1. AF Classification

• Paroxysmal AF: Self-terminating (≤7 days).

• Persistent AF: Sustained >7 days or requiring cardioversion.

• Long-standing Persistent AF: Continuous >12 months.

• Permanent AF: Accepted by patient/physician (no further attempts to restore sinus rhythm).

2. Stroke Risk Assessment (CHADS-65)

• CHADS-65 Score:

  • Congestive heart failure (1 point)

  • Hypertension (1)

  • Age ≥65 (1)

  • Diabetes (1)

  • Stroke/TIA/systemic embolism (2 points)

• Anticoagulation:

  • DOACs first-line (apixaban, rivaroxaban, dabigatran, edoxaban) for CHADS-65 ≥1 (men) or ≥2 (women).

  • Avoid in severe renal impairment (use warfarin).

  • Consider LAA occlusion (e.g., Watchman) if anticoagulation contraindicated.

3. Rate vs. Rhythm Control

• Rate Control:

  • First-line: Beta-blockers (e.g., metoprolol) or non-DHP CCBs (diltiazem/verapamil).

  • Digoxin: Reserved for sedentary patients or HFrEF.

Rhythm Control:

• Antiarrhythmics:

  • No structural heart disease: Flecainide, propafenone.

  • HF or CAD: Amiodarone, sotalol.

• Catheter Ablation: Recommended earlier (e.g., symptomatic paroxysmal/persistent AF refractory to meds).

4. Acute AF Management

• Hemodynamically Unstable: Immediate cardioversion.

• Stable Patients:

  • Rate control: IV metoprolol/diltiazem.

  • Rhythm control: Electrical or pharmacological cardioversion (e.g., ibutilide) if onset <48h (or confirmed no thrombus).

  • Anticoagulation: Start immediately (unless contraindicated).

5. Integrated Care (ABC Pathway)

• Anticoagulation to prevent stroke.

• Better symptom management (rate/rhythm control).

• Cardiovascular risk and comorbidity management (e.g., HTN, OSA, obesity).

6. Lifestyle & Comorbidities

• Weight loss: Reduces AF burden in obese patients.

• Alcohol: Limit to ≤2 drinks/day.

• Exercise: Moderate aerobic activity (avoid excessive endurance training).

• Screen for OSA: Especially in resistant AF.

Key Updates (2021)

1. DOACs preferred over warfarin in most cases.

2. Earlier referral for ablation (Class I recommendation for symptomatic AF).

3. CHADS-65 replaces CHA₂DS₂-VASc for simplicity.

4. Focus on lifestyle modifications (weight loss, alcohol reduction).

Clinical Pearl: Use the 4S-AF scheme to guide management:

• Stroke risk (anticoagulate) → Symptoms (rate/rhythm control) → Severity (comorbidities) → Substrate (lifestyle).

CCS Pocket Guide

1. Classification

• HFrEF: EF ≤40% (reduced ejection fraction).

• HFmrEF: EF 41–49% (mid-range).

• HFpEF: EF ≥50% (preserved).

2. Diagnosis

• Symptoms/Signs: Dyspnea, fatigue, orthopnea, edema, elevated JVP, rales.

• Key Tests:

  • BNP/NT-proBNP: Elevated levels (BNP >35 pg/mL; NT-proBNP >125 pg/mL) support HF diagnosis.

  • Echo: Mandatory for EF assessment and structural evaluation (e.g., valve disease, wall motion abnormalities).

  • ECG/CXR/Labs: Rule out ischemia, arrhythmia, pulmonary edema, anemia, renal dysfunction.

3. Chronic Management

A. HFrEF(Core Therapies)

• First-line:

  • ARNI (sacubitril/valsartan) or ACEi/ARB.

  • Beta-blockers (bisoprolol, carvedilol, metoprolol).

  • MRA (spironolactone/eplerenone).

• Add-ons:

  • SGLT2i (dapagliflozin/empagliflozin) – now recommended for all HF subtypes.

  • Ivabradine: If HR >70 bpm on beta-blocker.

