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Canada recently updated its guidelines for the prevention and management of cardiovascular disease, the fourth update
since they were first published in 2008.
In the new guidelines, recommendations are given
for cardiovascular prophylaxis in a wide range of patients.
In daily life, how to prevent cardiovascular disease in the general population, obese, diabetic and hypertensive patients, this article is summarized according to the latest guidelines for readers
.
Healthy behaviors for everyone
Diet
• Intake of nutritious foods is the foundation of a healthy diet (new recommendations, strong evidence).
• In daily life, vegetables, fruits, whole grains and protein-rich foods
should be consumed regularly.
;
• It is recommended to replace foods containing saturated fat with foods
containing unsaturated fats.
• Water is the beverage
of choice.
➤ High blood pressure prevention
• Healthy adults are advised to abstain from alcohol or consume ≤ 2 drinks daily to prevent high blood pressure (new recommendation, category B).
<b20>
2.
Physical activity and athletic behavior
➤ Screening and diagnostic strategies
•People at risk of stroke and stroke should be assessed for vascular disease risk factors, lifestyle management issues (diet, sodium intake, exercise, body weight, alcohol intake, smoking), and use of oral contraceptives or hormone replacement therapy (grade B)
➤ Treatment goals and thresholds
•In people who have been sedentary or inactive in the past, it is best to have a comprehensive health behavior change program and engage in physical activity
.
For optimal health benefits, a progressive and individualized program
is recommended.
The goal plan is 30-60 minutes/day of moderate-intensity physical activity
most of the week.
Practical tools can be applied to facilitate physical activity, such as pedometers, smartwatches or mobile phones (New Recommendation, Level B).
•The following obese adult population should spend most of the week with moderate to vigorous aerobic activity of 30 to 60 minutes/day (new recommendation):
✓ Reduces body weight and fat (B,2a); ✓ Reduce visceral fat and ectopic fat, such as liver and heart fat, even without weight loss (A, 1a); ✓ Beneficial for weight maintenance after weight loss, good for maintaining fat-free mass, increasing cardiopulmonary function and flexibility (B,2a)during weight loss.
3.
Quit smoking
➤ Screening and diagnostic strategies
•Healthcare providers should explicitly advise patients to quit smoking and regularly update all patients on tobacco use (A, 1).
➤ Risk-reducing medications and procedural treatments
•Counseling and smoking cessation medications are more effective than alone, so they should be offered to patients or clients simultaneously when feasible (New Advice, A, 1).Healthy behaviors for obese people
➤ Screening and diagnostic strategies
•A thorough history evaluation is recommended to identify underlying causes of weight gain, obesity complications, and potential barriers to treatment (new recommendations; Level D recommendation, 4 types of evidence).
➤ Risk-reducing medications or procedural treatments
•Bariatric pharmacologic therapy may be given to patients with a body mass index (BMI) ≥30 kg/m² or BMI ≥27 kg/m² with obesity-related comorbidities; It is combined with pharmacotherapeutic nutrition, physical activity exercise, and psychological interventions, such as liraglutide 3.
0 mg, naltrexone/bupropion combination, and orlistat (new recommendations, grade B recommendations, class 2a evidence).
•Bariatric surgery may be considered in patients with a BMI ≥ 40 kg/m² or BMI ≥ 35 kg/m² with at least one obesity-related comorbidity (new recommendation, level D recommendation, level 4 evidence):
✓ Reduction in long-term overall mortality (grade B recommendation; Class 2b evidence) ✓ May result in significant long-term weight improvement compared with medication management alone (Level A recommendation, category 1a evidence).Health behaviors for people with diabetes
➤ Screening and diagnostic strategies
•Patients ≥ age 40 years or at high risk (risk calculator) should be screened for diabetes every three years, with fasting blood glucose (FPG) and/or glycosylated hemoglobin (A1C) levels
.
Very high-risk patients as determined by the risk calculator or those with other diabetes risk factors should consider early detection or more frequent follow-up, with an FPG, A1C, or 75g oral glucose tolerance test (75g OGTT) and a 2h blood glucose test (2hPG) every 6 to 12 months (new recommendation, level D evidence, consensus).
•Diabetes is diagnosed if any of the following criteria are met (updated recommendation):
✓ FPG≥ 7.0 mmol/L (grade B recommendation, type 2 evidence); ✓ A1C≥6.
5% (available in adults without factors affecting A1C accuracy, but not in people with suspected type 1 diabetes), (level B recommendation, type 2 evidence); 2hPG≥11.
1 mmol/L in 75 g OGTT (grade B recommendation, type 2 evidence); ✓ Random blood glucose (PG) ≥ 11.
1 mmol/L (grade B recommendation, type 2 evidence).
