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BCGuidelines.ca - By BC Physicians, for BC Physicians

Cardiovascular Disease - Primary Prevention

Effective Date: 2008

Summary | Flow Sheet | Patient Guide | Full Guideline in PDF

Recommendations and Topics

Scope

Objectives & Strategies

Figure 1: Coronary Heart/Cardiovascular Disease Risk Assessment

Lifestyle Management

Cardiovascular Disease Risk Control

Table 1: Framingham risk levels and desirable lipid results

Rationale

References

Resources

Sponsors

Appendices

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Scope

This guideline describes: (1) the prevention of heart disease, stroke, peripheral vascular disease, congestive heart failure and kidney disease in adults with no known cardiovascular disease (CVD) and (2) the management of elevated cholesterol. For the purpose of this guideline, coronary heart disease (CHD) risk is used as a proxy for CVD risk.

Diagnostic codes: 401 (hypertension); 250 (diabetes); 585 (chronic kidney disease); 272 (disorders of lipid metabolism)

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Objectives & Strategies

Objectives

  1. Reduce the risk of clinical CVD (heart attack, stroke, peripheral vascular disease, heart failure and kidney disease) by providing a summary of strategies for the assessment and mitigation of factors that increase the risk of cardiovascular disease; and
  2. Integrate these strategies with the existing GPAC guidelines for Hypertension, Diabetes, Chronic Kidney Disease and Overweight, Obesity and Physical Inactivity.

Strategies *

  1. Prevent heart disease through lifestyle management, including smoking cessation (Appendix A), increased physical activity, maintenance of a healthy weight and healthy eating habits.
  2. Assess the 10-year CHD risk. This should be a part of a physical examination or done at intervals during other patient-physician interactions. CHD risk assessment charts are provided (Appendix B and C).
  3. Provide tools for patient self-assessment and access to resources.

* Figure 1 (below) provides an overview of risk assessment and management strategies for cardiovascular disease.

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Figure 1. Coronary Heart/Cardiovascular Disease Risk Assessment

(printable PDF)

Figure 1. Coronary Heart/Cardiovascular Disease Risk Assessment

Abbreviations: BP, blood pressure; CHD, coronary heart disease; HDL, high-density lipoprotein; L, liter; mgt, management; TC, total cholesterol; TG, triglycerides; UKPDS, United Kingdom Prospective Diabetes Study; y, years.

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Lifestyle Management

Heart disease and stroke are often caused by modifiable risk factors related to diet and lifestyle. These factors include smoking,1 lack of physical activity,2 unhealthy eating habits and excess body weight.3 Excess body weight and lack of physical activity contribute to diabetes, increased blood pressure and dyslipidemia, which in turn significantly increase the risk of heart disease and stroke.

  1. Encourage all patients to adopt a healthy lifestyle to lower their risk of CVD (see the resources section at the end of this guideline and at the end of the associated patient guide).
  2. Provide adequate explanation and support to patients so that they clearly understand the nature and significance of CVD and that they have the primary responsibility for making the lifestyle changes required for reducing their risk.
  3. Provide patients with information, tools, resources and available supports, such as those offered by the Heart and Stroke Foundation of British Columbia and Yukon. These resources include self-assessment tools, personalized lifestyle management plans and self-management courses.

Offer and review the following lifestyle recommendations at each visit:

Smoking cessation: Cigarette smoking is responsible for approximately 30% of CHD deaths in North America.1 Complete cessation of smoking and exposure to second hand smoke is recommended. For assistance to quit, refer patients to QuitNow Services at 1-877-455-2233 (toll-free in BC; available 24/7/365) and at www.quitnow.ca to obtain self-help materials. Refer to Appendix A for additional information.

Physical activity: A sedentary lifestyle is an important modifiable risk factor. Moderate intensity dynamic activity (such as walking 3 km [2 miles] in 30 minutes once per day or walking 1.5 km [1 mile] in 15 minutes two times per day, jogging, cycling or swimming) is beneficial for cardiac health and has been shown to reduce hypertension, prevent diabetes and improve survival.3 Writing a prescription for physical activity, such as walking (or another equivalent form of activity) for at least 30-60 minutes per day, 4-7 days per week, is an effective way to promote increased physical activity.

