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Guideline group Grading system or methodology Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-Informed Tobacco Treatment1 This independent expert body in guideline review conducted a review and identified 6 guidelines that met criteria for quality and applicability to local context. Summary statements were extracted and assigned a grade of recommendation and level of evidence by a second expert panel.2 The ADAPTE framework was used to guide the contextual adaptation (www.g-i-n.net/working-groups/adaptation/history); AGREE II was used to rate and select appropriate guidelines. Canadian Cardiovascular Society – guideline for the management of heart failure3 GRADE Canadian Cardiovascular Society – guideline for the management of dyslipidemia4 GRADE Canadian Association of Cardiovascular Prevention and Rehabilitation Hypertension Canada process (www.hypertension.ca) Canadian Society for Exercise Physiology5 The Canadian Society for Exercise Physiology guideline steering committee used the AMSTAR tool (www.amstar.ca/docs/AMSTARguideline.pdf) to assess the methodological quality of the systematic reviews; conclusions from the reviews were assigned a level of evidence6–9 based on quality of the study, and level of evidence was used to develop appropriate wording for the guideline. Diabetes Canada10 Diabetes Canada process (www.guidelines.diabetes.ca/) Hypertension Canada11 Hypertension Canada process (www.hypertension.ca) Canadian Association of Bariatric Physicians and Surgeons/Obesity Canada12 GRADE Heart and Stroke Foundation13 GRADE Note: AGREE II = Appraisal of Guidelines for Research & Evaluation II, AMSTAR = Assessment of Multiple Systematic Reviews, C-CHANGE = Canadian Cardiovascular Harmonized National Guidelines Endeavour, GRADE = the Grading of Recommendations, Assessment, Development and Evaluation framework.14
- Table 2:
Body habitus: New or updated recommendations in the 2018 C-CHANGE harmonized guideline*
Recommendation Source guideline Heart failure We suggest daily morning weight should be monitored in patients with heart failure, with fluid retention or congestion that is not easily controlled with diuretics, or in patients with significant renal dysfunction. HF† Note: C-CHANGE = Canadian Cardiovascular Harmonized National Guidelines Endeavour, HF = Canadian Cardiovascular Society – Heart Failure.
↵* 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).
↵† Based on consensus opinion.
- Table 3:
Diet, and sodium and alcohol intake: New or updated recommendations in the 2018 C-CHANGE harmonized guideline*
Recommendation Source guideline (key supporting reference) All To prevent hypertension and reduce blood pressure in hypertensive adults, consider reducing sodium intake toward 2000 mg (5 g of salt or 87 mmol of sodium) per day. HC19 We suggest that all individuals be encouraged to moderate energy (caloric) intake to achieve and maintain a healthy body weight and adopt a healthy dietary pattern to lower their risk of cardiovascular disease: Mediterranean dietary pattern
Portfolio dietary pattern
DASH dietary pattern
Dietary patterns high in nuts (≥ 30 g/d)
Dietary patterns high in legumes (≥ 4 servings/wk)
Dietary patterns high in olive oil (≥ 60 mL/d)
Dietary patterns rich in fruits and vegetables (≥ 5 servings/d)
Dietary patterns high in total fibre (≥ 30 g/d); and whole grains (≥ 3 servings/d)
Low glycemic load or low glycemic index dietary patterns
Vegetarian dietary patterns
CCS20 Diabetes People with diabetes should be offered timely self-management education that is tailored to enhancing self-care practices and behaviours. DC21 Overweight or obesity A dietary plan for improving health for adults with obesity should be part of a weight-management strategy. Obesity22 A comprehensive healthy lifestyle intervention is recommended for people with overweight and obesity. Obesity23 Note: C-CHANGE = Canadian Cardiovascular Harmonized National Guidelines Endeavour, CCS = Canadian Cardiovascular Society – Dyslipidemia, DASH = Dietary Approaches to Stopping Hypertension, DC = Diabetes Canada (formerly Canadian Diabetes Association), HC = Hypertension Canada, Obesity = Obesity Canada.
