THE 2009
CANADIAN HYPERTENSION
   EDUCATION PROGRAM
     RECOMMENDATIONS




      AN ANNUAL UPDATE
Hypertension recommendations designed for patient
and public education have been developed in 2008.
Bulk orders of 25 or m...
TAblE Of CONTENTS

Scientific Summary .......................................................................................
On behalf of the Canadian
Hypertension Education Program
Acknowledgement:
This manuscript was written by
Dr. N. Campbell w...
SCIENTIfIC SUMMARY
2



Summary
The 2009 Canadian Hypertension Education Program (CHEP)
recommendations are the 10th annual update. Recent su...
3



Key Words
Hypertension, High Blood Pressure, Clinical Practice
Guidelines, Knowledge Translation.

2009 marks the ten...
4



overall healthy lifestyle change for most people.4 After
being diagnosed with hypertension, there was a slight
increa...
5



blood pressure.7 In people with diabetes and hypertension
reducing blood pressure results in a large reduction in dea...
6



due to syncope and renal impairment compared with rami-
pril. Specifically, combination therapy was associated with a...
7



(~3%), adverse events, principally hypotensive symptoms,
syncope and atrial fibrillation were more common in the
telm...
8



The TRANSCEND trial has not changed the CHEP recom-
mendation to prescribe an ACE inhibitor for most people
with hype...
9



cardiovascular risk reduction can more than double car-
diovascular risk reduction compared to blood pressure
managem...
10



analysis on the effects of regular aerobic exercise showed
physical activity reduced blood pressure by 3.8/2.6 mm Hg...
11



Further, in 2010, the results of another survey that assesses
patient knowledge, attitudes and barriers to care will...
TABlE 1:
Considerations in the Individualization of Antihypertensive Therapy†*
ACE: angiotensin converting enzyme; TIA: tr...
Initial Therapy                                  Second-line Therapy                                              Notes an...
Initial Therapy                                  Second-line Therapy                                                Notes ...
15



TABlE 2:
Target Values for Blood Pressure*

 Setting                                                         Target
...
16



TABlE 4:
CHEP Reduces the Impact of Bias
by the Following Methods*

   1       A history of requiring a high level o...
17



TABlE 5:
Internet Resources for Patient Information†*

 Resource                   Description                Source...
18



Reference list
1. Mohan S, Campbell NR. Hypertension management in Canada: good news, but important
   challenges re...
19




28. The EURopean trial On reduction of cardiac events with Perindopril in stable coronary Artery
    disease invest...
PART 1




DiAgNosis & AssEssmENT
22



I ACCURATE MEASUREMENT OF BlOOD PRESSURE
    1) The blood pressure (BP) of all adult patients
       should be asses...
23



4) At visit 2 for the assessment of hypertension, patients with
   macrovascular target organ damage, diabetes melli...
24



  7) If at the last diagnostic visit the patient is not diagnosed
     to be hypertensive and has no evidence of mac...
25



   iii) fasting blood glucose (Grade D)

   iv) fasting total cholesterol and high density lipoprotein
       choles...
26



    normal renal function) (Grade B). Captopril-enhanced
    radioisotope renal scan is not recommended for those
  ...
27



   ii) patients with hypertension and multiple symptoms
       suggestive of catecholamine excess (e.g., headaches,
...
28



   recent requirements of the British Hypertension Society
   protocol or the International Protocol for validation
...
29



       24 h ambulatory SBP of 130 mm Hg or higher and/or DBP
       of 80 mm Hg or higher and/or awake SBP of 135 mm...
30



ii) Choose a cuff with an appropriate bladder size matched
    to the size of the arm. For measurements taken by aus...
31



     to examine for postural hypotension, if present, which
     may modify the treatment.

viii) If Korotkoff sound...
32



Hypertensive Retinopathy
Left Ventricular Dysfunction
Coronary Artery Disease
    Myocardial infarction
    Angina p...
33



TABlE 5:
E x a m p l e s o f E xo g e n o u s Fa c t o r s t h a t c a n
Induce/Aggravate Hypertension*
Prescription...
34



iii) Definition of a positive screening test: plasma aldosterone/
     renin activity ratio greater than 550 pmol/L/...
35



TABlE 7:
Pheochromocytoma: Screening and Diagnosis*
1) Biochemical screening tests for
   pheochromocytomas:
   a) t...
FigURE 1: The Expedited Assessment and Diagnosis of Patients with Hypertension:
                        Focus on Validated...
BP: 140 -179/90 -109 mm Hg


                          Clinic BPM                                     ABPM (if available) ...
PART 2




THERAPY
40



I lIFESTYlE MANAGEMENT
 A) Physical Exercise
   1) For non-hypertensive individuals (to reduce the pos-
      sibili...
41



      hypertension consume a diet that emphasizes fruits,
      vegetables, low-fat dairy products, dietary and solu...
42



  3) Antihypertensive therapy should be strongly con-
     sidered if systolic blood pressure readings average
     ...
43



       is more likely or more poorly tolerated (e.g., elderly
       patients) from initial combination therapy.

  ...
44



    (Grade A), and beta-blockers are not recommended as
    first-line therapy for isolated systolic hypertension in...
45



  B) Recommendations for Patients with
     Hypertension who have had a Recent ST-
     elevation Myocardial Infarct...
46



VIII TREATMENT OF HYPERTENSION IN ASSOCIATION
     WITH CEREBROVASCUlAR DISEASE
     1) Strong consideration should ...
47



  3) Thiazide diuretics are recommended as additive antihy-
     pertensive therapy (Grade D). For patients with chr...
48



    following are recommended: an ACE inhibitor (Grade
    A for patients 55 years or older, Grade B for patients
  ...
Chep Recommendations
Chep Recommendations
Chep Recommendations
Chep Recommendations
Chep Recommendations
Chep Recommendations
Chep Recommendations
Chep Recommendations
Chep Recommendations
Chep Recommendations
Chep Recommendations
Chep Recommendations
Chep Recommendations
Chep Recommendations
Upcoming SlideShare
Loading in...5
×

Chep Recommendations

3,581

Published on

Canadian hypertensive guidelines 2009

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
3,581
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
93
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Chep Recommendations

