Canada: challenges and opportunities for cardiologists

All correspondence relating to this paper should be sent to: [email protected] According to government figures, heart disease in Canada claims over 50 000 lives annually and ∼1 in 12 Canadian adults (∼2.6 million) are living with heart disease—the second leading cause of death in the country after cancer. Stroke is the third leading cause of death and when combined with heart disease represents a significant burden on healthcare resources. Michelle Graham is Director of the University of Alberta’s division of cardiology in Edmonton, Canada, and a past President of the Canadian Cardiovascular Society (Figure 1). Professor Michelle Graham, Director of the University of Alberta’s division of cardiology in Edmonton, Canada, a past President of the Canadian Cardiovascular Society. European colonization and settlement have shaped Canada’s disease landscape over time. Prof. Graham says an interplay of factors have contributed to the current national picture and created an east-west split in the where genetics, lower socioeconomic status combined with smoking, and other lifestyle factors contribute to higher rates of severe coronary artery disease on the east coast. Distance defines healthcare The vast nature of the country needs to be acknowledged in any discussion of healthcare provision. Canada is twice the size of the entire European Union, and the majority of the population lives close to the border with the United States. Canada has a universal healthcare system, and each of the 10 large provinces administer their own healthcare in a semi-autonomous way. Each province uses a hub and spoke model featuring large quaternary care centres—highly specialized medical facilities usually situated in the main cities and corresponding with outlying centres. Prof. Graham says: ‘You have high-tech resources in the big centres working closely with their referring hospitals which may be some distance away. For example, where I’m based, in Edmonton, my catchment area stretches from the city of Red Deer all the way up to the North Pole. Our catchment area is huge, so we have to adapt how we deliver care based on distance. Managing a heart attack in downtown Toronto is quite different from managing one out in Alberta’. Canada’s 10 provinces and 3 territories do well in raising public awareness about the importance of screening for long-term conditions. However, much of the screening falls to the primary care sector, which has faced challenges in recent years. ‘Family doctors are well-equipped to handle screening, but time constraints and patient hesitancy have made it harder. During the COVID-19 pandemic, many patients avoided clinics due to infection fears, leading to a drop in primary prevention. As a result, people who might have benefited from early care are now needing more complex, secondary interventions’. An advantage of the semi-autonomous status of the provinces means they can move quickly to prioritize emerging needs—such as upgrading IT systems, launching new grant programmes, or directing resources to specific gaps—giving them agility to tailor care to local realities. She says: ‘In Canada, access is everything: the right care, for the right patient, by the right provider, in the right place, at the right time, but how that’s achieved varies widely depending on geography and resources. For example, in my region, patients with acute myocardial infarction (MI) are more likely to receive thrombolytics, while in downtown Toronto, primary PCI is more accessible. Despite the differences, our centre has the lowest MI mortality rate in the country—showing that tailored, context-specific solutions work. Improving access means understanding what resources exist, where patients are coming from, and how to adapt to geographic inequities in a country as vast as ours’. Cardiovascular specialists are concentrated in large city quaternary care centres and rarely found in rural areas, but current workforce shortages mean there may also be gaps in major cities. Prof. Graham identifies COVID-19 as a major factor in senior specialists retiring early with burnout contributing to a further decline in numbers. ‘There is also a shortage of various subspecialties across the country. For example, adult congenital heart disease and cardiac transplantation specialties are undersubscribed and unfortunately we are facing these workforce challenges alongside a rise in vascular disease’. The Canadian Institute for Health Information (CIHI) collects extensive healthcare data to support quality assurance. Facilities are accredited and physicians certified to maintain standards. In provinces like Alberta, outcomes can be tracked at hospital level. Data-driven decisions guide funding, improve access, and optimize care. While privacy laws limit inter-provincial comparisons, provincial benchmarking is common and increasingly vital. Impactful research and practice-changing trials As a former head of the Canadian Cardiac Society, Prof. Graham is particularly proud of her country’s achievements in cardiovascular research. She says: ‘Canadian cardiologists, though few in number, have led impactful, internationally practice-changing trials in the fields of arrhythmia, acute coronary syndromes and heart failure, while cardiac surgeons nationwide have pioneered robotic surgery and minimally invasive coronary artery bypass surgery. Innovative interventional cardiologists and their surgical colleagues have led the way in percutaneous valve replacements and complex procedures. Our adult and paediatric congenital surgeons help children with limited life expectancy reach adulthood’. Virtual care for widely dispersed communities is an area at which Canada excels, says Prof. Graham. ‘I’ve cared for patients with post-op complications as far away as the Northwest Territories- a distance of over 1500 kilometres-and it feels as if they’re in a hospital. We send them home with equipment to track vital signs and I can work with nursing staff via Zoom. In some more urban communities, we can dispatch nearby paramedics if necessary’. She describes virtual care as ‘game changing if done right’ and says, ‘These are your patients, you visit them on rounds, review the results, make active changes to their therapy, just like you would if they were in a bricks and mortar space and you monitor them for complications. This way, we can keep patients out of hospital and at home where they recover better’. Overall, she says virtual care significantly improves access to healthcare and helps realize the concept of providing the right care for the right patient at the right time by bringing specialists directly to patients and expanding treatment opportunities. All authors declare no disclosure of interest for this contribution.

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