➤ Treatment goals and thresholds
• Ways to reduce cardiovascular risk, including (new recommendations):
✓ Early maintenance of diabetes A1C≤ 7.0% (grade C recommendation, 3 types of evidence); ✓ systolic blood pressure <130 mmHg and diastolic blood pressure <80 mmHg (class C recommendation, 3 types of evidence); </b11>
•Patients with diabetes with hypertension should be treated with a systolic blood pressure < 130 mmHg (class C, class 3) and a diastolic blood pressure < 80 mmHg (class B, class 1).
<b10>
•For most people with type 1 and type 2 diabetes, an A1C target of ≤7.
0 percent reduces the risk of:
•In people with type 2 diabetes, an A1C target of ≤6.
5 percent reduces the risk of:
•For adults with type 2 diabetes with ASCVD, heart failure, or CKD, the following drugs with demonstrated cardiovascular or renal benefit may be used (new recommendations):
✓ For patients with type 2 diabetes with ASCVD, glucagon-like peptide-1 receptor agonists (GLP1-RA) and sodium-glucose co-transporter 2 inhibitors (SGLT2i) with cardiovascular or renal benefits can be used to reduce the risk of MACE, hospitalization for heart failure, or progression ofkidney disease.
•For adults with type 2 diabetes with previous heart failure (ejection fraction <40 percent):
✓ If the eGFR > 30 mL/min/1.73 m², SGLT2i should be used to reduce the risk of
hospitalization or cardiovascular death due to heart failure.
✓ Satagliptin and thiazolidinedione should be avoided to prevent increased risk of heart failure (A,1A).
•For adults with type 2 diabetes mellitus > 30 mL/min/1.
73 m² of CKD or eGFR:
of progression of kidney disease, hospital admission for heart failure, and MACE.
✓ GLP1-RA may be considered to reduce MACE risk (B,2).
•Doses of ACE inhibitors or ARBs with demonstrated cardioprotective effects should be used to reduce cardiovascular risk in adults with type 1 or diabetes mellitus with any of the following diseases/conditions:
✓ Clinical cardiovascular disease (A, 1); ✓ Patients aged ≥ 55 years with additional cardiovascular risk factors or end-organ damage (proteinuria, retinopathy, left ventricular hypertrophy) (A, 1);• Microvascular complications (D, consensus).
•For patients with type 2 diabetes who require early initiation or modification of therapy to improve glycaemic control, hypoglycemic therapy should be individualized according to clinical priorities:
✓ For adults with type 2 diabetes ≥ 65 years of age with at least 2 cardiovascular risk factors, consideration should be given to including the following classes of agents in glycaemic management: ✎ GLP1-RA has been shown to have cardiovascular outcome benefits and reduce the risk of MACE; ✎ SGLT2i has a cardiorenal outcome benefit, and if the eGFR > 30 mL/min/1.73 m², it reduces the risk of hospital admission for heart failure or the risk
of progression of kidney disease.
✓ If reducing the risk of hypoglycemia is a priority, consider DPP4i or GLP1-RA, SGLT2i, acarbose, and/or pioglitazone as adjuvantives to improve glycaemic control
.
These drugs have a lower risk of hypoglycemia (A, 1A)
compared with other drugs.
✓If weight loss is a priority, consider GLP1-RA or SGLT2i as add-on medications to improve glycaemic control
.
These two classes of drugs are more likely to reduce weight than other drugs (New Recommendations, A, 1A).
•For people who cannot meet glucose-lowering targets with existing non-insulin-based antidiabetic agents, if the risk of hypoglycemia is reduced or weight gain, or both are a priority, consideration should be given to adding basal insulin regimens rather than premixed insulin or a single bolus regimen (new recommendation, B, 2).
•In patients with type 2 diabetes receiving basal insulin, replacement of NPH with long-acting insulin analogues (insulin glargine U-100, U-300, insulin detemir, insulin degludec) may be considered to reduce the risk of nocturnal and symptomatic hypoglycemia (new recommendations, A, 1A)
if minimizing the risk of hypoglycemia is a limited concern.
•During acute onset of illness or when certain tests are performed, clinical adjustment of pharmacotherapy may be required (new recommendations):
✓ metformin and SGLT2i therapy should be suspended during the risk of dehydration associated with acute illness or surgery associated with a high risk of acute kidney injury; ✓ If the dose of oral medication is reduced, the dose of insulin and insulin secretagogues should also be reduced or maintained to reduce the risk of hypoglycemia (D, consensus).Healthy behaviors for people with high blood pressure
➤ Screening and diagnostic strategies
•Routine laboratory tests that should be performed in all patients with hypertension include:
✓ Urinalysis (D); ✓ Blood biochemistry (potassium, sodium and creatinine) (D); ✓ fasting blood glucose and/or glycosylated hemoglobin or both (D); ✓ Serum total cholesterol, LDL, HDL, non-HDL cholesterol and triglycerides; Lipids can be detected with or without fasting (D); ✓ Standard 12-lead ECG (C);•Patients with hypertension with evidence of heart failure should have objective assessment of left ventricular ejection fraction (LVEF) by echocardiography (D).
