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Canadian Cardiovascular Society (CCS) CCS480 Oral: Imaging: Related Risks and Approaches to Improve Patient Care Monday, October 25, 2010
Abstracts
248
MECHANISMS OF ATRIAL FIBRILLATION ASSOCIATED WITH OBESITY AND OBSTRUCTIVE SLEEP APNEA Y Iwasaki, B Benito, MA Gillis, A Maguy, S Nattel Montréal, Québec BACKGROUND: Obesity and obstructive sleep apnea are independent risk factors for atrial fibrillation (AF). Obesity and obstructive sleep apnea are associated with multiple pathophysiological mechanisms like hypoxia, autonomic tone changes and intrathoracic pressure alterations, that may be directly implicated in the pathogenesis of AF. Consequently, the pathogenesis of AF in obesity and sleep apnea is still uncertain. The purpose of this study was to assess the AF-substrate in relation to obesity and sleep apnea in a rat model. CONCLUSION: Zucker obese rats show substantially-increased AF inducibility during obstructive apnea vs. lean rats, but there are no differences (AF non-inducible in either group) during non-obstructive apnea These results suggest that, in addition to hypoxia, increased negative intrathoracic pressure is an important factor in AF development in the obstructive sleep apnea syndrome. Repetitive forced respiration against closed upper respiratory airways, which generates substantial negative pressures in the chest cavity, might cause atrial stretch and autonomic changes leading to increased AF susceptibility. Our results point to an important AF-promoting interaction between obesity and obstructive sleep apnea that requires further investigation.
249
SEX DIFFERENCES IN THE EMERGENCY DEPARTMENT PRESENTATION OF ATRIAL FIBRILLATION: HOW ARE WOMEN AND MEN DIFFERENT? Z Mariano, M Trivieri, CL Atzema, P Dorian Toronto, Ontario BACKGROUND: Few studies have examined gender-related differences in common arrhythmias such as atrial fibrillation (AF) and atrial flutter (AFL). We examined gender in relation to frequency of presentation, treatment, and outcome of patients presenting to the emergency department (ED) with AF/AFL. CONCLUSION: Relative to the males presenting to our ED with AF/ AFL, the females were older, a greater proportion had a CHADS2 score = 2, and they had fewer contraindications to warfarin. However they were less likely to be on warfarin or rhythm control at ED arrival or at ED/hospital discharge and they were more likely to be hospitalized.
Canadian Cardiovascular Society (CCS) CCS480 Oral IMAGING: RELATED RISKS AND APPROACHES TO IMPROVE PATIENT CARE Monday, October 25, 2010 252
REAL WORLD RADIATION DOSES FROM COMMONLY USED CARDIAC TESTING AND PROCEDURAL MODALITIES J Yang, A Scott-Moncrieff, CM Taylor, J Leipsic, B Heilbron Vancouver, British Columbia BACKGROUND: The volume of cardiac diagnostic tests performed has increased significantly in recent years. The benefits of these tests should be weighed against the risks, including those imposed by exposure to ionizing radiation. Multiple dose reduction strategies exist, but these are often underutilized in clinical practice. CONCLUSION: In this retrospective single-centre study of all patients who underwent clinically indicated CCTA, MPI and CCA in 2009 there was a wide range in effective radiation dose. These tests provide different clinical information and the appropriate test must be chosen with its resultant effective radiation dose in mind. The implementation of dose reduction strategies has the potential to significantly reduce these doses.
Can J Cardiol Vol 26 Suppl D October 2010
Featured Research 253
THE CARCINOGENIC EFFECTS OF IONIZING RADIATION FROM CARDIAC IMAGING PROCEDURES AFTER ACUTE MYOCARDIAL INFARCTION: A POPULATION-BASED LONGITUDINAL STUDY J Afilalo, PR Lawler, L Pilote, H Richard, MJ Eisenberg Montréal, Québec BACKGROUND: Patients with acute myocardial infarction (AMI) are exposed to increasing levels of low-dose ionizing radiation (LDIR) from diagnostic and therapeutic cardiac imaging procedures, during both the acute hospitalization and subsequent follow-up. Exposure to LDIR has been associated with a linear risk of cancer in atomic bomb survivors and nuclear workers, but the risk in medical patients remains uncertain. CONCLUSION: In this population-based cohort of AMI patients, LDIR from cardiac imaging procedures was associated with a graded increase in risk of cancer. These findings underscore the need for judicious use of cardiac imaging procedures, consideration of imaging modalities without LDIR when clinically appropriate, and development of protocols and technologies to reduce the dose of radiation delivered to patients.
