The goal of the Canadian Cardiovascular Harmonized National Guideline Endeavour (C-CHANGE) process is to give all Canadian health care providers easy access to a comprehensive and practical set of harmonized guideline recommendations. Clinicians claim that there are too many guidelines with too many individual recommendations to be practical and accessible for primary care; that their patients' multimorbidity requires them to access many guidelines at the same time; and that at least in the past, some of the recommendations were not harmonized and seemed contradictory. (1)
Established in 2008 to address these issues, C-CHANGE produces a guideline that is a subset of recommendations chosen from guidelines developed by Canada's cardiovascular-focused guideline groups. It is designed to help clinicians formulate comprehensive treatment plans for use by all members of the health care team to address multimorbidity, as recommended by the Canadian Heart Health Strategy and Action Plan. (2) This fourth update was necessitated by recent changes to the guidelines included in previous updates and the addition of guidelines from 3 guideline groups new to the C-CHANGE process (Canadian Cardiovascular Society/Canadian Heart Rhythm Society guideline for the management of atrial fibrillation, Health Canada's Dietary Guideline and the Canadian Consensus Conference on Diagnosis and Treatment of Dementia) (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.220138/tab-related -content), thus increasing the comprehensiveness from the 2011, (1) 2014 (3) and 2018 (4) versions to a total of 11 guideline groups.
The Global Burden of Diseases survey identified that the risk factors accounting for the largest percentage of disability-adjusted life-years in Canada included tobacco use, dietary factors, high body mass index (BMI), high fasting blood glucose, increased systolic blood pressure, elevated cholesterol, alcohol and drug use, and low physical activity. (5) These risk factors frequently cluster, and their joint management is key for the prevention of and recovery from acute cardiovascular diseases, highlighting the need for a multimorbidity approach for chronic diseases. The importance of renewed attention to these risk factors is shown by the negative cardiovascular consequences of delayed treatment during the COVID-19 pandemic, heightening the importance of accessible, timely, equitable and comprehensive care. (6)
C-CHANGE specifically chooses implementable or actionable recommendations for primary care and helpful tools to organize how patient care is approached in clinic during periodic health and episodic visits (i.e., preventive strategies, screening, diagnostics and treatment). The recommendations are organized to address and individualize the management of patients with multiple comorbidities. This approach is inclusionary, nonjudgmental and unbiased, and focuses on the complexities of delivering comprehensive cardiovascular disease care in a primary care environment. Users of this guideline are encouraged to identify the individual root causes of cardiovascular risk and disease, complications and barriers to treatments, and to follow a patient-centred approach, including patient-identified health goals that incorporate the patient's values. (7) The C-CHANGE guideline also facilitates the discussion of treatment options beyond pharmacotherapy, including nutrition and physical activity, and procedural and psychological interventions.
Scope
The goal of C-CHANGE is to assist health care providers in managing patients who often have multiple cardiovascular comorbidities, through the...