Weight reduction: A body-mass index (BMI) greater than 27 kg/m2 is associated with increased risk of hypertension, type 2 diabetes and dyslipidemia.2,4-6 Maintenance of a healthy body weight (BMI 18.5-24.9 kg/m2; waist circumference [Asian/Caucasian] < 90 cm/102 cm [35"/40"] for men and < 80 cm/88 cm [32"/35"] for women) is recommended. Advise all overweight individuals to lose weight. Weight loss strategies should be long-term and employ a multidisciplinary approach that includes dietary education, increased physical activity and behavioural intervention.

Dietary recommendations: Recommend a diet that emphasizes fruits, vegetables, low-fat dairy products, fibre, whole grains, and protein sources that are low in trans-fat, saturated fat and cholesterol.7,8 In addition to a well-balanced diet, a reduced dietary sodium intake of ≤ 1,500 milligrams per day (approximately 1 tsp of table salt) is recommended for everyone. Advise patients about the "hidden" salt content of processed foods, such as lunchmeat, canned soups and pasta. As well, increased consumption (at least 2 servings per week) of fish that are high in omega-3 fatty acids decreases cardiovascular risk.8

Patients with CVD or identified risk factors such as diabetes, dyslipidemia, hypertension or obesity may benefit from personalized diet advice and may benefit from referral to a dietitian (see resources section for contact information for Dial-A-Dietitian). Disease-specific patient guides are provided at www.BCGuidelines.ca.

Additional lifestyle management information, specifically on healthy eating, physical activity and smoking cessation, may be found at www.actnowbc.ca. ActNowBC recommends the following:

0 Smoking: Complete avoidance of tobacco smoke

5 Servings of fruits and vegetables per day (minimum)

30 Minutes of moderate-intensity activity per day (minimum)


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Cardiovascular Disease Risk Control

A number of clinical conditions, including hypertension, diabetes, dyslipidemia and kidney disease contribute significantly to the risk of developing cardiovascular disease. Effective long-term control of these conditions can substantially decrease the risk of CVD. Individual guidelines for the management of hypertension, diabetes and chronic kidney disease may be found on this web site. The management of dyslipidemia is covered in this guideline.

The following are considerations for cardiovascular disease risk control. Atherosclerosis and vascular damage that precede clinical CVD can also be prevented by reduction of the risk factors discussed below.9

