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Major depressive disorder is an often chronic and recurring illness. Left untreated, major depressive disorder may result in progressive alterations in brain morphometry and circuit function. Recent findings, however, suggest that pharmacotherapy may halt and possibly reverse those effects. These findings, together with evidence that a delay in treatment is associated with poorer clinical outcomes, underscore the urgency of rapidly treating depression to full recovery. Early optimized treatment, using measurement-based care and customizing treatment to the individual patient, may afford the best possible outcomes for each patient. The aim of this article is to present recommendations for using a patient-centered approach to rapidly provide optimal pharmacological treatment to patients with major depressive disorder. Offering major depressive disorder treatment determined by individual patient characteristics (e.g., predominant symptoms, medical history, comorbidities), patient preferences and expectations, and, critically, their own definition of wellness provides the best opportunity for full functional recovery.

Canada has historically been among the world leaders in hypertension care, but hypertension treatment and control rates have regressed in recent years. This guideline is intended to provide pragmatic primary care–focused recommendations to improve hypertension management in adults at the population level. We employed Grading of Recommendations Assessment, Development and Evaluation and ADAPTE frameworks in accordance with Appraisal of Guidelines for Research and Evaluation (AGREE II) quality and reporting standards to develop recommendations on managing hypertension for adults aged 18 years and older. We used the HEARTS framework — a model of care developed by the World Health Organization to improve hypertension control and reduce cardiovascular burden — to integrate these recommendations into streamlined, pragmatic, and evidence-based algorithms. The guideline committee predominantly comprised primary care providers and also included patient, methodology, and hypertension specialist representatives. Our process for managing competing interests adhered to Guidelines International Network principles. The 9 recommendations for managing hypertension in adults are grouped under the categories of diagnosis and treatment. Diagnostic recommendations include a standardized approach to measuring blood pressure (BP) and confirming hypertension, as well as providing a uniform definition for hypertension of BP ≥ 130/80 mm Hg. Treatment recommendations include targeting a systolic BP < 130 mm Hg, implementing healthy lifestyle changes, and providing stepwise guidance on optimal medication choices for patients requiring pharmacotherapy. Our aim is to enhance the standard of hypertension care in the Canadian primary care setting. Accurate diagnosis and optimal treatment of hypertension can reduce adverse cardiovascular events and risk of death.

Jain et al discuss the Canadian Cardiovascular Harmonized National Guideline Endeavour (C-CHANGE) guideline. 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. 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. The recommendations are organized to address and individualize the management of patients with multiple comorbidities.

Many primary care physicians are wary about using direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (AF). Factors such as comorbidities, concomitant medications, and alcohol misuse increase concerns over bleeding risk, especially in elderly and frail patients with AF. This article discusses strategies to minimize the risk of major bleeding events in patients with AF who may benefit from oral anticoagulant therapy for stroke prevention. The potential benefits of the DOACs compared with vitamin K antagonists, in terms of a lower risk of intracranial hemorrhage, are discussed, together with the identification of reversible risk factors for bleeding and correct dose selection of the DOACs based on a patient's characteristics and concomitant medications. Current bleeding management strategies, including the new reversal agents for the DOACs and the prevention of bleeding during preoperative anticoagulation treatment, in addition to health care resource use associated with anticoagulation treatment and bleeding, are also discussed. Implementing a structured approach at an individual patient level will minimize the overall risk of bleeding and should increase physician confidence in using the DOACs for stroke prevention in their patients with nonvalvular AF.

In 2016, 270 204 people in Canada (excluding Quebec) were admitted to hospital for heart conditions, stroke and vascular cognitive impairment, including 107 391 women and 162 813 men, of whom 91 524 died. This equates to 1 out of every 3 deaths in Canada and outpaces other diseases; 13% more people die of heart conditions, stroke or vascular cognitive impairment than die from all cancers combined. The benefits of acetylsalicylic acid (ASA) for secondary prevention of atherosclerotic cardiovascular disease are well established. In contrast, although low-dose ASA therapy for primary prevention of atherosclerotic cardiovascular disease was once commonly recommended, this practice is now being reconsidered in light of recent evidence. The use of ASA for prevention (primary and secondary) of vascular events has been a common practice in Canada and elsewhere for decades. Based on a reappraisal of the evidence in light of recent publications of large neutral trials, we now recommend that ASA no longer be routinely used for primary prevention in most individuals.

Le Canada a longtemps figuré parmi les leaders mondiaux de la prise en charge de l’hypertension artérielle (HTA), mais ses taux de traitement et de maîtrise de l’HTA ont régressé ces dernières années. Le présent guide de pratique clinique vise à fournir des recommandations pragmatiques axées sur les soins de première ligne afin d’améliorer la prise en charge de l’HTA chez les adultes à l’échelle de la population. Conformément aux normes de qualité et de présentation du guide AGREE II (Appraisal of Guidelines for Research and Evaluation), nous avons utilisé la méthode GRADE (Grading of Recommendations Assessment, Development and Evaluation) et le processus ADAPTE pour formuler des recommandations sur la prise en charge de l’HTA chez les adultes de 18 ans et plus. Nous avons ensuite intégré ces recommandations dans des algorithmes simplifiés, pragmatiques et fondés sur les données probantes en nous appuyant sur le guide technique HEARTS — un modèle de soins mis au point par l’Organisation mondiale de la Santé (OMS) afin d’améliorer la maîtrise de l’HTA et de réduire le fardeau des maladies cardiovasculaires (MCV). Le comité qui a préparé ce guide de pratique clinique se composait principalement de prestataires de soins de première ligne, mais aussi de patients et patientes, de spécialistes de la méthodologie et de spécialistes de l’HTA. Notre processus de gestion des intérêts concurrents a respecté les principes du Guidelines International Network. Les 9 recommandations pour la prise en charge de l’HTA chez les adultes sont regroupées sous les rubriques « Diagnostic » et « Traitement ». Les recommandations diagnostiques comportent une méthode standardisée de mesure de la pression artérielle (PA) et de confirmation de l’HTA, ainsi qu’une définition uniforme de l’HTA, soit une PA ≥ 130/80 mm Hg. Les recommandations thérapeutiques comprennent l’établissement d’une cible de pression artérielle systolique (PAS) < 130 mm Hg, l’adoption de saines habitudes de vie, de même qu’une démarche par étapes pour guider un choix optimal de médicaments lorsqu’une pharmacothérapie est nécessaire. Notre objectif consiste à améliorer la norme de soins de l’HTA en soins de première ligne au Canada. Un diagnostic exact et un traitement optimal de l’HTA peuvent réduire le nombre d’événements cardiovasculaires indésirables ainsi que le risque de décès.

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. 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. 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. 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.