Featured Research 254
AGE AND SEX DIFFERENCES IN RISK OF CANCER WITH LOW-DOSE IONIZING RADIATION FROM CARDIAC IMAGING PROCEDURES AFTER ACUTE MYOCARDIAL INFARCTION J Afilalo, PR Lawler, MJ Eisenberg, H Richard, L Pilote Montréal, Québec WITHDRAWN
255
RATES OF DOWNSTREAM INVASIVE CORONARY ANGIOGRAPHY AND REVASCULARIZATION: COMPUTED TOMOGRAPHIC CORONARY ANGIOGRAPHY VERSUS TC-99M SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY V Tandon, D Hall, Y Yam, L Chen, T Ruddy, BJ Chow Ottawa, Ontario BACKGROUND: Computed tomographic coronary angiography (CTA) appears to be a useful modality for the detection of obstructive coronary artery disease (CAD). Recent data suggests that CTA has a positive impact upon referrals to invasive coronary angiography (ICA) and revascularization. However, there remains concern that the implementation of CTA could increase referrals to ICA. We followed a large cohort of CTA patients and a matched cohort of Tc-99m single photon emission computed tomography (SPECT) patients to determine downstream referrals for ICA and revascularization. CONCLUSION: Compared to SPECT, CTA had similar referrals for ICA, revascularization and false positive rates. CTA appears to be a viable non-invasive diagnostic modality and does not appear to negatively impact upon ICA resources.
256
PREVALENCE, APPROPRIATENESS AND TIMING OF TRANSTHORACIC ECHOCARDIOGRAPHY IN THE CORONARY CARE UNIT: A QUALITY ASSURANCE AUDIT KM Bhagirath, RA Ducas, JW Tam Winnipeg, Manitoba BACKGROUND: In an era of spiraling health care costs, the appropriate use of medical technologies such as imaging services is of major importance. In this quality assurance investigation, we sought to determine the
65D
Abstracts use and guideline assisted appropriateness of transthoracic echocardiography (TTE) in a single tertiary care centre coronary care unit (CCU). In addition, the timing of the echo study relative to the clinical indication may be of additional importance in decisions regarding oral anticoagulation or determination of cardioverter-defibrillator (ICD) candidacy. CONCLUSION: This is the first study to address the use, appropriateness and timing of TTE in a Canadian CCU population. TTE is performed in the majority of patients admitted to the CCU, with highly appropriate indications. Our study identified duplication of imaging services in a substantial minority of patients as well as major deficiencies in the timeliness of investigation. Delay in access to early echo for those with hemodynamic concern, premature timing of echo for evaluation of LV thrombus, and lack of delayed or repeat echo assessment for potential ICD candidacy were all identified. If our findings are indicative of the care in other tertiary care CCUs across the country, urgent strategies to bridge these major gaps in care are sorely needed.
257
ENHANCING QUALITY OF CARE IN THE ECHO LAB: A FOCUSED TEACHING INTERVENTION REDUCES INTEROBSERVER VARIABILITY IN THE ESTIMATION OF EJECTION FRACTION AM Johri, MH Picard, J Newell, ME King, J Marshall, J Hung Boston, Massachusetts BACKGROUND: Estimation of ejection fraction (EF) is an integral component of determining left ventricular (LV) function and one of the most common reasons for echo referral. Precise and reliable assessment of LVEF is necessary for clinical decision making and minimizing duplicative testing. Most cardiac ultrasound laboratories have interpreters with widely varying levels of training contributing to interobserver variability (IOV) in the visual estimation of EF. Our objective was to develop a focused teaching intervention to reduce IOV in the visual estimation of LVEF within a typical ultrasound laboratory comprised of interpreters with varying levels of expertise. CONCLUSION: In a large echo lab with a wide range of training levels and experience, a simple, formalized teaching intervention can successfully diminish IOV of LVEF assessment. This intervention provides not only discrete quality measures, but also serves as a tool to document and improve quality of reporting, potentially reducing clinical inefficiencies and repeat testing.