  1. Blood pressure (BP) control: Promote a healthy lifestyle through smoking cessation, weight reduction, increased physical activity, low-salt and low-fat food intake (DASH diet), and the use of antihypertensive medications where appropriate, with consideration for the presence of other CVD risk factors.10
  2. Diabetes management: Promote a healthy lifestyle through smoking cessation, a healthful diet and increased physical activity, and use medications where appropriate to control blood glucose.11,12
  3. Measure lipids under the following circumstances:
    1. Baseline full lipid profile (TG, TC, HDL, LDL) for men ≥40 yrs, women ≥ 50 yrs and postmenopausal women of any age. Reassess only if major CVD risk factors change.
    2. Full lipid profile if patient has hypertension, diabetes mellitus (type 1 or 2), chronic kidney disease or abdominal obesity, even if younger than 40 years-of-age.
    3. Full lipid profile if patient has a family history of premature CHD (onset before age 55 for men, and before age 65 for women), hypercholesterolemia, or signs of hyperlipidemia (for example, tendon xanthoma).
    4. Consider apolipoprotein B (apoB) for follow-up testing in high-risk patients who are undergoing treatment for hypercholesterolemia (but not for other dyslipidemias). Other lipid tests are not required if using apoB for follow-up. ApoB is a more accurate measurement of atherogenic particles than LDL.13 Fasting is not required for apoB measurement. See Appendix D for more information.
  4. Lipid management: Recommend lifestyle management (reduced dietary intake of saturated and trans-fats and cholesterol, increased physical activity) as first-line treatment for patients in all risk categories.14 If lifestyle management is insufficient in achieving desirable lipid levels, consider therapy with lipid-lowering medications, especially for patients at high risk (see Table 1).14 A decrease of 30-40% in lipids leads to sufficiently reduced CHD risk for most patients, including those with metabolic syndrome and diabetes.
  5. Global risk assessment: *
    1. Framingham risk chart for patients without diabetes: The Framingham risk assessment chart (Appendix B) is helpful in estimating the 10-year CHD risk for adults who do not have CVD or diabetes. The risk factors included in the Framingham calculation are: gender, age, total cholesterol, HDL cholesterol, systolic blood pressure and cigarette smoking.
    2. UKPDS risk chart for patients with diabetes: The United Kingdom Prospective Diabetes Study15 (UKPDS) risk assessment chart (Appendix C) is helpful in estimating the 10-year CHD risk for adults with diabetes. The risk factors included in the UKPDS risk assessment are: gender, age, hemoglobin A1c, total cholesterol, HDL cholesterol, systolic blood pressure and cigarette smoking. Refer to the BC diabetes guideline for further information on the UKPDS risk calculator.
    3. The U.S. Preventative Services Task Force (UPSTF) recently reviewed the use of non-traditional risk factors, including high sensitivity C-reactive protein (hs-CRP) and state that the current evidence is insufficient to assess the balance of benefits and harms of using hs-CRP to routinely screen asymptomatic men and women with no history of coronary heart disease in order to prevent coronary events.33

    * This excludes high-risk patients with known CVD.
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Table 1. Framingham risk levels and desirable lipid results

(printable PDF)

CLASSIFICATION RISK LEVEL LDL (mmol/L) ApoB (g/L) TC/HDL RATIO
High * ≥ 20% without CHD < 2.5 < 0.85 for follow-up < 4.0
Moderate ** 10% - 19% < 3.5 < 1.05 < 5.0
Low *** < 10% < 5.0 < 1.25 < 6.0

Abbreviations: Apo B, apolipoprotein B; CHD, coronary heart disease; LDL, low-density lipoprotein; TC/HDL, total cholesterol/high-density lipoprotein ratio

* Adults with diabetes or chronic renal disease should not automatically be considered high risk. Use the UKPDS risk assessment chart to determine the level of risk for patients with diabetes. Use the Framingham risk assessment charts to determine the level of risk for patients with chronic renal disease.

** Patients in the moderate risk category may be at high long-term CVD risk. This group includes many patients with abdominal obesity (metabolic syndrome).

*** Patients with severe genetic lipoprotein disorders, such as familial hypercholesterolemia or type III dyslipidemia should be treated regardless of their Framingham risk score.

Note: Although triglyceride levels are no longer indicated as a primary treatment target, the optimal level of triglycerides for high-risk patients is < 1.5 mmol /L.

  1. Albumin/creatinine ratio: In most patients with diabetes or hypertension, measurement of the albumin/creatinine ratio is recommended (for details, refer to the BC diabetes and hypertension guidelines). An elevated albumin/creatinine ratio (men: > 2.0 mg/mmol, women: > 2.8 mg/mmol) is associated with an increased risk of heart disease and stroke. Angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARBs) can be used to manage proteinuria, including microalbuminuria.16
  2. Kidney function: Impaired kidney function (eGFR < 60 mL/min) is associated with an increased risk of heart disease and stroke. ACEI and ARBs are effective in improving outcomes related to cardiovascular disease and kidney disease in patients with impaired kidney function.17,18 The benefits of statin therapy have not been fully evaluated in this patient group.
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Additional considerations

  1. Women: Statins do not appear to prevent heart disease or improve survival for most women without known heart disease (primary prevention), based on a large subset of women (5052) in the North American ALLHAT-LLT trial19 and a meta-analysis of more than 11,000 women.20
  2. Older adults: The PROSPER trial found that statins did not reduce CHD and stroke events in men and women over age 69 without heart disease.21 There was a significant reduction in cardiovascular events for individuals with coronary heart disease (secondary prevention).

