opinion: how to empower those at greatest risk of heart failure to pursue testing and treatment
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those who are 65 years and older are at the greatest risk of heart failure. their symptoms may include bloating or loss of or change in appetite, swelling of the ankles, feet, legs, sacrum, or abdomen, or lingering cough or cold symptoms, to name a few.
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today, a 75-year-old male might present in my office with fatigue, shortness of breath with mild activity and some swelling around the ankles. he will have been experiencing these symptoms for quite some time, but it got worse, and his family doctor recently diagnosed him with heart failure after some cardiac testing. he was then referred to me for assessment and treatment. this is the common reality for people living with heart failure in canada.
as a heart failure specialist in british columbia, it’s not uncommon for me to see patients like this. despite the best efforts of patients, caregivers, and healthcare providers, care can be fragmented for many reasons, care quality can suffer, and health outcomes are often impacted. unsurprisingly, heart failure is one of the top three reasons for hospital admissions in canada, with one in five canadians returning to hospital within 30 days.1, 2 this readmission rate has not changed in the last decade, despite significant advances in medical therapy.3
more often than not, there are signals that could have been detected that could have changed the trajectory. these signals could have prevented hospital admission or readmission but were not seen or recognized by the right health professional at the right time. this progresses to a health crisis for the patient and an expensive and potentially avoidable hospitalization to stabilize the person living with heart failure.
heart failure is a chronic, progressive condition that requires ongoing management.1,2 it occurs when the heart is not able to properly circulate blood throughout the body following heart damage, or because of a weak heart. those who are 65 years and older are at the greatest risk of heart failure and their symptoms may include:
- bloating or loss of or change in appetite
- swelling of the ankles, feet, legs, sacrum, or abdomen
- lingering cough or cold symptoms
- extreme fatigue
- shortness of breath
- confusion, compromised thinking, or lightheadedness
- increased urination at night
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as outlined in the ccs/canadian heart failure society (chfs) heart failure guidelines,4 diagnosing someone with heart failure requires a series of tests, including:
- an echocardiogram that creates images of the heart
- an electrocardiogram (ecg) that records the electrical signals in the heart
- lab testing with key indicators that signal the presence or absence of hf
gaps in accessing the appropriate cardiac testing remain across canada. this has been validated by a recent environmental scan of heart failure resources, services, and processes surveyed across acute care and out-patient settings. the findings revealed geographic variability and significant gaps in delivery and access to heart failure services across the country.5 isn’t health care in canada meant to be universal?
there are 787,000 canadians diagnosed with heart failure each year, and yet challenges persist with treatment.6 heart failure can be managed with medications, but the ability for people to access these medications looks different depending on where you live. some medications are paid for by the selected provincial, territorial, or federal drug benefit plans, while people with heart failure living in other parts of the country do not receive the same coverage.7, 8 this is not surprising, especially given that each drug benefit program has its own set of criteria to determine who (if anyone) will be reimbursed for heart failure medications. while the older heart failure medications are mostly covered across canada, the newer, more expensive medicines are harder to acquire despite being currently recommended by national guidelines. for example, almost all formularies (91 per cent) across canada do not offer reimbursement for angiotensin receptor-neprilysin inhibitor (arni) – a more recent guideline-directed therapy in the national heart failure guidelines.
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access to medication is also delayed due to a lag between when therapies are proven to be effective and when the drug is submitted and then approved by health canada.8 there is also a step in process for updating drug formularies based on new evidence in drugs or price changes. this can further delay access to life-saving medications. between all the clinical and administrative challenges, it is no wonder that less than 70 per cent of eligible canadian patients are on recommended medical therapies and less than 30 per cent are achieving target medication doses for heart failure.9-13 this is not a model that is sustainable for our health systems or for the patients we serve.
these challenges are also intensified by the health human resource shortages in primary care. primary health care providers – namely family doctors and nurse practitioners – are the first line of defense when it comes to diagnosing and treating people living with heart failure. yet 6.5 million canadians do not have a family doctor.14 in addition, we have assigned primary care providers the responsibility of managing the complex care of people living with heart failure when specialist wait times are long and not supportive to these primary care physicians.
while barriers in pursuing heart failure diagnosis and care persist, there are things canadians can do to navigate these complex health systems to manage their care. these include the following:
- educate yourself – understand your risk and review the signs and symptoms for heart failure. learn more about this condition from a reputable source with reliable information such as the heartlife foundation or heart and stroke foundation.