  1. 1. THE 2009 CANADIAN HYPERTENSION EDUCATION PROGRAM RECOMMENDATIONS AN ANNUAL UPDATE
  2. 2. Hypertension recommendations designed for patient and public education have been developed in 2008. Bulk orders of 25 or more copies can be obtained by contacting hyperten@ucalgary.ca. Hypertension recommendations for patients with diabetes, developed in 2009, are also available. These summaries are available electronically at www.hypertension.ca/bpc. A free, confidential tool is available at www.heartandstroke.ca/bp. Developed by the Heart and Stroke Foundation, the Blood Pressure Action Plan enables people to get a personalized action plan tailored to their risk profile, promote self-management and help people to make lifestyle changes, monitor their blood pressure and print reports to take to their healthcare provider.
  3. 3. TAblE Of CONTENTS Scientific Summary ......................................................................................................... 1 The 2009 Canadian Recommendations for the Management of Hypertension: Diagnosis & Assessment ....................................................................... 21 Therapy ............................................................................................................................. 39 Therapy Tables ..................................................................................................... 49 Evidence-Based Recommendations Task Force 2008 for the 2009 Recommendations........................................... 59
  4. 4. On behalf of the Canadian Hypertension Education Program Acknowledgement: This manuscript was written by Dr. N. Campbell with the assistance of the CHEP Executive, Dr. M. Hill, Dr. N. Khan and Dr. G. Tremblay.
  5. 5. SCIENTIfIC SUMMARY
  6. 6. 2 Summary The 2009 Canadian Hypertension Education Program (CHEP) recommendations are the 10th annual update. Recent surveil- lance data indicates that two-thirds of diabetic people with hypertension have uncontrolled blood pressure. The focus of this year’s update is on improving the blood pressure management in these people. Other management gaps include suboptimal use of pharmacotherapy in younger hypertensive people with multiple cardiovascular risk factors and a low uptake of lifestyle changes after a hypertension diagnosis. In 2009, CHEP specifically recommends not to combine an ACE inhibitor with an angiotensin receptor blocker (ARB) in people with uncomplicated hypertension, diabetes (without micro or overt albuminuria), chronic kidney disease (without proteinuria) and ischemic heart disease (without heart failure). Abstract This report highlights the key messages of the 2009 Canadian Hypertension Education Program recommendations for management of hypertension and the supporting clinical science. In 2009, CHEP emphasizes the need to improve control of hypertension in people with diabetes. Intensive reduction in blood pressure (<130/80 mm Hg) in people with diabetes leads to significant reductions in mortality rates, disability rates, and overall health care system costs and may lead to improved quality of life. The CHEP recommendations continue to emphasize the important role played by patient self-efficacy by promoting lifestyle change to prevent and control hypertension and by encouraging home measure- ment of blood pressure. Unfortunately, most Canadians make only minor changes in lifestyle after a diagnosis of hypertension. Routine blood pressure measurement at all appropriate visits and screening for and management of all cardiovascular risks are key to blood pressure manage- ment. Many young hypertensive Canadians with multiple cardiovascular risks are not treated with antihypertensive drugs. This is despite the evidence that those with multiple cardiovascular risks and hypertension should be strongly considered for antihypertensive drug therapy regardless of age. In 2009, CHEP now specifically recommends not to combine an ACE inhibitor with an ARB in people with uncomplicated hypertension, diabetes (without micro or macro albuminuria), chronic kidney disease (without nephropathy (micro or overt proteinuria)) or ischemic heart disease (without heart failure).
  7. 7. 3 Key Words Hypertension, High Blood Pressure, Clinical Practice Guidelines, Knowledge Translation. 2009 marks the tenth consecutive year that the Canadian Hypertension Education Program (CHEP) has had updated recommendations for the management of hypertension. CHEP is a program of the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the Heart and Stroke Foundation of Canada, the Canadian Council of Cardiovascular Nurses, the Canadian Pharmacists Association and the College of Family Physicians of Canada. CHEP makes substantive efforts to harmonize recommen- dations for the management of hypertension with other organizations that also produce guidelines that include blood pressure lowering therapy. In particular the 2009 CHEP recommendations are harmonized with those of the Canadian Diabetes Association, the Canadian Society of Nephrology and the Canadian Stroke Network. CHEP’s leadership in guidelines processes is characterized by the routine cycles of surveillance, evaluation of care gaps, and development of programs and educational resources to address the care gaps. In 2008, CHEP was aided by data that allowed identification not only of successes that could be attributed to the program but also of important clinical care gaps that continue to exist. A survey (ONBP) conducted by the Heart and Stroke Foundation found that while Ontario had a low prevalence of hypertension (21%) relative to other developed countries it had the world’s highest published rates of awareness, treatment and control of hypertension.1, 2 Nevertheless, the survey found that two-thirds of Ontarians with hypertension and diabetes have uncontrolled blood pressure (½ the control rate of those without diabetes). A national survey also demonstrated a care gap in that only ½ of younger people with hypertension were treated with medications and the rate of treatment did not increase with increasing number of concomitant cardiovascular risk factors. 3 In fact hypertensive people who smoked were less likely to be treated and those with five additional cardiovascular risk factors were no more likely to be treated than those with hypertension alone. The CHEP recommenda- tions continue to emphasize the importance of patient self-efficacy by promoting lifestyle change to prevent and control hypertension and by home measurement of blood pressure. In a prospective national cohort survey there was little indication that a diagnosis of hypertension triggered
  8. 8. 4 overall healthy lifestyle change for most people.4 After being diagnosed with hypertension, there was a slight increase in smoking cessation and an increase in physical activity; however, body mass index (BMI) increased and there was no change in excess alcohol consumption. Those who were not prescribed medications were not more likely to make lifestyle changes. CHEP will make efforts to develop resources and tools to improve care in these areas. There were several major hypertension clinical trials in 2008 as well as new information from trials published in 2007. The major changes in the evidence have resulted in new CHEP recommendations to specifically not combine an ACE inhibi- tor with an ARB in people with uncomplicated hypertension, ischemic heart disease in the absence of heart failure, past stroke, non-proteinuric chronic kidney disease or diabetes without nephropathy (albuminuria, see Table 1). The HYVET trial supported a previous CHEP recommendation to treat hypertension in those over age 80. The same cautions as indicated in the past need to be exercised when prescribing antihypertensive therapy in those who are at risk for adverse effects of blood pressure lowering (e.g. the frail elderly). The recent publication of the ADVANCE trial has resulted in CHEP recommending consideration of initial therapy with 2 antihypertensive drugs for people with diabetes and blood pressures >150/90 mm Hg.5, 6 This is a short scientific summary of the new clinical hyper- tension evidence and the 2009 CHEP recommendations as well as the opinions of the CHEP Executive regarding important issues in hypertension management in Canada. The full CHEP recommendations are available at www. hypertension.ca and will be published in the May 2009 issue of the Canadian Journal of Cardiology. Tables 2 and 3 contain the target values for treating hypertension and recommended lifestyle respectively. New evidence has allowed CHEP to address additional clinical questions in the management of hypertension for the 2009 recommendations. Why should I treat people with diabetes and hyperten- sion to a target of less than 130/80 mm Hg? In 2008, the ONBP survey found two-thirds of people with diabetes and hypertension had blood pressure that was 130/80 mm Hg or above. Up to 80% of people with diabetes die of cardiovascular complications and up to three-quarters of specific diabetic complications can be attributed to high
  9. 9. 5 blood pressure.7 In people with diabetes and hypertension reducing blood pressure results in a large reduction in death and disability.6, 8-12 In the Syst Eur trial of isolated systolic hypertension, hypertensive therapy in people with diabetes reduced total mortality by 55%, cardiovascular mortality by 76%, and all cardiovascular events by 67%.13 In the HOT trial, people with diabetes who had more intensive treatment of diastolic blood pressure had a 66% reduction in death from heart disease and stroke even though the difference in diastolic blood pressure was only 4 mm Hg at the end of the trial.14 In a meta analysis of randomized controlled trials, more vs. less intensive lowering of blood pressure reduced total mortality by 24% and major cardiovascular events by 25%.15 The use of an ACE inhibitor or ARB based therapeutic regime to lower blood pressure has additional advantages in people with proteinuric chronic kidney disease.15 CHEP recommends treating systolic blood pressure to <130 mm Hg and diastolic to <80 mm Hg. Economic analysis indicates that more intensive reduction in blood pressure in people with diabetes is one of the few medical interventions that may reduce overall health costs.16 What are the implications of new clinical trials for treating people with hypertension? Should I prescribe the combination of an ACE inhibitor with an ARB in my patients? The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) was a large, randomized double-blinded trial to determine if telmisartan was non-inferior to ramipril at full doses and whether the combination of telmisartan and ramipril was superior to ramipril alone.17, 18 People were enrolled into the study if they were aged 55 years and older and had evidence of vascular disease or diabetes with target organ damage. 25,620 people were randomized to either telmisartan 80 mg/day, ramipril 10 mg/day, or a combination of telmisartan 80 mg/day and ramipril 10 mg/day. After a median follow-up of 56 months, the telmisartan (-0.9/-0.6 mm Hg) and the combination therapy (-2.4/-1.4 mm Hg) groups had significantly lower blood pressures compared to the ramipril monotherapy group. There was no significant difference in the primary outcome (cardiovascular death, myocardial infarction, stroke or hospitalization for congestive heart failure) between the ramipril and telmisartan monotherapy groups as well as the combination therapy group compared with the ramipril monotherapy group. However, combination therapy was associated with significantly higher rates of discontinuation