↵* All recommendations are considered strong recommendations (Box 1); the quality of evidence supporting each recommendation varies (see Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10-1503/cmaj.180194/-/DC1, for a detailed discussion of the supporting evidence. Key references are indicated in this table.)
- 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 A1C 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 A1C 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 A1C 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 A1C 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
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, A1C = 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.
- Table 5:
Diagnostic strategies: New or updated recommendations in the 2018 C-CHANGE harmonized guideline*
Recommendation Source guideline (key supporting reference) Diabetes Diabetes should be diagnosed by any of the following criteria: FPG ≥ 7.0 mmol/L
A1C ≥ 6.5% (for use in adults in the absence of factors that affect the accuracy of A1C and not for use in those with suspected type 1 diabetes)
2hPG in a 75 g OGTT ≥ 11.1 mmol/L
Random PG ≥ 11.1 mmol/L
DC31 Heart failure We recommend that BNP/NT-proBNP levels be measured to help confirm or rule out a diagnosis of heart failure in the acute or ambulatory care setting in patients in whom the cause of dyspnea is in doubt. HF32 We recommend that patients who receive potentially cardiotoxic cancer therapy undergo evaluation of LVEF before the start of cancer treatments known to cause impairment in LV function. HF† 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 or A1C
Serum total cholesterol, LDL-C, HDL-C, non–HDL-C, and triglycerides; lipids may be drawn fasting or nonfasting
Standard 12-lead electrocardiography
HC34 Standardized office BP measurement should be used for follow-up. Measurement using electronic (oscillometric) upper arm devices is preferred over auscultation. HC25 In patients with large arm circumference when standard upper arm measurement methods cannot be used, validated wrist devices (used with arm and wrist supported at heart level) may be used for blood pressure estimation. HC† Note: 2hPG = post-load glucose, A1C = glycosylated hemoglobin, BNP = B-type natriuretic peptide, BP = blood pressure, C-CHANGE = Canadian Cardiovascular Harmonized National Guideline Endeavour, DC = Diabetes Canada (formerly Canadian Diabetes Association), FPG = fasting plasma glucose, FRS = Framingham Risk Score, HC = Hypertension Canada, HF = Canadian Cardiovascular Society – Heart Failure, HDL-C = high-density lipoprotein cholesterol, LDL-C = low-density lipoprotein cholesterol, LV = left ventricle, LVEF = left ventricle ejection fraction, NT-proBNP = N-terminal pro B-type natriuretic peptide, OGTT = oral glucose tolerance test, PG = plasma glucose.
↵* 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.
- Table 6:
Risk stratification: New or updated recommendations in the 2018 C-CHANGE harmonized guideline*
Recommendation Source guideline (key supporting reference) All We recommend that a cardiovascular risk assessment be completed every 5 yr for men and women aged 40 to 75 yr using the modified FRS or CLEM to guide therapy to reduce major cardiovascular events. A risk assessment might also be completed whenever a patient’s expected risk status changes. CCS34 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. We recommend sharing the results of the risk assessment with the patient to support shared decision-making and improve the likelihood that patients will reach lipid targets. CCS34 Note: C-CHANGE = Canadian Cardiovascular Harmonized National Guidelines Endeavour, CCS = Canadian Cardiovascular Society – Dyslipidemia, CLEM = Cardiovascular Life Expectancy Model, FRS = Framingham Risk Score.
↵* All recommendations are considered strong recommendations (Box 1); the quality of evidence supporting each recommendation varies (see Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10-1503/cmaj.180194/-/DC1, for a detailed discussion of the supporting evidence. Key references are indicated in this table.)