  • Diuretics (e.g., furosemide) for volume overload.

• Devices:

  • ICD: Primary prevention if EF ≤35% despite 3+ months of GDMT.

  • CRT: For QRS >150 ms (LVEF ≤35%).

B. HFmrEF/HFpEF:

• Manage comorbidities (HTN, AF, diabetes, obesity).

• Empagliflozin reduces hospitalizations in HFpEF.

• Diuretics for symptomatic relief.

4. Acute Decompensated HF

• Identify Triggers: Infection, non-compliance, ischemia, arrhythmia.

• Therapy:

  • IV loop diuretics (e.g., furosemide) for congestion.

  • Vasodilators (nitroglycerin) if BP >110 mmHg.

  • Inotropes (dobutamine) or vasopressors (norepinephrine) in cardiogenic shock.

• Monitor electrolytes, renal function, and volume status.

5. Lifestyle & Prevention

• Patient Education: Sodium/fluid restriction, daily weight monitoring.

• Exercise: Cardiac rehab improves outcomes.

• Vaccinations: Influenza/pneumococcal.

Key 2021 Updates

1. SGLT2i expanded to all HF subtypes (reduces mortality/hospitalization).

2. ARNI preferred over ACEi/ARB in HFrEF.

3. Empagliflozin now indicated for HFpEF.

Clinical Pearl: Start GDMT early in HFrEF (titrate rapidly!) and prioritize SGLT2i as a foundational therapy.

CCS Pocket Guide

1. Risk Stratification

• Prioritize ASCVD risk:

  • Very High Risk: Clinical ASCVD (e.g., CAD, stroke, PAD) or diabetes with end-organ damage.

  • High Risk: Diabetes ≥40 years, CKD (eGFR <60), or FRS ≥20%.

  • Moderate Risk: FRS 10-19%.

  • Low Risk: FRS <10%.

2. LDL-C Targets

• Very High Risk: <1.8 mmol/L (or ≥50% reduction from baseline).

• High Risk: <2.0 mmol/L (or ≥50% reduction).

• Moderate/Low Risk: <3.4 mmol/L.

3. First-Line Therapy

• High-Intensity Statins:

  • Atorvastatin 40-80 mg or rosuvastatin 20-40 mg for very high/high risk.

  • Moderate-intensity statins for lower-risk patients.

• Combination Therapy (if targets not met):

  • Add ezetimibe (reduces LDL-C by ~20%).

  • PCSK9 inhibitors (alirocumab, evolocumab) for very high-risk patients failing statin + ezetimibe.

4. Hypertriglyceridemia

• Triglycerides ≥5.6 mmol/L:

  • Rule out secondary causes (alcohol, diabetes, hypothyroidism).

  • Fibrates (e.g., fenofibrate) or omega-3 fatty acids (icosapent ethyl 4 g/day) to reduce pancreatitis risk.

5. Special Populations

• Diabetes:

  • LDL-C target <2.0 mmol/L if ≥40 years or with microvascular complications.

• Familial Hypercholesterolemia (FH):

  • Screen family members; treat aggressively with statins + ezetimibe ± PCSK9 inhibitors.

6. Monitoring & Safety

• Baseline: Check lipids, LFTs, CK.

• Follow-up: Repeat lipids at 3 months; monitor for statin side effects (myalgias, elevated LFTs).

• Safety: Avoid statins in pregnancy; use caution in CKD.

7. Lifestyle Interventions

• Diet: Mediterranean diet, minimize saturated/trans fats.

• Exercise: ≥150 min/week moderate-intensity activity.

• Smoking cessation: Critical for ASCVD risk reduction.

Key 2022 Updates

1. Lower LDL-C targets for very high-risk patients (<1.8 mmol/L).

2. Icosapent ethyl recommended for ASCVD patients with persistent TG ≥1.5 mmol/L despite statins.

3. Inclisiran (small interfering RNA therapy) now approved as adjunct for FH/ASCVD.

4. Emphasis on lifetime risk: Earlier intervention in younger patients with FH or high genetic risk.

Clinical Pearl: Start high-intensity statins early in high/very high-risk patients; treat to target and escalate therapy aggressively if needed.

