Practical Competency-based Exercise on the CanMEDS

The average life
span of a HF
patient is:
A. 2 years
B. 3 years
C. 5 years
D. 7 years

The Four
Pillars for
Excellence
in Clinical
Practice
EQCP • Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-Centered
•Medical Expert
•Advocate
•Communication
•Scholar
•Leader
•Collaborator
•Professional
• Evidence: Clinically
relevant research literature
• Expectations: Patient’s
characteristics,
preferences & values
• Experience: Practitioner’s
knowledge & experience
•Respect for patients’ values,
preferences and expressed
needs
•Coordination and integration
of care
•Information, communication
and education
•Physical comfort
•Emotional support and
alleviation of fear and anxiety
•Involvement of family and
friends
•Continuity and transition
•Access to care
PCP
Patient-
Centered
Practice
EBP
Evidence-
based
Practice
QBP
Quality-
based
Practice
CBP
Competency-
based
Practice

The Four
Pillars for
Excellence
in Clinical
Practice
• How-to-do:
Bridging the
how-to-do Gap
• Skills-to-Do Gap:
Bridging the
Knowledge-
Practice-Attitude-do
Gap
• What to do:
Bridging the
knowledge-to-
action Gap
• Personalized Care-
to Do Gap: Bridging
Patient-Physician
Decision Making
Gap
PCP
Patient-
Centered
Practice
EBP
Evidence-
based
Practice
QBP
Quality-
based
Practice
CBP
Competency-
based
Practice
EQCP

The Four
Pillars for
Excellence
in Clinical
Practice
The Case of
Spironolactone in
Heart Failure
• How-to-do:
How to initiate,
precautions,
monitoring etc.
• Skills-to-Do Gap:
Communication,
quality
improvement tools
etc.
• What-to-do:
Evidence/
Recommendation
for using
Spironolactone in
HF
• Personalized Care-
to-Do-Gap: Use of
Decision Aids etc.
PCP
Patient-
Centered
Practice
EBP
Evidence-
based
Practice
QBP
Quality-
based
Practice
CBP
Competency-
based
Practice

Case Scenario
F 66, admitted mid-Nov 2019-breathlessness (at rest) -4th
admission since Feb 2020- average length of stay 11 days
(range 6-22 days)
Severe global HF evolving for last 9 months
LVEF at 20% in Feb 2020 (last echo).
Type II diabetes, HTN and hyperlipidemia
S/P stent in Cx-marginal in 2014
Not regular with meds especially diuretics
Symptoms of OTP, PND and LL swelling
Home bound last 2 months.
Says her doctors are not caring enough.

What else
would you like
to know on
history?
1.PO frusemide 80mg bid
2.Lisinopril 15mg OD
3.Amlodipine 5 mg OD
4.Spironolactone 25mg OD
5.Metoprolol MR 50 mg OD
6.Gliclazide MR 120 mg OD
7.Metformin 500 mg BID
8.Aspirin 81 mg OD
9.Atorvastatin 20 mg OD
10. Omeprazole 20 mg OD
Meds?

Case Scenario
O/E
Breathless,
O2 2L/min with 95% saturation
BP 156/78
Regular HR, 112/min
Raised JVP, Marked bilateral, pitting,
symmetric LL edema.
Bi-basal end-inspiratory crackles and
scattered wheeze up to mid zones
posteriorly.

Echocardiogram shows:
•LVH
•LVEF 20%
•Cardiac index 1.8L/min/m2 (no inotropes)
•Moderate RV dysfunction
•PAP 48mmHg
•LA: mod dilatation
•Mild MR, Moderate TR,
•CVP estimated 20mmHg

What is the
Diagnosis &
Treatment
Recurrent heart failure
IV frusemide 40 mg twice daily
Daily weight
Intake/Output chart
Daily P2 and P3.
DVT prophylaxis

The Essential Entrustable Professional Activities:
Medical Expert as per the SCHS One45
Able to complete a
comprehensive, Hypothesis-
driven (ACS vs Esophageal
Spasm) and Patient centered
(Psychosocial Impact) H & P.
Able to select the most
appropriate test(s) based on
indications and sensitivity,
Specificity or Likelihood
Ratios (CXR vs BNP in CHF).
Able to formulate
appropriate differential
diagnosis e.g. Anatomic,
Physiologic, Aetio-Pathologic
etc. relevant to the clinical
presentation.
Able to analyze, integrate,
and formulate effective
management strategies e.g.
using the 5S scheme.
Able to discuss relevant
knowledge to a wide variety
of medical problems and
develops a plan of
secondary prevention.

