CAEP - Acute Heart Failure - BEST PRACTICES CHECKLIST

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Assessment

Treatment

Disposition & Follow-up

Assessment

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1. What is acute heart failure (AHF)?

2. How does acute heart failure present?

3. Diagnosis of acute heart failure

1. What is acute heart failure (AHF)?

Heart failure (HF) is a syndrome that results from the structural or functional impairment of ventricular filling or ejection of blood.
Cardinal manifestations include dyspnea, fatigue, pulmonary and/or splanchnic congestion, peripheral edema.
Acute heart failure is a common condition that frequently results in poor outcomes or death.^{1 2}
- patients typically present to the emergency department (ED) with increased shortness of breath.
- may be the first episode of HF (new onset) or, more frequently, be due to acute decompensation of chronic HF.
Diagnosis is primarily clinical assisted by selected investigations.³

Left ventricular ejection fraction (LVEF) in heart failure is classified as:
HF with preserved ejection fraction	(HFpEF)	LVEF >50%
HF with mildly reduced ejection fraction	(HFmrEF)	LVEF 41%-49%
HF with reduced ejection fraction	(HFrEF)	LVEF <40%
HF with improved ejection fraction	(HFimpEF)	compared to baseline

2. How does acute heart failure present?

There are four major clinical presentations with possible overlap:

(ADHF)

onset of dyspnea over days
pulmonary congestion, jugular venous distension, peripheral edema
the most common form, accounting for 50-70% of ED presentations

(aka “flash pulmonary edema”)

onset of dyspnea over hours
pulmonary congestion causes dyspnea with orthopnea, tachypnea, and hypoxia

caused by RV dysfunction, severe pulmonary hypertension, or severe tricuspid valve disease
symptoms often nonspecific: exertional dyspnea, fatigue, early satiety, symptoms of right-sided volume overload
physical findings include jugular venous distension, often with a prominent V wave and positive Kussmaul sign, ascites, leg edema
often poor outcomes

due to primary cardiac dysfunction that results inadequate cardiac output and life-threatening tissue hypoperfusion, which can lead to multiorgan failure and has >30% mortality
may be precipitated by acute events (e.g. myocardial infarction (MI), myocarditis) or acute decompensation of chronic left ventricular (LV) dysfunction
diagnosis is based on evidence of hypoperfusion:
- signs: cold wet extremities, mottling, oliguria, mental confusion, narrow pulse pressure
- blood pressure Is often low (SBP < 90mmHg) but may bepreserved by reflex vasoconstriction
- low urine output
- laboratory: metabolic acidosis with elevated serum lactate, creatinine, and/or liver enzymes

3. Diagnosis of acute heart failure

There are four major clinical presentations with possible overlap:

should be considered:

non-adherence with diet/sodium/water
non-adherence with or recent change in medication; chemotherapeutic agents
infections (pneumonia, influenza, endocarditis, myopericarditis)
arrhythmias (atrial fibrillation (AF), atrial flutter (AFL), bradycardia, ventricular tachycardia)
pulmonary embolism
MI, acute coronary syndrome (ACS)
hypertensive emergency

Tip:

Consider alternative or precipitating diagnoses for acute severe dyspnea:

myocardial infarction (MI)
pneumonia
pulmonary embolism
exacerbation of asthma/COPD
pericardial tamponade
pneumothorax
acute valve regurgitation
acute aortic syndrome
arrhythmias: VT, SVT, AF, AFL

focuses on:

worsening symptoms (dyspnea, orthopnea, paroxysmal nocturnal dyspnea)
recent weight gain
history of heart failure and echocardiography results
history of coronary artery disease
medications

focuses on impact of lung congestion:

agitation, somnolence, confusion
poor perfusion, cyanosis, diaphoresis
breathless speech
inability to lie supine
usually afebrile, tachypnea, low oxygen saturation, tachycardia
peripheral/sacral edema
jugular venous distension (JVD), hepatojugular reflux (HJR)
crackles, wheezing
extra heart sounds, murmurs

can rapidly assess:

lung congestion (pleural effusion, bilateral B-lines)
qualitative LV function
JVD
RV filling pressure estimation by measurement of inferior vena cava (IVC)
pericardial effusion

helps identify:

rhythm abnormalities (AF/AFL, heart block, bradycardia, ventricular tachycardia)
acute myocardial ischemia
RV, LV, or atrial hypertrophy or strain
myopericarditis
use 15-lead ECG for posterior ischemia, if shock

include hematology, chemistry, and troponin.

