 1.23–7.54)
Frailty and cardiac surgery
Afilalo et al J Am Coll Cardiol 2010Afilalo et al J Am Coll Cardiol 2010
Heart Failure Guidelines
Viability and LV functional recovery after revascularization
Bax et al J Am Coll Cardiol 1997Bax et al J Am Coll Cardiol 1997
Systematic review of non-invasiveImaging techniques in predicting Regional myocardial recovery
37 observational studies
Thallium, FDG PET and DSE show high degree of sensitivity
DSE and FDG PET show greatest specificity
Systematic review of non-invasiveImaging techniques in predicting Regional myocardial recovery
37 observational studies
Thallium, FDG PET and DSE show high degree of sensitivity
DSE and FDG PET show greatest specificity
Heart Failure Guidelines
Viability and survival after revascularization
Allman et al, J Am Coll Cardiol 2002Allman et al, J Am Coll Cardiol 2002
Systematic review of 24 observational studiesEvaluating relationship between death,
viability and revascularization
Systematic review of 24 observational studiesEvaluating relationship between death,
viability and revascularization
Heart Failure Guidelines
STICH AnalysisImproved prognosis with viability
Analysis of 601 patients with viability testing data available
Viability defined as ≥ 11 segments on SPECT or ≥ 5 segments on DSE imaging
Analysis of 601 patients with viability testing data available
Viability defined as ≥ 11 segments on SPECT or ≥ 5 segments on DSE imaging
Bonow et al, N Engl J Med 2011Bonow et al, N Engl J Med 2011
Heart Failure Guidelines
STICH AnalysisViability doesn’t necessarily predict improved outcomes with surgery vs medical therapy
Bonow et al, N Engl J Med 2011Bonow et al, N Engl J Med 2011
Heart Failure Guidelines
We recommend that the decision to refer patients with heart failure and ischemic heart disease for coronary revascularization should be made on a individual basis and in consideration of all cardiac and non- cardiac factors which affect procedural candidacy.
Strong RecommendationLow Quality Evidence
Recommendations - Revascularization Procedures
Disease Management, Referral and Peri-operative Care
Heart Failure Guidelines
Practical Tips Revascularization Procedures
Imaging
1.Several non-invasive methods for detection of coronary artery disease are in widespread use
• Dobutamine stress echocardiography (DSE)• perfusion cardiac magnetic resonance (CMR)• cardiac positron emission testing (PET)• nuclear stress imaging
Local factors (availability, price, expertise, practice patterns) will determine the optimal strategy for imaging.
2.Non- invasive imaging modalities may provide critical information such as the degree of ischemic or hibernating myocardium, and may be used to determine the likelihood of regional and global improvement in left ventricular systolic function.
Heart Failure Guidelines
Practical Tips (cont’d)Revascularization Procedures
Imaging
3. Patients with heart failure, and reduced LV ejection fraction are likely to experience significant improvement in LVEF following successful coronary revascularization if they demonstrate:
a) Reversible ischemia or a large segment of viable myocardium (> 30% of LV) by nuclear stress testing/ viability study;
b) Reversible ischemia or >7% hibernating myocardium on PET scanning;
c) Reversible ischemia or > 20% of LV shown as viable by DSE;
d) Less than 50% wall thickness scarring as shown by late gadolinium enhancement by cardiac CMR.
Heart Failure Guidelines
Tsuyuki et al, CMAJ 2006Tsuyuki et al, CMAJ 2006
4200 patients with HFreferred for angiography in Alberta 1995-2001
Adjusted for baseline risk and propensity for revascularization
2538 underwent revascularization; 1690 managed medically
Majority of patients had ischemic syndromesMedical management was suboptimal
Revascularization with CABG or PCI associated with improved survival
Signal for differential outcome, favoring CABG
4200 patients with HFreferred for angiography in Alberta 1995-2001
Adjusted for baseline risk and propensity for revascularization
2538 underwent revascularization; 1690 managed medically
Majority of patients had ischemic syndromesMedical management was suboptimal
Revascularization with CABG or PCI associated with improved survival
Signal for differential outcome, favoring CABG
PCI or CABG for ischemic symptoms and heart failure? (Angina included!!)