    Overall (mixed primary and secondary prevention), there was a significant reduction in cardiovascular events, but a corresponding increase in major adverse events, such as cancer and hemorrhagic stroke. There is currently insufficient evidence for the safety of statins and improved overall outcomes in older adults.
  3. Aspirin therapy: Low-dose aspirin (e.g. 81 mg) to prevent platelet aggregation is recommended for people under age 70 who are not aspirin intolerant and who have a ten-year CHD risk ≥ 20% (no known CHD).22 Blood pressure must be well controlled. Low-dose aspirin therapy for patients (men and women) over age 70 is not recommended at this time due to insufficient evidence.23
  4. Metabolic syndrome: Metabolic syndrome includes three or more of the following criteria:
    • Abdominal obesity (waist circumference: men > 102 cm, women > 88 cm)
    • Triglycerides ≥ 1.7 mmol/L
    • HDL (men < 1.0 mmol/L, women < 1.3 mmol/L)
    • BP > 130/85 mm Hg
    • Fasting glucose 5.7-6.9 mmol/L

    The American Heart Association recommends lifestyle intervention as first-line therapy for the management of metabolic syndrome as there is insufficient evidence to recommend the use of drugs as first-line therapy for treating the underlying causes.24
  5. Socioeconomic factors: Socioeconomic factors may play a role in exacerbating risk and should be considered.25
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Rationale

Cardiovascular disease is the leading cause of death in BC, accounting for one in three deaths each year.26 Studies have shown that vascular injury, progressing to cardiovascular disease in adulthood, begins in adolescence.9 Emphasizing the early prevention of atherosclerosis and vascular damage by modifying risk factors such as smoking, excess body weight, low levels of physical activity and poor eating habits is of utmost importance.9

The following subsections include a brief review of the literature used to generate recommendations for the management of diabetes and elevated cholesterol in the prevention of cardiovascular disease. The final subsection provides the methodology used for obtaining evidence and describes the types of evidence used throughout this guideline.

Diet: Recommendations for the management and treatment of elevated cholesterol are based on recommendations from the Canadian Cardiovascular Society14 and the National Cholesterol Education Program (NCEP).27,28 Dietary strategies to improve morbidity and mortality from cardiovascular disease are based on the Canada Food Guide7 and the American Heart Association dietary guidelines.8

Diabetes: Strategies to manage diabetes are based on the 2003 Canadian guideline11 and the 2005 BC guideline Diabetes Care.12 The BC diabetes guideline recommends a risk-based approach for lipid management. High-risk patients (≥ 20 % CHD risk using the UKPDS chart) should be treated to an LDL target of 2.5 mmol/L. This approach is consistent with the 2003 Canadian diabetes guideline recommendations11 as well as the ASPEN trial (lower risk: 12% smokers),29 which showed no benefit with statins, and the CARDS trial,30 which showed a benefit for a population at higher-risk (23% smokers). Lifestyle modification, including weight loss, reduced intake of saturated and trans fats, increased dietary fibre and moderate exercise can reduce the risk of diabetes by 58%.5,31 In women, lifestyle management and smoking cessation are associated with a 91% reduction in the risk of developing type II diabetes, excess weight being identified as the most significant contributing factor.32

Dyslipidemia: Recommendations for lipid testing and treatment of dyslipidemia are based on the 2006 Canadian Cardiovascular Society (CCS) position statement for the diagnosis and treatment of dyslipidemia14 as well as peer-reviewed articles.16,20,29 The recommendation for treatment of high-risk patients without heart disease to a target of 2.5 mmol/L LDL is consistent with the CCS statement that a target of 2.5 may provide adequate control for patients without established CVD. There is currently insufficient evidence to recommend the more aggressive treatment target of 2.0 for this patient population. It is recommended that apoB be used for follow-up of high-risk patients undergoing treatment with statins because this measure is more accurate than the calculated LDL value. If apoB is used, then a full lipid profile is unnecessary for follow-up.

