Prevention and management of cardiovascular disease in 6 types of patients, the new Canadian guidelines give key points

Recently, Canada has updated guidelines for cardiovascular disease prevention and management . This article summarizes the key points of cardiovascular disease prevention for 6 types of patients, including dyslipidemia, atherosclerotic cardiovascular disease (ASCVD), congestive heart failure, and atrial fibrillation, for readers.

< section> Dyslipidemia

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➤Screening and Diagnostic Strategies

•It is recommended that individuals ≥40 years of age or any age with other special conditions undergo lipid or lipoprotein screening (fasting or non-fasting status).

•It is recommended that patients aged 40-75 years undergo a cardiovascular risk assessment every 5 years, using the Modified Framingham Risk Score (FRS) or the Cardiovascular Life Expectancy Model (CLEM ) to guide treatment to reduce the risk of major cardiovascular events.

•It is recommended that patients with triglycerides>1.5 mmol/L use non-HDL-C or ApoB instead Low-density lipoprotein cholesterol (LDL-C) is the preferred blood lipid parameter for screening. (new recommendation)

➤Treatment Goals and Thresholds

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•It is recommended that patients with indications should be treated with statins for primary prevention. If LDL-C is always >2.0 mmol/L or ApoB>0.8 g/L or non-HDL-C>2.6 mmol/L after the maximum tolerated dose of statin therapy, additional drug therapy can be performed. Ezetimibe can be used as the first choice, and bile acid sequestrants can be used as an alternative. (NEW RECOMMENDATIONS)

➤Risk Reducing Medications and Procedures

•Statin therapy is recommended for moderate-risk patients with LDL-C ≥ 3.5 mmol/L (modified FRS 10%-19%) to Reduce the risk of cardiovascular events. Intermediate-risk population with LDL-C<3.5 mmol/L but ApoB≥1.2 g/L or non-HDL-C≥4.3 mmol/L, and males ≥50 years old and females ≥60 years old with ≥1 cardiovascular risk factors Statin therapy should also be considered. (Update suggestion)

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ASCVD

➤Screening and diagnostic strategies

Consider Inform patients of their lifetime ASCVD risk to increase the effectiveness of improving modifiable risk factors.

➤Treatment Goals and Thresholds

People with cardiovascular disease who require a cardiovascular rehabilitation program should receive aerobic and resistance exercise to reduce cardiovascular mortality and hospitalization rate and improve the quality of life. (NEW RECOMMENDATIONS)

➤Risk Reducing Drugs and Procedures

•For patients with established cardiovascular disease, low-dose aspirin therapy (81-162 mg) should be administered to Prevention of cardiovascular events.

•Not recommended for diabetesThe patient used aspirin for the primary prevention of cardiovascular disease. (New recommendation)

•It is recommended that all patients with cardiovascular disease use high-intensity statins for secondary prevention treatment, and patients who cannot tolerate high-intensity statins are recommended to use the maximum tolerated dose .

Congestive Heart Failure

< span>➤Screening and diagnostic strategies

• Recommended for BNP/NT-proBNP levels should be measured in patients with suspected causes of dyspnea to aid in the diagnosis or exclusion of heart failure diagnosed in acute or ambulatory care settings. (NEW RECOMMENDATIONS)

➤Risk Reducing Drugs and Procedures

•In the absence of contraindications, patients with heart failure with reduced ejection fraction (HFrEF) should receive the following: Combination therapy with similar drugs, including ARNI (or ACEI/ARB), β-blockers, MRA and SGLT-2 inhibitors.

•Advise patients to use loop diuretics to control symptoms of congestion and peripheral edema.

•If HFrEF patients still have symptoms after receiving appropriate doses of guideline-guided drug therapy, it is recommended to use ARNI instead of ACEI or ARB for treatment to reduce cardiovascular death, Heart failure hospitalization and symptoms.

•It is recommended that patients with ACEI intolerance, acute myocardial infarction with heart failure, or LVEF<40% after myocardial infarction be treated with ACEI or ARB as soon as possible after myocardial infarction.

•It is recommended that patients with acute myocardial infarction with LVEF≤40%, patients with heart failure symptoms or diabetes undergo MRA treatment to reduce cardiovascular mortality and hospitalization for cardiovascular events .

• SGLT-2 inhibitors are recommended in HFrEF patients with or without type 2 diabetes to improve symptoms and quality of life and reduce heart failure or cardiovascular death, and The risk of hospitalization for both.

