Table 4:

Risk factor screening: New or updated recommendations in the 2018 C-CHANGE harmonized guideline^*

Recommendation	Source guideline (key supporting reference)
All
Screening for diabetes using FPG and/or A_1C should be performed every 3 yr in individuals aged ≥ 40 yr or at high risk, using a risk calculator. Earlier testing and more frequent follow-up (every 6 to 12 mo) 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 type 2 diabetes. These risk factors include: Age ≥ 40 yr First-degree relative with type 2 diabetes Member of high-risk population (e.g., African, Arab, Asian, Hispanic, Indigenous or South Asian descent; low socioeconomic status) History of prediabetes (lGT, lFG or A_1C 6.0%–6.4%) History of GDM History of delivery of a macrosomic infant Presence of end organ damage associated with diabetes: Microvascular (retinopathy, neuropathy, nephropathy) Cardiovascular (coronary, cerebrovascular, peripheral) Presence of vascular risk factors: HDL-C < 1.0 mmol/L in men, < 1.3 mmol/L in women TG ≥ 1.7 mmol/L Hypertension Overweight Abdominal obesity Smoking Presence of associated diseases: History of pancreatitis Polycystic ovary syndrome Acanthosis nigricans Hyperuricemia or gout Nonalcoholic steatohepatitis Psychiatric disorders (bipolar disorder, depression, schizophrenia) HIV infection Obstructive sleep apnea Cystic fibrosis Use of drugs associated with diabetes: Glucocorticoids Atypical antipsychotics Statins Highly active antiretroviral therapy Antirejection drugs	DC^†
Testing with 2hPG in a 75 g OGTT may be considered in individuals with FPG 6.1–6.9 mmol/L and/or A_1C 6.0%–6.4% in order to identify individuals with lGT or diabetes.	DC24
Use of standardized measurement techniques and validated equipment for all methods (AOBP, non-AOBP, home BP monitoring and ambulatory BP monitoring) is recommended. Measurement using electronic (oscillometric) upper arm devices is preferred over auscultation. (Unless specified otherwise, electronic [oscillometric] measurement should be used.)	HC25
Four approaches can be used to assess BP: AOBP is the preferred method of performing in-office BP measurement. When using AOBP, a displayed mean SBP ≥ 135 mm Hg or DBP ≥ 85 mm Hg is high. When using non-AOBP, a mean SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg is high, and an SBP between 130 and 139 mm Hg and/or a DBP between 85 and 89 mm Hg is high-normal. Using ambulatory BP monitoring, patients can be diagnosed as hypertensive if the mean awake SBP is ≥ 135 mm Hg or the DBP is ≥ 85 mm Hg, or if the mean 24-hour SBP is ≥ 130 mm Hg or the DBP is ≥ 80 mm Hg. Using home BP monitoring, patients can be diagnosed as hypertensive if the mean SBP is ≥ 135 mm Hg or the DBP is ≥ 85 mm Hg. If the office BP measurement is high and the mean home BP is < 135/85 mm Hg, it is advisable to either repeat home monitoring to confirm the home BP is < 135/85 mm Hg or perform 24-hr ambulatory BP monitoring to confirm that the mean 24-hr ambulatory BP monitoring is < 130/80 mm Hg and the mean awake ambulatory BP monitoring is < 135/85 mm Hg before diagnosing white coat hypertension.
Screening of plasma lipids for men aged ≥ 40 yr; women aged ≥ 40 yr (or postmenopausal). Consider earlier in ethnic groups at increased risk, such as South Asian or First Nations individuals.	CCS26
Screen lipids at any age for: Clinical evidence of atherosclerosis Abdominal aortic aneurysm Diabetes mellitus Arterial hypertension Current cigarette smoking Stigmata of dyslipidemia (arcus cornealis xanthelasma or xanthoma) Family history of cardiovascular disease^‡ Chronic kidney disease^§ Obesity (BMI ≥ 30 kg/m²) Inflammatory disease HIV infection Erectile dysfunction Chronic obstructive pulmonary disease Hypertensive diseases of pregnancy
Tobacco use status of all patients should be updated on a regular basis and health care providers should clearly advise patients to quit smoking.	HC27
Consider informing patients of their global risk to improve the effectiveness of risk factor modification. Consider also using analogies that describe comparative risk, such as “cardiovascular age,” “vascular age,” or “heart age” to inform patients of their risk status.	HC28
Heart failure
We recommend that patients with known or suspected heart failure should be assessed for multimorbidity, frailty, cognitive impairment, dementia and depression, all of which may affect treatment, adherence to therapy, follow-up or prognosis.	HF29
Hypertension
Global cardiovascular risk should be assessed. Multifactorial risk assessment models can be used to: Predict more accurately an individual’s global cardiovascular risk Help engage individuals in conversations about health behaviour change to lower BP Use antihypertensive therapy more efficiently In the absence of Canadian data to determine the accuracy of risk calculations, avoid using absolute levels of risk to support treatment decisions.	HC30
Stroke
Persons at risk of stroke and patients who have had a stroke should be assessed for vascular disease risk factors, lifestyle management issues (diet, sodium intake, exercise, weight, alcohol intake, smoking) and use of oral contraceptives or hormone replacement therapy. Persons at risk of stroke should receive information and counselling about possible strategies to modify their lifestyle and risk factors. Referrals to appropriate specialists should be made where required. They may provide more comprehensive assessments and structured programs to manage specific risk factors.	Stroke^†

Note: 2hPG = post-load glucose, A_1C = glycosylated hemoglobin, ACR = albumin-to-creatinine ratio, AOBP = automated office blood pressure, BMI = body mass index, BP = blood pressure, C-CHANGE = Canadian Cardiovascular Harmonized National Guideline Endeavour, CCS = Canadian Cardiovascular Society – Dyslipidemia, DBP = diastolic blood pressure, DC = Diabetes Canada (formerly Canadian Diabetes Association), eGFR = estimated glomerular filtration rate, FPG = fasting plasma glucose, GDM = gestational diabetes mellitus, HC = Hypertension Canada, HF = Canadian Cardiovascular Society – Heart Failure, HDL-C = high-density liproprotein cholesterol, IFG = impaired fasting glucose, IGT = impaired glucose tolerance, OGTT = oral glucose tolerance test, SBP = systolic blood pressure, Stroke = Heart and Stroke Foundation, TG = triglycerides.
↵* All recommendations are considered strong recommendations (Box 1); the quality of evidence supporting each recommendation varies (see Appendix 1 for a detailed discussion of the supporting evidence. Key references are indicated in this table.)
↵† Based on consensus opinion.
↵‡ Men aged < 55 yr and women aged < 65 yr of age in first-degree relative.
↵§ Chronic kidney disease: eGFR < 60 mL/min/1.73 m² or ACR > 3 mg/mmol for at least 3-mo duration.