Background: Although brain and heart conditions share overlapping risk factors and commonly co-occur, current cardiac and neurologic clinical guidelines are typically produced within specialty silos. The objective of this guideline from a Canadian Cardiovascular Harmonized National Guideline Endeavour (C-CHANGE) panel is to expand on current cardiovascular guidelines to include evidence from the neurologic and mental health literature, with specific recommendations for providers managing comorbid brain and heart conditions. Methods: The guideline development panel comprised an Executive Steering Committee; 10 expert subgroups to develop research questions and draft recommendations for specific brain-heart conditions; an Evidence Review Team to ensure the rigour and consistent application of the methodology; and an Implementation Committee to facilitate uptake of the recommendations by clinicians and into electronic medical records. The McMaster Evidence Review and Synthesis Team supported the literature searches and critical appraisal. A panel of people with lived experience of specific conditions and caregivers provided input on patient values and perspectives throughout the guideline development process. Our consensus process followed the Appraisal of Guidelines for Research and Evaluation II framework. We used an established evidence appraisal approach to determine the level of evidence and strength of each recommendation, and adhered to the Guidelines International Network's principles for managing competing interests. Recommendations: We developed 11 recommendations for the management of joint brain and heart diseases. Key recommendations include screening for cognitive decline in atrial fibrillation and depression in coronary artery disease; treatment of depression in coronary artery disease, cognitive impairment in hypertension, and dyslipidemia in stroke; and vaccination to prevent stroke, myocardial infarction, and dementia. We also recommend shared decision-making, including the use of evidence-based decision aids, to support patients with heart-brain diseases. Interpretation: We sought to produce an implementable and actionable guideline for patients with brain and heart comorbidity. It is primarily targeted to primary care providers, but also relevant to help address and individualize subspeciality care and for interprofessional teams caring for patients with joint brain and heart diseases.

PURPOSE:The objective of this study was to characterize the impact of multimorbidity and cardiorespiratory fitness (CRF) on mortality in patients completing cardiac rehabilitation (CR).METHODS:This cohort study included data from patients with a history of cardiovascular disease (CVD) completing a 12-wk CR program between January 1996 and March 2016, with follow-up through March 2017. Patients were stratified by the presence of multimorbidity, which was defined as having a diagnosis of ≥2 noncommunicable diseases (NCDs). Cox regression analyses were used to evaluate the effects of multimorbidity and CRF on mortality in patients completing CR. Symptom-limited exercise tests were completed at baseline, immediately following CR (12 wk), with a subgroup completing another test at 1-yr follow-up. Peak metabolic equivalents (METs) were determined from treadmill speed and grade.RESULTS:Of the 8320 patients (61 ± 10 yr, 82% male) included in the analyses, 5713 (69%) patients only had CVD diagnosis, 2232 (27%) had CVD+1 NCD, and 375 (4%) had CVD+≥2 NCDs. Peak METs at baseline (7.8 ± 2.0, 6.9 ± 2.0, 6.1 ± 1.9 METs), change in peak METs immediately following CR (0.98 ± 0.98, 0.83 ± 0.95, 0.76 ± 0.95 METs), and change in peak METs 1 yr after CR (0.98 ± 1.27, 0.75 ± 1.17, 0.36 ± 1.24 METs) were different ( P < .001) among the subgroups. Peak METs at 12 wk and the presence of coexisting conditions were each predictors ( P < .001) of mortality. Improvements in CRF by ≥0.5 METS from baseline to 1-yr follow-up among patients with or without multimorbidity were associated with lower mortality rates.CONCLUSION:Increasing CRF by ≥0.5 METs improves survival regardless of multimorbidity status.

