C-CHANGE: Harmonizing Cardiovascular Prevention Guidelines in Canada

1. C-CHANGE: Harmonizing Cardiovascular Prevention Guidelines in Canada

2. Disclosure Dr. Tobe has within the last 2 years: • Received honoraria for giving talks for most cardiovascular pharmaceutical companies • Served on advisory boards for Boehringer-Ingelheim, BMS/Sanofi-Aventis, Merck, Pfizer, Janssen • Participated in research funded by the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Astra-Zeneca, Baxter, Bayer, Boehringer-Ingelheim, Bristol Myers Squibb Sanofi-Aventis, Merck, Novartis, Ortho Biotec, Pfizer, Roche.

3. Deaths worldwide from chronic disease > infectious diseases • Cardiovascular disease is worldwide #1 killer, claiming 17.1 million lives annually. This is “impending disaster” for health, society and economy. • NCD/CVD was a focus of the UN Summit on chronic diseases – seeking a global solution World Health Organization Report (April 27, 2011)

4. 55 yo female, increasing wt (BMI 31), has HBP of 155/90 mmHg on multiple office readings. She is busy with new job. • What would be your target & priority for: • Blood pressure (155/90) • Lipids (LDL 3.7; HDL 0.9) • Fasting glucose (7.1; HbA1C 7.9%) • Waist circumference (100 cm) • Physical activity Case: Office Management of CV Risk

5. Vulnerable Plaque in Early CAD BiomarkersRF hsCRP ?Lp-LPA Fibrinogen Imaging Strategies IMT/IVUS Molec Imaging CT-CAC Perfus’n

6. ACEi?AT1Rb SmokingCessation BP ControlTarget Protec’n HMGCoARiFibrates Antibiotics Folate,B6,12 GlycemicControlACEi ASAAbciximab Risk Factors & Plaque Remodeling Hypertension Smoking Cholesterol Diabetes ?Infection Platelet Activ’n /Inflammation? ?Homocysteine ?Angiotensin

7. Age- and Sex-Adjusted Trends in Hypertension, Smoking, and Diabetes Stratified by Body Mass Index From 1994 to 2005 Smoking Trends by Body Mass Index Diabetes Trends by Body Mass Index Hypertension Trendsby Body Mass Index % Respondents Year Body mass index: <25 normal, 25-29.9 overweight, ≥30 obese Lee D, Tu J, CCORT. CMAJ 2009; 181:E55-66

8. Interactions of SBP & Cholesterol Effects

9. Risk Factors Synergistic

10. Knowledge Translation Gap

11. Many overlapping guidelines: • National Guidelines Clearinghouse lists more than 7,000 guidelines, and 469 of which pertains to cardiovascular disease • http://www.guideline.gov/browse/by-topic.aspx • CMAJ website 9 of 57 guidelines in Canada all address atherosclerosis and cardiovascular disease http://www.cmaj.ca/misc/service/guidelines.dtl World Wide Guideline Challenges

12. Canada excels in producing evidence based guidelines, but they are not translated into practice, because of: • High level of complexity • Redundancy in recommendations • Conflicting recommendations • Difficulties in implementation • Non-synchronization of guidelines Cardiovascular Prevention Guidelines

13. If you put all of the previous organization’s guidelines together, how many recommendations would you have in total? • 87 • 132 • 215 • 290 • >350 Question

15. C-CHANGE: Canadian Cardiovascular HArmonized National Guidelines Endeavour

16. Founding Partners • Institute of Circulatory and Respiratory Health (ICRH) and the Public Health Agency of Canada (PHAC) • Partner Organizations • Canadian Association for Cardiac Rehabilitation (CACR) • Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment (CAN ADAPT) • Canadian Cardiovascular Society (CCS) - Lipids • Canadian Diabetes Association (CDA) • Canadian Hypertension Education Program (CHEP) • Canadian Society for Exercise Physiology (CSEP) • Canadian Stroke Network (CSN) • Cardiac Care Network of Ontario (CCN) • Centre for Effective Practice (CFEP) • Heart and Stroke Foundation of Canada • Heart and Stroke Foundation of Ontario • Obesity Canada • KT Canada The C-Change Collaborative

17. The Principles of C-CHANGE • Informed by evidence • Implementable in practice • Improve care and outcomes that are measurable

18. The C-CHANGE Timelines

19. Hypertension Diagnosis • Routine laboratory tests that should be performed for the investigation of all patients with hypertension include: i) urinalysis; ii) blood chemistry (potassium, sodium, and creatinine); iii) fasting blood glucose; iv) fasting serum total cholesterol and high density lipoprotein cholesterol, low density lipoprotein cholesterol and triglycerides; and v) standard 12-lead ECG. • Patients with hypertension and evidence of heart failure should have an objective assessment of left ventricular ejection fraction, either by echocardiogram or nuclear imaging. • The use of home blood pressure monitoring on a regular basis should be considered for patients with hypertension, particularly those with: a. diabetes mellitus; b. chronic kidney disease; c. suspected non-adherence; d. demonstrated white coat effect; and e. blood pressure controlled in the office but not at home (masked hypertension).

