Harmonizing
Cardiovascular
Risk Intervention
Guidelines in Canada –
The C-CHANGE
Initiative
February 6, 2013
Montreal, Quebec
Case: Management of CV Risk
55 yo female, increasing wt (BMI 31), has
family history of premature CV deaths.
She is worried but very busy c new job.
What should be done for her profile of:
• Blood pressure (155/90 mmHg)
• Lipids (LDL 3.7; HDL 0.9 mmol/L)
• Fasting glucose (7.1; HbA1C 7.9%)
• Waist circumference (100 cm)
• Occasional visit to the gym
Clustering of Risk Factors
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
Hypertension Trends
by Body Mass Index
30.0
Diabetes Trends
by Body Mass Index
30.0
9.0
<25
% Respondents
25.0
8.0
25-29.9
25.0
>=30
7.0
20.0
20.0
6.0
5.0
15.0
15.0
4.0
10.0
10.0
3.0
2.0
5.0
5.0
1.0
0.0
1994
0.0
1996
2001
2003
2005
1994
0.0
1996
2001
2003
2005
1994
1996
Year
Body mass index: <25 normal, 25-29.9 overweight, 30 obese
Lee D, Tu J, CCORT. CMAJ 2009; 181:E55-66
2001
2003
2005
Knowledge Translation Gap
Guideline Frequencies
Guidelines
Frequency Last Update
Hypertension
q. 1 yr
2012
Lipids
q. 4 yr
2012
Diabetes
q. 5 yr
2008
Exercise
Smoking
Obesity
2009
Position
Statement
2007
Question
If you put all of the previous
organization’s guidelines together,
how many recommendations would
you have in total?
1.
2.
3.
4.
5.
87
132
215
290
>350
Physician time required per day
Management of 5 chronic conditions (hyperlipidemia, HTN, depression,
asthma, diabetes)
Preventative task-force
16
14
Hours per day
12
10
6.5
Recs don’t agree c each other.
8
6
4
2
0
7.4
Multitude of Guidelines
Guide
A
Guide
B
Guide
C
Guide
X…
CHS
CCS
CDA
Other
Evidence
C-CHANGE:
Canadian
Cardiovascular
HArmonized National
Guidelines Endeavour
The Principles of C-CHANGE
1. Informed by evidence
2. Implementable in practice
3. Integrated with a patient
centred focus
4. Improve care and outcomes
that are measurable
Harmonizing Guidelines: The
C-CHANGE Approach
CHS
Add’n
Core C-CHANGE
Recommendations
CCS
Add’n
Harmonized
Implementable Guidelines
(CHS/CCS/CDA/Obesity…)
Graded Evidence:
Strengths & Impact Evalu’n
13
14
Results of C-CHANGE
• Over 450 recommendations reduced
to 73 actionable items on
– Diagnosis
– Risk stratification
– Lifestyle measures
– Treatment including targets and monitoring
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.
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.
C-CHANGE Implementation
• C-CHANGE & ME
– Patient focused tools for self management
• C-CHANGE & WE
– Provider case personalized tools for
management on the web and smartphone
• C-CHANGE & HERE
– Integrated electronic record tools with
screening and reminders
The C-Change Collaborative
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)
• 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
• Obesity Canada
• KT Canada
• Provincial Ministries of Health
• University of Ottawa Heart Institute