  10. 10. 6 due to syncope and renal impairment compared with rami- pril. Specifically, combination therapy was associated with a significantly increased rate of dialysis and doubling of serum creatinine compared to ramipril monotherapy (HR: 1.09; 95% CI: 1.01-1.18, p=0.037). The findings of this study provide evidence that telmisartan is equally as effective as ramipril for people with cardiovascular disease or diabetes with target organ damage. The findings also demonstrate that the combination of telmisartan and ramipril do not provide additional cardiovascular benefits above and beyond either therapy alone but does increase the adverse event rate in the ONTARGET population. The COOPERATE trial has been used as evidence in favour of prescribing the combination of an ACE inhibitor with an ARB.19 In 2008, serious concerns have been raised regarding several data inconsistencies in the study.20 To date, the only data supporting improved patient-related outcomes from prescribing the combination of an ACE inhibitor with an ARB have been from secondary outcome analysis of heart failure trials.21,22 There are ongoing trials in proteinuric people with substantive chronic kidney disease. In the absence of evidence there is no recommenda- tion to use the combination aside from in people with heart failure. CHEP recommends specifically to not prescribe the combination of an ACE inhibitor with an ARB in people with uncomplicated hypertension, ischemic heart disease in the absence of heart failure, past stroke, non-proteinuric chronic kidney disease or diabetes without albuminuria. Should I prescribe an ARB in people who have had a stroke? The PRoFESS study was a large randomized 2x2 factorial trial of an ARB based blood pressure lowering therapy and antiplatelet therapy to prevent recurrent strokes.23 Over twenty thousand patients aged 50 or older with a prior ischemic stroke were randomized to telmisartan vs. placebo regardless of their pre-treatment blood pressure. No statisti- cally significant interaction effect between antiplatelet and telmisartan arms was observed. In the latter arm, the blood pressure was 3.8/2.0 mm Hg lower than placebo, with a mean follow-up of 2.5 years. The ARB therapy did not reduce the primary endpoint of recurrent stroke (HR: 0.95 (0.86-1.04, p=0.23)) nor the secondary outcome of major cardiovascular events (stroke, MI, vascular death, worsening CHF), (HR: 0.94 (0.87-1.01, p=0.11)). Exploratory analyses suggested that a difference in outcome in favour of telmisartan began to emerge after the first 6 months of therapy. Although the absolute risk increase was small
  11. 11. 7 (~3%), adverse events, principally hypotensive symptoms, syncope and atrial fibrillation were more common in the telmisartan group compared to placebo. It is possible that the modest reduction in blood pressure in a PRoFESS study population and the relatively low entry blood pres- sure (144/84 mm Hg) may be the reason for the negative results. CHEP recommendations currently support a target blood pressure of <140/90 mm Hg in post-stroke patients; hence, many of the PRoFESS trial patients would have been within CHEP targets at the start of the trial. Taken within the context of a previous large randomized controlled trial (PROGRESS with a combination of a diuretic (indapamide) and ACE inhibitor (perindopril)) and meta analyses of blood pressure lowering trials showing a reduction in recurrent stroke24, 25, the PRoFESS trial has not impacted the CHEP recommendations. The PROGRESS trial entered people with an average blood pressure of 147/86 mm Hg. In the PROGRESS trial people who received ACE inhibitor therapy only, the reduction in stroke was not significant (post hoc analysis) but a large reduction in stroke was seen in the trial overall and in particular in those who received the ACE inhibitor with the diuretic indapamide. CHEP recommends that strong consideration should be given to the initiation of antihypertensive therapy and preferably an ACE inhibitor plus diuretic combination after the acute phase of a stroke or transient ischemic attack. In people who are intolerant to an ACE inhibitor and who have cardiovascular disease or diabetes, should I prescribe an ARB? The TRANSCEND study randomized 5,926 people with coronary disease, prior stroke or diabetes mellitus with end- organ damage and who were intolerant of ACE inhibitors to telmisartan or placebo with an average blood pressure at baseline of 141/69 mm Hg.26 The mean blood pressure difference was 3.2/1.3 mm Hg lower at study end in the telm- isartan group. Over a median follow-up of just over 2.5 years, the telmisartan therapy did not reduce the primary outcome (composite of cardiovascular death, myocardial infarction, stroke or hospitalization for heart failure (HR: 0.92 (0.81-1.05, p=0.216)). The study does not exclude a small therapeutic benefit and a secondary endpoint of cardiovascular death, myocardial infarction or stroke was close to conventional significance level (HR: 0.87 (0.76-1.00, p=0.068)). Syncopal spells were more common in the telmisartan group but the absolute risk difference was small (0.44%) and overall adverse events were not different between the two groups.
  12. 12. 8 The TRANSCEND trial has not changed the CHEP recom- mendation to prescribe an ACE inhibitor for most people with hypertension and documented coronary artery disease based on the HOPE, EUROPA and PEACE studies.27-29 Should I start people with diabetes and hypertension on a combination of two antihypertensive drugs? The ADVANCE trial was a randomized controlled trial that included 11,140 people with type 2 diabetes and at least another cardiovascular risk factor.6 The ADVANCE trial used a factorial design to assess both the effects of an intensive glucose lowering regimen and antihypertensive treatment. In the hypertension aspect of the trial people were random- ized to a fixed combination tablet consisting of perindopril (an ACE inhibitor) and indapamide (a diuretic) or placebo. The treatment reduced both cardiovascular death (HR: 0.82; 95% CI: 0.68 – 0.98) and total mortality (HR: 0.86; 95% CI: 0.75 – 0.98). In 2008, it was established that there was no in- teraction between the glucose lowering and blood pressure lowering therapies; hence, CHEP recommends consideration of initial therapy with a combination of first-line drugs in people with diabetes if blood pressure is 150/90 mm Hg or higher.5, 6 Caution is required in people where a substantial fall in blood pressure is more likely or would be poorly tolerated (e.g. those with postural hypotension). How do I optimally reduce cardiovascular risk in my patients? Although it remains important to stay up to date with new evidence and recommendations, much of what is important to improve patient outcomes remains unchanged. Because most Canadians will develop hypertension during their lives, routine assessment of blood pressure is recom- mended in all people at all appropriate visits. Most people with high normal blood pressure (130-139 mm Hg systolic or 85-89 mm Hg diastolic) will develop hypertension in the next 2-4 years and require annual assessment of blood pressure. To encourage self-efficacy, people with hypertension are recommended to measure their blood pressure at home. Nine in ten Canadians with hypertension will have other risks for cardiovascular disease. Hence, optimum management of hypertension requires assessment of overall cardiovascular risk. This includes identifying and managing these other risks (e.g. smoking, dyslipidemia, dysglycemia (e.g. impaired fasting glucose, diabetes)), abdominal obesity, unhealthy diet, physical inactivity. A comprehensive approach to
  13. 13. 9 cardiovascular risk reduction can more than double car- diovascular risk reduction compared to blood pressure management alone. To optimally reduce cardiovascular risk, blood pressure should be lowered to less than 140/90 mm Hg in most people and in those with diabetes or chronic kidney disease, to less than 130/80 mm Hg. Although it is usually more difficult to lower systolic than diastolic blood pressure, the risk reduc- tion from lowering the systolic blood pressure is as large if not larger than the diastolic blood pressure. Combinations of both lifestyle and drug therapies are generally necessary to achieve target blood pressures. Most people require more than one antihypertensive drug and many with diabetes or chronic kidney disease may require three or more drugs. People whose blood pressure is above target should be monitored at least every 2 months and the intensity of treatment increased until the targets are achieved. Lack of adherence to therapy is an important cause of poor blood pressure control and poor outcomes. Patient adherence to therapy should be assessed at each visit and interventions to improve adherence should be a part of clinical routine. What lifestyle changes are effective in preventing hypertension, in treating people with hypertension and in reducing blood pressure? High blood pressure as well as other cardiovascular risk fac- tors can be prevented or reduced through simple sustained lifestyle changes. Lifestyle interventions can bring about a similar reduction in blood pressure to single antihypertensive drugs. A healthy diet, regular physical activity, moderation in alcohol consumption, reductions in dietary sodium, and a smoke-free environment are the cornerstone of prevention and management of hypertension. In selected people, stress reduction, including behaviour modification, is helpful. A recent meta analysis found decreasing dietary sodium intake by 1,860 mg/day reduced blood pressure 5.1/2.7 mm Hg.30 In Canada it has been estimated that a 1,860 mg/day decrease in dietary sodium would cause a substantive reduction in prevalence of hypertension, health costs and cardiovascular complications.31,32 In the DASH trial, a diet rich in fruits, veg- etables and low-fat dairy products with reduced saturated and total fat decreased blood pressure by 5.5/3.0 mm Hg overall and by 11.4/5.5 mm Hg in those with hypertension.33 A meta
  14. 14. 10 analysis on the effects of regular aerobic exercise showed physical activity reduced blood pressure by 3.8/2.6 mm Hg in people who were previously inactive.34 The TOHP study found a decrease in weight of 4.4 kg led to a blood pressure reduction of 4.0/2.8 mm Hg.35 Brief clinical interventions increase the probability of a patient adhering to lifestyle changes even for addictive behaviours such as smoking and problem alcohol consump- tion36,37 and more comprehensive interdisciplinary care approaches are more effective.33,38-41 Because few Canadians change their lifestyle after a diagnosis of hypertension it is important that health professionals assist people in implementing lifestyle interventions.4 For this reason, Blood Pressure Canada, the Heart and Stroke Foundation and CHEP have developed a variety of patient resources including paper copies, videos and web-based interactive monitor- ing systems to assist people making lifestyle changes.4 These resources can be found at www.hypertension.ca and www.heartandstroke.ca/bp. Comments from the CHEP Executive CHEP believes that, reliable up-to-date, evidence-based recommendations that are broadly disseminated in easy- to-use formats are important to the care of Canadians with hypertension. The CHEP program has taken a number of steps to reduce personal and commercial bias (Table 4). CHEP also supports regular evaluation of the impact of its program to identify ongoing clinical issues where care needs to improve. Further, CHEP monitors ongoing changes in the health care system that will change the way hypertension will be managed in the future and is actively developing new partnerships, educational resources and dissemina- tion strategies. Important to the prevention and control of hypertension is active involvement of people in their care. CHEP partners with Blood Pressure Canada, the Heart and Stroke Foundation of Canada, the Public Health Agency of Canada and other organizations to develop resources to assist people to become more informed about hypertension and more engaged in their care (Table 5). Recently the increase in treatment of hypertension has been found to be strongly associated with reductions in death and hospitalization of major cardiovascular events in Canada.42 In 2010, the results of a national survey on hypertension prevalence, treatment and control will be released by Statistics Canada. The survey results will allow CHEP to more carefully assess the hypertension care gaps that remain.