Canadian Cardiovascular Society (CCS) CCS485 Oral SCREENING AND CARDIOVASCULAR RISK Monday, October 25, 2010
became low risk with the 2009 FRS calculator but this does not affect treatment. The intermediate FRS patients who became low risk were all young smokers who received higher risk scores with the 2006 FRS calculator.
261
ACCURACY OF CARDIOVASCULAR (CV) RISK STRATIFICATION BY CANADIAN PRIMARY CARE PHYSICIANS: PRELIMINARY RESULTS FROM THE PRIMARY CARE AUDIT OF GLOBAL RISK MANAGEMENT (PARADIGM) STUDY M Gupta, M Kajil, S Hirjikaka, M Tsigoulis, R Nisenbaum, M Mamdani, S Verma Hamilton, Ontario BACKGROUND: CV risk stratification is the foundation for optimal clinical management. Proper risk stratification can however be cumbersome. Guidelines recommend the routine use of validated tools such as the Framingham Risk Score (FRS), but such tools are not universally adopted by primary care physicians. The PARADIGM study prospectively evaluated the methods and accuracy of CV risk stratification used by primary care physicians in Canada. CONCLUSION: Overall agreement between physician and central risk assessment is only fair, improves only marginally in physicians who report routinely using the FRS, and is poor for all other methods of risk assessment. Importantly, physicians only correctly identified one third of highrisk subjects, and half of intermediate-risk subjects. Physician education regarding the proper application of the FRS, and better risk assessment tools, are warranted. AstraZeneca
262
THERE IS NO RELATIONSHIP BETWEEN COMMON CAROTID ARTERY INTIMAL MEDIAL THICKNESS AND BODY MASS INDEX MF Matangi, DW Armstrong, M Nault, D Brouillard Kingston, Ontario BACKGROUND: Increasing common carotid artery intimal medial thickening (CCA IMT) is associated with increased cardiovascular risk. The purpose of our investigation was to see if there was any relationship between the different ranges of body mass index with CCA IMT. Body mass index was divided into normal, overweight, obese and morbidly obese. CONCLUSION: Obesity is an increasing problem within our society. Obesity is generally felt to be associated with an increased cardiovascular risk. This data would suggest that obesity alone does not appear to be associated with increased carotid atherosclerosis.
263 260
THE IMPACT OF THE 2009 CANADIAN LIPID GUIDELINES ON THE CATEGORIZATION OF LOW AND INTERMEDIATE FRAMINGHAM RISK SCORES COMPARED TO 2006 MF Matangi, DW Armstrong, M Nault, D Brouillard Kingston, Ontario BACKGROUND: In the fall of 2009 new Canadian lipid guidelines were published. In comparison to the 2006 guidelines a major change was in the Framingham Risk Score (FRS) calculator. The 2009 FRS calculator now includes all cardiovascular events rather than just coronary events. This will have an impact in the number of patients who could change from low and intermediate FRS to high FRS and who therefore may require lipid lowering treatment. The purpose of our investigation was to retrospectively recalculate the 2009 FRS in patients who by the 2006 FRS calculations were classified as low or intermediate risk. CONCLUSION: Implementing the FRS calculator in the 2009 Canadian lipid guidelines will lead to treatment of a further 41% of previously categorized low and intermediate patients who did not receive statin therapy based on the 2006 guidelines. A small number of intermediate patients
66D
ASSESSING THE QUALITY OF CARDIOVASCULAR MANAGEMENT AND PREVENTION IN PRIMARY CARE PRACTICES IN EASTERN ONTAIRO CE Liddy, W Hogg, A Akbari, J Singh, L Mayo-Bruinsma Ottawa, Ontario BACKGROUND: Extensive evidence exists illustrating the important role that family practices play in the prevention and management of cardiovascular disease. Despite this significant role, many family physicians struggle to stay current with cardiovascular treatment guidelines, resulting in patient care that is suboptimal. The objective of this study is to provide a current snapshot of the quality of cardiovascular care in Ontario by examining family practice adherence to evidence-based cardiovascular treatment guidelines. CONCLUSION: Although adherence to guidelines for patients with hypertension, dyslipidemia, and CAD were relatively high, results indicate that guidelines for diabetes management, waist circumference management, smoking cessation, and the prescribing of aspirin are not being adequately followed in practices throughout Eastern Ontario. Results of this study indicate that there is room for improvement in the quality of primary
