Cardiovascular Disease Prevention and Management Clinical Practice Guidelines (2018)

Pharmacologic and Procedural Therapy for CVD Risk Reduction

Coronary artery disease or ischemic heart disease

For those with established CVD, use low-dose acetylsalicylic acid (ASA) therapy (81 mg) to prevent CV events.

Diabetes

Use statin therapy for CV risk reduction in adults with type 1 or 2 diabetes with any of the following features:

Clinical CVD
Age ≥40 years
Age <40 years and one of the following: diabetes >15 years and age >30 years; microvascular complications; therapy warranted due to the presence of other CV risk factors (based on the 2016 Canadian Cardiovascular Society guideline for the diagnosis and treatment of dyslipidemia)

To reduce the risk of major CV events in adults with type 2 diabetes and clinical CVD in whom existing antiglycemic medication is not achieving glycemic targets, add an antihyperglycemic agent with demonstrated CV outcome benefit, such as empagliflozin, liraglutide, or canagliflozin. To reduce the risk of heart failure admission, a sodium–glucose cotransporter 2 (SGLT2) inhibitor with demonstrated reduction in inpatient heart failure admissions may be added.

Use an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB), at doses with demonstrated vascular protection, for CV risk reduction in adults with type 1 or 2 diabetes with any of the following: clinical CVD, age ≥55 years with an additional CV risk factor or end-organ damage (albuminuria, retinopathy, LV hypertrophy), or microvascular complications.

Dyslipidemia

Management should include statin therapy to reduce CVD events and death in high-risk conditions (eg, clinical atherosclerosis, abdominal aortic aneurysm, most diabetes mellitus, chronic kidney disease [age >50 years]) and those with an LDL-C level of ≥5.0 mmol/L.

For those not at LDL-C goal despite statin therapy, use a combination of statin therapy with second-line agents. Select the agent on the basis of the existing gap to the LDL-C goal.

Management should include statin therapy for those at high risk (modified FRS ≥20%) to reduce the risk of CV events.

Management should include statin therapy for individuals at intermediate risk (modified FRS 10%-19%) with an LDL-C level of ≥3.5 mmol/L to reduce the risk of CVD events. Consider statin therapy for those at intermediate risk with an LDL-C level <3.5 mmol/L but with an apoB level of ≥1.2 g/L or non-HDL-C level of ≥4.3 mmol/L, or in men aged at least 50 years and women aged at least 60 years with one or more CV risk factor.

Heart failure

Use triple therapy to treat most patients with heart failure with reduced ejection fraction (HFrEF). This regimen includes an ACEI (or an ARB for ACEI-intolerant patients), a beta blocker, and a mineralocorticoid receptor antagonist (MRA) in the absence of contraindications.

Use loop diuretics to control symptoms of congestion and peripheral edema.

New oral anticoagulants (NOACs) are the agent of choice for stroke prophylaxis in those with heart failure and nonvalvular atrial fibrillation (AF). The treatment dose should be guided by patient-specific characteristics (eg, age, weight, renal function).

Use an angiotensin receptor-neprilysin inhibitor (ARNI), rather than an ACEI or ARB, in persistently symptomatic patients with HFrEF despite therapy with appropriate guideline-directed medical therapy (GDMT) to reduce CV death, heart failure admissions, and symptoms.

Hypertension

Initiate therapy with either monotherapy or single-pill combination.

Recommended monotherapy selections are as follows:

A thiazide or thiazide-like diuretic (longer-acting preferred)
A beta blocker (patients aged <60 years)
An ACEI (non-black patients)
An ARB
A long-acting calcium channel blocker (CCB)

Recommended single-pill combinations are those in which an ACEI is combined with a CCB, ARB with a CCB, or ACEI or ARB with a diuretic.

Avoid hypokalemia in patients on thiazide or thiazide-like diuretic monotherapy.

Either a beta blocker or a CCB can be used as initial therapy for patients with stable angina pectoris but without previous heart failure, myocardial infarction, or coronary artery bypass surgery.

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 ≥60 years; and ACEIs 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.

Stroke

Appropriate options, based on the clinical setting, include ASA (80-325 mg), combined ASA (25 mg) and extended-release dypridamole (200 mg), or clopidogrel (75 mg).

Administer oral anticoagulation to patients with transient ischemic attack or ischemic stroke and nonvalvular AF. Direct non-vitamin K anticoagulants (DOACs) are preferred over warfarin for most patients requiring anticoagulation for AF.

Consider patient-specific criteria when selecting oral anticoagulants.

For more information, please go to Primary and Secondary Prevention of Coronary Artery Disease.

For more Clinical Practice Guidelines, please go to Guidelines.

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