2015 CHEP Hypertension Recommendations

The 2015 CHEP
Recommendations
What’s new in the treatment of hypertension?
What’s still really important?

2015
Hypertension Canada
• Mission:
– Advancing health through the prevention and
control of high blood pressure and its
complications.
• Vision:
– Canadians will have the healthiest blood pressure
in the world.

2015
Evidence-based Annual Recommendations
• Canada has the world’s highest reported national blood
pressure control rates
• CHEP is known as the most credible source for
evidence-based chronic disease management
recommendations, with annual updates, a well-
validated review process and effective dissemination
techniques across Canada

2015
2015 CHEP Recommendations Task Force

2015
Hypertension Canada
Knowledge Translation Organizational Chart
Recommendations Task Force

2015
Hypertension Canada’s Annual KT Cycle for
developing management recommendations
Adapted from Graham ID, Logan, J., Harrison MB, Straus, S., Tetroe, JM, Caswell, W.
et al. (2006). Lost in knowledge translation: Time for a map? Journal of Continuing
Education in Health Professions, 26, 13-24.

2015
CHEP 2015 Recommendations
What’s new?
• Assess clinic blood pressures using electronic (oscillometric)
monitors
• The diagnosis of hypertension should be based on out-of-
office measurements
• The management of hypertension is all about global
cardiovascular risk management and vascular protection
including advice and treatment for smoking cessation
• Treatment of atherosclerotic renal artery stenosis is primarily
medical

2015
What’s still important?
• Know the BP threshold and treat to target
• Adopting healthy behaviours is integral to the
management of hypertension
• The most important step in prescription of
antihypertensive therapy is achieving patient “buy-in”

2015
Population SBP > DBP >
Diabetes 130 80
High risk (TOD or CV risk factors) 140 90
Low risk (no TOD or CV risk
factors)
160 100
Very elderly* (≥80 yrs.) 160 NA
Usual blood pressure threshold values for
initiation of pharmacological treatment
TOD = target organ damage
*This higher treatment target for the very elderly reflects current evidence and
heightened concerns of precipitating adverse effects, particularly in frail patients.
Decisions regarding initiating and intensifying pharmacotherapy in the very elderly
should be based upon an individualized risk-benefit analysis.

2015
Population SBP < DBP <
Diabetes 130 80
All others < 80 yrs. (including
CKD)
140 90
Very elderly (≥ 80 yrs.) 150 NA
Treatment consists of health behaviour ±pharmacological management
Recommended Treatment Targets
In patients with coronary artery disease
be cautious when lowering blood pressure
if diastolic blood pressures are < 60mmHg

2015
• Know the BP threshold and treat to the target
• Adopting healthy behaviours is integral to the

2015
Impact of health behaviour management
on blood pressure
Intervention
Systolic BP
(mmHg)
Diastolic BP
(mmHg)
Diet and weight control -6.0 -4.8
Reduced salt/sodium intake - 5.4 - 2.8
Reduced alcohol intake (heavy
drinkers)
-3.4 -3.4
DASH diet -11.4 -5.5
Physical activity -3.1 -1.8
Relaxation therapies -5.5 -3.5
Clinical Guideline: Methods, evidence and recommendations
National Institute for Health and Clinical Excellence (NICE) May 2011

2015
Health Behaviour Management: Summary
Intervention Target
Reduce foods with added
sodium → 2000 mg /day
Weight loss BMI <25 kg/m2
Alcohol restriction < 2 drinks/day
Physical activity 30-60 minutes 4-7 days/week
Dietary patterns DASH diet
Smoking cessation Smoke free environment
Waist circumference Men <102 cm Women <88 cm

2015
Adherence to antihypertensive management
can be improved by a multi-pronged approach
• Encourage greater patient responsibility/autonomy in regular
monitoring of their blood pressure
• Educate patients and patients' families about their
disease/treatment regimens verbally and in writing
• Use an interdisciplinary care approach coordinating with
work-site health care givers and pharmacists if available
• Encouraging adherence to therapy by healthcare practitioner-
based telephone contact, particularly, over the first three
months of therapy

2015
Adherence to antihypertensive management can be
improved by a multi-pronged approach-II
• Assess adherence to pharmacological and health behaviour
therapies at every visit
• Teach patients to take their pills on a regular schedule
associated with a routine daily activity e.g. brushing teeth.
• Simplify medication regimens using long-acting once-daily
dosing
• Utilize single pill combinations
• Utilize unit-of-use packaging e.g. blister packaging

2015
What’s new?
• Monitor blood pressures in clinic using an electronic
(oscillometric) device
office measurements
medical

2015
Criteria for the diagnosis of hypertension
and recommendations for follow-up: overview
Measurement using electronic (oscillometric) upper arm devices is preferred over auscultation
ABPM: Ambulatory Blood Pressure Measurement
AOBP: Automated Office Blood Pressure
HBPM: Home Blood Pressure measurement
OBPM: Office Blood Pressure measurement