Can J Cardiol Vol 26 Suppl D October 2010
248
MECHANISMS OF ATRIAL FIBRILLATION ASSOCIATED WITH OBESITY AND OBSTRUCTIVE SLEEP APNEA Y Iwasaki, B Benito, MA Gillis, A Maguy, S Nattel Montréal, Québec BACKGROUND: Obesity and obstructive sleep apnea are independent risk factors for atrial fibrillation (AF). Obesity and obstructive sleep apnea are associated with multiple pathophysiological mechanisms like hypoxia, autonomic tone changes and intrathoracic pressure alterations, that may be directly implicated in the pathogenesis of AF. Consequently, the pathogenesis of AF in obesity and sleep apnea is still uncertain. The purpose of this study was to assess the AF-substrate in relation to obesity and sleep apnea in a rat model. CONCLUSION: Zucker obese rats show substantially-increased AF inducibility during obstructive apnea vs. lean rats, but there are no differences (AF non-inducible in either group) during non-obstructive apnea These results suggest that, in addition to hypoxia, increased negative intrathoracic pressure is an important factor in AF development in the obstructive sleep apnea syndrome. Repetitive forced respiration against closed upper respiratory airways, which generates substantial negative pressures in the chest cavity, might cause atrial stretch and autonomic changes leading to increased AF susceptibility. Our results point to an important AF-promoting interaction between obesity and obstructive sleep apnea that requires further investigation.
249
SEX DIFFERENCES IN THE EMERGENCY DEPARTMENT PRESENTATION OF ATRIAL FIBRILLATION: HOW ARE WOMEN AND MEN DIFFERENT? Z Mariano, M Trivieri, CL Atzema, P Dorian Toronto, Ontario BACKGROUND: Few studies have examined gender-related differences in common arrhythmias such as atrial fibrillation (AF) and atrial flutter (AFL). We examined gender in relation to frequency of presentation, treatment, and outcome of patients presenting to the emergency department (ED) with AF/AFL. CONCLUSION: Relative to the males presenting to our ED with AF/ AFL, the females were older, a greater proportion had a CHADS2 score = 2, and they had fewer contraindications to warfarin. However they were less likely to be on warfarin or rhythm control at ED arrival or at ED/hospital discharge and they were more likely to be hospitalized.
Canadian Cardiovascular Society (CCS) CCS480 Oral IMAGING: RELATED RISKS AND APPROACHES TO IMPROVE PATIENT CARE Monday, October 25, 2010 252
REAL WORLD RADIATION DOSES FROM COMMONLY USED CARDIAC TESTING AND PROCEDURAL MODALITIES J Yang, A Scott-Moncrieff, CM Taylor, J Leipsic, B Heilbron Vancouver, British Columbia BACKGROUND: The volume of cardiac diagnostic tests performed has increased significantly in recent years. The benefits of these tests should be weighed against the risks, including those imposed by exposure to ionizing radiation. Multiple dose reduction strategies exist, but these are often underutilized in clinical practice. CONCLUSION: In this retrospective single-centre study of all patients who underwent clinically indicated CCTA, MPI and CCA in 2009 there was a wide range in effective radiation dose. These tests provide different clinical information and the appropriate test must be chosen with its resultant effective radiation dose in mind. The implementation of dose reduction strategies has the potential to significantly reduce these doses.
Can J Cardiol Vol 26 Suppl D October 2010
Featured Research 253
THE CARCINOGENIC EFFECTS OF IONIZING RADIATION FROM CARDIAC IMAGING PROCEDURES AFTER ACUTE MYOCARDIAL INFARCTION: A POPULATION-BASED LONGITUDINAL STUDY J Afilalo, PR Lawler, L Pilote, H Richard, MJ Eisenberg Montréal, Québec BACKGROUND: Patients with acute myocardial infarction (AMI) are exposed to increasing levels of low-dose ionizing radiation (LDIR) from diagnostic and therapeutic cardiac imaging procedures, during both the acute hospitalization and subsequent follow-up. Exposure to LDIR has been associated with a linear risk of cancer in atomic bomb survivors and nuclear workers, but the risk in medical patients remains uncertain. CONCLUSION: In this population-based cohort of AMI patients, LDIR from cardiac imaging procedures was associated with a graded increase in risk of cancer. These findings underscore the need for judicious use of cardiac imaging procedures, consideration of imaging modalities without LDIR when clinically appropriate, and development of protocols and technologies to reduce the dose of radiation delivered to patients.