CCS Pocket Guide

1. Primary Prevention

• Routine aspirin not recommended for asymptomatic adults without CVD.

• Exceptions: Consider in select high-risk diabetes patients (40–70 years) after individualized risk-benefit discussion.

2. Secondary Prevention in Stable CAD

• Lifelong low-dose aspirin (75–100 mg/day).

• Dual antiplatelet therapy (DAPT) not routinely recommended unless recent ACS or PCI.

3. Acute Coronary Syndrome (ACS)

• DAPT for 12 months:

  • Aspirin + potent P2Y12 inhibitor (ticagrelor or prasugrel preferred over clopidogrel).

  • Exceptions:

    • Prasugrel contraindicated in prior stroke/TIA or age ≥75.

    • Clopidogrel if ticagrelor/prasugrel not tolerated.

• Early de-escalation (e.g., switching to clopidogrel) may be considered in high bleeding risk.

4. Post-Percutaneous Coronary Intervention (PCI)

• DAPT Duration:

  • ACS patients: 12 months (minimum 6 months if high bleeding risk).

  • Elective PCI: 1–6 months based on stent type (BMS vs. DES) and bleeding risk.

• Extended DAPT (>12 months): Consider in high ischemic/low bleeding risk (e.g., complex PCI, prior MI).

5. Atrial Fibrillation + CAD (Triple Therapy)

• Combining antiplatelets + anticoagulants:

  • Short-term triple therapy (aspirin + clopidogrel + DOAC) for 1–6 weeks post-PCI/ACS.

  • Transition to dual therapy (clopidogrel + DOAC) for up to 12 months.

  • Use CHA2DS2-VASc and HAS-BLED scores to guide decisions.

6. Special Populations

• CABG: Resume DAPT post-surgery if ACS indication.

• High Bleeding Risk:

  • Shorten DAPT duration (e.g., 3–6 months).

  • Use proton pump inhibitors (PPIs) with DAPT to reduce GI bleeding.

• Renal Impairment: Avoid prasugrel; prefer clopidogrel or ticagrelor.

7. Perioperative Management

• Elective surgery: Stop P2Y12 inhibitors 5–7 days pre-op (if possible).

• Aspirin: Continue perioperatively unless high bleeding risk.

8. Key Updates (2018)

1. Personalized DAPT duration: Tailor to ischemic/bleeding risk (e.g., PRECISE-DAPT or DAPT score).

2. De-escalation strategies: Transition from potent P2Y12 inhibitors to clopidogrel in high bleeding risk.

3. Ticagrelor/prasugrel preferred over clopidogrel in ACS.

4. Clopidogrel monotherapy may replace aspirin in aspirin-intolerant patients.

Clinical Pearl: Balance ischemic vs. bleeding risk in every patient. When in doubt, default to 12 months DAPT for ACS/PCI, but shorten duration in high bleeding risk.

CCS Pocket Guide

1. Definition & Classification

• Cardiorenal Syndrome (CRS): Bidirectional dysfunction of the heart and kidneys, classified into 5 types:

  • Type 1: Acute cardiac dysfunction → acute kidney injury (e.g., ADHF).

  • Type 2: Chronic cardiac dysfunction → progressive CKD (e.g., chronic HFrEF).

  • Type 3: Acute kidney injury → acute cardiac dysfunction (e.g., volume overload).

  • Type 4: Chronic CKD → chronic cardiac disease (e.g., LVH, HFpEF).

  • Type 5: Systemic disease (e.g., sepsis, diabetes) → simultaneous cardiac/kidney injury.

2. Diagnostic Workup

• Cardiac Assessment:

  • BNP/NT-proBNP (elevated in HF).

  • Echocardiography (LVEF, diastolic function, valvular disease).

• Renal Assessment:

  • Serum creatinine/eGFR, urine albumin-to-creatinine ratio (ACR).

  • Renal ultrasound (rule out obstruction).

• Rule Out: Hypovolemia, nephrotoxins (NSAIDs, contrast), sepsis.