2015
BP measurement methods
• Office (attended, OBPM)
– Auscultatory (mercury, aneroid)
– Oscillometric (electronic)
• Office Automated (unattended, AOBP)
– Oscillometric (electronic)
• Ambulatory (ABPM)
• Home (HBPM)
For information on blood pressure measurement devices:
• http://www.dableducational.org/sphygmomanometers.html
• http://www.bhsoc.org/bp-monitors/bp-monitors/

2015
Office (attended, OBPM)
Auscultatory (mercury, aneroid) Oscillometric (electronic)
http://www.dableducational.org/sphygmomanometers.html
http://www.bhsoc.org/bp-monitors/bp-monitors/

2015
Office Automated (unattended, AOBP)
Oscillometric (electronic)

2015
New 2015 Recommendation: BP Measurement
Office BP measurement (OBPM):
• Measurement using electronic (oscillometric) upper arm
devices is preferred to auscultatory devices (Grade C).

2015
Auscultatory OBPM is inaccurate
• In the real world, the accuracy of auscultatory OBPM
can be adversely affected by provider, patient and
device factors such as:
– too rapid deflation of the cuff
– digit preference with rounding off of readings to 0 or 5
– also, mercury sphygmomanometers are being phased out
and aneroid devices are less likely to remain calibrated
• Consequence: Routine auscultatory OBPMs are 9/6
mm Hg higher than standardized research BPs
(primarily using oscillometric devices)
Myers MG, et al. Can Fam Physician 2014;60:127-32

2015
Keys to accurate OBPM
• Use standardized measurement techniques and
validated equipment
• Measurement using electronic (oscillometric) upper
arm devices is preferred over auscultation
• The first reading should be discarded and the latter two
averaged.

2015
Clinic BP as alternate method
Out of office assessment is the preferred
means of diagnosing hypertension

2015
Out of office BP measurement methods:
Ambulatory (ABPM)

2015
Out of office BP measurement methods:
Home (HBPM)

2015
Out-of-office BP Measurements
• ABPM has better predictive ability than OBPM and is
the recommended out-of-office measurement method.
• HBPM has better predictive ability than OBPM and is
recommended if ABPM is not tolerated, not readily
available or due to patient preference.
• Identifies white coat hypertension (as well as
diagnosing masked hypertension)

2015
Out-of-office BP measurements are more
highly correlated with BP-related risk
Mule et al. J Cardiovasc Risk 2002;9:123-9.
SBP
DBP

2015
Only relying on office pressures misses out on
white coat and masked hypertension
Manual Office BP mmHg
AmbulatoryBPmmHg
True
Hypertension
Normotension White Coat
Hypertension
Masked
Hypertension
200
180
160
140
120
100
100 120 140 160 180 200
135
From Pickering et al. Hypertension 2002;40:795-796

2015
The prognosis of white coat and masked
hypertension
0
5
10
15
20
25
30
35
Normal
23/685
White coat
24/656
Uncontrolled
41/462
Masked
236/3125
CVeventsper1000patient-year
CV Events
Okhubo et al. J. Am. Coll. Cardiol. 2005;46;508-515

2015
White coat hypertension: risk factors
• women
• older adults
• non-smokers
• subjects recently diagnosed with hypertension with a
limited number of routine OBPM
• subjects with mild hypertension
• pregnant women
• subjects without evidence of target organ damage
Franklin SS, et al. Hypertension 2013;62:982-7
Lovibond K, et al. Lancet 2011;378:1219-30

2015
• high normal clinic BPs
• older adults
• males
• higher BMI
• smoker
• excess alcohol consumption
• diabetes
• peripheral arterial disease
• orthostatic hypotension
• LVH
Masked hypertension: risk factors
Hanninen MR et al, J Hypertens. 2011;29:1880-88
Barochiner J et al. Am J Hypertens. 2013;28:872-78
Andalib A et al. Intern M ed J. 2012;42:260-66

2015
Summary of evidence
• Out-of-office is needed to identify white coat
hypertension (and to rule out masked hypertension)
• ABPM has better predictive ability than OBPM
• HBPM has better predictive ability than OBPM

2015
Criteria for the diagnosis of hypertension
and recommendations for follow-up: summary
Measurement using electronic (oscillometric) upper arm devices is preferred over auscultation
ABPM: Ambulatory Blood Pressure Measurement
AOBP: Automated Office Blood Pressure
HBPM: Home Blood Pressure measurement
OBPM: Office Blood Pressure measurement

2015
What’s new?
• Assess clinic blood pressures using electronic (oscillometric)
monitors
office measurements
medical
.

2015
Assess global cardiovascular risk in all
hypertensive patients
8 out of 10 hypertensive patients have at least 1 additional risk factor
 Risk factors =  Global CV risk
Gee ME, Bienek A, McAlister FA, et al. Factors Associated With Lack of Awareness and Uncontrolled High Blood Pressure Among
Canadian Adults With Hypertension. Can J Cardiol. 2012;28:375-382.