Evidence: Evidence was obtained through a systematic review of peer-reviewed literature (up to June, 2007) using the databases MEDLINE, PubMed, EBSCO, Ovid, and the Cochrane Collaboration's Database for Systematic Reviews. Clinical practice guidelines from other jurisdictions for the primary prevention of cardiovascular disease, and the prevention and management of hypertension, diabetes, chronic kidney disease, dyslipidemia, congestive heart failure, cerebrovascular disease and overweight/obesity were also reviewed (up to June 2007). Pharmacologic recommendations are based on large, randomized controlled trials (RCTs) wherever possible. Lifestyle recommendations are based on large, prospective cohort trials. Evidence for the optimal frequency of lipid testing is lacking. Recommendations in this area are based on expert opinion.

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References

  1. Ockene IS, Miller NH. Cigarette smoking, cardiovascular disease, and stroke: A statement for healthcare professionals from the American Heart Association. American Heart Association Task Force on Risk Reduction. Circulation 1997;96(9):3243-47.
  2. Shaw K, Gennat H, O'Rourke P, et al. Exercise for overweight or obesity. Cochrane Database Syst. Rev. 2006(4):CD003817
  3. Lau DCW, Douketis JD, Morrison KM, et al. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. CMAJ 2007;176(8):s1-s13.
  4. Stevens VJ, Obarzanek E, Cook NR, et al. Long-term weight loss and changes in blood pressure: Results of the trials of hypertension prevention, phase II. Ann Intern Med 2001;134(1):1-11.
  5. Tuomilehto J, Lindström J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. NEJM 2001;344(18):1343-50.
  6. Dattilo AM, Kris-Etherton PM. Effects of weight reduction on blood lipids and lipoproteins: A meta-analysis. Am J Clin Nutr 1992;56(2):320-28.
  7. Canada's Food Guide. www.hc-sc.gc.ca/fn-an/food-guide-aliment/index_e.html. Accessed January 30, 2008.
  8. Lichtenstein AH, Appel LJ, Brands M, et al. Diet and lifestyle recommendations revision 2006: A scientific statement from the American Heart Association Nutrition Committee. Circulation 2006;114:82-96.
  9. Andersen LB, Harro M, Sardinha LB, et al. Physical activity and clustered cardiovascular risk in children: A cross-sectional study (The European Youth Heart Study). Lancet 2006 9532;368(9532):299-304.
  10. Health Canada. Canadian Hypertension Education Program. 2007 CHEP Recommendations for the management of hypertension. 2007. www.hypertension.ca/chep. Accessed January 30, 2008.
  11. Harris SB, Lank CN, Capes SE, et al. Canadian Diabetes Association 2003 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2003;27:suppl 2.
  12. BC Ministry of Health. Diabetes Care. 2005. www.BCGuidelines.ca.
  13. Barter PJ, Ballantyne CM, Carmena R, et al. Apo B versus cholesterol in estimating cardiovascular risk and in guiding therapy: Report of the thirty-person/ten-country panel. J Intern Med 2006;259(3):247-258.
  14. McPherson R, Frohlich J, Fodor G, et al. Canadian Cardiovascular Society position statement: Recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease. Can J Cardiol 2006;22(11):913-27.
  15. Stevens RJ, Kothari V, Adler AI, et al. The UKPDS risk engine: A model for the risk of coronary heart disease in type II diabetes (UKPDS 56). Clin Sci (Lond) 2001;101(6):671-9.
  16. Asselbergs FW, Diercks GF, Hillege HL, et al. Effects of fosinopril and pravastatin on cardiovascular events in subjects with microalbuminuria. Circulation 2004;110(18):2809-16.
  17. Jafar TH, Stark PC, Schmid CH, et al. Progression of chronic kidney disease: The role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition. Ann Intern Med 2003;139(4):244.
  18. Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. NEJM 2001;345(12):861-869.
  19. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs. diuretic: The Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT). JAMA 2002;288(23):2981. Correction of Table 6: JAMA 2003;289:178.
  20. Walsh JME, Pignone M. Drug treatment of hyperlipidemia in women. JAMA 2004;291(18):2243-52.
  21. Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 2002;360(9346):1623-30.
  22. Pearson TA, Blair SN, Daniels SR, et al. AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update: Consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. American Heart Association Science Advisory and Coordinating Committee. Circulation 2002;106(3):388-91.
  23. Baigent C. Aspirin for everyone older than 50? Against. BMJ. 2005;330(7505):1442-1443.
  24. Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome: An American Heart Association/National Heart, Lung, and Blood Institute scientific statement. Circulation 2005;112(17):2735-52.
  25. Tunstall-Pedoe H, Woodward M. By neglecting deprivation, cardiovascular risk scoring will exacerbate social gradients of disease. Heart 2006;92:307-10.
  26. British Columbia Vital Statistics Agency. Selected Vital Statistics and Health Status Indicators. One hundred and thirty-fourth Annual Report. 2005.
  27. Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004;110(2):227-39.
  28. Wilson PW, D'Agostino RB, Levy D, et al. Prediction of coronary heart disease using risk factor categories. Circulation 1998;97(18):1837-47.
  29. Knopp RH, d'Emden M, Smilde JG, et al. Efficacy and safety of atorvastatin in the prevention of cardiovascular end points in subjects with type 2 diabetes: The Atorvastatin Study for Prevention of Coronary Heart Disease Endpoints in non-insulin-dependent diabetes mellitus (ASPEN). Diabetes Care 2006:1478-85.
  30. Colhoun H, Betteridge DT, Durrington PN et al. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): Multicentre randomised placebo-controlled trial. Lancet 2004;364(9435):685-96.
  31. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. NEJM 2002;346(6):393-403.
  32. Hu FB, Manson JE, Stampfer MJ, et al. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. NEJM 2001;345(11):790-97.
  33. U.S. Preventative Services Task Force: Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment: U.S. Preventative Services Task Force Recommendation Statement. 2009. Ann Intern Med 2009;151:474-482.
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Resources