NT-proBNP strongly recommended:
- <300 pg/ml – unlikely AHF
- 300-900 pg/ml (age 50-75) or 300-1800 (age >75) – consider use of PRIDE HF Score
- >900 pg/ml (age 50-75) or >1800 (age >75) – likely AHF

for cardiomegaly, lung congestion (redistribution, Kerley B lines, interstitial fluid), other conditions.

can can be helpful when the diagnosis is uncertain:⁴

PRIDE Acute Heart Failure Score⁴

Predictor			Score
	Interstitial edema on CXR		2
	Orthopnea		2
	Lack of fever		2
	On loop diuretic		1
	Age >75 years		1
	Crackles/rales on lung exam		1
	Lack of cough		1
	Elevated NT-proBNP		4
	> 450 pg/mL if age <50 > 900 pg/mL if age >50
		Total

Likelihood of HF	Total Score
Low	0-5
Intermediate	6-8
High	9-14

CONTINUE

Assessment

◀

2. How does acute heart failure present?

There are four major clinical presentations with possible overlap:

(ADHF)

onset of dyspnea over days
pulmonary congestion, jugular venous distension, peripheral edema
the most common form, accounting for 50-70% of ED presentations

(aka “flash pulmonary edema”)

onset of dyspnea over days
pulmonary congestion, jugular venous distension, peripheral edema
the most common form, accounting for 50-70% of ED presentations

caused by RV dysfunction, severe pulmonary hypertension, or severe tricuspid valve disease
symptoms often nonspecific: exertional dyspnea, fatigue, early satiety, symptoms of right-sided volume overload
physical findings include jugular venous distension, often with a prominent V wave and positive Kussmaul sign, ascites, leg edema
often poor outcomes

due to primary cardiac dysfunction that results inadequate cardiac output and life-threatening tissue hypoperfusion, which can lead to multiorgan failure and has >30% mortality
may be precipitated by acute events (e.g. myocardial infarction (MI), myocarditis) or acute decompensation of chronic left ventricular (LV) dysfunction
diagnosis is based on evidence of hypoperfusion:
- signs: cold wet extremities, mottling, oliguria, mental confusion, narrow pulse pressure
- blood pressure Is often low (SBP < 90mmHg) but may bepreserved by reflex vasoconstriction
- low urine output
- laboratory: metabolic acidosis with elevated serum lactate, creatinine, and/or liver enzymes

CONTINUE

Assessment

◀

3. Diagnosis of acute heart failure

There are four major clinical presentations with possible overlap:

should be considered:

non-adherence with diet/sodium/water
non-adherence with or recent change in medication; chemotherapeutic agents
infections (pneumonia, influenza, endocarditis, myopericarditis)
arrhythmias (atrial fibrillation (AF), atrial flutter (AFL), bradycardia, ventricular tachycardia)
pulmonary embolism
MI, acute coronary syndrome (ACS)
hypertensive emergency

Tip:

Consider alternative or precipitating diagnoses for acute severe dyspnea:

myocardial infarction (MI)
pneumonia
pulmonary embolism
exacerbation of asthma/COPD
pericardial tamponade
pneumothorax
acute valve regurgitation
acute aortic syndrome
arrhythmias: VT, SVT, AF, AFL

focuses on:

worsening symptoms (dyspnea, orthopnea, paroxysmal nocturnal dyspnea)
recent weight gain
history of heart failure and echocardiography results
history of coronary artery disease
medications

focuses on impact of lung congestion:

agitation, somnolence, confusion
poor perfusion, cyanosis, diaphoresis
breathless speech
inability to lie supine
usually afebrile, tachypnea, low oxygen saturation, tachycardia
peripheral/sacral edema
jugular venous distension (JVD), hepatojugular reflux (HJR)
crackles, wheezing
extra heart sounds, murmurs

