HF often progresses from asymptomatic LVSD to symptomatic HF. Early detection of LVSD may allow intervention on contributing risk factors and pharmacotherapy to delay or reverse the progression of adverse LV remodeling. Data on medications, including ACEs, ARBs, and beta- blockers are summarized online in evidence reviews at www.ccs.ca.

Recommendation 1: We suggest clinical assessment in all patients to identify known or potential risk factors for the development of heart failure (Weak Recommendation, Moderate Quality Evidence).

Recommendation 2: We recommend ACE inhibitors be used in all asymptomatic patients with an EF < 35% (Strong Recommendation, Moderate Quality Evidence).

Recommendation 3: We recommend that an ACE inhibitor should be prescribed in established effective doses to reduce the risk of developing HF in patients with evidence of vascular disease or diabetes with end-organ damage (Strong Recommendation, High Quality Evidence).

Recommendation 4: We recommend that in ACE-intolerant patients, an ARB may be considered for reduction of the risk of developing HF in patients with evidence of vascular disease or diabetes with end-organ damage (Strong Recommendation, High Quality Evidence).

Recommendation 5: We recommend that health professionals caring for overweight or obese individuals should educate them about the increased risk of HF (Strong Recommendation, Moderate Quality Evidence).

Recommendation 6: We recommend physical activity to reduce the risk of developing HF in all individuals (Strong Recommendation, Moderate Quality Evidence).

• Natriuretic peptide (NP) screening of individuals at risk for the development of HF can aide decision making on whom to send for echocardiography. A value of BNP > 50 pg/mL or NT-proBNP > 125 pg/mL should prompt a request for specialist consultation and imaging, and/or initiation or intensification of neurohormonal blocking agents and lifestyle interventions.
• Dyslipidemia should be treated in patients with evidence of vascular disease or diabetes with lipid-lowering drugs, especially statins.
• Smoking cessation, improved cardiorespiratory fitness and weight reduction for overweight or obese individuals are important preventive strategies for HF.
• Patients at high risk for developing HF should receive annual influenza vaccine and periodic pneumococcal pneumonia immunizations.