[Voir la version anglaise de l’article ici: www.cmaj.ca/lookup/doi/10.1503/cmaj.220138][1] Points clés L’objectif du projet C-CHANGE (Canadian Cardiovascular Harmonized National Guideline Endeavour), une initiative d’harmonisation des lignes directrices nationales de prévention et de

KEY POINTS 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

This guideline synthesizes clinical trial data supporting the role of glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter 2 inhibitors (SGLT2i) for treatment of heart failure (HF), chronic kidney disease, and for optimizing prevention of cardiorenal morbidity and mortality in patients with type 2 diabetes. It is on the basis of a companion systematic review and meta-analysis guided by a focused set of population, intervention, control, and outcomes (PICO) questions that address priority cardiorenal end points. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system and a modified Delphi process were used. We encourage comprehensive assessment of cardiovascular (CV) patients with routine measurement of estimated glomerular filtration rate, urinary albumin-creatinine ratio, glycosylated hemoglobin (A1c), and documentation of left ventricular ejection fraction (LVEF) when evaluating symptoms of HF. For patients with HF, we recommend integration of SGLT2i with other guideline-directed pharmacotherapy for the reduction of hospitalization for HF when LVEF is > 40% and for the reduction of all-cause and CV mortality, hospitalization for HF, and renal protection when LVEF is ≤ 40%. In patients with albuminuric chronic kidney disease, we recommend integration of SGLT2i with other guideline-directed pharmacotherapy to reduce all-cause and CV mortality, nonfatal myocardial infarction, and hospitalization for HF. We provide recommendations and algorithms for the selection of glucagon-like peptide-1 receptor agonists and SGLT2i for patients with type 2 diabetes and either established atherosclerotic CV disease or risk factors for atherosclerotic CV disease to reduce all-cause and CV mortality, nonfatal stroke, and for the prevention of hospitalization for HF and decline in renal function. We offer practical advice for safe use of these diabetes-associated agents with profound cardiorenal benefits.

Patients with widespread atherosclerosis such as peripheral artery disease (PAD) have a high risk of cardiovascular and limb symptoms and complications, which affects their quality of life and longevity. Over the past 2 decades there have been substantial advances in diagnostics, pharmacotherapy, and interventions including endovascular and open surgical to aid in the management of PAD patients. To summarize the evidence regarding approaches to diagnosis, risk stratification, medical and intervention treatments for patients with PAD, guided by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework, evidence was synthesized, and assessed for quality, and recommendations provided—categorized as weak or strong for each prespecified research question. Fifty-six recommendations were made, with 27% (15/56) graded as strong recommendations with high-quality evidence, 14% (8/56) were designated as strong recommendations with moderate-quality evidence, and 20% (11/56) were strong recommendations with low quality of evidence. Conversely 39% (22/56) were classified as weak recommendations. For PAD patients, strong recommendations on the basis of high-quality evidence, include smoking cessation interventions, structured exercise programs for claudication, lipid-modifying therapy, antithrombotic therapy with a single antiplatelet agent or dual pathway inhibition with low-dose rivaroxaban and aspirin; treatment of hypertension with an angiotensin converting enzyme or angiotensin receptor blocker; and for those with diabetes, a sodium-glucose cotransporter 2 inhibitor should be considered. Furthermore, autogenous grafts are more effective than prosthetic grafts for surgical bypasses for claudication or chronic limb-threatening ischemia involving the popliteal or distal arteries. Other recommendations indicated that new endovascular techniques and hybrid procedures be considered in patients with favourable anatomy and patient factors, and finally, the evidence for perioperative risk stratification for PAD patients who undergo surgery remains weak.

Purpose: To examine the feasibility of screening for chronic obstructive pulmonary disease (COPD) in an outpatient cardiac rehabilitation (CR) setting and to evaluate the detection rate of COPD using a targeted screening protocol. Methods: A total of 95 patients (62.5 ± 10.0 yr; men, n = 77), >40-yr old with a history of smoking were included in the study sample. Each participant answered the 5-item Canadian Lung Health Test (CLHT) questionnaire assessing symptoms such as coughing, phlegm, wheezing, shortness of breath, and frequent colds. Endorsing ≥1 item was indicative of potential COPD and warranted pulmonary function testing (PFT) and/or spirometry to diagnose or rule out COPD. Results: The CLHT questionnaire identified 44 patients at risk for COPD, with an average of 1.9 ± 1.2 items endorsed. Of the patients who underwent PFT, 6 new cases of mild COPD were diagnosed, resulting in a true positive rate with CLHT screening of 19% and a false-positive rate of 81%. Conclusions: Implementing the CLHT to patients referred to CR correctly identified COPD in <20% of cases. Using the CLHT to screen for COPD prior to starting CR may not be optimal, due to disparities between true- and false-positive rates.