can rapidly assess:

lung congestion (pleural effusion, bilateral B-lines)
qualitative LV function
JVD
RV filling pressure estimation by measurement of inferior vena cava (IVC)
pericardial effusion

helps identify:

rhythm abnormalities (AF/AFL, heart block, bradycardia, ventricular tachycardia)
acute myocardial ischemia
RV, LV, or atrial hypertrophy or strain
myopericarditis
use 15-lead ECG for posterior ischemia, if shock

include hematology, chemistry, and troponin.

NT-proBNP strongly recommended:
- <300 pg/ml – unlikely AHF
- 300-900 pg/ml (age 50-75) or 300-1800 (age >75) – consider use of PRIDE HF Score
- >900 pg/ml (age 50-75) or >1800 (age >75) – likely AHF

for cardiomegaly, lung congestion (redistribution, Kerley B lines, interstitial fluid), other conditions.

can can be helpful when the diagnosis is uncertain:⁴

PRIDE Acute Heart Failure Score⁴

Predictor			Score
	Interstitial edema on CXR		2
	Orthopnea		2
	Lack of fever		2
	On loop diuretic		1
	Age >75 years		1
	Crackles/rales on lung exam		1
	Lack of cough		1
	Elevated NT-proBNP		4
	> 450 pg/mL if age <50 > 900 pg/mL if age >50
		Total

Likelihood of HF	Total Score
Low	0-5
Intermediate	6-8
High	9-14

CONTINUE

Treatment

◀

Treat underlying causes:
- infections, arrhythmias, pulmonary embolism, ACS, hypertension.
Oxygen should be used cautiously in patients with normal oxygen saturation because of concerns of increasing systemic vascular resistance and reducing cardiac output.
- give oxygen for patients who are hypoxemic, titrated to an oxygen saturation >90%.
Noninvasive ventilation (NIV) through BiPAP or CPAP should be considered for patients with a high respiratory rate (>25 breaths/min), respiratory fatigue, and persistent hypoxemia despite high-flow oxygen.
- routine use of NIV is not advisable due to risk of worsening right HF, hypercapnia, aspiration, and pneumothorax.
- NIV may be useful in hemodialysis patients with acute HF.
Endotracheal intubation should be used if less invasive modes of oxygen delivery and ventilation support fail.
- order blood gases if ventilatory fatigue a concern.
IV diuretics remain the mainstay of therapy and should be administered as early as possible.
- use bolus administration as no advantage to continuous infusion.⁵
- start with an initial IV dose of furosemide:
  - if patient already taking diuretics, give 1-2 times the daily oral dose as the initial IV dose.
  - if patient not on oral diuretics, suggest:
    - 20 mg furosemide for eGFR >60
    - 40 mg furosemide for eGFR 30-60
    - 60-80 mg furosemide for eGFR <30
  - assess for satisfactory diuretic response:
    - urine output >100-150 mL/h during the first 6 hours.
    - urine sodium content >50-70 mEq/L at 2 hours.
- if insufficient diuretic response: confirm diagnosis of AHF and then double the IV diuretic dose.
- if response remains suboptimal patient may be in normotensive cardiogenic shock.
IV morphine should not be used as it increases morbidity and mortality.
Vasodilators and inotropic agents should only be used in selected patients (e.g. pulmonary edema, cardiogenic shock) as they do not improve outcomes in most patients.
Beta-blockers and calcium-channel blockers should be avoided in management of tachycardia and AF/AFL if LVEF is low or not known.

