The 2017 update of The Canadian Stroke Best Practice Recommendations for the Secondary Prevention of Stroke is a collection of current evidence-based recommendations intended for use by clinicians across a wide range of settings. The goal is to provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations include those related to diagnostic testing, diet and lifestyle, smoking, hypertension, hyperlipidemia, diabetes, antiplatelet and anticoagulant therapies, carotid artery disease, atrial fibrillation, and other cardiac conditions. Notable changes in this sixth edition include the development of core elements for delivering secondary stroke prevention services, the addition of a section on cervical artery dissection, new recommendations regarding the management of patent foramen ovale, and the removal of the recommendations on management of sleep apnea. The Canadian Stroke Best Practice Recommendations include a range of supporting materials such as implementation resources to facilitate the adoption of evidence to practice, and related performance measures to enable monitoring of uptake and effectiveness of the recommendations. The guidelines further emphasize the need for a systems approach to stroke care, involving an interprofessional team, with access to specialists regardless of patient location, and the need to overcome geographic barriers to ensure equity in access within a universal health care system.
The approach to treatment of depression that exhibits the greatest potential for achieving full symptomatic and functional recovery is early optimized treatment: early diagnosis followed by rapid individualized treatment. Monitoring symptoms and function early in treatment is crucial to ensuring that patients do not remain on ineffective or poorly tolerated treatment, which may delay recovery and heighten the risk of residual functional deficits.
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.
I n 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. 1 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. 1 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. Three large randomized controlled trials on primary prevention found no net benefit of ASA for prevention of cardiovascular events or mortality in healthy older adults (defined in the ASPREE [Aspirin in Reducing Events in the Elderly] trial as > 65 yr) or persons with diabetes or other risk factors. 2-4 Moreover, 2 recent systematic reviews incorporating the evidence from these trials provided somewhat conflicting results. 5,6 Both found that the risk of major bleeding events was significantly increased in participants receiving ASA. However, 1 systematic review found that the use of ASA did not reduce the risk of all-cause mortality or ischemic stroke, 6 while the other reported that ASA did reduce the risk of a composite of cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke and ischemic stroke. 5 With greater awareness of the risks and benefits of ASA, overall lower rates of cardiovascular events in contemporary populations compared with those in older studies, and conflicting recommendations in guidelines and systematic reviews, clinicians are increasingly uncertain about the role of ASA for primary prevention. 2 The actual number of people in Canada who are taking ASA prophylactically (either as prescribed by a health professional or of their own volition) is not known, although it is likely substantial. A US study reported results from a public poll that found 29 million people were taking ASA in that country, with 23% doing so without a physician's recommendation. 7
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