Harmonizing Cardiovascular
Risk Intervention Guidelines in Canada –
The C-CHANGE Initiative
February 6, 2013Montreal, Quebec
Harmonizing Cardiovascular
Risk Intervention Guidelines in Canada –
The C-CHANGE Initiative
February 6, 2013Montreal, 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
0.0
5.0
10.0
15.0
20.0
25.0
30.0
1994 1996 2001 2003 2005
<25
25-29.9
>=30
Body mass index: <25 normal, 25-29.9 overweight, 30 obese
Age- and Sex-Adjusted Trends in Hypertension, Smoking, and Diabetes Stratified by Body Mass Index From
1994 to 2005
Year
% R
espo
nden
ts
Hypertension Trendsby Body Mass Index
Smoking Trendsby Body Mass Index
Diabetes Trendsby Body Mass Index
0.0
5.0
10.0
15.0
20.0
25.0
30.0
1994 1996 2001 2003 20050.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
1994 1996 2001 2003 2005
Lee D, Tu J, CCORT. CMAJ 2009; 181:E55-66
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 2009
Smoking Position Statement
Obesity 2007
Question
If you put all of the previous organization’s guidelines together, how many recommendations would you have in total?
1. 872. 1323. 2154. 2905. >350
Physician time required per day
7.4
6.5
0
2
4
6
8
10
12
14
16
Ho
urs
pe
r d
ay
Management of 5 chronic conditions (hyperlipidemia, HTN, depression,asthma, diabetes)Preventative task-force
Too many guidelines!
Recs don’t agree c each other.
What’s really important?
Multitude of Guidelines
C-CHANGE:Canadian
Cardiovascular HArmonized National Guidelines Endeavour
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
Harmonized Implementable Guidelines
(CHS/CCS/CDA/Obesity…)
Core C-CHANGE Recommendations
Graded Evidence:Strengths & Impact Evalu’n
CHSAdd’n
CCS Add’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