Three treatments should be commenced, if indicated, simultaneously:
1. Oxygen should be given using NIV or high-flow nasal cannula.⁶
2. IV diuretics remain the mainstay of therapy and should be administered as early as possible.
  - use bolus administration as no advantage to continuous infusion.⁵
  - start with an initial IV dose of furosemide:
    - if patient already taking diuretics, give 1-2 times the daily oral dose as the initial IV dose.
    - if patient not on oral diuretics, suggest:
      20 mg furosemide for eGFR >60
      
      40 mg furosemide for eGFR 30-60
      
      60-80 mg furosemide for eGFR <30
    - assess for satisfactory diuretic response:
      - urine output >100-150 mL/h during the first 6 hours.
      - urine sodium content >50-70 mEq/L at 2 hours.
  - if insufficient diuretic response: confirm diagnosis of AHF and then double the IV diuretic dose.
  - if response remains suboptimal patient may be in normotensive cardiogenic shock.
3. Nitroglycerin should be given if systolic BP (SBP) >100 mmHg, to reduce LV afterload.
  - consider immediate sublingual nitroglycerin spray (1-2 sprays at 400 μg/spray) followed by IV.
  - give IV nitroglycerin in an initial dose of 5 to 10 μ g/min increase by 5 to 10 μg/min every 3-5 minutes as required and tolerated (dose range 10 to 200 μg/min).
  - high-dose nitrates may be considered if SBP ≥ 160 mmHg:^{7 8}
    - start at 100 μg/min and rapidly titrate as tolerated to 200 μg/min (maximum 400 μg/min).
    - decrease dose as dyspnea and SBP improve.
  - IV nitroprusside may be used by experienced physicians.

Rule out ACS with RV involvement or pulmonary embolism.
Diuretics are the main therapy for venous congestion.
Involve cardiology early if the patient has severe pulmonary hypertension or fails to respond to diuretics.

Consult cardiology/critical care urgently.
Identify and treat underlying causes:
- if ACS, consider percutaneous coronary intervention (PCI).
- if tamponade, consider pericardiocentesis.
- if papillary muscle rupture, consider surgery.
- other (acute valve regurgitation, pulmonary embolism, infection, myocarditis, arrhythmia).
Provide oxygen and consider ventilatory support.
- if intubation is needed, choose a sedative agent with caution – consider ketamine or etomidate.
- for ongoing sedation, consider IV midazolam and fentanyl and avoid propofol.
Consider inotropes/vasopressors:⁹
Weight in Kilograms

• norepinephrine (first line)
0.05 ug/min

• dobutamine
2-10 ug/min

• milrinone
0.25-0.75 ug/min
- norepinephrine is first line: start at 0.05 ug/kg/min and titrate up
- dobutamine 2-10 ug/kg/min
- milrinone 0.25-0.75 ug/kg/min
Consider expert consultation for mechanical circulatory support (percutaneous LV assist devices or ECMO).

CONTINUE

CAEP Acute Heart Failure Checklist

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What is acute heart failure (AHF)? - Assessment

Acute Decompensated Heart Failure - Assessment

Acute Pulmonary Edema - Assessment

Isolated Right Ventricular (RV) Failure - Assessment

Cardiogenic Shock - Assessment

Etiology and Precipitating Factors - Assessment

History - Assessment

Clinical Exam - Assessment

Point-of-care Ultrasound (POCUS) - Assessment

ECG Indicators - Assessment

Investigations - Assessment

Chest X-ray - Assessment

The PRIDE HF Scale - Assessment

Overall Approach - Treatment

Acute Pulmonary Edema - Treatment

Isolated Right Ventricular Failure - Treatment

Cardiogenic Shock - Treatment

How to Decide if Patient Can be Discharged Home - Disposition and Follow-up

What is the HEARTRISK6 Scale? - Disposition and Follow-up

How to Optimize Discharge Medications - Disposition and Follow-up

What is Appropriate Follow-up? - Disposition and Follow-up

Background and Methods

Advisory Committee Members

References

Acknowledgements

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Background and Methods

We created the CAEP Acute Heart Failure Best Practices Checklist to assist emergency physicians in Canada and elsewhere manage patients who present to the emergency department (ED) with acute heart failure. While there are several excellent cardiology society heart failure guidelines, there is nothing specific for ED management. The checklist attempts to fill that gap and focuses on patients presenting with one of four heart failure syndromes, acute decompensated heart failure, acute pulmonary edema, isolated right ventricular failure, and cardiogenic shock. There are detailed sections on diagnosis, treatment, disposition and follow-up.