  15. 15. 11 Further, in 2010, the results of another survey that assesses patient knowledge, attitudes and barriers to care will be released, enabling much more focused patient education programs to be developed. The development of a com- prehensive hypertension evaluation program in Canada with ongoing assessment of care gaps and subsequent development of tailored intervention programs is expected to result in further reductions in cardiovascular disease.
  16. 16. TABlE 1: Considerations in the Individualization of Antihypertensive Therapy†* ACE: angiotensin converting enzyme; TIA: transient ischemic attack; ARB: angiotensin receptor blocker Initial Therapy Second-line Therapy Notes and/or Cautions HYPERTENSION WITHOUT OTHER COMPELLING INDICATIONS - TARGET < 140/90 mm Hg Diastolic +/- systolic hypertension Thiazide diuretics, beta-blockers, ACE inhibitors, Combinations of first-line drugs Beta-blockers are not recommended as initial therapy in those over 60 years ARBs or long-acting calcium channel blockers of age. Hypokalemia should be avoided by using potassium-sparing agents in (consider ASA and statins in selected patients). those who are prescribed diuretics as monotherapy. ACE inhibitors are not recom- Consider initiating therapy with a combination mended as monotherapy in blacks. 12 of two first-line drugs if the blood pressure ACE inhibitors, ARBs and direct renin inhibitors are potential teratogens and cau- is ≥20 mm Hg systolic or ≥10 mm Hg diastolic tion is required if prescribing to women of child bearing potential. Combinations above target. of an ACE inhibitor with an ARB is specifically not recommended. Isolated systolic hypertension without Thiazide diuretics, ARBs or long-acting Combinations of first-line drugs Same as diastolic +/- systolic hypertension other compelling indications dihydropyridine calcium channel blockers DIABETES MELLITUS - TARGET < 130/80 mm Hg Diabetes mellitus with nephropathy ACE inhibitors or ARBs Addition of thiazide diuretics, cardioselective beta- If the serum creatinine level is >150 μmol/L, a loop diuretic should be used as blockers, long-acting calcium channel blockers a replacement for low-dose thiazide diuretics if volume control is required
  17. 17. Initial Therapy Second-line Therapy Notes and/or Cautions Diabetes mellitus without nephropathy ACE inhibitors, ARBs, dihydropyridine calcium Combination of first-line drugs, or if first-line Normal albumin to creatinine ratio [ACR] < 2.0 mg/mmol in men and channel blockers or thiazide diuretics agents are not tolerated, addition of < 2.8 mg/mmol in women. cardioselective beta-blockers and/or long-acting Combinations of an ACE inhibitor with an ARB is specifically not recommended. nondihydropyridine calcium channel blockers CARDIOVASCULAR AND CEREBROVASCULAR DISEASE - TARGET < 140/90 mm Hg Angina Beta-blockers; ACE inhibitors except in low risk Long-acting calcium channel blockers Avoid short-acting nifedipine. Combinations of an ACE inhibitor with an ARB is patients specifically not recommended. Prior myocardial infarction Beta-blockers and ACE inhibitors Long-acting calcium channel blockers Combinations of an ACE inhibitor with an ARB is specifically not recommended (ARBs if ACEI-intolerant) 13 Heart failure ACE inhibitors (ARBs if ACEI-intolerant) and ARBs or hydralazine/isosorbide dinitrate Titrate doses of ACE inhibitor and ARB to those used in clinical trials. Avoid beta-blockers. Spironolactone in patients (thiazide or loop diuretics, as additive therapy) nondihydropyridine calcium channel blockers (diltiazem, verapamil). with NYHA Class III or IV symptoms. Monitor potassium and renal function if combining an ACE inhibitor with an ARB Left ventricular hypertrophy Does not affect initial treatment recommendations Combinations of additional agents Hydralazine and minoxidil can increase left ventricular hypertrophy Past cerebrovascular accident or TIA ACE inhibitor/diuretic combinations Combinations of additional agents This does not apply to acute stroke. Blood pressure reduction reduces recurrent cerebrovascular events in stable patients. Combinations of an ACE inhibitor with ARB is specifically not recommended.
  18. 18. Initial Therapy Second-line Therapy Notes and/or Cautions NON-DIABETIC CHRONIC KIDNEY DISEASE - TARGET < 130/80 mm Hg Non-diabetic chronic kidney disease ACE inhibitors (ARBs if ACEI-intolerant), Combinations of additional agents Avoid ACE inhibitors or ARBs if bilateral renal artery stenosis or unilateral with proteinuria diuretics as additive therapy disease with solitary kidney. Patients placed on an ACE inhibitor or an ARB should have their serum creatinine and potassium carefully monitored. Combinations of an ACE inhibitor and ARB is specifically not recommended in patients with chronic kidney disease without proteinuria. Renovascular disease Does not affect initial treatment recommendations Combinations of additional agents Avoid ACE inhibitors or ARBs if bilateral renal artery stenosis or unilateral disease with solitary kidney OTHER CONDITIONS - TARGET < 140/90 mm Hg 14 Peripheral arterial disease Does not affect initial treatment recommendations Combinations of additional agents Avoid beta-blockers in patients with severe disease Dyslipidemia Does not affect initial treatment recommendations Combinations of additional agents Overall vascular protection Statin therapy for patients with three or more Caution should be exercised with the ASA recommendation if blood cardiovascular risk factors or with atherosclerotic pressure is not controlled disease. Low-dose ASA in patients with controlled blood pressure. † It is recommended that normotensive adults with established cardiovascular disease be treated with an ACE inhibitor. Normotensive adults who have had a stroke or TIA should be treated with an ACE inhibitor and a diuretic. *With permission of the Canadian Hypertension Education Program
  19. 19. 15 TABlE 2: Target Values for Blood Pressure* Setting Target (SBP/DBP mm Hg) Home: Home blood pressure <135/85 and daytime ABPM†‡ Office: Diastolic ± systolic hypertension <140/90 Isolated systolic hypertension <140 Diabetes <130/80 Chronic kidney disease <130/80 † The target value readings taken by home measurement and ABPM in those with diabetes or chronic kidney disease have not been established. ‡ ABPM – Ambulatory blood pressure monitoring TABlE 3: lifestyle Therapy to Reduce the Possibility of Becoming Hypertensive, to Reduce Blood Pressure and to Reduce the Risk of Blood Pressure-related Cardiovascular Complications in Hypertensive Patients** 1. Healthy diet: high in fresh fruits and vegetables, low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources, low in saturated fat, cholesterol and salt, in accordance with Canada’s Guide to Healthy Eating 2. Regular physical activity: accumulation of 30-60 minutes of moderate intensity dynamic exercise 4-7 days per week in addition to daily activities 3. Low-risk alcohol consumption (≤2 standard drinks/day and less than 14/week for men and less than 9/week for women) 4. Attaining and maintaining ideal body weight (BMI 18.5-24.9 kg/m2) 5. A waist circumference: Europid < 94 cm for men < 80 cm for women South Asian, Japanese, Chinese < 90 cm for men < 80 cm for women 6. Reduction in sodium intake to less than 2, 300 mg/day 7. A smoke-free environment *With permission of the Canadian Hypertension Education Program
  20. 20. 16 TABlE 4: CHEP Reduces the Impact of Bias by the Following Methods* 1 A history of requiring a high level of evidence with patient rel- evant outcomes for pharmacotherapy recommendations 2 A centralized systematic literature review by a Cochrane Group librarian 3 Multiple clinical experts in subgroups to represent different perspectives 4 A Central Review Committee (CRC) that is “free of com- mercial conflicts of interest” to oversee the evaluation of evidence, the development of recommendations and to present the evidence/recommendations 5 A consensus conference chaired by the CRC and with the evidence primarily presented by the CRC 6 Overt written disclosure of potential conflicts of interest at the time of the consensus conference when the recom- mendations are discussed 7 Voting on recommendations with the removal of recommendations voted against by 30% or more of members 8 Annual hypertension management themes, key messages and major implementation tools are developed through a consensus of the full CHEP Executive. Other internal imple- mentation tools require the consensus of two members of the Executive. * With permission of the Canadian Hypertension Education Program
  21. 21. 17 TABlE 5: Internet Resources for Patient Information†* Resource Description Source 2008 Patient General www.hypertension.ca/bpc Hypertension information on Recommendations prevention and treatment of hypertension 2009 Patient Specific www.hypertension.ca/bpc Hypertension information on Recommendations the management of hypertension in the diabetic patient Diabetes & Information on www.diabetes.ca Hypertension hypertension for people with diabetes On-line, Create a www.heartandstroke.ca/bp personalized blood personalized pressure plan action plan for healthy living DASH diet The DASH diet and www.nhlbi.nih.gov/hbp/ healthy eating to prevent/h_eating/h_eating. improve blood html pressure control Canada’s Food Canada’s official www.hc-sc.gc.ca/fn-an/ Guide guide to healthy food-guide-aliment/ eating and index_e.html lifestyle choices. Personalize your own food guide! Dietitians of Tips for eating well www.dietitians.ca Canada and living well On-line health and Learn about your www.healthtoolsonline. fitness calculators risk factors using com/health-fit.html different tools to calculate your personal factors † Many of the resources can be downloaded and printed or hard copies ordered for patients who do not use the internet. * With permission of Blood Pressure Canada