3. Management Principles

A. Heart Failure with CRS

• GDMT for HFrEF:

  • ARNI/ACEi/ARB, beta-blockers, MRAs, SGLT2 inhibitors (e.g., dapagliflozin, empagliflozin).

  • Adjust doses for eGFR (e.g., avoid ARNI if eGFR <30).

• Diuretics:

  • Loop diuretics (furosemide) for volume overload; combine with thiazides if refractory.

  • Monitor electrolytes (K+, Mg²⁺).

B. Kidney Protection

• ACEi/ARBs or SGLT2 inhibitors for proteinuria.

• Avoid nephrotoxic agents (NSAIDs, iodinated contrast).

• Referral: Nephrology consult if eGFR <30 or rapid decline.

C. Advanced Therapies

• Ultrafiltration: Consider in diuretic-resistant volume overload.

• Dialysis: For refractory hyperkalemia, acidosis, or uremia.

4. Special Considerations

• Hyperkalemia:

  • Use patiromer or sodium zirconium cyclosilicate if chronic.

  • Limit ACEi/ARB/MRA doses if recurrent.

• Anemia: Treat iron deficiency (IV iron preferred in CKD).

• Palliative Care: For end-stage CRS with poor prognosis.

5. Key 2023 Updates

1. SGLT2 inhibitors recommended for all CRS types (reduce HF hospitalizations and CKD progression).

2. ARNI preferred over ACEi/ARB in HFrEF with CKD (better renal outcomes).

3. Individualized diuretic regimens (avoid over-diuresis worsening renal function).

4. Biomarkers: Emerging role of galectin-3 and sST2 for risk stratification.

6. Lifestyle & Monitoring

• Sodium/fluid restriction: ≤2–3 g/day Na⁺; daily weights.

• Diet: Low-protein diet in advanced CKD (individualized).

• Monitoring:

  • Weekly labs (creatinine, K⁺) during GDMT titration.

  • eGFR trajectory (decline >30% warrants reassessment).

Clinical Pearl: Prioritize SGLT2 inhibitors (cardio-renal-metabolic benefits) and multidisciplinary care (cardiology/nephrology collaboration).

CCS Pocket Guide

1. Indications for CRT

• Primary Candidates:

  • Sinus rhythm, LVEF ≤35%, NYHA class III/IV (or ambulatory class IV) on optimal medical therapy, with:

    • LBBB morphology + QRS duration ≥150 ms (Class I recommendation).

    • LBBB + QRS 120–149 ms (Class IIa).

    • Non-LBBB + QRS ≥150 ms (Class IIb).

• Milder Symptoms (NYHA II):

  • LVEF ≤30%, LBBB + QRS ≥150 ms, ischemic cardiomyopathy (Class I).

2. Device Selection

• CRT-P (Pacemaker): For symptom relief and LV reverse remodeling.

• CRT-D (Defibrillator): Add defibrillator function if life-threatening arrhythmia risk (e.g., prior sudden cardiac arrest, ischemic cardiomyopathy).

3. Implantation Procedure

• LV Lead Placement: Target lateral/posterolateral coronary vein for optimal resynchronization.

• Coronary Sinus Venography: Essential for anatomical mapping.

• Device Programming: Optimize AV/VV intervals (echocardiography-guided).

4. Follow-Up & Optimization

• Post-Implant:

  • Assess pacing thresholds, lead stability, and phrenic nerve stimulation.

  • Repeat echocardiography at 3–6 months to evaluate LVEF improvement.

• Non-Responders (~30% of patients):

  • Verify >95% biventricular pacing.

  • Optimize medical therapy (diuretics, neurohormonal agents).

5. Contraindications

• Mechanical right heart valve.

• Expected survival <1 year.

• Permanent atrial fibrillation without pacemaker control (unless AV nodal ablation planned).

6. Special Populations

• Atrial Fibrillation:

  • CRT may still benefit if ventricular rate controlled (e.g., AV nodal ablation + CRT).