The methodology and the format are similar to that of the 2021 CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist.¹¹ We chose to adapt, for use by emergency physicians, existing high-quality clinical practice guidelines previously developed by the Canadian Cardiovascular Society (CCS).^{1 12} These guidelines were developed and revised using a rigorous process that is based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system of evaluation.¹³ With the assistance of our PhD methodologist (IDG), we used the recently developed Canadian CAN-IMPLEMENT© process adapted from the ADAPTE Collaboration.^{14 15} We also reviewed heart failure guidelines from the European Society of Cardiology and the American College of Cardiology/American Heart Association/Heart Failure Society of America.^{2 9} We created an Advisory Committee consisting of 16 academic emergency physicians, three community emergency physicians, seven cardiologists, one general internist, three PhD methodologists, and two patient partners. The checklist was prepared and revised through a process of iterative feedback and discussions on all issues by all panel members. There were nine rounds of revisions until consensus was achieved. We then circulated the draft checklist for comment to approximately 500 Canadian emergency medicine and cardiology colleagues. Finally, the CAEP Standards Committee posted the Checklist online for all CAEP members to provide feedback. Only minor changes resulted from this feedback. The document has been approved by the CAEP Board.

While the panelists did offer the option of high dose nitrates for acute pulmonary edema, they chose not to use the term “SCAPE” (sympathetic crashing acute pulmonary edema) because it is not widely used and because the supporting evidence is weak.

Our hope is that the CAEP Acute Heart Failure Best Practices Checklist will standardize and improve care of acute heart failure in large and small EDs alike.

References

Ezekowitz JA, O'Meara E, McDonald MA, et al. 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure. Can J Cardiol 2017;33(11):1342-433. doi: 10.1016/j.cjca.2017.08.022 [published Online First: 2017/11/08]
McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021;42(36):3599-726. doi: 10.1093/eurheartj/ehab368 [published Online First: 2021/08/28]
Bozkurt B, Coats AJS, Tsutsui H, et al. Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure: Endorsed by the Canadian Heart Failure Society, Heart Failure Association of India, Cardiac Society of Australia and New Zealand, and Chinese Heart Failure Association. Eur J Heart Fail 2021;23(3):352-80. doi: 10.1002/ejhf.2115 [published Online First: 20210303]
Baggish AL, Siebert U, Lainchbury JG, et al. A validated clinical and biochemical score for the diagnosis of acute heart failure: the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) Acute Heart Failure Score. Am Heart J 2006;151(1):48-54. doi: 10.1016/j.ahj.2005.02.031
Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011;364(9):797-805. doi: 10.1056/NEJMoa1005419
Yan L, Lu Y, Deng M, et al. Efficacy of high-flow nasal cannula in patients with acute heart failure: a systematic review and meta-analysis. BMC Pulm Med 2023;23(1):476. doi: 10.1186/s12890-023-02782-0 [published Online First: 20231128]
Long B, Brady WJ, Gottlieb M. Emergency medicine updates: Sympathetic crashing acute pulmonary edema. Am J Emerg Med 2025;90:35-40. doi: 10.1016/j.ajem.2024.12.061 [published Online First: 20250105]
Siddiqua N, Mathew R, Sahu AK, et al. High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial. Emerg Med J 2024;41(2):96-102. doi: 10.1136/emermed-2023-213285 [published Online First: 20240122]
Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022;79(17):e263-e421. doi: 10.1016/j.jacc.2021.12.012 [published Online First: 2022/04/06]
Stiell IG, Perry JJ, Eagles D, et al. The HEARTRISK6 Scale: Predicting Short-Term Serious Outcomes in Emergency Department Acute Heart Failure Patients. JACC Adv 2024;3(7):100988. doi: 10.1016/j.jacadv.2024.100988 [published Online First: 20240524]
Stiell IG, de Wit K, Scheuermeyer FX, et al. 2021 CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist. Cjem 2021 doi: 10.1007/s43678-021-00167-y [published Online First: 2021/08/13]
Ducharme A, Zieroth S, Ahooja V, et al. Canadian Cardiovascular Society-Canadian Heart Failure Society Focused Clinical Practice Update of Patients With Differing Heart Failure Phenotypes. Can J Cardiol 2023;39(8):1030-40. doi: 10.1016/j.cjca.2023.04.022 [published Online First: 20230509]
Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924-26.
Collaboration A. The ADAPTE Process: resource toolkit for guideline adaptation, 2009:1-95.
Harrison MB, van den Hoek J, Graham ID. CAN-IMPLEMENT: Planning for best-practice implementation. Philadelphia, PA, 2014:1-148.