  22. 22. 18 Reference list 1. Mohan S, Campbell NR. Hypertension management in Canada: good news, but important challenges remain. CMAJ 2008;178:1458-1460. 2. Leenen FH, Dumais J, McInnis NH et al. Results of the Ontario survey on the prevalence and control of hypertension. CMAJ 2008;178:1441-1449. 3. Campbell NR, So L, Amankwah E, Quan H, Maxwell C. Characteristics of hypertensive Canadians not receiving drug therapy. Can J Cardiol 2008;24:485-490. 4. Neutel CI, Campbell NR. Changes in lifestyle after hypertension diagnosis in Canada. Can J Cardiol 2008;24:199-204. 5. Patel A, MacMahon S, Chalmers J et al. Intensive blood glucose control and vascular out- comes in patients with type 2 diabetes. N Engl J Med 2008;358:2560-2572. 6. Patel A, MacMahon S, Chalmers J et al. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. Lancet 2007;370:829-840. 7. Sowers JR, Epstein M, Frohlich ED. Diabetes, hypertension, and cardiovascular disease: an update. Hypertension 2001;37:1053-1059. 8. Schrier RW, Estacio RO, Esler A, Mehler P. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney Int 2002;61:1086-1097. 9. Gerstein HC, Yusuf S, Mann JFE et al. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 2000;355:253-259. 10. Lewis EJ, Hunsicker LG, Clarke WR et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001;345:851-860. 11. 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. N Engl J Med 2001;345:861-869. 12. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998;317:703-713. 13. Tuomilehto J, Rastenyte D, Birkenhager WH et al. Effects of calcium-channel blockade in older patients with diabetes and systolic hypertension. Systolic Hypertension in Europe Trial Investigators. N Engl J Med 1999;340:677-684. 14. Hansson L, Zanchetti A, Carson DS et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998;351:1755-1762. 15. Anderson C, Arima H, Belmans A et al. Effects of different blood pressure-lowering regimens on major cardiovascular events in individuals with and without diabetes mellitus. Arch Intern Med 2005;165:1410-1419. 16. CDC Diabetes Cost-effectiveness Group. Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes. JAMA 2002;287:2542-2551. 17. Yusuf S, Teo KK, Pogue J et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 2008;358:1547-1559. 18. Mann JF, Schmieder RE, McQueen M et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double- blind, controlled trial. Lancet 2008;372:547-553. 19. Chalmers J. Enhancing risk stratification in hypertensive subjects: how far should we go in routine screening for target organ damage? J Hypertens 2002;20:1255-1257. 20. Kunz R, Wolbers M, Glass T, Mann JF. The COOPERATE trial: a letter of concern. Lancet 2008;371:1575-1576. 21. Arnold JMO, Liu P, Demers C et al. Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: diagnosis and management. Can J Cardiol 2006;22:23-45. 22. McMurray JJV, Ostergren J, Swedberg K et al. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting- enzyme inhibitors: the CHARM-Added trial. Lancet 2003;362:767-771. 23. Yusuf S, Diener HC, Sacco RL et al. Telmisartan to prevent recurrent stroke and cardiovascular events. N Engl J Med 2008;359:1225-37. 24. MacMahon S, Neal B, Tzourio C et al. Randomised trial of a perindopril-based blood-pressure- lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 2001;358:1033-1041. 25. Rashid P, Leonardi-Bee J, Bath P. Blood pressure reduction and secondary prevention of stroke and other vascular events: a systematic review. Stroke 2003;34:2741-2748. 26. Yusuf S, Teo K, Anderson C et al. Effects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensin-converting enzyme inhibitors: a randomised controlled trial. Lancet 2008;372:1174-1183. 27. The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin- converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. New Engl J Med 2000;342:145-153.
  23. 23. 19 28. The EURopean trial On reduction of cardiac events with Perindopril in stable coronary Artery disease investigators. Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet 2003;362:782-788. 29. Braunwald E, Domanski MJ, Fowler SE et al. Angiotensin-converting-enzyme inhibition in stable coronary artery disease. N Engl J Med 2004;351:2058-2068. 30. He FJ, MacGregor GA. Effect of longer-term modest salt reduction on blood pressure. The Cochrane Database of Systematic Reviews 2004;1-64. 31. Joffres M, Campbell NRC, Manns B, Tu K. Estimate of the benefits of a population-based reduction in dietary sodium additives on hypertension and its related health care costs in Canada. Can J Cardiol 2007;23:437-443. 32. Penz ED, Joffres MR, Campbell NR. Reducing dietary sodium and decreases in cardiovascular disease in Canada. Can J Cardiol 2008;24:497-501. 33. Appel LJ, Moore TJ, Obarzanek E et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 1997;336:1117-1124. 34. Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med 2002;136:493-503. 35. The Trials of Hypertension Prevention Collaborative Research Group. Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in over- weight people with high-normal blood pressure. The Trials of Hypertension Phase II. Arch Intern Med 1997;157:657-667. 36. Cromwell J, Bartosch WJ, Fiore MC, Hasselblad V, Baker T. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. JAMA 1997;278:1759-1766. 37. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices. JAMA 1997;277:1039-1045. 38. Family Heart Study Group. Randomised controlled trial evaluating cardiovascular screening and intervention in general practice: principal results of British Family Heart Study. BMJ 1994;308:313-320. 39. Elmer PJ, Obarzanek E, Vollmer WM et al. Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial. Ann Intern Med 2006;144:485-495. 40. Appel LJ, Champagne CM, Harsha DW et al. Effects of comprehensive lifestyle modification on blood pressure control. Main results of the premier clinical trial. JAMA 2003;289:2083-2093. 41. Wister A, Loewen N, Kennedy-Symonds H, McGowan B, McCoy B, Singer J. One-year follow-up of a therapeutic lifestyle intervention targeting cardiovascular disease risk. CMAJ 2007;177:859-865. 42. Campbell NR, Brant R, Johansen H et al. Increases in antihypertensive prescriptions and reductions in cardiovascular events in Canada. Hypertension 2008;In Press.
  24. 24. PART 1 DiAgNosis & AssEssmENT
  25. 25. 22 I ACCURATE MEASUREMENT OF BlOOD PRESSURE 1) The blood pressure (BP) of all adult patients should be assessed at all appropriate visits for de- termination of cardiovascular risk and monitoring of antihypertensive treatment by health care profession- als who have been specifically trained to measure BP accurately (Grade D). 2) Use of standardized measurement techniques (Table 1) is recommended when assessing blood pressure (Grade D). II CRITERIA FOR DIAGNOSIS OF HYPERTENSION AND RECOMMENDATIONS FOR FOllOW-UP (Figure 1) 1) At visit 1, patients demonstrating features of a hypertensive urgency or emergency ( Table 2) should be diagnosed as hypertensive and require im- mediate management (Grade D). 2) If systolic BP (SBP) is 140 mm Hg or greater and/or diastolic BP (DBP) is 90 mm Hg or greater a specific visit should be scheduled for the assessment of hypertension (Grade D). If BP is high-normal (SBP 130-139 mm Hg and/ or DBP 85-89 mm Hg) annual follow-up is recommended (Grade C). 3) At the initial visit for the assessment of hypertension, if systolic BP (SBP) is 140 mm Hg or greater and/or diastolic BP (DBP) is 90 mm Hg or greater, at least two more read- ings should be taken during the same visit using a vali- dated device and according to the recommended pro- cedure for accurate BP determination (Table 1). The first reading should be discarded and the latter two averaged. A history and physical examination should be per- formed and, if clinically indicated, diagnostic tests to search for target organ damage (Table 3) and associated cardiovascular risk factors (Table 4) should be arranged within two visits. Exogenous factors that can induce or aggravate hypertension should be assessed and removed if possible (Table 5). Schedule visit 2 within one month (Grade D). Bold typeface in the body text indicates a new or revised recommendation
  26. 26. 23 4) At visit 2 for the assessment of hypertension, patients with macrovascular target organ damage, diabetes mellitus, or chronic kidney disease (CKD; GFR <60 mL/min/1.73m2) can be diagnosed as hypertensive if SBP is 140 mm Hg or greater and/or DBP is 90 mm Hg or greater (Grade D). 5) At visit 2 for the assessment of hypertension, patients without macrovascular target organ damage, diabetes mellitus, and/or chronic kidney disease can be diag- nosed as hypertensive if SBP is 180 mm Hg or greater and/or DBP is 110 mm Hg or greater (Grade D). Patients without macrovascular target organ damage, diabetes mellitus, or CKD but with lower blood pressure levels should undergo further evaluation using any of the three approaches outlined below: i) Office BPs: Using office BP measurements, patients can be diagnosed as hypertensive if the SBP is 160 mm Hg or higher or the DBP is 100 mm Hg or higher averaged across the first 3 visits, OR if the SBP averages 140 mm Hg or higher or the DBP aver- ages 90 mm Hg or higher averaged across 5 visits (Grade D). ii) Ambulatory BP Monitoring (ABPM): Using ABPM (see Section VIII), patients can be diagnosed as hypertensive if the mean awake SBP is 135 mm Hg or higher or the DBP is 85 mm Hg or higher, OR if the mean 24 hour SBP is 130 mm Hg or higher or the DBP is 80 mm Hg or higher (Grade C). iii) Home BP Measurement: Using home BP measurements (see Section VII), pa- tients can be diagnosed as hypertensive if the average SBP is 135 mm Hg or higher or the DBP is 85 mm Hg or higher (Grade C). If the average home BP is lower than 135/85 mm Hg, it is advisable to perform 24 h ABPM to confirm the mean 24 h ABPM is lower than 130/80 mm Hg and the mean awake ABPM is lower than 135/85 mm Hg before diagnosing white coat hypertension (Grade D). 6) Investigations for secondary causes of hypertension should be initiated in patients with suggestive clinical and/or laboratory features (outlined below) (Grade D).
  27. 27. 24 7) If at the last diagnostic visit the patient is not diagnosed to be hypertensive and has no evidence of macrovascular target organ damage, the patient’s BP should be assessed at yearly intervals (Grade D). 8) Hypertensive patients receiving lifestyle modification advice alone (non-pharmacological treatment) should be followed up at three-to-six month intervals. Shorter intervals (one or two monthly) are needed for patients with higher BPs (Grade D). 9) Patients on antihypertensive drug treatment should be seen monthly or every two months, depending on BP, until readings on two consecutive visits are below their target (Grade D). Shorter intervals between visits will be needed for symptomatic patients and those with severe hypertension, intolerance to antihypertensive drugs or those with target organ damage (Grade D). Once the target BP has been reached, patients should be seen at three-to-six month intervals (Grade D). III ASSESSMENT OF OVERAll CARDIOVASCUlAR RISK IN HYPERTENSIVE PATIENTS 1) Global cardiovascular risk should be assessed. Multifactorial risk assessment models can be used to predict more accurately an individual’s global cardiovascular risk (Grade A) and to use antihypertensive therapy more efficiently (Grade D). In the absence of Canadian data to determine the accuracy of risk calculations, avoid using absolute levels of risk to support treatment decisions (Grade C). 2) Consider informing patients of their global risk to improve the effectiveness of risk factor modification (Grade C). IV ROUTINE AND OPTIONAl lABORATORY TESTS FOR THE INVESTIGATION OF PATIENTS WITH HYPERTENSION 1) Routine laboratory tests should be performed for the investigation of all patients with hypertension, including: i) urinalysis (Grade D) ii) blood chemistry (potassium, sodium, and creatinine) (Grade D)
  28. 28. 25 iii) fasting blood glucose (Grade D) iv) fasting total cholesterol and high density lipoprotein cholesterol, low density lipoprotein cholesterol and triglycerides (Grade D) v) standard 12-lead electrocardiography (Grade C) 2) Assess urinary albumin excretion in patients with diabetes (Grade D). 3) i) All treated hypertensive patients should be moni- tored according to the current Canadian Diabetes Association guidelines for a new appearance of diabetes (Grade B) ii) During the maintenance phase of hypertension management, tests (including those for electrolytes, creatinine, glucose and fasting lipids) should be repeated with a frequency reflecting the clinical situation (Grade D). V ASSESSMENT FOR RENOVASCUlAR HYPERTENSION 1) Patients presenting with two or more of the clinical clues listed below, suggesting renovascular hyperten- sion, should be investigated (Grade D): i) sudden onset or worsening of hypertension and age older than 55 years or younger than 30 years ii) the presence of an abdominal bruit iii) hypertension resistant to three or more drugs iv) a rise in serum creatinine level of 30% or more as- sociated with use of an ACE inhibitor or ARB v) other atherosclerotic vascular disease, particularly in patients who smoke or have dyslipidemia vi) recurrent pulmonary edema associated with hyper- tensive surges 2) When available, the following tests are recommended to aid in the usual screening for renal vascular disease: captopril-enhanced radioisotope renal scan, Doppler sonography, magnetic resonance angiography, computed tomographic angiography (for those with
