1. Harmonizing Cardiovascular Risk Intervention Guidelines in Canada – The C-CHANGE Initiative February 6, 2013 Montreal, Quebec Harmonizing Cardiovascular Risk Intervention Guidelines in Canada – The C-CHANGE Initiative February 6, 2013 Montreal, Quebec

2. 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

3. Clustering of Risk Factors

4. 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 % Respondents Hypertension Trends by Body Mass Index Smoking Trends by Body Mass Index Diabetes Trends by Body Mass Index Lee D, Tu J, CCORT. CMAJ 2009; 181:E55-66

5. Knowledge Translation Gap

6. Guideline Frequencies GuidelinesFrequencyLast Update Hypertensionq. 1 yr2012 Lipidsq. 4 yr2012 Diabetesq. 5 yr2008 Exercise2009 SmokingPosition Statement Obesity2007

7. Question If you put all of the previous organization’s guidelines together, how many recommendations would you have in total? 1.87 2.132 3.215 4.290 5.>350

8. Too many guidelines! Recs don’t agree c each other. What’s really important?

9. Multitude of Guidelines

10. C-CHANGE: Canadian Cardiovascular HArmonized National Guidelines Endeavour C-CHANGE: Canadian Cardiovascular HArmonized National Guidelines Endeavour

11. 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

12. Harmonizing Guidelines: The C-CHANGE Approach Harmonized Implementable Guidelines (CHS/CCS/CDA/Obesity…) Core C-CHANGE Recommendations Graded Evidence: Strengths & Impact Evalu’n CHS Add’n CCS Add’n

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15. Results of C-CHANGE Over 450 recommendations reduced to 73 actionable items on – Diagnosis – Risk stratification – Lifestyle measures – Treatment including targets and monitoring

16. 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.

17. 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.

18. 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

21. 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