Featured Research 254
AGE AND SEX DIFFERENCES IN RISK OF CANCER WITH LOW-DOSE IONIZING RADIATION FROM CARDIAC IMAGING PROCEDURES AFTER ACUTE MYOCARDIAL INFARCTION J Afilalo, PR Lawler, MJ Eisenberg, H Richard, L Pilote Montréal, Québec WITHDRAWN
255
RATES OF DOWNSTREAM INVASIVE CORONARY ANGIOGRAPHY AND REVASCULARIZATION: COMPUTED TOMOGRAPHIC CORONARY ANGIOGRAPHY VERSUS TC-99M SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY V Tandon, D Hall, Y Yam, L Chen, T Ruddy, BJ Chow Ottawa, Ontario BACKGROUND: Computed tomographic coronary angiography (CTA) appears to be a useful modality for the detection of obstructive coronary artery disease (CAD). Recent data suggests that CTA has a positive impact upon referrals to invasive coronary angiography (ICA) and revascularization. However, there remains concern that the implementation of CTA could increase referrals to ICA. We followed a large cohort of CTA patients and a matched cohort of Tc-99m single photon emission computed tomography (SPECT) patients to determine downstream referrals for ICA and revascularization. CONCLUSION: Compared to SPECT, CTA had similar referrals for ICA, revascularization and false positive rates. CTA appears to be a viable non-invasive diagnostic modality and does not appear to negatively impact upon ICA resources.
256
PREVALENCE, APPROPRIATENESS AND TIMING OF TRANSTHORACIC ECHOCARDIOGRAPHY IN THE CORONARY CARE UNIT: A QUALITY ASSURANCE AUDIT KM Bhagirath, RA Ducas, JW Tam Winnipeg, Manitoba BACKGROUND: In an era of spiraling health care costs, the appropriate use of medical technologies such as imaging services is of major importance. In this quality assurance investigation, we sought to determine the
65D
Abstracts use and guideline assisted appropriateness of transthoracic echocardiography (TTE) in a single tertiary care centre coronary care unit (CCU). In addition, the timing of the echo study relative to the clinical indication may be of additional importance in decisions regarding oral anticoagulation or determination of cardioverter-defibrillator (ICD) candidacy. CONCLUSION: This is the first study to address the use, appropriateness and timing of TTE in a Canadian CCU population. TTE is performed in the majority of patients admitted to the CCU, with highly appropriate indications. Our study identified duplication of imaging services in a substantial minority of patients as well as major deficiencies in the timeliness of investigation. Delay in access to early echo for those with hemodynamic concern, premature timing of echo for evaluation of LV thrombus, and lack of delayed or repeat echo assessment for potential ICD candidacy were all identified. If our findings are indicative of the care in other tertiary care CCUs across the country, urgent strategies to bridge these major gaps in care are sorely needed.
257
ENHANCING QUALITY OF CARE IN THE ECHO LAB: A FOCUSED TEACHING INTERVENTION REDUCES INTEROBSERVER VARIABILITY IN THE ESTIMATION OF EJECTION FRACTION AM Johri, MH Picard, J Newell, ME King, J Marshall, J Hung Boston, Massachusetts BACKGROUND: Estimation of ejection fraction (EF) is an integral component of determining left ventricular (LV) function and one of the most common reasons for echo referral. Precise and reliable assessment of LVEF is necessary for clinical decision making and minimizing duplicative testing. Most cardiac ultrasound laboratories have interpreters with widely varying levels of training contributing to interobserver variability (IOV) in the visual estimation of EF. Our objective was to develop a focused teaching intervention to reduce IOV in the visual estimation of LVEF within a typical ultrasound laboratory comprised of interpreters with varying levels of expertise. CONCLUSION: In a large echo lab with a wide range of training levels and experience, a simple, formalized teaching intervention can successfully diminish IOV of LVEF assessment. This intervention provides not only discrete quality measures, but also serves as a tool to document and improve quality of reporting, potentially reducing clinical inefficiencies and repeat testing.