  29. 29. 26 normal renal function) (Grade B). Captopril-enhanced radioisotope renal scan is not recommended for those with CKD (GFR < 60 mL/min/1.73 m2) (Grade D). VI ENDOCRINE HYPERTENSION A) Hyperaldosteronism: Screening and Diagnosis 1) Screening for hyperaldosteronism should be considered for the following patients (Grade D): i) hypertensive patients with spontaneous hypo- kalemia (potassium level lower than 3.5 mmol/L) ii) hypertensive patients with marked diuretic- induced hypokalemia (potassium level lower than 3.0 mmol/L) iii) patients with hypertension refractory to treatment with three or more drugs iv) hypertensive patients found to have an incidental adrenal adenoma 2) Screening for hyperaldosteronism should include assessment of plasma aldosterone and plasma renin activity (Table 6). 3) For patients with suspected hyperaldosteronism (on the basis of the screening test, Table 6 [Section iii]), a diagnosis of primary aldosteronism should be estab- lished by demonstrating inappropriate autonomous hypersecretion of aldosterone using at least one of the maneuvers listed in Table 6 [Section iv]. When the diagnosis is established, the abnormality should be localized using any of the tests described in Table 6 [Section v]. B) Pheochromocytoma Screening and Diagnosis 1) If pheochromocytoma is strongly suspected, the patient should be referred to a specialized hypertension center, particularly if biochemistry screening tests (Table 7) have already been found to be positive (Grade D). 2) The following patients should be considered for screen- ing for pheochromocytoma (Grade D): i) patients with parox ysmal and/or severe (BP ≥180/110 mm Hg) sustained hypertension refractory to usual antihypertensive therapy
  30. 30. 27 ii) patients with hypertension and multiple symptoms suggestive of catecholamine excess (e.g., headaches, palpitations, sweating, panic attacks and pallor) iii) patients with hypertension triggered by beta-blockers, monoamine oxidase inhibitors, micturition or changes in abdominal pressure iv) patients with incidentally discovered adrenal mass, patients with hypertension and multiple endocrine neoplasia (MEN) 2A or 2B, von Recklinghausen disease (neurofibromatosis) or von Hippel-Lindau disease 3) For patients with positive biochemical screening tests, localization of pheochromocytomas should employ magnetic resonance imaging (preferable), computed tomography (if magnetic resonance imaging is unavail- able), and/or iodine I-131 meta-iodobenzylguanidine (MIBG) scintigraphy (Grade C for each modality). VII HOME MEASUREMENT OF BlOOD PRESSURE 1) Home BP readings can be used in the diagnosis of hypertension (Grade C). 2) The use of home BP monitoring on a regular basis should be considered for patients with hypertension, particularly those with: i) diabetes mellitus (Grade D) ii) chronic kidney disease (Grade C) iii) suspected non-adherence (Grade D) iv) demonstrated white coat effect (Grade C) v) BP controlled in the office but not at home (masked hypertension) (Grade C) 3) When white coat hypertension is suggested by home monitoring, its presence should be confirmed with ABPM before making treatment decisions (Grade D). 4) Patients should be advised to purchase and use only home BP monitoring devices that are appropriate for the indi- vidual and have met the standards of the Association for the Advancement of Medical Instrumentation, the most
  31. 31. 28 recent requirements of the British Hypertension Society protocol or the International Protocol for validation of automated BP measuring devices. Patients should be encouraged to use devices with data recording capabilities or automatic data transmission to increase the reliability of reported home BP values (Grade D). 5) Home SBP values of 135 mm Hg or higher or DBP values of 85 mm Hg or higher should be considered to be elevated and associated with an increased overall mortality risk analogous to office SBP readings of 140 mm Hg or higher or DBP readings of 90 mm Hg or higher (Grade C). 6) Health care professionals should ensure that patients who measure their BP at home have adequate train- ing and, if necessary, repeat training in measuring their BP. Patients should be observed to determine that they measure BP correctly and should be given adequate information about interpreting these read- ings (Grade D). 7) The accuracy of all individual patients’ validated devices (including electronic devices) must be regularly checked against a device of known calibration (Grade D). 8) Home BP values for assessing white coat hypertension or sustained hypertension should be based on duplicate measures, morning and evening, for an initial seven- day period. First-day home BP values should not be considered (Grade D). VIII AMBUlATORY BlOOD PRESSURE MEASUREMENT 1) Ambulatory BP readings can be used in the diagnosis of hypertension (Grade C). 2) ABPM should be considered when an office-induced increase in BP is suspected in treated patients with: i) BP that is not below target despite receiving appropri- ate chronic antihypertensive therapy (Grade C) ii) symptoms suggestive of hypotension (Grade C) iii) fluctuating office BP readings (Grade D) 3) Physicians should use only ABPM devices that have been validated independently using established protocols (Grade D). 4) Therapy adjustment should be considered in patients with
  32. 32. 29 24 h ambulatory SBP of 130 mm Hg or higher and/or DBP of 80 mm Hg or higher and/or awake SBP of 135 mm Hg or higher and/or DBP of 85 mm Hg or higher (Grade D). 5) The magnitude of changes in nocturnal BP should be taken into account in any decision to prescribe or with- hold drug therapy based upon ambulatory BP (Grade C) because a decrease in nocturnal BP of less than 10% is associated with increased risk of cardiovascular events. IX ROlE OF ECHOCARDIOGRAPHY 1) Routine echocardiographic evaluation of all hyperten- sive patients is not recommended (Grade D). 2) An echocardiogram for assessment of left ventricular hypertrophy is useful in selected cases to help define the future risk of cardiovascular events (Grade C). 3) Echocardiographic assessment of left ventricular mass, as well as systolic and diastolic left ventricular function, is recommended for hypertensive patients suspected to have left ventricular dysfunction or coronary artery disease (Grade D). 4) Patients with hypertension and evidence of heart failure should have an objective assessment of left ventricular ejection fraction, either by echo- cardiogram or nuclear imaging (Grade D). DIAGNOSIS & ASSESSMENT TABlES TABlE 1: Recommended Technique for Measuring Blood Pressure†* i) Measurements should be taken with a sphyg- momanometer known to be accurate. A recently calibrated aneroid or a validated and recently calibrated electronic device can be used (see text below for further discussion). Aneroid devices or mercury columns need to be clearly visible at eye level. † These are instructions for blood pressure measurement when using a sphygmomanom- eter and stethoscope; many steps may not apply when using automated devices. * With permission of the Canadian Hypertension Education Program
  33. 33. 30 ii) Choose a cuff with an appropriate bladder size matched to the size of the arm. For measurements taken by aus- cultation, bladder width should be close to 40% of arm circumference and bladder length should cover 80–100% of arm circumference. When using an automated device, select the cuff size recommended by its manufacturer. iii) Place the cuff so that the lower edge is 3 cm above the elbow crease and the bladder is centered over the bra- chial artery. The patient should be resting comfortably for 5 minutes in the seated position with back support. The arm should be bare and supported with the antecubital fossa at heart level, as a lower position will result in an erroneously higher SBP and DBP. There should be no talking, and the patients’ legs should not be crossed. At least three measurements should be taken in the same arm with the patient in the same position. The first reading should be discarded and the latter two averaged. Blood pressure also should be assessed after 2 minutes standing (with arm supported) and at times when patients report symptoms suggestive of postural hypotension. Supine BP measurements may also be helpful in the assessment of elderly and diabetic patients. iv) Increase the pressure rapidly to 30 mm Hg above the level at which the radial pulse is extinguished (to exclude the possibility of a systolic auscultatory gap). v) Place the bell or diaphragm of the stethoscope gently and steadily over the brachial artery. vi) Open the control valve so that the rate of deflation of the cuff is approximately 2 mm Hg per heart beat. A cuff deflation rate of 2 mm Hg per beat is necessary for accurate systolic and diastolic estimation. vii) Read the systolic level — the first appearance of a clear tapping sound (phase I Korotkoff ) — and the diastolic level (the point at which the sounds disappear (phase V Korotkoff )). Continue to auscultate at least 10 mm Hg below phase V to exclude a diastolic auscultatory gap. Record the blood pressure to the closest 2 mm Hg on the manometer (or 1 mm Hg on electronic devices) as well as the arm used and whether the patient was supine, sitting or standing. Avoid digit preference by not rounding up or down. Record the heart rate. The seated blood pressure is used to determine and monitor treatment decisions. The standing blood pressure is used
  34. 34. 31 to examine for postural hypotension, if present, which may modify the treatment. viii) If Korotkoff sounds persist as the level approaches 0 mm Hg, then the point of muffling of the sound is used (phase IV) to indicate the diastolic pressure. ix) In the case of arrhythmia, additional readings may be required to estimate the average systolic and diastolic pressure. Isolated extra beats should be ignored. Note the rhythm and pulse rate. x) Leaving the cuff partially inflated for too long will fill the venous system and make the sounds difficult to hear. To avoid venous congestion, it is recommended that at least one minute should elapse between readings. xi) Blood pressure should be taken in both arms on at least one visit and if one arm has a consistently higher pressure, that arm should be subsequently used for blood pressure measurement and interpretation. TABlE 2: Examples of Hypertensive Urgencies and Emergencies* Asymptomatic diastolic BP ≥ 130 mm Hg Hypertensive encephalopathy Acute aortic dissection Acute left ventricular failure Acute myocardial ischemia TABlE 3: Examples of Target Organ Damage* Cerebrovascular Disease Stroke Ischemic stroke and transient ischemic attack Intracerebral hemorrhage Aneurysmal sub-arachnoid hemorrhage Dementia Vascular dementia Mixed Vascular Dementia and Dementia of the Alzheimer’s Type *With permission of the Canadian Hypertension Education Program
