C-CHANGE 2022 recommendations for people with dyslipidemia, atherosclerotic vascular disease or congestive heart failure
| Source guideline | Recommendation | Grade or strength of recommendation and category or level of evidence*† |
|---|---|---|
| Dyslipidemia | ||
| Screening and diagnostic strategies | ||
| CCS Dyslipidemia (16) | We recommend lipid or lipoprotein screening (in either fasting or nonfasting state) for men and women aged > 40 yr or at any age with 1 of the specific conditions listed.‡ | Recommendation: strong; evidence: high-quality |
| CCS Dyslipidemia (16) | We recommend that a CV risk assessment be completed every 5 years for men and women aged 40 to 75 yr using the modified FRS or CLEM to guide therapy to reduce major CV events. A risk assessment might also be completed whenever a patient’s expected risk status changes. | Recommendation: strong; evidence: high-quality |
| CCS Dyslipidemia (16) | We recommend that for any patient with triglycerides > 1.5 mmol/L, non-HDL-C or ApoB be used instead of LDL-C as the preferred lipid parameter for screening. (New recommendation) | Recommendation: strong; evidence: high-quality |
| Treatment targets and thresholds | ||
| CCS Dyslipidemia (16) | Threshold in primary prevention, for intensification of maximally tolerated statin dose. If LDL-C consistently > 2.0 mmol/L or ApoB > 0.8 g/L or non-HDL-C > 2.6 mmol/L, discuss add-on therapy with patient. Evaluate reduction in CVD risk vs. cost or access and adverse effects. Ezetimibe can be added as first-line and bile acid sequestrants as alternative. (New recommendation) | Recommendation: strong; evidence: moderate-quality |
| Pharmacologic and procedural therapy for risk reduction | ||
| CCS Dyslipidemia (16) | 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 intermediate-risk people 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 50 years of age and older and women aged 60 yr and older with ≥ 1 CV risk factor. (Updated recommendation) | Recommendation: strong; evidence: high-quality |
| Atherosclerotic vascular disease | ||
| Screening and diagnostic strategies | ||
| Hypertension (9) | Consider informing patients of their global ASCVD 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. | Recommendation: grade B |
| Treatment targets and thresholds | ||
| CACPR (11) | Patients living with CVD entering cardiovascular rehabilitation programs should be offered both aerobic and resistance exercises to reduce CV mortality, reduce hospital readmissions and improve quality of life. (New recommendation) | Recommendation: grade A |
| Pharmacologic and procedural therapy for risk reduction | ||
| Diabetes (14) | In people with established CVD, low-dose ASA therapy (81–162 mg) should be used to prevent CV events. | Recommendation: grade B; evidence: level 2 |
| Diabetes (14) | We no longer recommend ASA for primary prevention of CVD in people with diabetes. (New recommendation) | Recommendation: grade A; evidence: level 1 |
| CACPR (11) | Cardiac rehabilitation programs and services are recommended for most, and potentially all, patients with documented CVD. (New recommendation) | Recommendation: grade A |
| CCS Dyslipidemia (16) | We recommend use of high-intensity statin therapy in addition to appropriate health behaviour modifications for all secondary prevention patients with CVD. For patients who do not tolerate a high-intensity statin, we recommend the maximally tolerated statin dose. | Recommendation: strong; evidence: high-quality |
| Congestive heart failure | ||
| Screening and diagnostic strategies | ||
| CCS HF (17) | We recommend that BNP/NT-proBNP levels be measured to help confirm or rule out a diagnosis of HF in the acute or ambulatory care setting in patients in whom the cause of dyspnea is in doubt. (New recommendation) | Recommendation: strong; evidence: high-quality |
| Pharmacologic and procedural therapy for risk reduction | ||
| CCS HF (18) | We recommend that in the absence of contraindications, patients with HFrEF be treated with combination therapy including 1 evidence-based medication from each of the following categories (new recommendation):
| Recommendation: strong; evidence: moderate-quality |
| CCS HF (17) | We recommend loop diuretics be used to control symptoms of congestion and peripheral edema. | Recommendation: strong; evidence: moderate-quality |
| CCS HF (17) | We recommend that an ARNI be used in place of an ACEi or ARB in patients with HFrEF who remain symptomatic despite treatment with appropriate doses of goal-directed medical therapy to decrease CV death, hospital admissions for HF, and symptoms. | Recommendation: strong; evidence: high-quality |
| CCS HF (17) | We recommend an ACEi or ARB in patients with ACEi intolerance, with acute MI with HF, or an LVEF < 40% post-MI, to be used as soon as safely possible post-MI. | Recommendation: strong; evidence: high-quality |
| CCS HF (17) | We recommend MRA treatment for patients with acute MI and LVEF ≤ 40%, and HF symptoms or diabetes, to reduce mortality, CV mortality and hospital admission for CV events. | Recommendation: strong; evidence: high-quality |
| CCS HF (17) | We recommend an SGLT2 inhibitor, such as dapagliflozin or empagliflozin, be used in patients with HFrEF, with or without concomitant type 2 diabetes, to improve symptoms and quality of life and to reduce the risk of hospital admission for HF or CV mortality or both. (New recommendation) | Recommendation: strong; evidence: high-quality |
Note: ACEi = angiotensin-converting enzyme inhibitor, ApoB = apolipoprotein B, ARB = angiotensin receptor blocker, ARNI = angiotensin receptor-neprilysin inhibitor, ASA = acetylsalicylic acid, ASCVD = atherosclerotic cardiovascular disease, BNP/NT = proBNP-N-terminal (NT)-prohormone BNP, CACPR = Canadian Association of Cardiovascular Prevention and Rehabilitation guideline, CCS Dyslipidemia = Canadian Cardiovascular Society Guidelines for Dyslipidemia guideline, CCS HF = Canadian Cardiovascular Society Guidelines for the Management of Heart Failure, CLEM = Cardiovascular Life Expectancy Model, CV = cardiovascular, CVD = cardiovascular disease, Diabetes = Diabetes Canada guideline, FRS = Framingham Risk Score, HDL-C = high-density lipoprotein cholesterol, HF = heart failure, HFrEF = heart failure with reduced ejection fraction, Hypertension = Hypertension Canada guideline, LDL-C = low-density lipoprotein cholesterol, LVEF = left ventricular ejection fraction, MI = myocardial infarction, MRA = mineralocorticoid receptor antagonists, SGLT2 = sodium–glucose cotransporter.
↵* Unless otherwise indicated.
↵† See Appendix 2a (available at www.cmaj.ca/lookup/doi/10.1503/cmaj.220138/tab-related-content) for summary of grading for each included guideline and Appendix 2b for comparison of grading schemes.
↵‡ See Appendix 5 (available at www.cmaj.ca/lookup/doi/10.1503/cmaj.220138/tab-related-content) for who to screen for dyslipidemia in adults at risk.