Medical Expert as per the SCHS One45
Able to identify (Generic &
Specific Severity Indicators)
and respond appropriately to
urgent cases.
Able to use evidence in
clinical decision-making e.g.
calculators (BMI, ABG
interpretation), Scoring Tools
e.g. CURB-65.
Able to apply relevant
information in problem-
solving e.g. proficiently
discuss the pros and cons for
the various differential
diagnosis, avoid Cognitive
Biases etc.
Able to articulate the
important pharmacodynamics
and pharmacokinetics as well
as the indications, adverse
events and serious
interactions of medications.
Able to perform diagnostic &
therapeutic procedures,
understands indications,
limitations & complications e.g.
Can demonstrate the use of a
Peak Flow meter or how a
metered-dose inhaler should be
used via a spacer device.

The 7 GOLDEN Steps in Patient Care
Prepare for Discharge & Follow-up
Order your “Immediate” Therapeutic Interventions
Order Tests Rationally
Propose a Differential Diagnosis
Propose a “comprehensive” Diagnostic label (+Problem List)
Summarize: Using “technical” language
Gather Information: H&P (History & Physical)

The Medical
Expert Input
Hypothesis-Driven History Taking and Physical Examination.
Detailed Problem-List for comprehensive care inputs
Use of Calculators and Scoring Tools for decision-making e.g. BMI
Calculator, CURB-65, Well’s Score for PE risk, Creatinine Clearance,
NIH Stroke Score, Bode Score for COPD survival prediction,
Ranson’s Score etc. UpToDate has a huge collection.
Patient- and Family Centered history-taking and management
decisions e.g. use of decision-aids.
Using the BESD and 5S for comprehensive immediate diagnostic
and therapeutic input.
Avoiding Cognitive Biases Skills: DD Scheme (Anatomical,
Physiological, Aetiopathologic), Rules of Thumb, Ruling out worst
scenario, ROWS, Red Flags etc.
Procedural skills-: CanMEDS Technical Skills Round/Simulation
Lab: e.g. Lumbar Puncture, Ascitic Tap etc.
Enabling
Actions

The Medical
Expert Input
Summary
Diagnostic Label/Problem List
Differential Diagnosis
Tests: Highest Sensitivity &/or
Specificity Tests for proposed clinical
diagnosis
Immediate Interventions
Calculations/Scoring Tools of relevance
Prognosis
Discharge Planning Actions
The Exercise

The Medical
Expert Input
Summary
66Y F with a background of IHD post-
stenting 2014, HFrEF, Type II diabetes,
HTN, hyperlipidemia and recurrent
admissions with heart failure
presented with symptoms of CHF. She
has poor compliance to meds and
significant social impact.
Clinically, hemodynamically stable,
uncontrolled BP, breathless with
tachycardia and bronchospasm and
signs of CHF.
The Exercise

The Medical
Expert Input
Diagnostic Label
Bedside Diagnosis
CHF/Cardiac Asthma-Recurrent admission with worsened
HFrEF
Etiology
Uncontrolled BP, ?Coronary, Iron def. ?Thiamine deficiency
Severity
Stage D, NYHA 4, Warm & Wet
Problem List
IHD, DM2, Hypertension, DLP, Poor Compliance, Social
Isolation, Patient-Physician Discordance
The Exercise

The Medical
Expert Input
Differential Diagnosis
For cause of Recurrent Heart Failure
1. Patient Factors:
◦ Continuous exposure to precipitant e.g. drugs (NSAID, LICORICE
etc.)
◦ Poor compliance/Wrong use of meds (salt/water restriction)
◦ Psychosocial factors
2. Physician Factors
◦ Complicated e.g. pneumonia, kidney failure etc.
◦ Suboptimal therapy e.g. suboptimal diuretic dose
◦ Failure to control the precipitant e.g. hypertension, ischemia,
iron/B1 Deficiency, myocarditis, pulmonary embolism, valvular,
endocarditis etc.
The Exercise

The Medical
Expert Input
Tests: Highest Sensitivity &/or
Specificity Symptoms, Signs and Tests
for the proposed clinical diagnosis.
The Exercise