Background We studied care gap in patients with familial hypercholesterolemia (FH) with respect to lipid‐lowering therapy. Methods and Results We enrolled patients with cardiovascular disease (CVD) or FH and low‐density lipoprotein‐cholesterol >2.0 mmol/L despite maximally tolerated statin therapy. During follow‐up physicians received online reminders of treatment recommendations of 2009 patients (median age, 63 years, 42% women), 52.4% had CVD only, 31.7% FH only, and 15.9% both CVD and FH. Patients with FH were younger and more likely to be women and non‐White with significantly higher baseline low‐density lipoprotein‐cholesterol level (mmol/L) as compared with patients with CVD (FH 3.92±1.48 versus CVD 2.96±0.94, P <0.0001). Patients with FH received less statin (70.6% versus 79.2%, P =0.0001) at baseline but not ezetimibe (28.1% versus 20.4%, P =0.0003). Among patients with FH only, 45.3% were at low‐density lipoprotein target (≥ 50% reduction from pre‐treatment level or low‐density lipoprotein <2.5 mmol/L) at baseline and increasing to 65.8% and 73.6% by visit 2 and 3, respectively. Among patients with CVD only, none were at recommended level (≤2.0 mmol/L) at baseline and 44.3% and 53.3% were at recommended level on second and third visit, respectively. When primary end point was analyzed as a difference between baseline and last available follow‐up observation, only 22.0% of patients with FH only achieved it as compared with 45.8% with CVD only ( P <0.0001) and 55.2% with both FH+CVD ( P <0.0001). Conclusions There is significant treatment inertia in patients with FH including those with CVD. Education focused on patients with FH should continue to be undertaken.

The 2021 guidelines primary panel selected clinically relevant questions and produced updated recommendations, on the basis of important new findings that have emerged since the 2016 guidelines. In patients with clinical atherosclerosis, abdominal aortic aneurysm, most patients with diabetes or chronic kidney disease, and those with low-density lipoprotein cholesterol ≥ 5 mmol/L, statin therapy continues to be recommended. We have introduced the concept of lipid/lipoprotein treatment thresholds for intensifying lipid-lowering therapy with nonstatin agents, and have identified the secondary prevention patients who have been shown to derive the largest benefit from intensification of therapy with these agents. For all other patients, we emphasize risk assessment linked to lipid/lipoprotein evaluation to optimize clinical decision-making. Lipoprotein(a) measurement is now recommended once in a patient's lifetime, as part of initial lipid screening to assess cardiovascular risk. For any patient with triglycerides ˃ 1.5 mmol/L, either non-high-density lipoprotein cholesterol or apolipoprotein B are the preferred lipid parameter for screening, rather than low-density lipoprotein cholesterol. We provide updated recommendations regarding the role of coronary artery calcium scoring as a clinical decision tool to aid the decision to initiate statin therapy. There are new recommendations on the preventative care of women with hypertensive disorders of pregnancy. Health behaviour modification, including regular exercise and a heart-healthy diet, remain the cornerstone of cardiovascular disease prevention. These guidelines are intended to provide a platform for meaningful conversation and shared-decision making between patient and care provider, so that individual decisions can be made for risk screening, assessment, and treatment.