- Table 7:
Treatment targets: New or updated recommendations in the 2018 C-CHANGE harmonized guideline*
Recommendation Source guideline (key supporting reference) Diabetes All individuals with diabetes should follow a comprehensive, multifaceted approach to reduce CV risk, including: A1C ≤ 7.0% implemented early in the course of diabetes
SBP of < 130 mm Hg and DBP of < 80 mm Hg
Additional vascular-protective medications in the majority of adult people with diabetes
Achievement and maintenance of healthy weight goals
Healthy eating
Regular physical activity
Smoking cessation
DC35 Therapy in most individuals with type 1 or type 2 diabetes should be targeted to achieve an A1C ≤ 7.0% to reduce the risk of microvascular and, if implemented early in the course of disease, CV complications. DC36 In people with type 2 diabetes, an A1C ≤ 6.5% may be targeted to reduce the risk of chronic kidney disease and retinopathy if they are assessed to be at low risk of hypoglycemia based on class of antihyperglycemic medication(s) used, and the person’s characteristics. DC37 A higher A1C target may be considered in people with diabetes with the goals of avoiding hypoglycemia and overtreatment related to antihyperglycemic therapy, with any of the following: Functionally dependent: 7.1%–8.0%
History of recurrent severe hypoglycemia, especially if accompanied by hypoglycemia unawareness: 7.1%–8.5%
Limited life expectancy: 7.1%–8.5%
Frail, older age or with dementia: 7.1%–8.5%
End of life: A1C measurement not recommended. Avoid symptomatic hyperglycemia and any hypoglycemia.
DC† An intensive healthy behaviour intervention program, combining dietary modification and increased physical activity, may be used to achieve weight loss, improve glycemic control and reduce CV risk. DC38 Dyslipidemia We recommend a target LDL-C consistently < 2.0 mmol/L or > 50% reduction of LDL-C in individuals for whom treatment is begun, to decrease the risk of CVD events. Alternative target variables are apoB < 0.8 g/L or non–HDL-C < 2.6 mmol/L. CCS39 We recommend a > 50% reduction of LDL-C for patients with LDL-C > 5.0 mmol/L in individuals for whom treatment is begun, to decrease the risk of CVD events and mortality. CCS39 Hypertension For nonhypertensive individuals (to reduce the possibility of becoming hypertensive) or for hypertensive patients (to reduce their BP), prescribe the accumulation of 30–60 min of moderate intensity dynamic exercise (e.g., walking, jogging, cycling or swimming) 4–7 d/wk in addition to the routine activities of daily living. HC† For high-risk patients aged 50 yr or older, with SBP levels ≥ 130 mm Hg, intensive management to target an SBP of ≤ 120 mm Hg should be considered. Intensive management should be guided by AOBP measurements. Patient selection for intensive management is recommended and caution should be taken in certain high-risk groups. HC40 Antihypertensive therapy should be prescribed for average DBP measurements of ≥ 100 mm Hg or average SBP measurements of ≥ 160 mm Hg in patients without macrovascular target organ damage or other cardiovascular risk factors. Antihypertensive therapy should be strongly considered for average DBP readings ≥ 90 mm Hg or for average SBP readings ≥ 140 mm Hg in the presence of macrovascular target organ damage or other independent cardiovascular risk factors. HC41,42 People with diabetes mellitus should be treated to attain SBP of < 130 mm Hg and DBP of < 80 mm Hg (these target BP levels are the same as BP treatment thresholds). DC43 Obesity All those considering beginning a vigorous exercise program are encouraged to consult their physician or health care team professionals. Obesity44 Note: A1C = glycosylated hemoglobin, AOBP = automated office blood pressure, apoB = apolipoprotein B-100, BP = blood pressure, C-CHANGE = Canadian Cardiovascular Harmonized National Guideline Endeavour, CCS = Canadian Cardiovascular Society – Dyslipidemia, CV = cardiovascular, CVD = cardiovascular disease, DBP = diastolic blood pressure, DC = Diabetes Canada (formerly Canadian Diabetes Association), HC = Hypertension Canada, HDL-C = high-density liproprotein cholesterol, HF = Canadian Cardiovascular Society – Heart Failure, LDL-C = low-density liproprotein cholesterol, Obesity = Obesity Canada, SBP = systolic blood pressure.
↵* 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.
