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1. Comparison of Hypertension Canada guidelines and
AHA/ACC hypertension guideline
Ernesto L. Schiffrin C.M., MD, PhD, FRSC, FRCPC, FACP
Department of Medicine, Sir Mortimer B. Davis-Jewish General Hospital,
Lady Davis Institute for Medical Research,
McGill University, Montreal, PQ, Canada.
2nd Vietnam Congress of Hypertension
NhaTrang City, May 12, 2018

2. Categories of BP in Adults in HC and AHA/ACC
BP Category SBP DBP
Normal <120 mm Hg and <80 mm Hg
Elevated 120–129 mm Hg and <80 mm Hg
Hypertension
Stage 1 130–139 mm Hg or 80–89 mm Hg
Stage 2 ≥140 mm Hg or ≥90 mm Hg
BP Category
Normal
<140/90 mm Hg
<135/85 mm Hg*
<130/80 mm Hg†
Hypertension
≥140/90
≥135/85*
≥130/80 mm Hg†
AHA/ACCHypertension Canada
* With AOBP; † with 24h ABPM

3. Prevalence of Hypertension with new definition in AHA/ACC guideline
• Prevalence of hypertension is estimated to be about 14% higher using the
proposed SBP and DBP cut-points for definition of hypertension (46% vs.
32%)
• However, nonpharmacological management is recommended
• BP-lowering medication in addition to nonpharmacological therapy only
when atherosclerotic cardiovascular disease (ASCVD) is >10% in 10 yrs.

4. 1. Out of office assessment
is the preferred means
of hypertension Dx
2. Measurement using
electronic
(oscillometric) upper arm
devices is preferred over
auscultation
Hypertension Diagnostic Algorithm
ABPM = ambulatory blood pressure measurement
AOBP = automated office blood pressure

5. • Assess BP at all appropriate visits.
• Use approved devices and proper technique to measure BP at home.
• Screen people with HTN for diabetes (and vice versa).
• Assess and manage overall cardiovascular risk in all people with hypertension
including: smoking, dyslipidemia, dysglycemia, abdominal obesity, unhealthy eating
(including importantly salt intake) and physical inactivity.
Key messages for the management of hypertension
in Hypertension Canada Guidelines

6. Accurate measurement of BP in AHA/ACC
• Accurate measurement of BP is essential for categorization of BP, determining risk
of ASCVD, and management of high BP.
• Errors in BP measurement, common in clinical practice, should be avoided by
following methods outlined in the guideline.
• Importance of out-of-office BP measurements (ABPM and HBPM) and how to use
in addition to office readings to recognize “white coat” and “masked”
hypertension and improve management in patients with hypertension.

7. Secondary Forms of Hypertension in
Hypertension Canada guidelines
Detailed description of Endocrinological forms of hypertension and
renovascular hypertension are provided, their diagnosis and
treatment.

8. Secondary Forms of Hypertension in
AHA/ACC Guideline
• Secondary causes of hypertension are found in approximately 10% of
patients with hypertension.
• Many of these forms of hypertension can either be cured or require
specific treatments.
• The guideline provides suggestions for clinical presentations that warrant
screening for secondary forms of hypertension and guidance for conduct of
specific screening tests.

9. Nonpharmacological management of high BP
in both guidelines
Nonpharmacological interventions aim to correct unhealthy diet, physical inactivity, and/or
excessive consumption of alcohol.
Most important nonpharmacological interventions:
• weight loss,
• a heart healthy diet such as the DASH Diet,
• reduced dietary sodium intake,
• increased intake of potassium (preferably by dietary modification),
• increased physical activity in moderation,
• avoidance of excessive alcohol intake.

10. Population SBP DBP
High Risk (SPRINT population) # ≥ 130 NA
Diabetes ≥ 130 ≥ 80
Moderate * ≥ 140 ≥ 90
Low risk (no TOD or CV risk factors) ≥ 160 ≥ 100
Usual Office BP Threshold Values for
Initiation of Pharmacological Treatment
AOBP = automated office blood pressure
TOD = target organ damage
SBP = systolic blood pressure
DBP = diastolic blood pressure
# Based on AOBP
*AOBP threshold  135/85 mmHg

11. Treatment consists of health behaviour ± pharmacological management
Population SBP DBP
High Risk # < 120 NA
Diabetes < 130 < 80
All others* < 140 < 90
Recommended Office BP Treatment Targets
# Based on AOBP
*AOBP threshold  135/85 mmHg

12. Padwal RS et al.
Hypertension. 2016;68:3-5.

13. Padwal RS et al.
Hypertension. 2016;68:3-5.

14. Drug management of hypertension
Decisions to manage hypertension using BP-lowering medication, in
addition to nonpharmacological interventions, are based on:
• level of BP
• risk for ASCVD.
Recommendations are provided for BP medication treatment
thresholds according Framingham risk score in Hypertension Canada
Guidelines, and to risk of ASCVD in AHA/ACC guideline,
• BP targets during therapy,
• and follow-up after initiation of therapy.

15. Choice of Antihypertensive Medication in
Hypertension Canada Guidelines
Five drug classes are recommended as options for initial choice of
antihypertensive drug therapy:
1. thiazide diuretics,
2. calcium channel blockers,
3. angiotensin converting enzyme inhibitors
4. angiotensin receptor blockers
5. beta blockers (not above 60 yrs of age unless there is a compelling
indication).
In most adults with hypertension, pharmacotherapy requires more
than one agent.
Hypertension Canada recommends use of single-pill combinations.