  35. 35. 32 Hypertensive Retinopathy Left Ventricular Dysfunction Coronary Artery Disease Myocardial infarction Angina pectoris Congestive heart failure Chronic Kidney Disease Hypertensive nephropathy (GFR < 60 mL/min/1.73 m2) Albuminuria Peripheral Artery Disease Intermittent claudication TABlE 4: Examples of Key Cardiovascular Risk Factors for Atherosclerosis* A history of clinically overt atherosclerotic disease indicates a very high risk for a recurrent atherosclerotic event (e.g., peripheral arterial disease, previous stroke or TIA) Non-Modifiable Age ≥ 55 years Male sex Family history of premature cardiovascular disease (age < 55 years in men and < 65 years in women) Modifiable Sedentary lifestyle Poor dietary habits Abdominal obesity Impaired glucose tolerance or diabetes mellitus Smoking Dyslipidemia Stress Target Organ Damage Left ventricular hypertrophy Microalbuminuria or proteinuria Chronic kidney disease (glomerular filtration rate < 60 mL/min/1.73 m2) * With permission of the Canadian Hypertension Education Program
  36. 36. 33 TABlE 5: E x a m p l e s o f E xo g e n o u s Fa c t o r s t h a t c a n Induce/Aggravate Hypertension* Prescription Drugs NSAIDs, including coxibs Corticosteroids and anabolic steroids Oral contraceptives and sex hormones Vasoconstricting or sympathomimetic decongestants Calcineurin inhibitors (cyclosporin, tacrolimus) Erythropoietin and analogues Monoamine oxidase inhibitors (MAOIs) Midodrine Other Substances and Conditions Licorice root Stimulants, including cocaine Salt Excessive alcohol use Sleep apnea TABlE 6: Hyperaldosteronism: Screening and Diagnosis** i) Plasma aldosterone and plasma renin activity (see Section ii below for conversion factors) should be measured under standardized conditions, including the collection of morning samples taken from patients in a sitting position after resting at least 15 minutes. Antihypertensive drugs may be continued, with the exception of aldosterone antagonists, angiotensin recep- tor blockers, beta-blockers and clonidine. ii) Renin, Aldosterone and Ratio Conversion Factors: A. To estimate: B. From: Multiply (B) by: Plasma renin Plasma renin activity 0.206 concentration (ng/mL/hr) (ng/mL) Plasma renin Plasma renin activity 0.278 activity (ng/mL/hr) (g/L/s) Plasma Plasma aldosterone 28 aldosterone concentration concentration (ng/dL) (pmol/L) *With permission of the Canadian Hypertension Education Program
  37. 37. 34 iii) Definition of a positive screening test: plasma aldosterone/ renin activity ratio greater than 550 pmol/L/ng/mL/hr (or 140 pmol/L/ng/L when renin is measured as renin mass or concentration). iv) Maneuvers to demonstrate autonomous hypersecretion of aldosterone: a) saline loading tests (2L of normal saline over 4 h with primary aldosteronism defined as failure to suppress plasma aldosterone to less than 280 pmol/L; or oral sodium 300 mmol/day for three days with primary aldosteronism defined as failure to suppress plasma aldosterone to less than 240 pmol/L) b) fludrocortisone suppression test (oral sodium loading plus oral fludrocortisone 0.25 mg per day for 2 days) positive for primary aldosteronism: plasma aldosterone of 140 pmol/L or greater in upright and/or supine positions c) a plasma aldosterone/PRA ratio greater than 1,400 pmol/L/ng/mL/hr with a plasma aldosterone greater than 440 pmol/L d) captopril suppression test (primary aldosteronism defined as failure to suppress plasma aldosterone to less than 240 pmol/L two hours after 25 mg of oral captopril) v) Differentiating potential causes of primary aldosteronism: a) for patients with established primary aldosteronism, attempts to differentiate potential causes should be made and may include localization with adrenal CT- scan (standard: 3 mm contiguous cuts) or magnetic resonance imaging (where available), or assessment of plasma aldosterone before (supine) and after 2 h to 4 h of upright posture. b) for patients with established primary aldosteronism and negative imaging studies, selective adrenal venous sampling should be considered because it may be the only way to reliably differentiate unilateral from bilateral overproduction of aldosterone. Adrenal venous sam- pling should be conducted in centres with experience in performing this diagnostic technique.
  38. 38. 35 TABlE 7: Pheochromocytoma: Screening and Diagnosis* 1) Biochemical screening tests for pheochromocytomas: a) to screen for pheochromocytomas, 24 h urinary total metanephrines (sensitivity 95%) and urinary metanephrine-to-creatinine ratio (sensitivity 100%) should be assessed. Plasma catecholamines and, where available, plasma metanephrines may also be considered if clinical suspicion is high, particularly dur- ing a hypertensive episode or for those with familial forms. Urinary or plasma VMA measurements should not be used as screening tests. In a low risk setting, plasma fractionated free metanephrine measure- ments can be used to rule out pheochromocytoma. b) in the presence of borderline biochemical test results (e.g., plasma noradrenaline and adrenaline levels of approximately 500 ng/L to 2,000 ng/L) or potentially false positive results, repeated testing and/or the clonidine suppression test may be used. * With permission of the Canadian Hypertension Education Program
  39. 39. FigURE 1: The Expedited Assessment and Diagnosis of Patients with Hypertension: Focus on Validated Technologies for Blood Pressure Assessment* Elevated Out-of-the-Office BP Measurement Elevated Random Office BP Measurement Hypertension Visit 1 BP Measurement, Hypertensive History and Physical Urgency / Emergency 36 Diagnostic tests ordering at visit 1 or 2 Hypertension Visit 2 within 1 month BP ≥ 180/110 mm Hg OR Yes Diagnosis BP 140-179/90-109 mm Hg Yes of HTN with Target Organ Damage, Diabetes or Chronic Kidney Disease No
  40. 40. BP: 140 -179/90 -109 mm Hg Clinic BPM ABPM (if available) Home BPM (if available) Hypertension Visit 3 Awake BP ≥135 mm Hg ≥160 mm Hg SBP or Diagnosis ≥100 mm Hg DBP Awake BP ≥135 mm Hg SBP or <135/85 mm Hg SBP of HTN <135/85 mm Hg ≥85 mm Hg DBP or and or ≥85 mm Hg 37 ABPM or 24-hour 24-hour <160/100 mm Hg DBP or Home BPM <130/80 mm Hg ≥130 mm Hg SBP or or if available ≥80 mm Hg DBP Hypertension Visit 4-5 ≥140 mm Hg SBP or Diagnosis ≥90 mm Hg DBP of HTN Continue to Diagnosis Continue to Diagnosis follow-up of HTN follow-up of HTN Continue to <140/90 mm Hg follow-up *With permission of the Canadian Hypertension Education Program
  41. 41. PART 2 THERAPY
  42. 42. 40 I lIFESTYlE MANAGEMENT A) Physical Exercise 1) For non-hypertensive individuals (to reduce the pos- sibility of becoming hypertensive) or for hypertensive patients (to reduce their blood pressure) prescribe the accumulation of 30 to 60 minutes of moderate intensity dynamic exercise (such as walking, jogging, cycling or swimming) 4 -7 days per week, in addition to the routine activities of daily living (Grade D). Higher intensities of exercise are no more effective (Grade D). B) Weight Reduction 1) Height, weight, and waist circumference (WC) should be measured and body mass index (BMI) calculated for all adults (Grade D). 2) Maintenance of a healthy body weight (BMI 18.5 to 24.9 kg/m² and WC of less than 102 cm for men and less than 88 cm for women) is recommended for non-hypertensive individuals to prevent hyper- tension (Grade C) and for hypertensive patients to reduce blood pressure (Grade B). All overweight hypertensive individuals should be advised to lose weight (Grade B). 3) Weight loss strategies should use a multidisciplinary approach that includes dietary education, increased physical activity and behavioral intervention (Grade B). C) Alcohol Consumption 1) To reduce blood pressure, alcohol consumption should be in accordance with Canadian low-risk drinking guidelines in both normotensive and hypertensive individuals. Healthy adults should limit alcohol consumption to 2 drinks or less per day, and consumption should not exceed 14 standard drinks per week for men and 9 standard drinks per week for women (Grade B). (Note: one standard drink is considered 13.6 g or 17.2 mL of ethanol, or approximately 44 mL of 80 proof (40%) spirits, 355 mL of 5% beer or 148 mL of 12% wine.) D) Dietary Recommendations 1) It is recommended that hypertensive patients and nor- motensive individuals at increased risk of developing
  43. 43. 41 hypertension consume a diet that emphasizes fruits, vegetables, low-fat dairy products, dietary and soluble fiber, whole grains and protein from plant sources that is reduced in saturated fat and cholesterol (Dietary Approaches to Stop Hypertension [DASH] diet; see Table 1) (Grade B). E) Salt Intake 1) For prevention of hypertension, in addition to a well-balanced diet, a dietary sodium intake of less than 100 mmol (2,300 mg) per day is recommended (Grade B). 2) In hypertensive patients, dietary sodium intake should be limited to 65 mmol to 100 mmol (1,495 mg to 2,300 mg) per day (Grade B). F) Potassium, Calcium and Magnesium Intake 1) Supplementation of potassium, calcium and mag- nesium is not recommended for the prevention or treatment of hypertension (Grade B). G) Stress Management 1) In hypertensive patients in whom stress may be contributing to blood pressure elevation, stress management should be considered as an interven- tion (Grade D). Individualized cognitive behavioral interventions are more likely to be effective when relaxation techniques are used (Grade B). II INDICATIONS FOR DRUG THERAPY FOR ADUlTS WITH HYPERTENSION WITHOUT COMPEllING INDICATIONS FOR SPECIFIC AGENTS 1) Antihypertensive therapy should be prescribed for average diastolic blood pressures of 100 mm Hg or higher (Grade A) or average systolic blood pressures of 160 mm Hg or higher (Grade A) in patients without macrovascular target organ damage or other cardiovas- cular risk factors (see Tables 3 and 4 from accompanying CHEP Diagnosis paper). 2) Antihypertensive therapy should be strongly consid- ered if diastolic blood pressure readings average 90 mm Hg or higher in the presence of macrovascular target organ damage or other independent cardiovascular risk factors (Grade A).
  44. 44. 42 3) Antihypertensive therapy should be strongly con- sidered if systolic blood pressure readings average 140 mm Hg or higher in the presence of macrovascular target organ damage (Grade C for 140 mm Hg to 160 mm Hg; Grade A for higher than 160 mm Hg). 4) Antihypertensive therapy should be considered in all patients meeting the above indications regardless of age (Grade B). Caution should be exercised in elderly patients who are frail. III CHOICE OF THERAPY FOR ADUlTS WITH HYPER- TENSION WITHOUT COMPEllING INDICATIONS FOR SPECIFIC AGENTS A) Recommendations for Individuals with Diastolic ± Systolic Hypertension 1) Initial therapy should be monotherapy with a thiazide diuretic (Grade A); a beta-blocker (in patients younger than 60 years of age, Grade B); an ACE inhibitor (in non-black patients, Grade B); a long-acting CCB (Grade B) or an ARB (Grade B). If there are adverse effects, another drug from this group should be substituted. Hypokalemia should be avoided in patients treated with thiazide diuretic monotherapy (Grade C). 2) Additional antihypertensive drugs should be used if target blood pressure levels are not achieved with standard dose monotherapy (Grade B). Add- on drugs should be chosen from first-line choices. Useful choices include a thiazide diuretic or CCB with an ACE inhibitor, ARB or beta-blocker (Grade B for the combination of thiazide diuretic with a di- hydropyridine CCB; Grade C for the combination of dihydropyridine CCB and ACE inhibitor and Grade D for all other combinations). Caution should be exercised in combining a nondihydropyridine CCB and a beta-blocker (Grade D). The combination of an ACE inhibitor and ARB is not recommended (Grade A). 3) Combination therapy using two first-line agents may also be considered as initial treatment of hypertension if systolic blood pressure is 20 mm Hg above target or if diastolic blood pressure is 10 mm Hg above target (Grade C). However, caution should be exercised in patients in whom a substantial fall in blood pressure