Stroke rehabilitation (SR) and cardiac rehabilitation (CR) are either closely related relatives or strange bedfellows. Although the atherosclerotic origins of cardiovascular disease (CVD) produce similar degrees of morbidity and mortality in both of these populations, the significant motor and cognitive damages associated with large strokes, traditionally, have not seemed to lend themselves well to the cardiovascular conditioning and CVD risk factor management environments of CR.1Prior P.L. Hachinski V. Unsworth K. et al.Comprehensive cardiac rehabilitation for secondary prevention after transient ischemic attack and mild stroke.Stroke. 2011; 42: 3207-3213Crossref PubMed Scopus (63) Google Scholar Yet, the devastating effects of stroke and heart attack would intuitively seem to lend themselves to a conjoint recovery, rehabilitation, and restoration environment. The clear evidence supporting the use of thrombolytic therapy in acute strokes, followed more recently by the use of endovascular therapy, has brought the 2 acute-care worlds of myocardial infarction and stroke therapy closer together.2Goyal M. Demchuk A.M. Menon B.K. et al.Randomized assessment of rapid endovascular treatment of ischemic stroke.N Engl J Med. 2015; 32: 1019-1030Crossref Scopus (3449) Google Scholar An ever-increasing population of poststroke patients are being discharged from hospital with minimal physical and cognitive impairments. It is these emerging populations who may very well benefit from improvements in cardiorespiratory fitness, treatment target–driven control of CVD risk factors, along with mental health assessments and interventions where appropriate.3Tang A. Marzolini S. Oh P. McIlroy W.E. Brooks D. Feasibility and effects of adapted cardiac rehabilitation after stroke: a prospective trial.BMC Neurol. 2010; 10: 40Crossref PubMed Scopus (72) Google Scholar Over the last 3 decades, CR programs around the world have evolved from primarily exercise-only programs to comprehensive CVD management programs. As a direct consequence of this, these types of programs have clearly demonstrated their superiority over usual care in reducing mortality and rehospitalization.4Martin B.J. Hauer T. Arena R. et al.Cardiac rehabilitation attendants and outcomes in coronary artery disease patients.Circulation. 2012; 126: 677-687Crossref PubMed Scopus (167) Google Scholar If similar programs of holistic chronic disease care could be developed and implemented for patients who have suffered transient ischemic attacks or those who have only mild-to-moderate physical and cognitive impairments after stroke, it is entirely possible that these programs may similarly improve morbidity and mortality. A recent trial evaluating the impacts of a modified CR program in 783 stroke survivors demonstrated a markedly low 1-year poststroke mortality of 1.47%5Cuccurullo S.J. Fleming T.K. Kostis W.J. et al.Impact of a stroke recovery program integrating modified cardiac rehabilitation on all-cause mortality, cardiovascular performance and functional performance.Am J Phys Med Rehabil. 2019; 98: 953-963Crossref PubMed Scopus (6) Google Scholar compared with the US national rate of 31%,6Fonarow G.C. Smith E.E. Reeves M.J. et al.Hospital-level variation in mortality and rehospitalization for Medicare beneficiaries with acute ischemic stroke.Stroke. 2011; 42: 159-166Crossref PubMed Scopus (90) Google Scholar possibly through improvements in both aerobic capacity and stroke-related function. Despite the purported benefits of CR, participation for stroke survivors remains low. Unfortunately, it is not as simple as: “If you build it they will come.” Existing CR programs must be willing to see and treat patients with cerebral vascular disease, and practitioners must be willing to refer their patients to these clinical practice environments. Moreover, for those CR programs willing and capable of admitting cerebrovascular event patients to their programs, funding must follow the patients. In this issue of CJC Open, Toma et al.7Toma J. Hammond B. Chan V. et al.Inclusion of people poststroke in cardiac rehabilitation programs in Canada: a missed opportunity for referral.Can J Cardiol Open. 2020; 2: 195-206Scopus (6) Google Scholar report results from a large national survey of stroke patients’ participation in CR programs. The authors aimed to characterize poststroke engagement in CR, highlight individual program offerings, and identify barriers/facilitators to patient participation. The web-based survey was provided to 160 CR programs across the country; 71% of contacted representatives responded, accounting for 130 programs in total. Of the respondent programs, most were in Ontario (39%), in urban areas (44%), and were hospital based/affiliated (60%). Although response rates to the questionnaire were high, the number of stroke survivors attending CR programs was not. Only 65% of CR programs accepted individuals with a diagnosis of stroke, and most (62.5%) had fewer than 11 stroke survivors participate in the previous year. Only 25% of programs required patients to have a concurrent cardiac diagnosis, with the majority accepting a diagnosis of stroke alone. So how and why, in a country that sees approximately 50,000 new stroke cases a year, do only a few hundred patients attend CR programs? Perhaps, unsurprisingly, the authors identify 2 critical barriers that seem to plague rehabilitation programs across the country: lack of both fiscal resources and staffing. But the story is more complex. The article by Toma et al.7Toma J. Hammond B. Chan V. et al.Inclusion of people poststroke in cardiac rehabilitation programs in Canada: a missed opportunity for referral.Can J Cardiol Open. 2020; 2: 195-206Scopus (6) Google Scholar clearly identifies individuals excluded from most CR programs as those with severe mobility, communication, and/or cognitive deficits. Unfortunately, these happen to be individuals who, in many cases, may greatly benefit from CR programs. In some parts of the country, these individuals participate in community exercise programs run by not-for-profit organizations to increase and maintain cardiorespiratory fitness (eg, Together In Movement and Exercise).8Nathoo C. Buren S. El-Haddad R. et al.Aerobic training in Canadian stroke rehabilitation programs.J Neurol Phys Ther. 2018; 42: 248-255Crossref PubMed Scopus (16) Google Scholar SR patients often transition to these programs after completing formal therapies. Accommodating patients with more severe stroke-related impairments in CR programs necessitates staff training in poststroke communication, cognitive issues, and motor recovery, and may require the purchase of modified equipment. Toma et al. indicate that, to date, only a few