. 2018 Oct 9;190(40):E1192–E1206. doi: 10.1503/cmaj.180194

Table 8:

Pharmacologic and procedural therapy for CVD risk reduction: New or updated recommendations in the 2018 C-CHANGE harmonized guideline^*

Recommendation	Source guideline (key supporting reference)
Coronary artery disease or ischemic heart disease

In people with established CVD, low-dose ASA therapy (81 mg) should be used to prevent CV events.	DC⁴⁵^,⁴⁶

Diabetes

Statin therapy should be used to reduce CV risk in adults with type 1 or type 2 diabetes with any of the following features: Clinical CVD Age ≥ 40 yr Age < 40 yr and 1 of the following: Diabetes duration > 15 yr and age > 30 yr Microvascular complications Warrants therapy based on the presence of other CV risk factors according to the 2016 CCS Guideline for the Diagnosis and Treatment of Dyslipidemia.⁴	DC⁴⁷

In adults with type 2 diabetes with clinical CVD in whom glycemic targets are not achieved with existing antihyperglycemic medication, an antihyperglycemic agent with demonstrated CV outcome benefit (empagliflozin, liraglutide, canagliflozin) should be added to reduce the risk of major CV events. An SGLT2 inhibitor with demonstrated reduction in hospital admissions for heart failure may be added to reduce the risk of admission for heart failure.	DC⁴⁸^–⁵⁰

ACE inhibitor or ARB, at doses that have demonstrated vascular protection, should be used to reduce CV risk in adults with type 1 or type 2 diabetes with any of the following: Clinical CVD Age ≥ 55 yr with an additional CV risk factor or end organ damage (albuminuria, retinopathy, left ventricular hypertrophy) Microvascular complications.	DC⁵¹

Dyslipidemia

We recommend management that includes statin therapy in high-risk conditions including clinical atherosclerosis, abdominal aortic aneurysm, most DM, chronic kidney disease (age > 50 yr), and those with LDL-C ≥ 5.0 mmol/L to decrease the risk of CVD events and mortality.	CCS⁵²
For individuals not at LDL-C goal despite statin therapy as described above, a combination of statin therapy with second-line agents may be used to achieve the goal; the agent used should be selected based upon the size of the existing gap to LDL-C goal.	DC^†

We recommend management that includes statin therapy for individuals at high risk (modified FRS ≥ 20%) to decrease the risk of CVD events.	CCS⁵³

We recommend management that includes statin therapy for individuals at intermediate risk (modified FRS 10%–19%) with LDL-C ≥ 3.5 mmol/L to decrease the risk of CVD events. Statin therapy should also be considered for persons at intermediate risk with LDL-C < 3.5 mmol/L but with apoB ≥ 1.2 g/L or non–HDL-C ≥ 4.3 mmol/L, or in men aged ≥ 50 yr and women aged ≥ 60 yr with ≥ 1 CV risk factor.	CCS⁵⁴

Heart failure

We recommend that most patients with HFrEF be treated with triple therapy including an ACE inhibitor (or an ARB in those who are ACE-inhibitor intolerant), a beta blocker and an MRA unless specific contraindications exist.	HF⁵⁵

We recommend loop diuretics be used to control symptoms of congestion and peripheral edema. HF^† We suggest that NOACs should be the agent of choice for stroke prophylaxis in patients with HF and nonvalvular AF, and that the treatment dose be guided by patient-specific characteristics including age, weight and renal function.	HF⁵⁶

We recommend that an ARNI be used in place of an ACE inhibitor or ARB, in patients with HFrEF who remain symptomatic despite treatment with appropriate doses of GDMT to decrease cardiovascular death, hospital admissions for heart failure, and symptoms.	HF⁵⁷

Initial therapy should be with either monotherapy or single-pill combination. Recommended monotherapy choices are: A thiazide or thiazide-like diuretic, with longer-acting diuretics preferred, A beta-blocker (in patients < 60 yr), An ACE inhibitor (in patients who are not black), An ARB, or A long-acting CCB. Recommended choices for single-pill combinations are those in which an ACE inhibitor is combined with a CCB, ARB with a CCB, or ACE inhibitor or ARB with a diuretic. Hypokalemia should be avoided in patients treated with thiazide or thiazide-like diuretic monotherapy.	HC⁵⁸

Alpha-blockers are not recommended as first-line agents for uncomplicated hypertension; beta-blockers are not recommended as first-line therapy for uncomplicated hypertension in patients aged ≥ 60 yr; and ACE inhibitors are not recommended as first-line therapy for uncomplicated hypertension in black patients. However, these agents may be used in patients with certain comorbid conditions or in combination therapy.	HC⁵⁹^,⁶⁰

For patients with stable angina pectoris but without prior heart failure, MI or coronary artery bypass surgery, either a beta-blocker or a CCB can be used as initial therapy.	HC⁶¹

Stroke

ASA (80–325 mg), combined ASA (25 mg) and extended-release dipyridamole (200 mg), or clopidogrel (75 mg) are all appropriate options; selection should depend on the clinical circumstances.	Stroke⁶²

Patients with transient ischemic attack or ischemic stroke and nonvalvular AF should receive oral anticoagulation. In most patients requiring anticoagulants for AF, direct non–vitamin K oral anticoagulants should be prescribed in preference over warfarin. When selecting choice of oral anticoagulants, patient-specific criteria should be considered.	Stroke⁶³

Note: ACE = angiotensin-converting enzyme, AF = atrial fibrillation, apoB = apolipoprotein B-100, ARB = angiotensin-receptor blocker, ARNI = angiotensin receptor-neprilysin inhibitor, ASA = acetylsalicylic acid, CCB = calcium channel blocker, CCS = Canadian Cardiovascular Society – Dyslipidemia, CV = cardiovascular, CVD = cardiovascular disease, DC = Diabetes Canada (formerly Canadian Diabetes Association), DM = diabetes mellitus, FRS = Framingham Risk Score, HC = Hypertension Canada, HDL-C = high-density liproprotein cholesterol, HF = Canadian Cardiovascular Society – Heart Failure, HFrEF = heart failure with reduced ejection fraction, GDMT = guideline-directed medical therapy, LDL-C = low-density liproprotein cholesterol, MI = myocardial infarction, MRA = mineralocorticoid receptor antagonist, NOAC = new oral anticoagulant, SGLT = sodium–glucose cotransporter 2, Stroke = Heart and Stroke Foundation.

All recommendations are considered strong recommendations (Box 1); the quality of evidence supporting each recommendation varies (see Appendix 1 for a detailed discussion of the supporting evidence. Key references are indicated in this table.)

^†

Based on consensus opinion.