Canadian Cardiovascular Society (CCS) CCS485 Oral SCREENING AND CARDIOVASCULAR RISK Monday, October 25, 2010
became low risk with the 2009 FRS calculator but this does not affect treatment. The intermediate FRS patients who became low risk were all young smokers who received higher risk scores with the 2006 FRS calculator.
261
ACCURACY OF CARDIOVASCULAR (CV) RISK STRATIFICATION BY CANADIAN PRIMARY CARE PHYSICIANS: PRELIMINARY RESULTS FROM THE PRIMARY CARE AUDIT OF GLOBAL RISK MANAGEMENT (PARADIGM) STUDY M Gupta, M Kajil, S Hirjikaka, M Tsigoulis, R Nisenbaum, M Mamdani, S Verma Hamilton, Ontario BACKGROUND: CV risk stratification is the foundation for optimal clinical management. Proper risk stratification can however be cumbersome. Guidelines recommend the routine use of validated tools such as the Framingham Risk Score (FRS), but such tools are not universally adopted by primary care physicians. The PARADIGM study prospectively evaluated the methods and accuracy of CV risk stratification used by primary care physicians in Canada. CONCLUSION: Overall agreement between physician and central risk assessment is only fair, improves only marginally in physicians who report routinely using the FRS, and is poor for all other methods of risk assessment. Importantly, physicians only correctly identified one third of highrisk subjects, and half of intermediate-risk subjects. Physician education regarding the proper application of the FRS, and better risk assessment tools, are warranted. AstraZeneca
262
THERE IS NO RELATIONSHIP BETWEEN COMMON CAROTID ARTERY INTIMAL MEDIAL THICKNESS AND BODY MASS INDEX MF Matangi, DW Armstrong, M Nault, D Brouillard Kingston, Ontario BACKGROUND: Increasing common carotid artery intimal medial thickening (CCA IMT) is associated with increased cardiovascular risk. The purpose of our investigation was to see if there was any relationship between the different ranges of body mass index with CCA IMT. Body mass index was divided into normal, overweight, obese and morbidly obese. CONCLUSION: Obesity is an increasing problem within our society. Obesity is generally felt to be associated with an increased cardiovascular risk. This data would suggest that obesity alone does not appear to be associated with increased carotid atherosclerosis.
263 260
THE IMPACT OF THE 2009 CANADIAN LIPID GUIDELINES ON THE CATEGORIZATION OF LOW AND INTERMEDIATE FRAMINGHAM RISK SCORES COMPARED TO 2006 MF Matangi, DW Armstrong, M Nault, D Brouillard Kingston, Ontario BACKGROUND: In the fall of 2009 new Canadian lipid guidelines were published. In comparison to the 2006 guidelines a major change was in the Framingham Risk Score (FRS) calculator. The 2009 FRS calculator now includes all cardiovascular events rather than just coronary events. This will have an impact in the number of patients who could change from low and intermediate FRS to high FRS and who therefore may require lipid lowering treatment. The purpose of our investigation was to retrospectively recalculate the 2009 FRS in patients who by the 2006 FRS calculations were classified as low or intermediate risk. CONCLUSION: Implementing the FRS calculator in the 2009 Canadian lipid guidelines will lead to treatment of a further 41% of previously categorized low and intermediate patients who did not receive statin therapy based on the 2006 guidelines. A small number of intermediate patients
66D
ASSESSING THE QUALITY OF CARDIOVASCULAR MANAGEMENT AND PREVENTION IN PRIMARY CARE PRACTICES IN EASTERN ONTAIRO CE Liddy, W Hogg, A Akbari, J Singh, L Mayo-Bruinsma Ottawa, Ontario BACKGROUND: Extensive evidence exists illustrating the important role that family practices play in the prevention and management of cardiovascular disease. Despite this significant role, many family physicians struggle to stay current with cardiovascular treatment guidelines, resulting in patient care that is suboptimal. The objective of this study is to provide a current snapshot of the quality of cardiovascular care in Ontario by examining family practice adherence to evidence-based cardiovascular treatment guidelines. CONCLUSION: Although adherence to guidelines for patients with hypertension, dyslipidemia, and CAD were relatively high, results indicate that guidelines for diabetes management, waist circumference management, smoking cessation, and the prescribing of aspirin are not being adequately followed in practices throughout Eastern Ontario. Results of this study indicate that there is room for improvement in the quality of primary
Can J Cardiol Vol 26 Suppl D October 2010