The Science of Numbers in Medicine
Item Sensitivity Specificity LR+ (5 or more rules in
the diagnosis)
Positive Test Result
LR- (0.3 or less rules-
out the diagnosis)
Negative Test Result
Dyspnea on
Exertion
0.84 0.34 1.3 0.48
Orthopnea 0.50 0.77 2.2 0.65
3rd Heart Sound 0.13 0.99 11 0.88
Raised JVP 0.39 0.92 5.1 0.66
Pulmonary venous
congestion
0.54 0.96 12 0.48
Interstitial edema 0.34 0.97 12 0.68
BNP more than
100pg/ml
0.93 0.66 2.7 0.11
According to this table the presence of a 3rd heart sound is a better sign for diagnosing heart failure than raised
JVP (LR 11 versus 5.1).
LR are higher when a test has a higher specificity i.e. test is diagnostic if positive (high diagnostic value)
and lower when a test has higher sensitivity i.e. test is good for screening (useful for excluding a
diagnosis if negative).

The Medical
Expert Input
Immediate Interventions: Treatment
(5S)
Site of Care: General ward
Symptomatic:-sit up, reassurance, morphia
Supportive:-oxygen, nitrate infusion, CPAP (if
indicated)
Specific: IV Frusemide Bolus 40 mg plus infusion
5mg/hr
Specialty Input: Cardiology, Endocrinology,
Physiotherapy, Psychiatry, Educator
The Exercise

The Medical
Expert Input
Calculations/Scoring Tools of
relevance
Prognosis
Examples:
1. BMI
2. NYHA
3. Creatinine Clearance
4. Seattle Heart Failure Prognostication Tool
5. American Heart Association Get With the
Guidelines Score
The Exercise

The Medical
Expert Input
The Exercise
1. Fill a Composite Problem List on admission
2. Home Medication reconciliation completed on admission
3. Fill relevant Consultation Requests
4. Timely completion of Consultation visit and timely feedbackto the team of its outcome/recommendations.
5. Criteria for Discharge outlined on admission
 Resolution or marked Improvement of cause of admission: Y/N
 No social issues/Patient and/or family education/training completed: Y/N
 Supporting Services /Appliances needs fulfilled: Y/N
 Specific Clinical or Imaging or Laboratory Targets:……………………………………………………….
6. Provisional Date of Discharge documented
7. Provisional Date of Discharge Alert inside Patient’s Room
8. Patient and Family are made aware of exact date& time of discharge 48 hrs. before.
9. Hospital to Home Medications Switch 48 hrs. pre-discharge
10. Home Tools Checklist
 Glucometer Y/N
 O2 Concentrator Y/N
 Suction Machine Y/N
 Home Supplies Y/N
 Physical Aids Y/N
 Other

The Medical
Expert Input
The Exercise
11. Preventive Interventions
 DVT prophylaxis: Y/N
 Bed sores prevention: Y/N
 Prevention of Device-related Complications: IV Line, Foley’s, PICC Line, Central Line etc. Y/N
 Aspiration Pneumonia prevention: Y/N
 Vaccinations: Y/N
 Self-management Plan: Y/N
 Refer to Physio. or Rehab. Service: Y/N
12. Education of Patient & Family Checklist and Self-Management Plan for each Medical Problem
13. Patient and Family notified of discharge at least 24 hrs. and preferably 48 hrs. pre-discharge.
14. Medications etc. prescribed 24 hrs. pre-discharge date
15. Medication Reconciliation by Internists &/or Pharmacist
16. Need for Medical Report
17. Need for Transport
18. Follow-up arranged
19. Pre-Appointment Test Forms written 24 hrs. pre-discharge
20. Contact Number for urgent calls
21. Post-discharge Home phone Call/Checklist
22. Actual Date of Discharge

Communicator as per the SCHS One45
Able to communicate
effectively with
patients, their
families, and HCPs.
Can use the various
communication styles-both
verbal and non-verbal as
appropriate:
• Therapeutic Communication
• Motivational Communication
• Handing-over
• Breaking Bad News
• Disclosure of Error
• Dealing with Angry Patient or
Relative
• Professional Communication
Able to maintain clear,
accurate &
appropriate records.
Able to write well
organized & legible
orders and progress
notes.
Able to write
Discharge Summaries
that are concise &
completed promptly.

