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