We read with interest the opinion letter of the Dr René Wittmer and his colleagues in The Duty of September 16 and we respect their position on the judicious use of health resources in a system where staffing levels are limited. This is a reality that we face daily. We applaud the commitment and sensitivity of the Choisir avec soin Québec campaign. We would like to clarify certain points raised.
Heart valve disease (poor functioning of the heart valves) affects nearly one million people in Canada and its frequency increases exponentially with age. These diseases manifest insidiously, especially in older people. They progress over several years without causing symptoms and, when they do appear, they are often underestimated by patients, who instead attribute them to aging. The OxValve study conducted in England revealed that nearly 50% of people with these diseases are not diagnosed and are not adequately managed.
In addition, evidence from randomized clinical trials shows that valve replacement or repair surgery performed before symptoms appear offers patients a better chance of survival and improved quality of life. Other studies show that when surgery is performed after symptoms appear, some heart damage is irreversible and survival and quality of life are poorer.
Dr. Wittmer and colleagues refer to data from retrospective studies that focus more on coronary cardiovascular disease (myocardial infarction) and stroke, and not on valvular heart disease, which has a very different course and clinical expression. It is therefore important to understand that medical management is personalized and does not apply to all diseases.
As with cancers and certain diseases such as diabetes, early detection and diagnosis of heart valve disease is essential for successful treatment and patient survival. Far too many patients are diagnosed with their valve disease, coronary artery disease, cancer or diabetes at an advanced stage and at this stage the risk of treatment failure or partial success is much higher.
Keystone
Family physicians and frontline health professionals are the keystone of this early detection strategy. Indeed, the best way to detect valvular diseases at an asymptomatic stage is for the family physician to auscultate a heart murmur during the medical examination.
Dr. Wittmer and colleagues suggest that there is no indication or benefit in performing an annual physical exam that includes cardiac auscultation, blood pressure, etc. We are concerned about the decline or removal of annual physical exams and chronic disease screening tests from family physician practice guidelines, particularly in the older population.
We fully understand the burden that screening and prevention examinations place on physicians, who are understaffed in Canada and Quebec. We wish to clarify that in our expert report on the care pathway for people with heart valve disease, we do not recommend an annual examination for the entire population regardless of age or medical history, but only for people over 60 years of age, in whom the prevalence of heart valve disease and other societal chronic diseases is much higher than in the rest of the population.
We are sensitive to the challenges faced by family physicians and health professionals, which is why we believe that new technologies that allow the recording of cardiac data (electrocardiogram, heart sounds, oximetry, blood pressure), automatically and in a few seconds, could be used to help family physicians and front-line health professionals carry out systematic screening of seniors.
We invite all health professionals to work together with the government, hospital and clinic administrators and patient associations to strengthen and expand the base of the health care pyramid in Quebec, which is made up of family doctors and professionals working on the front lines. It is urgent to increase the number of staff and resources in front-line care and to deploy the new technologies already available to enable family doctors to fulfill not only their mission of caring for patients, but also, and above all, to detect diseases at an early stage and contribute to sustainable health.
*Co-signed this letter: Lyne Bérubé, cardiologist-echocardiographer at the CHUM; Philippe Pibarot, professor at the Faculty of Medicine at Laval University, director of the Canada Research Chair on Valvular Heart Diseases, IUCPQ; Samer Mansour, cardiologist-hemodynamicist at the CHUM; Jean-Bernard Masson, cardiologist-hemodynamicist at the CHUM; Paolo Costi, cardiologist-electrophysiologist, head of cardiology and the cardiovascular group at the CHUM; Amilie Lebrun, nurse practitioner specializing in adult care (cardiology and cardiac surgery); François-Adrien Duvauchelle, nurse practitioner specializing in adult care (cardiology and cardiac surgery), health professional researcher at the CHUM research centre; Christine Bellemare-Ratelle, nurse practitioner specializing in adult care (cardiology and cardiac surgery), health professional researcher at the CHUM research centre.