- Table 8:
Pharmacologic and procedural therapy for CVD risk reduction: New or updated recommendations in the 2018 C-CHANGE harmonized guideline*
Recommendation Source guideline (key supporting reference) Coronary artery disease or ischemic heart disease In people with established CVD, low-dose ASA therapy (81 mg) should be used to prevent CV events. DC45,46 Diabetes Statin therapy should be used to reduce CV risk in adults with type 1 or type 2 diabetes with any of the following features: Clinical CVD
Age ≥ 40 yr
Age < 40 yr and 1 of the following:
Diabetes duration > 15 yr and age > 30 yr
Microvascular complications
Warrants therapy based on the presence of other CV risk factors according to the 2016 CCS Guideline for the Diagnosis and Treatment of Dyslipidemia.4
DC47 In adults with type 2 diabetes with clinical CVD in whom glycemic targets are not achieved with existing antihyperglycemic medication, an antihyperglycemic agent with demonstrated CV outcome benefit (empagliflozin, liraglutide, canagliflozin) should be added to reduce the risk of major CV events. An SGLT2 inhibitor with demonstrated reduction in hospital admissions for heart failure may be added to reduce the risk of admission for heart failure.
DC48–50 ACE inhibitor or ARB, at doses that have demonstrated vascular protection, should be used to reduce CV risk in adults with type 1 or type 2 diabetes with any of the following: Clinical CVD
Age ≥ 55 yr with an additional CV risk factor or end organ damage (albuminuria, retinopathy, left ventricular hypertrophy)
Microvascular complications.
DC51 Dyslipidemia We recommend management that includes statin therapy in high-risk conditions including clinical atherosclerosis, abdominal aortic aneurysm, most DM, chronic kidney disease (age > 50 yr), and those with LDL-C ≥ 5.0 mmol/L to decrease the risk of CVD events and mortality. CCS52 For individuals not at LDL-C goal despite statin therapy as described above, a combination of statin therapy with second-line agents may be used to achieve the goal; the agent used should be selected based upon the size of the existing gap to LDL-C goal. DC† We recommend management that includes statin therapy for individuals at high risk (modified FRS ≥ 20%) to decrease the risk of CVD events. CCS53 We recommend management that includes statin therapy for individuals at intermediate risk (modified FRS 10%–19%) with LDL-C ≥ 3.5 mmol/L to decrease the risk of CVD events. Statin therapy should also be considered for persons at intermediate risk with LDL-C < 3.5 mmol/L but with apoB ≥ 1.2 g/L or non–HDL-C ≥ 4.3 mmol/L, or in men aged ≥ 50 yr and women aged ≥ 60 yr with ≥ 1 CV risk factor. CCS54 Heart failure We recommend that most patients with HFrEF be treated with triple therapy including an ACE inhibitor (or an ARB in those who are ACE-inhibitor intolerant), a beta blocker and an MRA unless specific contraindications exist. HF55 We recommend loop diuretics be used to control symptoms of congestion and peripheral edema. HF† We suggest that NOACs should be the agent of choice for stroke prophylaxis in patients with HF and nonvalvular AF, and that the treatment dose be guided by patient-specific characteristics including age, weight and renal function. HF56 We recommend that an ARNI be used in place of an ACE inhibitor or ARB, in patients with HFrEF who remain symptomatic despite treatment with appropriate doses of GDMT to decrease cardiovascular death, hospital admissions for heart failure, and symptoms. HF57 Initial therapy should be with either monotherapy or single-pill combination. Recommended monotherapy choices are:
A thiazide or thiazide-like diuretic, with longer-acting diuretics preferred,
A beta-blocker (in patients < 60 yr),
An ACE inhibitor (in patients who are not black),
An ARB, or
A long-acting CCB.
Recommended choices for single-pill combinations are those in which an ACE inhibitor is combined with a CCB, ARB with a CCB, or ACE inhibitor or ARB with a diuretic.
Hypokalemia should be avoided in patients treated with thiazide or thiazide-like diuretic monotherapy.