CABGCABG
PCIPCI
Med RxMed Rx
Med RxMed Rx
Revasc.Revasc.
HR 0.50HR 0.50
Heart Failure Guidelines
We suggest consideration of percutaneous coronary angioplasty for patients with heart failure and limiting symptoms of cardiac ischemia, and for whom CABG is not considered appropriate.
Weak RecommendationLow Quality Evidence
Recommendations - Revascularization Procedures
Surgical Revascularization for Patients with IHD and HF
Heart Failure Guidelines
Practical Tips Revascularization Procedures
Surgical Revascularization for Patients with IHD and HF
1.In the setting of heart failure, angina and single territory coronary artery disease, PCI may be the treatment of first choice. However, PCI has not been shown to improve outcomes for patients with chronic stable heart failure, irrespective of underlying anatomy.
2.Urgent directed culprit vessel angioplasty continues to be the revascularization modality of choice for patients with heart failure and acute coronary syndrome.
Heart Failure Guidelines
Figure 1. Approach to Assessment for Coronary Artery Disease in Patients with Heart Failure
Heart Failure Guidelines
Figure 2. Decision Regarding Coronary Revascularization in Heart Failure
Heart Failure Guidelines
Case 3• 77 year old female, recent admission for worsening HF, now
stable NYHA II symptoms- quite happy with current state– Occasional exertional chest discomfort with more than usual activity
• Past history:– Anterior wall MI, late PCI (2005)- no angina since then– Family history of premature CAD– Mild CRF and COPD with FEV1 of 1.9 L (no admissions)– Dyslipidemia- longstanding– IGT but not DM
• Medications:– Lisinopril 20mg/d, bisoprolol 10mg/d, eplerenone 25mg/d,
ASA 81mg/d, atorvastatin 80mg/d, furosemide 20mg/d, metformin, gliclazide, nitroglycerin patch 0.8
• ECG:– Sinus rhythm, LBBB (QRS 144msec), multifocal PVCs
Heart Failure Guidelines
Case 3
• Cardiac SestaMibi with Exercise- 7 METS on treadmill, limited by SOB but not angina, normal recovery– Large area of moderate ischemia in infero-lateral territory on
persantine MIBI imaging. Large apical scar without viability and mild cardiac dilation during exercise.
• Cardiac MRI demonstrates subendocardial scar in inferior and lateral walls, transmural scar at apex with large region of anterior wall akinesis, LVEF 35%
Heart Failure Guidelines
Case 3
• Coronary angiogram during hospitalization shows progressive disease:– Left main disease– Moderate in stent restenosis with focal 80% lesion (mid LAD)– 70% ostial circumflex lesion– Diffuse flow limiting disease in dominant RCA– All vessels graftable– Large akinetic, apical segment of LV Angiogram- no thrombus.– LVEDP 22 mmHG – No valvular heart disease.
Heart Failure Guidelines
……prepare to provide your answers!prepare to provide your answers!
Heart Failure Guidelines
Case 3 - You recommend surgical revascularization with concomitant:
1. Medical therapy
2. Medical therapy + CABG
3. Medical therapy + CABG + SVR
4. Medical therapy + SVR + CRT/ICD
Heart Failure Guidelines
Case 3 - You recommend surgical revascularization with concomitant:
1. Medical therapy
2. Medical therapy + CABG
3. Medical therapy + CABG + SVR
4. Medical therapy + SVR + CRT/ICD
Heart Failure Guidelines
Jones et al, N Engl J Med 2009Jones et al, N Engl J Med 2009
STICH Hypothesis 2: CABG and CABG +SVR improved HF symptoms
1000 patients undergoing CABG in STICH trial further randomized to CABG alone vs CABG + SVR
Dominant anterior wall motion abnormality required for inclusion
Median f/u 48 months
CABG + SVR achieved a reduction in LV end-systolic index by 19% vs 6% for CABG alone
1000 patients undergoing CABG in STICH trial further randomized to CABG alone vs CABG + SVR
Dominant anterior wall motion abnormality required for inclusion
Median f/u 48 months
CABG + SVR achieved a reduction in LV end-systolic index by 19% vs 6% for CABG alone
Heart Failure Guidelines
Jones et al, N Engl J Med 2009Jones et al, N Engl J Med 2009
STICH Hypothesis 2: No difference in primary or secondary outcomes between CABG vs CABG + SVR
All cause deathAll cause deathAll cause death or cardiovascular hospitalizationAll cause death or cardiovascular hospitalization
Heart Failure Guidelines
Recommendations - Revascularization Procedures
Surgical Revascularization for Patients with IHD and HF
We recommend against routine performance of the SVR or surgical ventricular restoration for patients with heart failure undergoing CABG who have akinetic or dyskinetic LV segments.