CR programs in Canada have done so. This issue is particularly problematic for individuals who sustain concurrent stroke and myocardial infarction, or perioperative stroke during cardiac procedures, and are still unable to access CR programs. Although the authors identify who is and is not participating in existing CR programs, perhaps an important question to address is: which patients with stroke should definitely attend CR programs and how to best facilitate this? However, the aforementioned restrictions regarding patient eligibility criteria do not fully explain low participation rates. Lack of referrals was another important barrier, and given that most programs do not have a limit on the number of stroke patients they can enrol, the authors argue for a better partnership between CR and SR. Over half of respondents indicated that their CR program was within 25 km of an SR facility, underscoring the ease of developing a more seamless partnership and referral process. Undoubtedly, there needs to be improved communication across medical specialties; specifically, physiatry, neurology, and cardiology, as well as all the other members of the multidisciplinary SR and CR teams. Aerobic exercise in many SR programs has historically occurred in less than 25% of programs with programs typically focusing on facilitating neurologic recovery.8Nathoo C. Buren S. El-Haddad R. et al.Aerobic training in Canadian stroke rehabilitation programs.J Neurol Phys Ther. 2018; 42: 248-255Crossref PubMed Scopus (16) Google Scholar Anecdotally, the authors have witnessed practice pattern changes over the last 5 years, where aerobic exercise seems to be increasingly integrated into SR. Updates to guidelines on incorporating aerobic exercise into SR have recently been released and provide guidance around exercise testing and monitoring.9Time Program Listings.https://www.uhn.ca/TorontoRehab/Clinics/TIME/Documents/TR_PF_CC_TIME_Listings.pdfDate accessed: May 10, 2020Google Scholar Interestingly, Toma et al. reveal that just under half of stroke patients in CR programs actually underwent a regular preparticipation aerobic assessment, which included a graded exercise test, with electrocardiogram and blood pressure monitoring, or 6-minute walk tests for persons with mobility deficits. In SR, our experience suggests that clinicians are often reluctant to prescribe exercise in stroke patients without baseline exercise testing and are uncomfortable performing this testing themselves. Alternatively, many SR programs lack access to adequate equipment and monitoring (ie, electrocardiogram and blood pressure monitoring) to perform these tests. In the face of limited resources, SR clinicians and rehabilitation team members should be educated in identifying patients who require pre-exercise testing as well as how to best facilitate/interpret these investigations. Once identified, these individuals could be referred to a CR program for assessment and then either retained within that program to undergo rehabilitation or transferred back to the SR program, depending on their particular clinically dominant rehabilitation requirements. An important factor not highlighted by Toma et al. is that in SR, timing is critical. The brain undergoes a period of enhanced neural plasticity in the first few months after stroke.10MacKay-Lyons M. Billinger S.A. Enn J.J. et al.Aerobic exercise recommendations to optimize best practices in care after stroke: AEROBICS 2019 update.Phys Ther. 2020; 100: 149-156PubMed Google Scholar SR provided in the acute to subacute periods is thought to take advantage of this rewiring, such that stroke survivors can regain lost neurologic function. Intensity of therapy appears to play an important role in facilitating recovery. SR programs across the country take advantage of this by supplying the most intense therapy in the first few months after a stroke. Many of the stroke survivors discussed in the article by Toma et al.7Toma J. Hammond B. Chan V. et al.Inclusion of people poststroke in cardiac rehabilitation programs in Canada: a missed opportunity for referral.Can J Cardiol Open. 2020; 2: 195-206Scopus (6) Google Scholar are well past the point (median 11 years after stroke) when we would not expect to see much in the way of neurologic recovery, unless they spent several hours daily performing hundreds of movements to develop new skills.11Murphy T.H. Corbett D. Plasticity during stroke recovery: from synapse to behaviour.Nat Rev Neurosci. 2009; 10: 861-872Crossref PubMed Scopus (1044) Google Scholar Ultimately, the best timing for patients undergoing SR to consider CR needs further consideration. Importantly, CR programs have increasingly tried to shorten wait periods for patients, based on evidence regarding enhanced completion rates with reduced program delays, and multiple programs across the country now have effectively no waitlist.12Parker K. Stone J.A. Arena R. et al.An early cardiac access clinic significantly improves cardiac rehabilitation participation and completion rates in low risk ST-elevation myocardial infarction patients.Can J Cardiol. 2011; 27: 619-627Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar The wait time to begin CR in many programs in Canada is often dictated by patient delays rather than program delays. If, as suggested by Toma et al., toolkits and triage protocols could be developed that would facilitate rapid transition from acute care environments to ambulatory care environments, the number of home days for patients after acute stroke might be significantly improved through a blended care approach in SR and CR. Behind the scenes, this would require significant communication between SR and CR programs. From a patient perspective, however, the transitions of care in the rehabilitation program the patient is ultimately enrolled in, either SR or CR, should be seamless and clearly reflect the dominant needs of the patient. Certainly, not everyone who has a stroke needs CR. Some stroke survivors are young, fit, and without cardiovascular risk factors. Toma et al. clearly highlight many of the challenges facing stroke survivors who would benefit from participation in CR programming. Although overlap exists between the components of SR and CR, clinical experience suggests that many patients would benefit from both. Identifying the best candidates, determining optimal timing for CR, and improving access are critical to optimizing patient recovery and secondary prevention. The goal should be to provide patients with the best possible outcome, which will require close collaboration across rehabilitative spheres. S.D. received funding from Heart and Stroke Foundation of Canada, Canadian Institutes of Health Research.