• Right Bundle Branch Block (RBBB): Limited benefit; consider only if QRS ≥150 ms + LVEF ≤35%.

7. Outcomes

• Reduced Mortality/Hospitalizations: Supported by trials (e.g., COMPANION, CARE-HF).

• Symptom Improvement: 60–70% patients show better functional class, quality of life.

Key 2013 Updates

1. Expanded indications for NYHA class II patients with wide QRS/LBBB.

2. Emphasis on LBBB morphology as a predictor of CRT response.

3. Refined ECG criteria (QRS duration + morphology).

Clinical Pearls:

• Prioritize LBBB + QRS ≥150 ms for maximal benefit.

• Ensure >95% biventricular pacing; address AF or frequent PVCs that reduce pacing efficacy.

• Multidisciplinary care (HF specialist, electrophysiologist) improves outcomes.

CCS Pocket Guide

1. Diagnosis & Risk Stratification

• Clinical Evaluation:

  • Symptoms: Assess for classic angina (retrosternal discomfort, exertion/emotional triggers) and nonclassical presentations (e.g., in diabetes).

  • Risk Factors: Modifiable (smoking, dyslipidemia, diabetes) and nonmodifiable (age, family history).

  • Tests: ECG, lipid panel, fasting glucose, renal/hepatic/thyroid function, hemoglobin A1c.

• Pretest Probability: Use age, sex, and symptom characteristics to guide testing. Avoid testing if pretest probability is <10% or >90%.

• Noninvasive Testing:

  • Exercise ECG: First-line if interpretable and patient can exercise.

  • Imaging (SPECT, echocardiography, CCTA): For uninterpretable ECGs, LBBB, or inability to exercise.

  • CCTA: High negative predictive value; avoid in high-risk patients likely needing invasive angiography.

2. Medical Management

• Prognostic Therapy:

  • Antiplatelets: ASA 81 mg daily (clopidogrel if ASA-intolerant).

  • Statins: Per CCS Dyslipidemia Guidelines.

  • ACEi/ARBs: For hypertension, diabetes, LVEF <40%, or CKD.

  • Beta-blockers: First-line for angina post-MI or with LV dysfunction.

• Symptom Control:

  • First-line: Beta-blockers or calcium channel blockers (dihydropyridines preferred).

  • Add-ons: Long-acting nitrates if monotherapy fails.

  • Avoid: Nondihydropyridines (verapamil/diltiazem) with beta-blockers (risk of bradycardia).

• Timeline: Optimize medical therapy within 12–16 weeks before revascularization.

3. Revascularization Considerations

• Indications:

  • Refractory symptoms, high-risk features (Table 5: severe ischemia, LVEF <45%, multivessel disease).

  • Expedited angiography for high-risk noninvasive findings (e.g., ST depression, ventricular arrhythmias).

• Approach:

  • PCI vs CABG: Decision by multidisciplinary "heart team" (consider diabetes, anatomy, comorbidities).

  • CCTA: May precede invasive angiography in select cases.

4. Follow-Up & Rehabilitation

• Monitoring:

  • Annual ECG, metabolic labs, and symptom assessment.

  • Avoid routine stress testing in asymptomatic patients.

• Lifestyle:

  • Cardiac rehab: Referral for all patients, especially post-MI/revascularization.

  • Exercise: 150+ minutes/week of moderate activity.

• Reassessment: For new/worsening symptoms or occupational demands (e.g., commercial drivers).

Key Recommendations

• GRADE Strong/High: ASA, statins, ACEi/ARBs in high-risk patients, beta-blockers post-MI.

• GRADE Conditional/Moderate: CCTA for LBBB, cardiac rehab referral, no chelation/testosterone.

Take-Home Message:
SIHD management hinges on risk stratification, rapid initiation of guideline-directed medical therapy (GDMT), and judicious revascularization. Prioritize symptom control with beta-blockers/calcium channel blockers, optimize prognostic therapies (ASA, statins, ACEi), and reserve revascularization for high-risk features or refractory symptoms. Regular follow-up and lifestyle modification are critical for long-term outcomes.

CCS Society Guidelines