New guideline for professionals who manage comorbid brain and heart conditions

Current Canadian clinical practice guidelines for cardiac, neurologic and mental health conditions take disease-specific approaches, but many cardiovascular conditions co-occur with other diseases, conferring increased risks.1,2The Canadian Cardiovascular Harmonized National Guideline Endeavour (C-CHANGE) initiative, established in 2008, has provided healthcare professionals in Canada with a harmonized set of cardiovascular guideline recommendations.3 The C-CHANGE group has now expanded the current cardiovascular guideline to include evidence from the neurologic and mental health literature, to recognize the growing key connections between brain and heart diseases as a critical source of multimorbidity in older adults. This has resulted in 11 specific recommendations for healthcare professionals caring for patients with both brain and heart conditions.1The goal of the new brain–heart guideline is to provide up-to-date, evidence-based, patient-centred recommendations for the prevention and management of joint brain–heart conditions, while incorporating the principles of shared decision-making. The guideline is designed for primary care professionals, but will also be useful to subspecialists in cardiology, neurology and mental health, and members of interprofessional teams managing brain and heart diseases.1Many potential clinical presentations of comorbid brain–heart disease exist. However, the new clinical practice guideline focuses on the following comorbid conditions that have the most established evidence base and were identified to be of high priority importance to panel members with lived experience (PWLE) and caregivers:relationship between cognitive impairment and atrial fibrillation, as well as hypertensionrelationship between coronary artery disease and depressionrelationship between dyslipidemia and stroke, as well as overall cardiovascular disease riskvaccination to prevent stroke, myocardial infarction and dementia.1RecommendationsThe following joint brain–heart recommendations were developed by 10 expert subgroups, reviewed by the PWLE panel, and approved by the guideline development panel, using a consensus process.1 Screening1. Atrial fibrillation and risk of cognitive impairment The panel suggests that individuals with atrial fibrillation be screened using a validated screening tool to identify those at risk for cognitive impairment. 2. Coronary artery disease and depression The panel suggests that individuals with coronary artery disease be screened for depression using a validated screening tool.1Treatment3. Coronary artery disease and depression In individuals with coronary artery disease, if a diagnosis of depression is confirmed, the panel recommends treatment be initiated with a selective-serotonin reuptake inhibitor (SSRI); or 4. The panel suggests treatment with other evidence-based therapies, such as cognitive behavioural therapy, based on disease severity.5. Hypertension and risk for cognitive impairment The panel recommends that individuals who have a systolic blood pressure between 130–180 mmHg and an increased cardiovascular risk (defined as having clinical or subclinical cardiovascular disease, chronic kidney disease, a Framingham Risk Score of ≥ 15%, or age ≥ 75 yr) undergo intensive blood pressure lowering to < 120 mmHg to reduce the risk for cognitive impairment.6. Dyslipidemia and risk of stroke or cardiovascular disease The panel recommends that individuals with coronary artery disease with LDL-C levels above the threshold of 1.8 mmol/L undergo intensification of therapy to bring the LDL-C below target, to prevent stroke and reduce cardiovascular risk.7. The panel also suggests that individuals with stroke and LDL-C levels above the threshold of 1.8 mmol/L undergo intensification of therapy to bring the LDL-C below target, to reduce the risk of major cardiovascular events.8. Vaccination and risk of stroke, cardiovascular death, myocardial infarction or dementia The panel suggests routinely offering influenza vaccination to all individuals, particularly those older than 65 years, to reduce the risk of cardiovascular death and stroke, and possibly dementia.9. The panel suggests routinely offering pneumococcal vaccination to all individuals, particularly those older than 65 years, to reduce the risk of myocardial infarction and stroke.10. The panel suggests routinely offering herpes zoster vaccination to all individuals, particularly those older than 65 years, to reduce the risk of myocardial infarction and stroke, and possibly dementia.11. Shared decision-making and heart–brain health The panel recommends that clinicians support individuals with or at risk of brain and heart conditions to actively participate in decision-making about their care by using evidence-based decision aids in preparation for and during consultations, to facilitate the shared decision-making process.1For each of the preceding recommendations, the guideline provides an evidence summary and an assessment of evidence quality, to explain the basis for the panel’s decision-making.1 Supporting information for each recommendation is also included in a separate appendix to help healthcare professionals implement these recommendations into their practices.4 A supplemental table outlining sex and gender considerations for each of the recommendations is also offered.5The panel concludes that this guideline was spurred by the growing recognition of the important connections between brain and heart diseases as a critical source of multimorbidity in aging populations. Key recommendations in the guideline include screening for cognitive decline in atrial fibrillation, screening for depression in coronary artery disease, treatment of depression in coronary artery disease, treatment of hypertension to reduce the risk for cognitive impairment, and treatment of dyslipidemia to prevent stroke and reduce cardiovascular risk. Vaccination (influenza, pneumococcal, herpes zoster) to prevent stroke, myocardial infarction and dementia is also recommended, along with shared decision-making.1ReferencesEdwards JD, Li Z, McFarlane P, et al. Management of brain–heart multimorbidity: a clinical practice guideline. CMAJ 2026;198:E425-39. (accessed March 31, 2026).Canadian Medical Association Journal. New brain–heart guideline takes holistic approach to chronic disease management (press release). March 31, 2026. (accessed March 30, 2026).Jain R, Stone JA, Agarwal G, et al. Canadian Cardiovascular Harmonized National Guideline Endeavour (C-CHANGE) guideline for the prevention and management of cardiovascular disease in primary care: 2022 update. CMAJ 2022;194:E1460-80. (accessed March 31, 2026). Edwards JD, Li Z, McFarlane P, et al. Management of brain–heart multimorbidity: a clinical practice guideline. CMAJ 2026;198:E425-39. Appendix 3. Screening and treatment recommendation practice pearls, and clinical considerations. (accessed March 31, 2026).Edwards JD, Li Z, McFarlane P, et al. Management of brain–heart multimorbidity: a clinical practice guideline. CMAJ 2026;198:E425-39. Supplemental Table 2. Sex and gender considerations for recommendations. (accessed March 31, 2026).

New guideline for professionals who manage comorbid brain and heart conditions

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