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NYHA Class	Definition
I	No symptoms
II	Symptoms with ordinary activity
III	Symptoms with less than ordinary activity
IV	Symptoms at rest or with minimal activity

			Points
1. Initial Assessment
	a.History of valvular heart disease¹		1
	b.Heart Rate:
	i. HR > 100bpm to <120 bpm		2
	ii. HR >120 bpm		3
	c.Treated with non-invasive ventilation²		2
2. Investigations
	a.Creatinine:
	i. >150 umol/L to <300 umol/L		2
	ii. > 300 umol/L		3
	b.Troponin:
	i. > 3x or 4x upper limit of normal		1
	ii. >5x upper limit of normal (initial or repeat, local hospital assay)		2
3. Falls Reassessment after ED Treatment (2-6 hours)
	a.Resting vital signs abnormal (SpO2 <90% on RA or usual O2, or HR > 110, or RR >28)		1
	OR
	b.Unable to start or complete 3-minute walk test (vital signs become abnormal during walk)³		1

		TOTAL

Total Score	Absolute Risk	Category
0	6.4%	Low
1	8.5%
2	11.3%	Medium
3	14.9%
4	19.4%
5	24.8%
6	31.2%	High
7	38.3%
8	48%
9	53.9%
>10*	61.6%

Academic Emergency Medicine
Ian Stiell (Chair)	Ottawa Hospital, ON
Patrick Archambault	Hôtel-Dieu de Lévis, Lévis, QC
Bjug Borgundvaag	Sinai Health, Toronto, ON
Alexis Cournoyer	Hôpital du Sacré-Cœur, Montréal, QC
Kerstin de Wit	Kingston HSC, ON
Debra Eagles	Ottawa Hospital, ON
Andrew McRae	Foothills Hospital, Calgary, AB
Judy Morris	Hôpital du Sacré-Cœur, Montréal, QC
Robert Ohle	Health Sciences North, Sudbury, ON
Jeff Perry	Ottawa Hospital, ON
Brian H. Rowe	U of Alberta Hospital, Edmonton, AB
Frank Scheuermeyer	St Pauls Hospital, Vancouver, BC
Brian Steinhart	Unity Health, Toronto, ON
Alain Vadeboncoeur	Montreal Heart Institute, QC
Krishan Yadav	Ottawa Hospital, ON
Justin Yan	London HSC, ON
Community Emergency Medicine
Rupinder Sahsi	Grand River Hospital, Kitchener, ON
Troy Tebbenham	Peterborough Regional Health Center, ON
Suneel Upadhye	Niagara Falls, ON
Cardiology/Internal Medicine
Aws Almufleh	Kingston Health Science Centre, ON
Darshan Brahmbhatt	Sinai Health, Toronto, ON
Nadia Bouabdallaoui	Montreal Heart Institute, QC
Heather Clark	Ottawa Hospital, ON
Caroline McGuinty	Ottawa Heart Institute, ON
Robert J. Miller	Libin Cardiovascular Institute, Calgary, AB
Guillaume St-Pierre	Hôtel-Dieu de Lévis, Lévis, QC
Amelia Yip	St Mary’s Hospital, Kitchener, ON
Methodology (PhD)
Ian D. Graham	Ottawa Hospital Research Institute, ON
Stuart Nicholls	Ottawa Hospital Research Institute, ON
Sophie Boisvert	Université du Québec, Lévis, QC
Patient Partners
Marc Bains (Patient)	HeartLife Foundation
Christian Chabot (Patient)	Quebec City, QC

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