Table 1:

Updated or new recommendations for the 2014 Canadian Cardiovascular Harmonized National Guidelines Endeavour (C-CHANGE) guideline^*

Category; population; recommendation	Guideline group
Body habitus
Target population^† and children
• Measuring BMI is recommended in children aged 2 to 17 yr	Obesity Canada
Diet, sodium and alcohol intake
Target population^†
• To decrease blood pressure, consider reducing sodium intake toward 2000 mg (5 g of salt) per day.	CHEP
• All individuals should be encouraged to adopt healthy eating habits to lower their risk of cardiovascular disease: 1) moderate energy (caloric) intake to achieve and maintain a healthy body weight; 2) emphasize a diet rich in vegetables, fruit, whole-grain cereals and polyunsaturated and monounsaturated oils, including omega-3 fatty acids particularly from fish; 3) avoid trans fats, limit saturated and total fats to < 7% and < 30% of daily total energy (caloric) intake, respectively; 4) increase daily fibre intake to > 30 g; 5) limit cholesterol intake to 200 mg daily for individuals with dyslipidemia or at increased risk of cardiovascular disease.	CCS
People with diabetes
• People with diabetes should be offered timely diabetes education that is tailored to enhance self-care practices and behaviours.	CDA
Risk-factor screening
Target population^†
• Screening for diabetes using FPG and/or A_1c should be performed every 3 yr in individuals ≥ 40 yr of age or at high risk using a risk calculator. More frequent and/or earlier testing with either FPG and/or A_1c or 2hPG in a 75-g OGTT should be considered in those at very high risk using a risk calculator or in people with additional risk factors for diabetes. These risk factors include the following: - First-degree relative with type 2 diabetes - Member of high-risk population (e.g., Aboriginal, African, Asian, Hispanic or South Asian descent) - History of prediabetes (IGT, IFG or A_1c 6.0%–6.4%) - History of gestational diabetes mellitus - History of delivery of a macrosomic infant - Presence of vascular risk factors (low HDL [< 1.0 mmol/L in men, < 1.3 mmol/L in women], high triglyceride levels [≥ 1.7 mmol/L], hypertension, overweight/obesity) - Presence of associated diseases (polycystic ovary syndrome, acanthosis nigricans, obstructive sleep apnea, psychiatric disorders, HIV infection) - Use of drugs associated with diabetes (glucocorticoids, atypical antipsychotics, HAART)	CDA
• Testing with 2hPG in a 75-g OGTT should be undertaken in individuals with FPG 6.1–6.9 mmol/L and/or A_1c 6.0%–6.4% to identify individuals with IGT or diabetes.	CDA
• Screening of plasma lipids is recommended in men ≥ 40 and women ≥ 50 yr of age or in postmenopause. Screen lipids at any age for the following: smoking, diabetes, hypertension, overweight, rheumatoid arthritis, systemic lupus erythematosus, psoriatic arthritis, ankylosing spondylitis, inflammatory bowel disease, chronic obstructive pulmonary disease, chronic HIV infection, chronic kidney disease, abdominal aneurysm and erectile dysfunction. Consider screening individuals of First Nations or South Asian ancestry at an earlier age.	CCS
People with diabetes
• In people with diabetes, baseline resting ECG should be performed in individuals with any of the following: - Age > 40 yr - Duration of diabetes > 15 yr and age > 30 yr - End-organ damage (micro- or macrovascular) - Other cardiac risk factors • Repeat resting ECG every 2 yr	CDA
Diagnostic strategies
People with hypertension
• Routine laboratory tests that should be performed for the investigation of all patients with hypertension include the following: urinalysis; blood chemistry (potassium, sodium and creatinine); fasting blood glucose and/or A_1c; fasting serum total cholesterol, HDL cholesterol, LDL cholesterol and triglyceride levels; and standard 12-lead ECG.	CHEP
Risk stratification
Target population^†
• We recommend that a cardiovascular risk assessment, using the “10-year risk” provided by the Framingham model, be completed every 3–5 yr for men aged 40–75 and women aged 50–75 yr. This should be modified (percent risk doubled) when family history of premature cardiovascular disease is positive (i.e., first-degree relative aged < 55 yr for men and < 65 yr for women). A risk assessment might also be completed whenever a patient’s expected risk status changes. Younger individuals with at least 1 risk factor for premature cardiovascular disease might also benefit from a risk assessment to motivate them to improve their lifestyle.	CCS