The
Communicator
Input
Documentation: H&P, SOAP, SBAR/I-PASS
Handover, Discharge Summary, Medical
Report etc.
Consultation Referrals-using SBAR/I-PASS
Counseling Skills, Dealing with angry
clients, Breaking Bad News, Disclosure of
Error
Motivational and Therapeutic
Communication
Presentations in meetings, committees,
conferences etc.
Enabling
Actions

The
Communicator
Input
Present to Consultant/Colleague/Consultation
Situation: Um…. is a 66 year F with 4th admission with
acute decompensated congestive heart failure secondary
to poor compliance and ?ACS with increased cardiac
enzymes.
Background: IHD-post stent 2014, Hypertension, DM2,
DLP
Assessment: hemodynamically stable and improving on
treatment
Recommendations: review regarding issue of ischemia as
an alternative cause for recurrent admissions
The Exercise

The
Communicator
Input
Communicate results of ABNORMAL
tests to patient.
The Sandwich Technique
The Exercise

The
Communicator
Input
Communicate prognosis.
The Exercise

The
Communicator
Input
Examples of Therapeutic
Communication (Unhappy with
Physicians).
Rapport
Empathy/Magic of touch
Willing to sit beside his/her patient
Approachability
Good listener
Gives hope
The Exercise

The
Communicator
Input
Example of Motivational Communication (Compliance issues).
SPIKES Cognitive Scheme
SETTING UP the interview
Perception: Assess the Patient’s perception-assist the patient to name the discrepancy
between current status and ideal: open-ended question-What are your views of your current
and future health and heart issue? Patient should indicate the risk/harm of status quo!
INVITATION: Obtain the Patient’s “willing” to change otherwise STOP!
Knowledge: Giving KNOWLEDGE and Information to the Patient about their current health
and future prognosis.
Empathy: Addressing the Patient’s EMOTIONS with empathic responses: +NURSE
Strategy and Summary PLUS obtain and rate patient’s willingness & chance of success to
follow the plan (e.g. out of 10 with 10 being best and zero no chance) and support self-
efficacy if any. Agree on a time plan, follow-up and enroll supporters-family, patients 'group
etc.!
The Exercise

Collaborator as per the SCHS One45
Works effectively in a team
environment with attending,
juniors & nursing staff.
Coaches
Shows How
Says “We”
Says “Thanks”
“Asks politely”
Says “Let’s go”
Committed to one Goal
Democratic etc.
Not in One45:
Resolution of Interpersonal Conflicts
Community Collaboration: Patient Support Groups, Government Bodies
Collaboration etc. Community Service Rotation.
International Collaboration: Research Collaboration, Quality of Care
Collaboration etc. International Exchange Programs.

The
Collaborator
Input
Effective Team work: Multidisciplinary & Interdisciplinary,
Committee Membership etc.
Team Building Skills: Committed to one Goal, Coherence,
Communication, Creative, Democratic etc.
Multidisciplinary/ Interdepartmental Care Dynamics
Resolution of Interpersonal Conflicts
Discharge Planning: Completing a problem list, Criteria for
Discharge, Patient/Family Education, Drug Counseling, Appliances,
Transport etc.
Community Collaboration: Patient Support Groups, Government
Bodies Collaboration etc. Community Service Rotation.
International Collaboration: Research Collaboration, Quality of
Care Collaboration etc. International Exchange Programs.
Enabling
Actions

The
Collaborator
Input
Examples of hospital Collaborators
Examples of community
collaborators
Examples of international
collaborators
The Exercise

The Essential Entrustable Professional
Activities: Advocate as per the SCHS One45
Able to identify the
psychosocial, economic,
environmental & biological
factors which influence the
health of patients and society.
Able to offers advocacy on
behalf of patients at practice
and general population levels.
Can speak and act on behalf
of patients to promote their
well-being mentally, physically
and socially.
Can initiate educational,
screening and preventative
action for patients, their
families and communities.
Social Determinants of
Health

The Advocate
Input
 Patient Needs: Psychosocial and
Biological needs, Education, Screening,
Preventive Interventions, Timely
Referrals (Home Healthcare) etc.
 Membership of Patient’s Help Groups
 Community Care Service/
Participation
Enabling
Actions

The Advocate
Input
Itemize the determinants
of health of relevance to
this case
Itemize the screening
interventions
Itemize the preventative
interventions.
The Exercise

