C-CHANGE Updates recommendations for cardiovascular disease

C-CHANGE Updates recommendations for cardiovascular disease

The Canadian Cardiovascular Harmonized National Guideline Endeavor (C-CHANGE) has updated its guidelines for the prevention and management of cardiovascular disease in primary care.

Of the 83 recommendations in the latest recommendation, more than half (48) are new or have been revised. The paper recommends that clinicians design pedometers and smartphone apps as a means of encouraging patients to exercise more, promote water as a drink of choice, encourage reduction or elimination of alcohol intake, and promote smoking cessation.

“These are the kinds of individualized recommendations that you can tailor to the patient in front of you,” said Rahul Jain, MD, MScCH, co-chair of C-CHANGE and a family physician at Sunnybrook Health Sciences Center in Toronto. Medscape Medical News. “We’re opening up a discussion about where they feel they can change.”

The guidelines were published online on November 7 CMJ.

Towards individualized care

The C-CHANGE guidelines, established in 2008, have been updated several times. The last revision was published in 2018.



Dr. Rahul Jain

The guidelines build on the work of other Canadian cardiovascular guideline groups, such as the Canadian Cardiovascular Society/Canadian Heart Rhythm Society. Many of these organizations have published new evidence-based recommendations in recent years. Revisions in those documents range from changes in medication management to new thresholds for lipid levels in secondary prevention, Jain said.

The new version of the C-CHANGE guidelines is intended to serve as a comprehensive resource for the care of patients with common cardiovascular comorbidities such as obesity, hypertension, and diabetes. Among other things, it deals with the fact that some drugs can help people deal with obesity and possibly avoid diabetes.

In his own work as a family physician, Jain said he might recommend joining a local gym and seeking out water activities for a patient who needs more exercise and likes swimming but has knee arthritis. Local cooking classes on how to use herbs and spices as a salt substitute may be helpful for patients who want to adapt to the Dietary Approaches to Stop Hypertension (DASH) diet.

“Guidelines are meant to help us manage populations, but we as doctors often do

know the patients best,” Jain said. “We should provide individualized, person-centered care based on evidence and best practices.”

The team of doctors and researchers who designed the update convened focus groups and conducted interviews to gather patient feedback.

Among the authors’ suggestions is greater emphasis on the role of depression as a risk factor for the development of cardiovascular diseases and for worse outcomes from these conditions. Comorbidity screening in people with atherosclerotic cardiovascular disease or at risk for atherosclerotic cardiovascular disease should include depression, the authors wrote, because mood disorders may be present in about a quarter of older adults.

Acceptance phase

Commenting on the revised C-CHANGE update for Medscape, Michael Vallis, PhD, associate professor of family medicine at Dalhousie University in Halifax, Nova Scotia, said it presents a well-organized overview of cardiovascular medicine guidelines that will be particularly useful to the primary care physician.

“Every single guideline that’s been created goes into the primary care physician’s office. So there’s no way he can follow them,” Vallis said. “One of the biggest barriers for doctors to comply with the new guidelines is that they are overwhelmed.”

But the problem with guidelines like the new C-CHANGE document, and with chronic disease management in general, is that they tend to assume that patients will immediately be on board with treatment, Vallis said.

Too often, doctors prescribe drugs without first addressing the critical question of whether the patient intends to take the drugs as directed, Vallis said. Doctors may assume that the patient is ready (immediately after receiving a new diagnosis) to adapt and make the necessary lifestyle changes, including adherence to complex treatment regimens.

“The person who comes in and says, ‘Doctor, you tell me what to do and I’ll do it. Take three drugs? Okay. Five drugs? Okay. You want me to take eight drugs? Thanks, doctor, that’s exactly what I’m going to do.’ I have to be honest with you: that patient is as rare as hen’s teeth,” Vallis said.

He added that there needs to be more awareness of the stages of admission that patients must go through after being diagnosed with a chronic illness. Doctors may describe patients as being in denial about their medical condition when what they really need is help to adjust to it.

“They’re not in denial. They’re just trying to accept the diagnosis,” Vallis said. “They don’t want to be sick. Nobody wants to be sick. They don’t want to organize their lives around their illness. They just want to be normal.”

The C-CHANGE update was supported by the Canadian Institutes of Health Research, the Public Health Agency of Canada, and the Ontario Ministry of Health and Long-Term Care. Jain had no relevant financial information. Vallis has received research funding, consulting arrangements, and speaking fees from AbbVie, Abbott, Bausch, Lifescan, Lyceum, Novo Nordisk, Pfizer, Roche, and Sanofi.

CMJ. Posted on November 7, 2022. Full text

Kerry Dooley Young is a freelance journalist based in Miami Beach. Follow her on Twitter: @kdooleyyoung .


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