A recent acute coronary syndrome provides an opportunity to optimise secondary prevention strategies to reduce the risk of future cardiovascular events. This review provides an updated synopsis of current evidence-based approaches. New clinical trial data on the use of antiplatelet and anticoagulants allow choices of the selection and duration of treatment. Lipid lowering after an acute coronary syndrome is now enhanced, with proprotein convertase subtilisin-kexin type 9 inhibitors providing added benefit on top of statin and ezetimibe treatment in high-risk patients. In addition, a recent trial of icosapent ethyl, a highly purified ethyl ester of eicosapentaenoic acid, addresses residual risk in patients with elevated triglycerides already treated with statins. The use of both sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide-1 receptor agonists in patients with type 2 diabetes reduces cardiovascular events independently of glucose lowering.

Background: Despite the widespread use of statins, approximately 40% to 50% of Canadian patients with known cardiovascular disease do not achieve the low-density lipoprotein cholesterol (LDL-C) goal. Guidelines Oriented Approach to Lipid lowering (GOAL) is an investigator-initiated study aiming to ascertain the use of second-and third-line therapy and its impact on LDL-C goal achievement in a real world setting.Methods: GOAL enrolled patients with clinical vascular disease or familial hypercholesterolemia and LDL-C > 2.0 mmol/L despite maximally tolerated statin therapy. During follow-up, physicians managed patients as clinically indicated but with online reminders of guideline recommendations.Results: Of 2009 patients enrolled (median age 63 years, 42% were female), baseline total cholesterol was 5.5 + 1.4 mmol/L, LDL-C was 3.3 + 1.3 mmol/L, nonehigh-density lipoprotein cholesterol was 4.1 + 1.4 mmol/L, high-density lipoprotein cholesterol was 1.3 + 0.4 mmol/L, and triglycerides were 2.0 + 1.5 mmol/L. Lipid-lowering therapy used at baseline was statin therapy in 76% (with 24% statin intolerant) and ezetimibe in 25%. During follow-up, the proportion of patients achieving an LDL-C level of < 2.0 mmol/L increased signifi-cantly to 50.8% as a result of additional lipid-lowering therapy. Patients achieving the recommended LDL-C level were more likely to not be statin intolerant (83.8% vs 70.7%, P < 0.0001) and to be taking a high-efficacy type and dose of statin (52.4% vs 35.9%, P < 0.0001). The 3 top reasons for not using the recommended therapy with ezetimibe were patient refusal in 33%, not needed in 22%, and intolerance in 20%, whereas for PCSK9i the reasons were cost in 26%, not needed in 27%, or patient refusal in 25%.Conclusion: The results indicate the feasibility of optimizing management, resulting in achievement of the guideline-recommended LDL-C level. This has the potential to translate into reductions in cardiovascular morbidity and mortality of Canadian patients.