St. Paul's Healthy Heart Program Web site:
www.heartcentre.ca/services_program.shtml

The Heart and Stroke Foundation of BC and Yukon (Web site: www.heartandstroke.bc.ca Telephone: 1-888-473-4636) has an extensive array of online healthy living resources including self-assessment tools and personalized management plans. The Foundation can also be contacted for community resources that are available for the prevention of cardiovascular disease.

Canada's Food Guide Web site:
www.hc-sc.gc.ca/fn-an/food-guide-aliment/index_e.html

The American Heart Association (Web site: www.americanheart.org) has a number of resources available online, including an extensive diet guide www.deliciousdecisions.org

BC HealthGuide Online Web site: www.bchealthguide.org

Dial-A-Dietitian Web site: www.dialadietitian.org. Telephone: 1-800-667-3438 (Toll free) or 1-604-732-9191 (Greater Vancouver)

Healthy Heart Society of BC Web site: www.heartbc.ca

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Appendices

Appendix A - Part I: Smoking Cessation

Appendix A - Part II: Effective pharmacological aids to smoking cessation

Appendix A - Part III: Patient Handout "Quit Smoking: It's Time to Act"

Appendix B: Framingham Instruction Sheet

Appendix C: Framingham and UKPDS Risk Assessment Charts

Appendix D: Apolipoprotein B

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Sponsors

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission.

This guideline is based on scientific evidence current as of the effective date.

The principles of the Guidelines and Protocols Advisory Committee are to:

  • encourage appropriate responses to common medical situations
  • recommend actions that are sufficient and efficient, neither excessive nor deficient
  • permit exceptions when justified by clinical circumstances.

Contact Information
Guidelines and Protocols Advisory Committee
PO Box 9642 STN PROV GOVT
Victoria BC V8W 9P1
E-mail: hlth.guidelines@gov.bc.ca
Web site: www.BCGuidelines.ca

 

Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.  We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.

A mobile version of this and other guidelines is also available at www.BCGuidelines.ca

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