16. Hypertension Canada Guideline 2017
What’s new?
• Longer acting (thiazide-like) diuretics are preferred vs. shorter acting
(thiazides)
• Single-pill (fixed-dose) combinations should be used as a first line
treatment (regardless of the extent of BP elevation)

17. Choice of Antihypertensive Medication in
AHA/ACC Guideline
Four drug classes are recommended as options for initial choice of
antihypertensive drug therapy:
1. thiazide diuretics,
2. calcium channel blockers,
3. angiotensin converting enzyme inhibitors
4. angiotensin receptor blockers
In most adults with hypertension, pharmacotherapy requires more
than one agent.
AHA/ACC recommends single-pill (fixed-dose) combinations when BP
20/10 mm Hg above target BP.

18. Choice of Pharmacological Treatment in Hypertension Canada
Guidelines for compelling indications and in diabetes
• Compelling indications:
• Ischemic Heart Disease
• Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI
• Left Ventricular Systolic Dysfunction
• Cerebrovascular Disease
• Left Ventricular Hypertrophy
• Non Diabetic Chronic Kidney Disease
• Renovascular Disease
• Smoking
• Diabetes Mellitus
• With Diabetic Nephropathy
• Without Diabetic Nephropathy

19. Management of Hypertension in Adults with Comorbidities
and in Special Patient Groups in AHA/ACC Guideline
Management of hypertension in adults with one or more comorbidities:
• heart failure
• CKD or renal transplantation
• peripheral vascular disease
• diabetes mellitus or metabolic syndrome
• atrial fibrillation
• valvular heart disease
• aortic disease
Specific patient groups:
• different race/ethnicity,
• women (including those who are pregnant),
• older adults
• children or adolescents
• resistant hypertension or a hypertensive crisis or emergency

20. Improving Treatment and Control in Adults with Hypertension
• A majority of adults receiving antihypertensive drug therapy have an
average SBP and/or DBP above target level recommended in the
guidelines.
• Several strategies for improving control of hypertension that have
been demonstrated to be effective are recommended in both
guidelines.

21. Comparison of the 2017 AHA/ACC and the 2017 Hypertension Canada Guidelines
Thresholds Targets
American Heart Association/American College of Cardiology Hypertension Guideline
Elevated systolic blood pressure ≥120†
Definition of hypertension ≥130/80
No clinical cardiovascular disease or 10-y atherosclerotic
cardiovascular disease risk <10%
≥130/80† ≥140/90‡
<130/80
Clinical cardiovascular disease or 10-y atherosclerotic
cardiovascular disease risk ≥10%
≥130/80 <130/80
Elderly (≥65 y of age) ≥130/80 <130/80
Secondary stroke prevention ≥140/90 <130/80
All other comorbidities* ≥130/80 <130/80
2017 Hypertension Canada’s Guideline
Definition of hypertension ≥140/90
≥135/85§
Low-risk (no target organ damage or cardiovascular risk
factors)
≥160/100 <140/90
High risk (SPRINT-like individuals), systolic blood pressure ≥130§ <120§
Elderly (≥75 y of age; SPRINT-based), systolic blood pressure ≥130§ <120§
Secondary stroke prevention ≥140/90 <140/90
Diabetes mellitus ≥130/80 <130/80
All other hypertensive subjects with comorbidities ≥140/90 <140/90*Other comorbidities include diabetes mellitus, chronic kidney disease, coronary artery disease, congestive heart failure, peripheral artery
disease, secondary prevention of lacunar stroke. †Threshold to initiate lifestyle modification. ‡Threshold to initiate pharmacological therapy.
§BP based on AOBP. Schiffrin EL. Circulation. 2018;137:883-885.

22. Major differences between AHA/ACC and Hypertension Canada guidelines (1)
• HC strictly evidence based, AHA/ACC pragmatic simplified thresholds and goals.
• HC not extending intensified treatment to low-risk hypertensives, AHA/ACC adopting uniform
intensified thresholds and goals
• HC adopting SPRINT-based recommendation for high-risk patients, and recommending AOBP,
AHA/ACC adjusting a less intense BP lowering uniform for most patients probably to accommodate
the use of nonautomated BP devices in clinical practice that tend to overestimate BP readings.
• AHA/ACC provides pragmatic equivalence between office, ABPM and HBPM which are based on
little evidence, but facilitate management.

23. Major differences between AHA/ACC and Hypertension Canada guidelines (2)
• Whereas HC recommends use of single-pill (fixed dose) combinations to initiate
pharmacologic treatment, AHA/ACC recommends monotherapy as first line for treatment
initiation, and initiating 2 first-line antihypertensive medications and single-pill combinations
when BP is >20/10 mm Hg above the target in stage 2 hypertension (>140/90 mm Hg).
• No guidance in HC guidelines for renal transplantation, atrial fibrillation, valvular heart
disease or aortic disease, different race/ethnicity, patients with resistant hypertension,
hypertensive crisis, or hypertensive emergency.

24. • Insistence on proper standardized technique for BP measurement.
• Insistence on out-of-office BP measurement for management of HBP.
• Insistence on nonpharmacologic measures for management of hypertension including
increased potassium intake via the diet, as well as initiation of pharmacologic treatment
when hypertensive individuals are at higher risk.
• Essentially similar recommendations for pharmacologic treatment except regarding
initiation with single-pill (fixed-dose) combinations in HC guidelines.
Major similarities between AHA/ACC and Hypertension Canada guidelines