  45. 45. 43 is more likely or more poorly tolerated (e.g., elderly patients) from initial combination therapy. 4) If blood pressure is still not controlled with a combination of two or more first-line agents, or there are adverse effects, other antihypertensive drugs may be added (Grade D). 5) Possible reasons for poor response to therapy (Table 2) should be considered (Grade D). 6) Alpha-blockers are not recommended as first-line agents for uncomplicated hypertension (Grade A); beta-blockers are not recommended as first-line therapy for uncomplicated hypertension in patients aged 60 years of age or older (Grade A) and ACE inhibitors are not recommended as first-line therapy for uncomplicated hypertension in black patients (Grade A). However, these agents may be used in patients with certain comorbid conditions or in combination therapy. B) Recommendations for Individuals with Isolated Systolic Hypertension 1) Initial therapy should be monotherapy with a thiazide diuretic (Grade A); a long-acting dihydropyridine CCB (Grade A) or an ARB (Grade B). If there are ad- verse effects, another drug from this group should be substituted. Hypokalemia should be avoided in patients treated with thiazide diuretic monotherapy (Grade C). 2) Additional antihypertensive drugs should be used if target blood pressure levels are not achieved with standard-dose monotherapy (Grade B). Add-on drugs should be chosen from first-line choices (Grade D). 3) If blood pressure is still not controlled with a com- bination of two or more first-line agents, or there are adverse effects, other classes of drugs (such as alpha-blockers, ACE inhibitors, centrally acting agents or nondihydropyridine CCBs) may be added or substi- tuted (Grade D). 4) Possible reasons for poor response to therapy (Table 2) should be considered (Grade D). 5) Alpha-blockers are not recommended as first-line agents for uncomplicated isolated systolic hypertension
  46. 46. 44 (Grade A), and beta-blockers are not recommended as first-line therapy for isolated systolic hypertension in patients aged 60 years or older (Grade A). However, both agents may be used in patients with certain comorbid conditions or in combination therapy. IV GlOBAl VASCUlAR PROTECTION THERAPY FOR ADUlTS WITH HYPERTENSION WITHOUT COMPEllING INDICATIONS FOR SPECIFIC AGENTS 1) Statin therapy is recommended in hypertensive pa- tients with three or more cardiovascular risk factors as defined in Table 3 (Grade A in patients older than 40 years) or with established atherosclerotic disease (Grade A, regardless of age). 2) Strong consideration should be given to the addition of low-dose ASA therapy in hypertensive patients (Grade A in patients older than 50 years). Caution should be exercised if blood pressure is not controlled (Grade C). V GOAl OF THERAPY FOR ADUlTS WITH HYPERTENSION WITHOUT COMPEllING INDICATIONS FOR SPECIFIC AGENTS 1) The systolic blood pressure treatment goal is lower than 140 mm Hg (Grade C). The diastolic blood pressure treatment goal is lower than 90 mm Hg (Grade A). VI TREATMENT OF HYPERTENSION IN ASSOCIATION WITH ISCHEMIC HEART DISEASE A) Recommendations for Hypertensive Patients with Coronary Artery Disease 1) An ACE inhibitor is recommended for most patients with hypertension and documented coronary artery disease (Grade A). 2) For patients with stable angina, beta-blockers are preferred as initial therapy (Grade B). Long-acting CCBs may also be used (Grade B). 3) Short-acting nifedipine should not be used (Grade D). 4) For patients with CAD, but without coexisting systolic heart failure, the combination of an ACE inhibitor and ARB is not recommended (Grade B).
  47. 47. 45 B) Recommendations for Patients with Hypertension who have had a Recent ST- elevation Myocardial Infarction or Non-ST Segment Elevation Myocardial Infarction 1) Initial therapy should include both a beta-blocker and an ACE inhibitor (Grade A). An ARB may be used if the patient is intolerant of an ACE inhibitor (Grade A in patients with left ventricular systolic dysfunction). 2) Long-acting CCBs may be used in post-myocardial infarction patients when beta-blockers are contraindi- cated or not effective. Nondihydropyridine CCBs should not be used when there is heart failure as evidenced by pulmonary congestion on examination or radiograph (Grade D). VII TREATMENT OF HYPERTENSION IN ASSOCIATION WITH HEART FAIlURE 1) In patients with systolic dysfunction, ACE inhibitors (Grade A) and beta-blockers (Grade A) are recom- mended for initial therapy. Aldosterone antagonists (Grade B) are also recommended for patients with NYHA Class III or IV symptoms of heart failure or follow- ing MI. Other diuretics are recommended as additional therapy if needed (Grade B for thiazide diuretics for blood pressure control, Grade D for loop diuretics for volume control). Beyond considerations of blood pres- sure control, doses of ACE inhibitors or ARBs should be titrated to those found to be effective in trials unless adverse effects are manifest (Grade B). 2) An ARB is recommended if ACE inhibitors are not toler- ated (Grade A). 3) A combination of hydralazine and isosorbide dinitrate is recommended if ACE inhibitors and ARBs are con- traindicated or not tolerated (Grade B). 4) For hypertensive patients with heart failure whose blood pressure is not controlled, an ARB may be added to an ACE inhibitor and other antihypertensive drug treatment (Grade A). Careful monitoring should be used if combining an ACE inhibitor and an ARB due to potential adverse effects such as hypotension, hyperkalemia and worsening renal function (Grade C). Additional therapies may also include long-acting dihydropyridine CCBs (Grade C).
  48. 48. 46 VIII TREATMENT OF HYPERTENSION IN ASSOCIATION WITH CEREBROVASCUlAR DISEASE 1) Strong consideration should be given to the initiation of antihypertensive therapy after the acute phase of a stroke or transient ischemic attack (Grade A). 2) Caution is indicated in deciding whether to lower blood pressure in the acute stroke situation; pharmacological agents and routes of administration should be chosen to avoid precipitous falls in blood pressure (Grade D). 3) Following the acute phase of a stroke, patients should have their blood pressure chronically controlled to a target of lower than 140/90 mm Hg (Grade C). 4) Treatment with an ACE inhibitor plus diuretic combina- tion is preferred (Grade B). 5) For patients who have had a stroke the combination of an ACE inhibitor and ARB is not recommended (Grade B). IX TREATMENT OF HYPERTENSION IN ASSOCIATION WITH lEFT VENTRICUlAR HYPERTROPHY 1) Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events (Grade C). 2) The choice of initial therapy can be influenced by the presence of left ventricular hypertrophy (Grade D). Initial therapy can be drug treatment using ACE inhibitors, ARBs, long-acting CCBs or thiazide diuretics. Direct arte- rial vasodilators such as hydralazine or minoxidil should not be used. X TREATMENT OF HYPERTENSION IN ASSOCIATION WITH NON-DIABETIC CHRONIC KIDNEY DISEASE 1) For patients with non-diabetic chronic kidney disease, target blood pressure is lower than 130/80 mm Hg (Grade C). 2) For patients with hypertension and proteinuric chronic kidney disease (urinary protein greater than 500 mg/24h or albumin to creatinine ratio [ACR] greater than 30 mg/mmol), initial therapy should be an ACE inhibitor (Grade A) or an ARB if there is intolerance to ACE inhibitors (Grade B).
  49. 49. 47 3) Thiazide diuretics are recommended as additive antihy- pertensive therapy (Grade D). For patients with chronic kidney disease and volume overload, loop diuretics are an alternative (Grade D). 4) The combination of an ACE inhibitor and ARB is not recommended for patients with nonproteinuric chronic kidney disease (Grade B). XI TREATMENT OF HYPERTENSION IN ASSOCIATION WITH RENOVASCUlAR DISEASE 1) Renovascular hypertension should be treated in the same manner as hypertension without compelling indications, except for caution in using ACE inhibi- tors or ARBs due to the risk of acute renal failure in bilateral disease or unilateral disease with a solitary kidney (Grade D). 2) Close follow-up and early intervention (angioplasty and stenting or surgery) should be considered for patients with uncontrolled hypertension despite therapy with three or more drugs, deteriorating kidney function, bilateral atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a single kidney) or recurrent episodes of flash pulmonary edema (Grade D). XII TREATMENT OF HYPERTENSION IN ASSOCIATION WITH DIABETES MEllITUS 1) Persons with diabetes mellitus should be treated to attain systolic blood pressure lower than 130 mm Hg (Grade C) and diastolic blood pressure lower than 80 mm Hg (Grade A). (These target blood pressure levels are the same as the blood pressure treatment thresholds.) Combination therapy using two first-line agents may also be considered as initial therapy of hypertension (Grade B) if the SBP is 20 mm Hg above target or the DBP is 10 mm Hg above target. However, caution should be exercised in patients in whom a substantial fall in blood pressure is more likely or poorly tolerated (e.g., elderly patients, patients with autonomic nephropathy). 2) For patients with diabetes and normal urinary albumin excretion (ACR lower than 2.0 mg/mmol in men and lower than 2.8 mg/mmol in women) and without chronic kidney disease, with blood pressure 130/80 mm Hg or higher despite lifestyle interventions, any one of the
  50. 50. 48 following are recommended: an ACE inhibitor (Grade A for patients 55 years or older, Grade B for patients younger than 55 years); ARB (Grade A for persons with left ventricular hypertrophy and age of 55 years or older, Grade B for persons without left ventricular hypertrophy irrespective of age); a dihydropyridine CCB (Grade A for patients 55 years of age or older, Grade B for patients younger than 55 years of age); or a thiazide or a thiazide-like diuretic (Grade A for patients 55 years of age or older, Grade B for patients younger than 55 years of age) is recommended, with special consideration to the ACE inhibitor and ARB, given their additional renal benefits. If these drugs are contraindicated or cannot be tolerated, a cardioselective beta-blocker (Grade B) or nondihydropyridine CCB (Grade B) may be substituted. Additional antihypertensive drugs should be used if target blood pressure is not achieved with standard-dose monotherapy (Grade B). Add-on drugs should be chosen from first-line choices. 3) For patients with diabetes and albuminuria (persistent ACR greater than 2.0 mg/mmol in men and greater than 2.8 mg/mmol in women), an ACE inhibitor or an ARB is recommended as initial therapy (Grade A). If blood pressure remains 130/80 mm Hg or higher despite lifestyle interventions and the use of an ACE inhibitor or ARB, additional antihypertensive drugs should be used to obtain target blood pressure. 4) For patients with diabetes and a normal urinary albumin excretion rate (ACR lower than 2.0 mg/mmol in men and lower than 2.8 mg/mmol in women) with no chronic kidney disease and with isolated systolic hyperten- sion, a long-acting dihydropyridine CCB (Grade C) is an alternative initial choice to an ACE inhibitor (Grade B), ARB (Grade B), or a thiazide or a thiazide-like diuretic (Grade C). 5) Alpha-blockers are not recommended as first-line agents for the treatment of hypertension in patients with diabetes (Grade A). XIII CONCORDANCE STRATEGIES FOR PATIENTS 1) Adherence to an antihypertensive prescription can be improved by a multi-pronged approach, as outlined in Table 4.

×