HC58 Alpha-blockers are not recommended as first-line agents for uncomplicated hypertension; beta-blockers are not recommended as first-line therapy for uncomplicated hypertension in patients aged ≥ 60 yr; and ACE inhibitors are not recommended as first-line therapy for uncomplicated hypertension in black patients. However, these agents may be used in patients with certain comorbid conditions or in combination therapy. HC59,60 For patients with stable angina pectoris but without prior heart failure, MI or coronary artery bypass surgery, either a beta-blocker or a CCB can be used as initial therapy. HC61 Stroke ASA (80–325 mg), combined ASA (25 mg) and extended-release dipyridamole (200 mg), or clopidogrel (75 mg) are all appropriate options; selection should depend on the clinical circumstances. Stroke62 Patients with transient ischemic attack or ischemic stroke and nonvalvular AF should receive oral anticoagulation. In most patients requiring anticoagulants for AF, direct non–vitamin K oral anticoagulants should be prescribed in preference over warfarin.
When selecting choice of oral anticoagulants, patient-specific criteria should be considered.Stroke63 Note: ACE = angiotensin-converting enzyme, AF = atrial fibrillation, apoB = apolipoprotein B-100, ARB = angiotensin-receptor blocker, ARNI = angiotensin receptor-neprilysin inhibitor, ASA = acetylsalicylic acid, CCB = calcium channel blocker, CCS = Canadian Cardiovascular Society – Dyslipidemia, CV = cardiovascular, CVD = cardiovascular disease, DC = Diabetes Canada (formerly Canadian Diabetes Association), DM = diabetes mellitus, FRS = Framingham Risk Score, HC = Hypertension Canada, HDL-C = high-density liproprotein cholesterol, HF = Canadian Cardiovascular Society – Heart Failure, HFrEF = heart failure with reduced ejection fraction, GDMT = guideline-directed medical therapy, LDL-C = low-density liproprotein cholesterol, MI = myocardial infarction, MRA = mineralocorticoid receptor antagonist, NOAC = new oral anticoagulant, SGLT = sodium–glucose cotransporter 2, Stroke = Heart and Stroke Foundation.
↵* 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.
- Table 9:
National and international guidelines for the management of cardiovascular disease
Organization Recommendations Canadian Task Force on Preventive Health Care98 Recommend measuring height and weight and calculating BMI at appropriate primary care visits. American College of Cardiology/American Heart Association Hypertension guideline67 Lowered the definition of hypertension to 130/80 mm Hg. Target blood pressure for all groups is now < 130/80 mm Hg. European Society of Hypertension/European Society of Cardiology67 Base diagnosis of hypertension on out-of-office BP measures ambulatory BPM and home BPM if possible, or repeated office measures. Treatment threshold for very high CV risk now 130/85 mm Hg. BP treatment recommended for BP 140/90 mm Hg and higher in low-risk patients if no response to lifestyle intervention. Target BP < 140/90 mm Hg in all patients, < 120 mm Hg systolic if younger than 65 years, target systolic 130–139 mm Hg if 65 years or older.102 American Diabetes Association and European Association of the Study of Diabetes99 Recommend in addition to metformin, adding the newer antihyperglycemic agents, including DPP4 inhibitor, SGLT2 inhibitor and GLP-1 RA, and all groups recommend an A1c < 7.0 for most patients. American College of Cardiology/American Heart Association Lipid guideline100 Did not recommend a specific target but did advocate more intensive therapy or combination for those who did achieve a good response to statins (i.e., > 50% reduction). European Society of Cardiology101 Treat-to-target approach for lipid management, targeting an LDL-C < 1.8 mmol/L for very high-risk patients. Note: A1C = glycosylated hemoglobin, BMI = body mass index, BP = blood pressure, BPM = blood pressure monitoring, CV = cardiovascular, DPP4 = dipeptidyl peptidase-4, GLP-1 RA = glucagon-like peptide-1 receptor agonists, LDL-C = low-density liproprotein cholesterol, SGLT2 = sodium–glucose cotransporter 2.
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