• We recommend calculating and discussing a patient’s “cardiovascular age” to improve the likelihood that patients will reach lipid targets and that poorly controlled hypertension will be treated.	CCS
People with dyslipidemia
• We recommend that high risk be defined in patients who have clinical atherosclerosis, abdominal aortic aneurysm or an adjusted FRS of ≥ 20%. We have also included diabetes of > 15 yr duration and age > 30 yr, diabetes with age > 40 yr, or the presence of microvascular disease, high-risk kidney disease or high-risk hypertension.	CCS
• We recommend that the Intermediate Risk (IR) category include individuals with adjusted FRS ≥ 10% and < 20%.	CCS
Treatment targets
People with dyslipidemia
• We recommend a target LDL cholesterol level ≤ 2.0 mmol/L, or ≥ 50% reduction of LDL cholesterol for high-risk individuals in whom treatment is initiated. We recommend that apolipoprotein B ≤ 0.80 g/L or non-HDL cholesterol ≤ 2.6 mmol/L be considered as alternative treatment targets for optimal risk reduction.	CCS
• In intermediate-risk patients with LDL cholesterol < 3.5 mmol/L, the presence of an apolipoprotein B ≥ 1.2 g/L or non-HDL cholesterol ≥ 4.3 mmol/L identifies patients at increased risk of cardiovascular disease who might benefit from pharmacotherapy. We recommend a target LDL cholesterol level of ≤ 2.0 mmol/L, or a ≥ 50% reduction of LDL cholesterol for intermediate-risk individuals in whom treatment is initiated. Alternative target variables are apolipoprotein B ≤ 0.8 g/L or non-HDL cholesterol ≤ 2.6 mmol/L.	CCS
People with diabetes
• Less stringent A_1c targets (7.1%–8.5% in most cases) may be appropriate in patients with type 1 or type 2 diabetes with any of the following: - Limited life expectancy - High level of functional dependency - Extensive coronary artery disease with high risk of ischemic events - Multiple comorbidities - History of recurrent severe hypoglycemia - Hypoglycemia unawareness - Long-standing diabetes in which it is difficult to achieve an A_1c ≤ 7.0% despite effective doses of multiple antihyperglycemic agents, including intensified basal–bolus insulin therapy.	CDA
• An intensive lifestyle-intervention program combining dietary modification and increased physical activity may be used to achieve weight loss and improvements in glycemic control and cardiovascular risk factors.	CDA
People with hypertension
• In very elderly patients (age ≥ 80 yr) who do not have diabetes or target organ damage, the systolic blood pressure threshold for initiating drug therapy is ≥ 160 mm Hg and the systolic blood pressure target is < 150 mm Hg.	CHEP
Pharmacologic and/or procedural therapy
People with diabetes
• Statin therapy should be used to reduce cardiovascular risk in adults with type 1 or type 2 diabetes with any of the following: a) clinical macrovascular disease; b) age ≥ 40 yr; c) age < 40 yr and one of the following: diabetes duration > 15 yr and age > 30 yr or microvascular complications.	CDA
• Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, at doses that have demonstrated vascular protection, should be used to reduce cardiovascular risk in adults with type 1 or type 2 diabetes with any of the following: a) clinical macrovascular disease; b) age ≥ 55 yr; c) age < 55 yr and microvascular complications.	CDA

Note: 2hPG = 2-h plasma glucose test, A_1c = glycated hemoglobin, BMI = body mass index, CCS = Canadian Cardiovascular Society, CDA = Canadian Diabetes Association, CHEP = Canadian Hypertension Education Program, ECG = electrocardiogram, FPG = fasting plasma glucose, FRS = Framingham Risk Score, HAART = highly active antiretroviral therapy, HDL = high-density lipoprotein, IFG = impaired fasting glucose, IGT = impaired glucose tolerance, LDL = low-density lipoprotein, OGTT = oral glucose tolerance test.
↵* The entire list of recommendations is available in Appendix 1, at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.140387/-/DC1.
↵† The target population is adults (aged ≥ 18 yr).