2015
Informing patients of their global risk improves
the effectiveness of risk factor modification
Grover SA , et al. J Gen Intern Med. 2009;24(1);33–39

2015
Impact on blood pressure treatment of
discussing coronary risk with patients
Grover SA, et al. J Gen Intern Med 2009;24(1);33-9

2015
The treatment of hypertension is all about
vascular protection
• Male
• 55 y or older
• Smoking
• Type 2 Diabetes
• Total-C/HDL-C ratio of 6 or higher
• Premature Family History of CV disease
• Previous Stroke or TIA
• LVH
• ECG abnormalities
• Microalbuminuria or
Proteinuria
• Peripheral Vascular Disease
ASCOT-LLA Lancet 2003;361:1149-58
Statins are recommended in high risk hypertensive patients based on having
established atherosclerotic disease or at least 3 of the following:

2015
Vascular Protection
for Hypertensive Patients: ASA
Low dose ASA in hypertensive patients >50 years
Caution should be exercised if BP is not controlled.
Hansson L, Zanchetti A, Carruthers SG, 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.

2015
Tobacco use status of all patients should be updated on a
regular basis and health care providers should clearly
advise patients to quit smoking.
New 2015 Recommendation:
Vascular Protection

2015
Effect of advice on smoking cessation rates
Cochrane Database Syst Rev. 2013 May
31;5:CD000165. doi: 10.1002/14651858.CD000165.pub42015

2015
Advice in combination with pharmacotherapy (e.g.,
varenicline, bupropion, nicotine replacement therapy)
should be offered to all smokers with a goal of smoking
cessation.
New 2015 Recommendation:
Vascular Protection

2015
Cochrane network meta-analysis 2014
Kate Cahill et al
• Nicotine replacement therapy (NRT), antidepressant
bupropion, and nicotine receptor partial agonist
varenicline
• Impact on long term abstinence- 6 months or longer
• Synthesis of 12 Cochrane reviews
– 267 studies
– Over 10,000 participants

2015
Network meta-analysis of smoking cessation
pharmacotherapies studies
Cochrane Database Syst Rev. 2013 May 31;5:CD000165.
doi: 10.1002/14651858.CD000165.pub4

2015
What’s new?
• Clinic blood pressures should be using electronic
(oscillometric) monitors
office measurements
including advice and treatment supporting smoking
cessation
medical

2015
Patients with hypertension attributable to atherosclerotic
renal artery stenosis (RAS) should be primarily medically
managed because renal angioplasty and stenting offer no
benefits over optimal medical therapy alone.
CHEP Recommendations 2015: Therapy

CORAL: Cooper et al, Stenting & Medical Rx
for Atherosclerotic RAS
947 Patients:
-HT with SBP≥155 while on ≥2 drugs; OR
-CKD: GFR <60 mL/min/1.73 m2 AND
-RAS ≥80% or ≥60% with SBP gradient ≥20
mmHg
Intervention (1:1):
-Palmaz Genesis stent (Cordis)
Concurrent Medical Rx:
-antiplatelet;
-Anti-HT to <140/90 (DM: 130/80) with
candesartan, HCT, amlodipine;
-lipid Rx (atorvastatin); glucose
Primary Outcome:
-Composite: Death (CV/renal), stroke, MI,
stroke, HFhosp, prog renal insuff, perm RRT
NEJM 2014; 370; 13-22.

2015
CORAL: Cooper et al, Stenting & Medical Rx
for Atherosclerotic RAS
• Conclusion:
– Renal-artery stenting did not confer a significant benefit
with respect to the prevention of clinical events when
added to comprehensive, multifactorial medical therapy in
people with atherosclerotic RAS and HT or CKD.
NEJM 2014; 370; 13-22.

2015
Meta-Analysis of all RCTs for RAS
• Summary Estimates of CV Outcomes for
Revascularization vs Medical Therapy:
– Mortality:14.0% vs 15.3% (P = 0.37)
– Hospitalization for CHF: 9.4% vs 10.4% (P = 0.40)
– Stroke: 4.1% vs 5.1% (P = 0.30)
– Worse renal function: 15.3% vs 16.1% (P = 0.67).
Bavry AA, et al. JAMA Intern Med. 2014;174(11):1849-1851.

2015
Renal artery angioplasty and stenting for atherosclerotic
hemodynamically significant renal artery stenosis could
be considered for patients with uncontrolled
hypertension resistant to maximally tolerated
pharmacotherapy, progressive renal function loss, and
acute pulmonary edema.
CHEP Recommendations 2015: Therapy

2015
Why RCTs might not define best care for some patients
with RAS: they included patients
who were not “resistant”
RCT Inclusion Criteria Enrolled Subjects
BP #AHT % stenosis SBP #AHT % stenosis
CORAL S≥155 ≥2 drugs ≥60/80% 150 2.1 drugs 67%
ASTRAL n/a n/a ≥70% 149-152 2.8 drugs 75%
STAR “Controlled BP” ≥50% 160-163 2.8-2.9 70-90%
DRASTIC D≥95 ≥2 drugs ≥50% 179-180 2.0 72-76%
SNRASCG D≥95 ≥2 drugs ≥50% 182-190
EMMA D≥95 Yes ≥60/75% 158-165 1.33 DDD <75%
#AHT= number of antihypertensive drugs

2015
• Know the BP threshold and treat to the target
• Adopting health behaviours is integral to the

2015
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