20. Diabetes Risk Assessment • Assessment for CV risk should be performed periodically in people with diabetes: • CV history (dyspnea, chest discomfort) • Lifestyle (smoking, sedentary lifestyle) • Duration of diabetes • Sexual function • Abdominal obesity • Lipid profile • Blood pressure • Glycemic control • Retinopathy • eGFR & random albumin to creatinine ratio • Periodic ECGs .

22. Diabetes Risk Stratification • The following individuals with diabetes should be considered at high risk for CV events: • Men age>45 years, women aged >50 years • Men <45 years and women <50 years with >1 of the following • Macrovascular disease (e.g. silent myocardial infarction or ischemia, evidence of peripheral arterial disease, carotid arterial disease or cerebrovascular disease) • Microvascular disease (especially nephropathy and retinopathy) • Multiple additional risk factors, especially with a family history of premature coronary or cerebrovascular disease in first-degree relative • Extreme level of a single risk factor (e.g. LDL-C >5.0 mmol/L, systolic BP >180 mm Hg) • Duration of diabetes >15 years with age >30 years

24. Lipid Treatment Targets • Treatment target is based on the person’s risk level. • High or moderate risk: LDL-C <2.0 mmol/L or 50% in LDL-C; alternate target: apoB<0.80 g/L. • Low risk: If LDL-C ≥5.0 mmol/L, reduce LDL-C ≥50%; apoB<0.90 g/L.

25. Lipid Treatment Strategies • LDL Therapies. Statin monotherpay is the initial Rx of choice in patients whose LDL level is elevated based on their level of CVD risk (moderate and high-risk patients LDL > 2.0 mmol/L or Apo-B > 0.80). • Minority requires combination therapy (cholestyramine, ezetimibe, niacin, fibrates) to achieve, or move closer to, LDL treatment targets. • Triglyceride therapies. In patients with extreme hypertriclyceridemia (>10.0 mmol/L), fibrates may prevent pancreatities

26. Glucose Rx Targets • Glycemic targets must be individualized, however, therapy in most individuals with type 1 or type 2 diabetes should be targeted to achieve an A1C ~7.0% in order to reduce the risk of microvascular and, in individuals with type 1 diabetes, macrovascular complications. • A target A1C of ~6.5% may be considered in some patients with type 2 diabetes to further lower the risk of nephropathy, but this must be balanced against the risk of hypoglycemia and increased mortality in patients who are at significantly elevated risk of cardiovascular disease.

28. Obesity Targets • Maintenance of a healthy body weight (body mass index 18.5 to 24.9 kg/m2, and waist circumference less than 102 cm for men and less than 88 cm for women) is recommended for non-hypertensive individuals to prevent hypertension (Grade C) and for hypertensive patients to reduce blood pressure. All overweight hypertensive individuals should be advised to lose weight. • A comprehensive healthy lifestyle intervention is recommended for overweight and obese people. • The initial weight loss goal in obese individuals should be 5% to 10% of baseline body weight. • Adults with class III obesity (BMI >40.0 kg/m2) or class II obesity (BMI 35.0 to 39.9 kg/m2) with other co- morbidities may be considered for bariatric surgery when other lifestyle interventions are inadequate in achieving weight goals.

30. Physical Activity • Adults aged 18-64 years and Older Adults 65 and over should accumulate 150 minutes/week of moderate intensity physical activity, or 90 minutes of vigorous-intensity physical activity in periods of at least 10 minutes each. Greater amounts of activity and more vigorous activity provide additional benefits. • Engage in resistance activities on 2-4 days per week. • Engage in flexibility activities 4-7 days per week.

32. Smoking • All patients being evaluated should be asked about their smoking status (smoker, former smoker, never smoked, passive smoker) and this should be documented on their health record. • All smokers should receive non-judgmental, clear, and unambiguous advice to consider making a quit attempt using a clear, personalized message. • All physicians, nurses and other health care workers should strongly advise all patients who smoke to quit and provide brief advice.

34. Ready to See Change?

35. 68 yo female just underwent PCI for LAD/RCA diseases. RF: Smoker 1 pk/d, BMI 35, FBS 7.2, HbA1C 8.5%, LDL 3.5., HDL 0.8, TG 2.8 mmol/L. • Meds: ASA, Atorvastatin 20 mg, metoprolol 25 mg bid, diet for DM2 • How would you change her natural hx to prevent MI/stroke/death? Case: Post Intervention Risk Rx

39. Mr Aged • 86 year old man admitted to K wing following a hip fracture • 20 year history of hypertension • BP controlled to < 160 systolic • Creatinine is 120 umol/L • Urine albumin in the microalbuminuria range • On a low dose thiazide diuretic and a beta blocker • BP consistently 150-160 systolic • Should we bother treating his BP?

40. Mr Albuminuria • 66 year old man with • 20 year history of T2 DM • BP controlled to < 150 systolic • Creatinine is 120 umol/L • Urine albumin in the macroalbuminuria range • On a an ACEi • BP consistently 150-160 systolic • Can we do better for his BP? • What about his nephropathy?

41. Thank You!