•Four methods can be used to assess a patient's blood pressure:
✓ Automated Office Blood Pressure Measurement (AOBP) is the preferred methodfor measuring blood pressure in the office.
When AOBP is used, mean systolic blood pressure ≥ 135 mmHg or diastolic blood pressure ≥85 mmHg is considered hypertension (D); ✓ When performing office blood pressure measurement (OBPM), the first blockage should be discarded and the average
of subsequent blood pressure readings taken.
A mean systolic blood pressure of 130 to 139 mmHg or a diastolic blood pressure of 85 to 89 is considered to be a normal high value; A mean systolic blood pressure ≥ 140 mmHg or a diastolic blood pressure ≥90 mmHg is considered hypertension (C); ✓ Ambulatory blood pressure monitoring (ABPM), mean systolic blood pressure ≥ 135 mmHg or diastolic blood pressure ≥85 mm Hg when awake, or systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg when awake is considered hypertension (class C); ✓ Home blood pressure measurement (HBPM), mean systolic blood pressure ≥ 135 mmHg or diastolic blood pressure ≥85 mmHg, which can be considered hypertension and is associated with an increased overall risk of death (C).
HBPM values should be based on the average blood pressure measured repeatedly in the morning and evening over 7 days, and should not take into account HBPM values on the first day (D).
•Patients with hypertension should consider regular HBPM, particularly those with the following conditions:
✓ Poor blood pressure control (B); ✓ Diabetes (D); ✓ Chronic kidney disease (C); ✓ Suspected poor adherence (D); ✓ White coat effect (C); ✓ Occult hypertension (C).•If a patient's arm circumference is large and cannot use a validated standard upper arm blood pressure measurement, a validated wrist device can be used to assess blood pressure levels (class D).
➤ Treatment targets and thresholds
•In high-risk patients ≥ 50 years of age with a systolic blood pressure ≥ 130 mmHg, intensive blood pressure reduction should be considered to target systolic blood pressure ≤ 120 mmHg
.
Intensive blood pressure management should be guided
by AOBP measurement.
Selective intensive therapy is recommended for patients, and caution should be taken in certain high-risk groups (B).
•In patients without macrovascular target organ injury or other cardiovascular risk factors, antihypertensive therapy should be given when the mean diastolic blood pressure ≥ 100 mmHg or the mean systolic blood pressure ≥ 160 mmHg (A).
•Consideration of antihypertensive therapy
is strongly recommended when diastolic blood pressure ≥90 mmHg (A) or mean systolic blood pressure ≥140 mmHg (B) in the setting of large-vessel target organ injury or other independent cardiovascular risk factors.
➤ Risk-reducing medications or procedural treatments
•Initial treatment
with monotherapy or combination monotherapy may be considered.
<b10>
•Recommended monotherapy combinations include ACEI with CCB, ARB with CCB, or ACE or ARB with diuretics
.
•Hypokalemia should be avoided in patients treated with thiazide diuretic monotherapy (C).
•If target blood pressure levels cannot be achieved with standard-dose monotherapy, additional antihypertensive drugs should be considered (B).
•Additional antihypertensive medications should be selected
from first-line antihypertensive agents.
Available options include a thiazide diuretic, or CCB, with ACE/ARB or one of the β blockers
.
• Caution should be exercised in the combined application of non-dihydropyridine CCBs with β receptor blockers (D).
• Joint use of ACEI and ARB(A)
is not recommended.
•α blockers are not recommended as first-line agents in patients with uncomplicated hypertension; β blockers are not recommended as first-line agents ≥ 60 years of age with uncomplicated hypertension (A).
•Initial treatment
with ACE inhibitors or ARBs is recommended in patients with cardiovascular or renal disease, including microalbuminuria, or in patients with cardiovascular risk factors other than diabetes and hypertension.
•Choice of initial therapy:
✓ ACE or ARB(A)is recommended for most hypertensive patients with coronary artery disease.
✓ For patients with high-risk hypertension, the choice
should be individualized when performing combination therapy.
ACEI + dihydropyridine CCB or superior to ACEI + thiazide diuretics (A).
✓ For patients with stable angina who have not had previous heart failure, myocardial infarction, or coronary bypass surgery, β receptor blockers or CCBs can be used as initial therapy (B).
✓ For patients with a recent myocardial infarction, initial treatment should include β blockers and ACE inhibitors or ARBs (A).
✓ For pregnant patients with chronic hypertension, gestational hypertension, or preeclampsia, mean systolic blood pressure > 140 mmHg or mean diastolic blood pressure >90 mmHg Antihypertensive therapy
is recommended.
Initial antihypertensive therapy may be considered monotherapy with first-line oral formulations such as labetalol, methyldopa, long-acting nifedipine, or other β blockers (acetaminol, metoprolol, indolol, and propranolol) (new recommendation, C).
✓Antihypertensive drugs available to breastfeeding patients include labetalol, methyldopa, long-acting nifedipine, enalapril, or captopril (new recommendation, class D).
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.