Background We studied whether significant differences in care gaps exist between specialists and primary care physicians (PCPs). Methods GOAL Canada enrolled patients with CVD or familial hypercholesterolemia (FH) and LDL-C > 2.0 mmol/L despite maximally tolerated statin therapy. During follow-up, physicians received online reminders of treatment recommendations based on Canadian Guidelines. Results A total of 177 physicians (58% PCPs) enrolled 2009 patients; approximately half of the patients were enrolled by each physician group. Patients enrolled by specialists were slightly older (mean age 63 years vs 62), female (45% vs 40%), Caucasian (77% vs 65%), and had a slightly higher systolic pressure and lower heart rate. Patients enrolled by specialists had less frequent history of FH, diabetes, hypertension, chronic kidney disease and liver disease but more frequent history of coronary artery disease, atrial fibrillation and premature family history of CVD. There was no significant baseline difference in LDL-C, HDL-C or non-HDL-C, although total cholesterol and triglycerides were slightly higher in patients managed by PCPs. At baseline, PCPs were more likely to use statins (80% vs 73%, P = .0002) and other therapies such as niacin or fibrate (10% vs 6%, P = .0006) but similar use of ezetimibe (24% vs 27%, P = .15). At the end of follow-up, specialists used less statins (70% vs 77%, P = .0005) and other therapies (6% vs 10%, P = .007) but more ezetimibe (45% vs 38%, P = .01) and the same frequency of PCSK9i (28% vs 27%, P = .65). The proportion of patients achieving the recommended LDL-C level of 2.0 mmol/L or below (primary endpoint) was similar at last available visit between specialists and PCPs (44% vs 42%, P = .32). Conclusion Despite minor differences in the clinical profile of their patients, both PCPs and specialists actively participate in the management of lipid-lowering therapy in high-risk CVD patients and experience similar challenges and care gaps.

The evidence base supporting cardiac rehabilitation is substantial and overwhelmingly supports its utilization for all qualified patients. However, important lines of inquiry remain and require attention. This commentary provides a model for cardiac rehabilitation centers that provide patient care to meaningfully contribute to our scientific understanding of this lifestyle intervention.