Atrial Fibrillation

➤Screening and diagnostic strategy

Recommended patient history and physical examination, 12-lead electrocardiogram, transthoracic echocardiogram, and basic laboratory investigations [full blood count, coagulation profile, serum electrolytes (including calcium and magnesium), renal function, liver function, thyroid function, fasting lipid profile, fasting Blood glucose and HbA1c]. (new recommendation)

➤Treatment Goals and Thresholds

When rate-controlled in patients with persistent AF, it is recommended to titrate rate-control medications to achieve a resting heart rate of <100 beats /Minute. (NEW RECOMMENDATIONS)

➤Risk Reducing Drugs and Procedures

•It is recommended to use the “CCS algorithm” (CHAD-65) to guide the selection of antithrombotic therapy in patients with NVAF to prevent stroke or Systemic embolism. (New recommendation)

•It is recommended to prescribe OAC for most patients with AF and AF ≥65 years old or with a CHADS₂ score ≥1. (new recommendation)

When using OACs for NVAF, it is recommended that most patients be given DOACs (apixaban, dabigatran, edoxaban, or rivar saban), not warfarin. (New recommendation)

•It is recommended that patients with atrial fibrillation implanted with mechanical prosthetic valves and with moderate-to-severe mitral stenosis be treated with warfarin. (New recommendation)

•Atrial fibrillation patients treated with OAC should have renal function evaluated at baseline and at least annually thereafter to detect underlying renal disease and determine whether OAC Appropriate and adjust the dosage. (New recommendation)

•For patients with AF and CKD, antithrombotic therapy should be based on the risk of stroke or systemic embolism and the severity of renal insufficiency. (New recommendation)

•It is recommended that patients with atrial fibrillation who are ≥65 years old or have a CHADS₂ score≥1 and are combined with stable coronary arteries or arterial vascular diseases should be treated with OAC alone. (New recommendation)

•OAC therapy is recommended for most frail elderly patients with AF. (new recommendation)

For patients with gastrointestinal or genitourinary bleeding after oral anticoagulant therapy, after the cause of the bleeding has been identified and corrected, high risk of stroke is recommended The patient restarted anticoagulation therapy as soon as possible. (new recommendation)

•Beta blockers or non-dihydropyridine calcium channel blockers (diltiazem or verapamil) are recommended as First-line drug for heart rate control in patients without significant left ventricular dysfunction (such as LVEF > 40%).

•Evidence-based beta-blockers (bisoprolol, carvedilol, metoprolol) are recommended as Obvious left ventricular dysfunction (LVEF≤40%), blood flowFirst-line agents for rate control in patients with mechanically stable atrial fibrillation.

Stroke

➤ Screening and diagnostic strategies

• Recommended for all stroke or Blood pressure assessment and management in patients with transient ischemic attack (TIA).

•For patients with embolic stroke or unexplained TIA, long-term ECG monitoring is recommended if the initial short-term ECG does not show AF but a cardioembolic mechanism is suspected (≥2 weeks) to identify patients ≥55 years of age with paroxysmal AF not receiving anticoagulant therapy (potential candidates for anticoagulant therapy).

➤Treatment Goals and Thresholds

•It is recommended that patients suffering from ischemic stroke or TIA should be treated with antihypertensive therapy, and the target blood pressure should be <140/90 mmHg.

➤Risk Reducing Drugs or Procedures

•Symptoms consistent with new acute stroke or TIA within 48 hours (especially transient focal motor/speech symptoms, Persistent stroke symptoms), the risk of recurrent stroke is highest, and immediate referral to an emergency department with stroke management capabilities (including on-site brain imaging and even acute stroke treatment) is warranted. (New recommendation)

• Unless there are indications for anticoagulation, it is recommended that patients with ischemic stroke or TIA receive long-term antiplatelet therapy as a strategy for secondary prevention of stroke. Reduce the risk of stroke recurrence and other vascular events. (New recommendation)

•According to the patient’s condition and clinical situation, aspirin (80-325 mg/d) or clopidogrel (75 mg/d) or Aspirin combined with dipyridamole as a long-term drug for secondary prevention of secondary stroke.

•Oral anticoagulation is strongly recommended for ischemic stroke or TIA patients with atrial fibrillation.

Dementia

Yes Objectively assess patients’ cognitive function through rapid psychometric screening tools, such as AD8 questionnaire, clock drawing test, mini cognitive screening (mini-Cog), clock drawing, etc. (New suggestion)

Compiled from: Rahul Jain, James A. Stone, Gina Agarwal, et al. Canadian Cardiovascular Harmonized National Guideline Endeavour (C-CHANGE) guideline for the prevention and management of cardiovascular disease in primary care: 2022 update. CMAJ..November 07, 2022 194 (43) E1460-E1480. DOI: https://doi.org /10.1503/cmaj.220138.