Strong RecommendationModerate Quality Evidence
Heart Failure Guidelines
Practical Tips Revascularization Procedures
Surgical Revascularization for Patients with IHD and HF
1.In highly selected cases, patients with advanced HF symptoms in association with large areas of dyskinetic and non-viable myocardium may experience significant clinical improvement with SVR or similar type procedures, when performed by experienced surgeons.
2.Mitral valve repair may, when used concomitantly during CABG, may, in selected cases, lead to clinical improvement in symptoms of heart failure.
Heart Failure Guidelines
……prepare to provide your answers!prepare to provide your answers!
Heart Failure Guidelines
Case 3: When should you insert the ICD/CRT?
1. At the time of surgery
2. Before Surgery (CRT may obviate need of CABG)
3. After surgery, before discharge
4. After 3-6 months stable following surgery
Heart Failure Guidelines
Case 3: When should you insert the ICD/CRT?
1. At the time of surgery
2. Before Surgery (CRT may obviate need of CABG)
3. After surgery, before discharge
4. After 3-6 months stable following surgery
Heart Failure Guidelines
Timing of implantable device therapy in ischemic cardiomyopathy
Study Comparison Included Survival benefit with
device
CABG patch (1997) ICD vs no ICD Implanted at the time of CABG
-
MADIT II (2002) ICD vs no ICD MI > 1month;
Revasc > 3months
+
DINAMITE (2004) ICD vs no ICD MI < 40 days -
COMPANION (2004) ICD vs CRT-ICD vs medical rx
MI > 2months;
Revasc >2 months
+
+
SCD HeFT (2005) ICD vs amio vs placebo
MI > 1month;
Revasc >1 month
+
CARE (2005) CRT vs medical rx MI > 6 weeks +
IRIS (2009) ICD vs no ICD MI < 1 month -
RAFT (2010) CRT-ICD vs ICD Revasc >1 month +
Heart Failure Guidelines
We recommend that following successful cardiac surgery, patients with HF undergo assessment for implantable cardiac devices within 3-6 months of optimal treatment.
Strong RecommendationHigh Quality Evidence
Recommendations - Revascularization Procedures
Device Considerations in HF Patients Following Cardiac Surgery
We recommend that patients with implantable cardiac devices in situ should be evaluated for programming changes prior to surgery and again following surgery, in accordance with existing CCS recommendations.
Strong RecommendationLow Quality Evidence
Heart Failure Guidelines
Practical Tip Revascularization Procedures
Device Considerations in HF Patients Following Cardiac Surgery
1.During surgical revascularization, consideration should be given to implantation of epicardial LV leads to facilitate biventricular pacing in eligible patients who may be candidates for cardiac resynchronization therapy, especially if the coronary sinus anatomy is known to be unfavourable for lead placement.
Heart Failure Guidelines
Heart Failure Guidelines
We Value Your Opinion! Please take a few minutes to complete and
return the Evaluation Form when you receive it.
Your evaluations can have a direct impact on the quality of programming and help ensure the CCC
meets your educational needs.
THANK YOU !
Heart Failure Guidelines
Please visit our website for more information and
download our CCS guideline Apps
www.ccsguidelineprograms.ca