- speak up – if you or your family member is experiencing one or more symptoms, visit your family doctor or nurse practitioner. identify the symptoms and request further testing to verify the presence/absence of heart failure. check to see if all the testing is covered by your provincial/territorial/federal health care plan.
- connect with other people living with heart failure – there are communities of people living with heart failure who can support you with navigating the path to diagnosis, care management, mental health, lifestyle changes, among other things. we encourage you to reach out to a patient organization such as the heartlife foundation or heart and stroke foundation.
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dr. sean virani is the president of the canadian cardiovascular society.
the canadian cardiovascular society received an unrestricted grant from innovative medicines canada (imc) for the creation of this article. imc had no influence on the design or creation of this article and the views expressed in this paper are those of the author alone.
heart failure resources for patients
- ccs heart failure hub (https://ccs.ca/guideline/2021-heart-failure-reduced-ef/)
- a patient & caregiver guide: understanding guideline-directed medical therapy for heart failure with reduced ejection fraction (hfref) (https://ourhearthub.ca/heart-failure-medications-guide/)
- heartlife foundation (https://heartlife.ca/)
- heart and stroke foundation (https://www.heartandstroke.ca/)
references
- heart and stroke foundation. falling short: how canada is failing people with heart failure – and how we can change that. available at: https://heartstrokeprod.azureedge.net/-/media/pdf-files/canada/2022-heart-month/hs-heart-failure-report-2022-final. accessed on: april 20, 2022.
- canadian institute for health information. hospital stays in canada. available at: https://www.cihi.ca/en/hospital-stays-in-canada. accessed on: may 11, 2022.
- poon s, leis b, lambert l et al. the state of heart failure in canada: minimal improvement in readmissions over time despite an increased number of evidence-based therapies. cjc open 2022;4:667-675.
- mcdonald m, virani s, chan m et al. ccs/chfs heart failure guidelines update: defining a new pharmacologic standard of care for heart failure with reduced ejection fraction. can j cardiol 2021;37:531-546.
- moghaddam n, lindsay mp, hawkin nm et al. access to heart failure services in canada: findings of the heart and stroke national heart failure resources and services inventory. can j cardiol 2023;39:1469-1479.
- health canada. canadian chronic disease surveillance system. available at: https://health-infobase.canada.ca/ccdss/data-tool/comp?g=00&v=11&m=5. accessed on january 8, 2024.
- laverdure m, clifford cr, barry q et al. can the present canadian health care system provide evidence-based pharmaceutical care? consideration of two important cardiovascular clinical contexts. can j cardiol 2025;41:60-67.
- virani s, bains m, code j et al. the need for heart failure advocacy in canada. can j cardiol 2017;33:1450-1454.
- komajda m, anker sd, cowie mr et al. physicians’ adherence to guideline-recommended medications in heart failure with reduced ejection fraction: data from the qualify global survey. eur j heart fail 2016;18:514-522.
- de groote p, isnard r, clerson p et al. improvement in the management of chronic heart failure since the publication of the updated guidelines of the european society of cardiology: the impact-reco programme. eur j heart fail 2009;11:85-91.
- greene sj, butler j, albert nm et al. medical therapy for heart failure with reduced ejection fraction: the champ-hf registry. j am coll cardiol 2018;72:351-366.
- lamb da, eurich dt, mcalister fa, et al. changes in adherence to evidence-based medications in the first year after initial hospitalization for heart failure observational cohort study from 1994 to 2003. circ cardiovasc qual outcomes 2009;2:228-235.
- thanassoulis g, karp i, humphries k et al. impact of restrictive prescription plans on heart failure medication use. circ cardiovasc qual outcomes 2009; 2:484-490.
- duong d, vogel l. national survey highlights worsening primary care access. cmaj 2023;195:e592-e593.
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