Activities: Scholar as per the SCHS One45
Able to regularly attend e.g.
80% of MM and contribute to
rounds, seminars, and other
learning events.
Able to positively react in
response to constructive
feedback.
Able to educate patients,
junior residents, house staff,
and students (Teaching Skills).
Able to successfully complete
a Research Project.
Not in One45
CPD

The Scholar
Input
 EBM: PICO, Literature Searching, Critical Appraisal,
Implementation of Evidence, Assessment of EBM process.
EBM Rotation.
 Teaching: Presentation Skills, Time Management Skills,
Personal Performance Skills, Teaching e.g. supervision,
mentoring. Teaching Skills Rotation.
 Research: Research & Biostatics, Creating Research
Ideas/Banks, Writing Research Proposals, Funding your
Research, Writing Papers & Thesis, Publishing Research.
Research Rotation. Technology Rotation.
 Continuous Professional Development: Learning
Activities-Individual or group learning activities that occur on
a regular or day to day basis, Self-Assessment Programs.
Enabling
Actions

The Scholar
Input
IV boluses versus Infusion of Furosemide in heart
failure?
The NNT/NNH for medical and non-medical
interventions
Preventing readmissions?
Innovations in heart failure care
Different interventions Economic effectiveness
The Exercise

Activities: Leader as per the SCHS One45
Able to serve in administration
and leadership roles as
appropriate e.g. Clinical Roles:
Consultant, Senior Resident,
Junior Resident etc.
Able to appropriately &
efficiently use health care
resources.
Not in One45
Quality Improvement
Career Management (CV Writing,
Job Search/Application,
Interviewing Skills etc.)

The Leader
Input
 Time Management
 Quality Management/Improvement: Mortality &
Morbidity review, Safety issues, Audit, PDSA,
Fishbone Diagram etc.
 Career Management: Job Search, Covering Letter,
Personal Statement, Writing Resume, Interview
Skills etc.
 Leadership Skills: Coaches, Shows How, Says
“We”, Says “Thanks”, “Asks”, Says ”Let’s go” etc.
 Clinical Roles: Consultant, Senior Resident, Junior
Resident etc.
Enabling
Actions

The Leader
Input
Auditing the care of heart
failure e.g. readmissions
Investigating and dealing with
a serious medical error e.g.
hypokalemic cardiac arrest.
The Exercise

Professional as per the SCHS One45
Able to deliver the
highest quality of care
with integrity &
compassion.
Recognizes limitations
and seeks advice and
consultations when
necessary.
Able to abide to the
highest standards of
excellence in clinical
care and ethical
conduct.
Not in One45
Self-care
* Can act professionally upholding and applying
the Code of Conduct)/Islamic Cultural Values &
Legislative Regulations.
* Can identify the important domains of quality
and apply them in practice.
• Can articulate and explain the important Ethical
Principles governing patient care e.g.
confidentiality, autonomy etc.
• Can proficiently and successfully deal with
common ethical dilemmas in practice e.g. refusing
medications or “No Code/Not for Resuscitation,
unprofessional colleagues etc.

The
Professional
Input
 Ethical Patient Care: Dealing with Ethical
Dilemmas e.g. refusing medication or “No
Code/Not for Resuscitation”.
 Personal Professional Conduct (Code of
Conduct)/Islamic Moral Values & Legislative
Regulation).
 Self-Care: Physical and Psychological
Health/Stress Management.
Enabling
Actions

The
Professional
Input
 Patient refusing to have a blood transfusion
despite a hemoglobin of 48 gm/L. What will
you do?
 Mistake by your colleague? Ethical practice
for dealing with such an incident?
 Resident does not attend to the patient in a
timely manner? Ethical practice for dealing
with such behavior?
The Exercise

Offers for improvement?
 Diagnostic labelling of Heart Failure patients
 Cause for recurrence of heart failure:
Risk stratification and
prognostication-need for higher
level expert input Use of IV Diuretics in ADHF?
 Choice of home PO diuretic drug?
 Guideline-directed medical therapy.
 Use of Heart failure-friendly anti-hypertensives?
 Use of heart failure-friendly anti-diabetics?
 Prevention of re-admission interventions.
 Co-morbidities: Renal Failure, OSA, Depression, Deconditioning etc.

Risk Scores to Predict Outcomes in HF
Risk Score Reference (from full-text guideline)/Link
Chronic HF
All patients with chronic HF
Seattle Heart Failure Model (204) / http://SeattleHeartFailureModel.org
Heart Failure Survival Score (200) / http://handheld.softpedia.com/get/Health/Calculator/HFSS-Calc-
37354.shtml
CHARM Risk Score (207)
CORONA Risk Score (208)
Specific to chronic HFpEF
I-PRESERVE Score (202)
Acutely Decompensated HF
ADHERE Classification and Regression Tree
(CART) Model
(201)
American Heart Association Get With the
Guidelines Score
(206) /
http://www.heart.org/HEARTORG/HealthcareProfessional/GetWithTheGuidelin
esHFStroke/GetWithTheGuidelinesHeartFailureHomePage/Get-With-The-
Guidelines-Heart-Failure-Home- %20Page_UCM_306087_SubHomePage.jsp
EFFECT Risk Score (203) / http://www.ccort.ca/Research/CHFRiskModel.aspx
ESCAPE Risk Model and Discharge Score (215)

Admission Rate
and Mortality
Any association?

Interventions to Reduce Re-Hospitalizations
What

Based on SRs & MAs: Interventions to
Reduce Re-Hospitalizations
Multicomponent QI interventions can be effective at reducing readmissions relative
to the status quo! –
1. Patient and family education (inclusive of neurocognitive and literacy
assessment, Self-management etc.)
2. Hospital Heart Failure Care System Redesign (Specialized Clinic, Care
Team, Care Transitions/Discharge Planning etc.)
3. Telemedicine
4. Telemonitoring
5. Mobile Health Platforms
6. Cardiac Rehabilitation Program

Meds:
1. Beta-Blockers (BB)
2. Angiotensin-converting enzyme (ACE) inhibitors
3. Angiotensin II Receptor Blockers (ARBs)
4. Angiotensin Receptor Neprilysin Inhibitor (ARNI)
5. Aldosterone Antagonists (AA)
6. Digoxin
7. Combined therapy with Hypertonic Saline plus furosemide
8. Torsemide/?Bumetanide (versus Frusemide)
9. Ivabradine

10. SGLT-2 Inhibitors (in diabetics with heart failure)
11. Trimetazidine
12. Omega 3 Fatty Acids
13. Intravenous Iron (in patients with low transferrin sats (less than
20%)
14. ? Thiamine
15. ? Vitamin C
16. ? Vitamin D (a potent Renin Synthesis inhibitor).

Device-based Interventions:
◦Cardiac Resynchronization Therapy (CRT)
◦? Left Ventricular Assist Device (LVAD)

What is the
Diagnosis &
Treatment
Clinical Element Intervention
Bedside Diagnosis
Etiology
Severity
Prognosis
Treatment (5S)
Comorbidities
Preventive

What is the
Diagnosis &
Treatment
Clinical
Element
Intervention
Bedside Diagnosis CCF-Recurrent admission with worsened HFrEF
Etiology Uncontrolled BP, Iron def. ?Thiamine deficiency,
?Coronary
Severity Stage D, NYHA 4, Warm & Wet
Prognosis Less than 1 year median expected survival
Treatment (5S) Site of Care: General ward
Symptomatic:-sit up, reassurance, morphia
Supportive:-oxygen, nitrate infusion, CPAP (if indicated)

What is the
Diagnosis &
Treatment
Clinical Element Intervention
Treatment (5S) Specific: IV Frusemide Bolus 40 mg plus infusion
5mg/hr
GDMT-improve dosing of triple therapy, BP to target,
?add ARNI.
Thiamine, IV Iron, Ascorbic Acid
Add SGLT-2 Inhibitor, Digoxin, ?Trimetazidine
Specialty Input: Cardiology, Endocrinology,
Physiotherapy, Psychiatry, Educator
Comorbidities AF, Depression, Deconditioning, OSA
Preventive DVT prophylaxis, Vaccination, Warfarin or NOACs,
Readmission (Team based Protocolized Care etc.),
Education, SMP

The Bottom Line
We can do it!

Medical Therapy for Stage C HFrEF: Magnitude of
Benefit Demonstrated in RCTs
GDMT
RR Reduction in
Mortality
NNT for Mortality
Reduction
(Standardized to 36 mo)
RR Reduction
in HF Hospitalizations
ACE inhibitor or ARB 17% 26 31%
Beta blocker 34% 9 41%
Aldosterone antagonist 30% 6 35%
Hydralazine/nitrate 43% 7 33%

Practical Competency-based Exercise on the CanMEDS

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