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2007 Canadian Hypertension Education Program Recommendations 2
Assess blood pressure at all appropriate visits. Almost one half of those with blood pressure 130-139/85-89 will develop hypertension within 2 years. They require annual reassessment.Assess global cardiovascular risk in all hypertensive patients. Lifestyle modification is the cornerstone for the prevention and management of hypertension and CVD.
Key CHEP messages for the management of hypertension
2007 Canadian Hypertension Education Program Recommendations 3
Key CHEP messages for the management of hypertension
Treat to target (<140/90 mmHg; <130/80 mmHg in patients with diabetes or chronic kidney disease). To achieve targets sustained lifestyle modification and more than one drug is usually required.Follow patients with uncontrolled blood pressure at least monthly until blood pressure targets are achieved.Strategies to improve patient adherence to lifestyle modifications and antihypertensive therapy need to be incorporated in every patients management
2007 Canadian Hypertension Education Program Recommendations 4
• A red flaghas been posted where recommendations were updated for 2007.
• A slide kit for medical education can be downloaded (English and French versions) fromhttp://www.hypertension.ca
2007 Canadian Hypertension Education Program
2007 Canadian Hypertension Education Program Recommendations 5
Treatment Approaches:• Lifestyle• Pharmacological
2007 Canadian Hypertension Education Program
2007 Canadian Hypertension Education Program Recommendations 6
2007 Canadian Hypertension Education Program
What's New for 2007
• Approximately 95% of Canadians will develop hypertension if they live an average lifespan
• Most overweight patients with high normal blood pressure (130-139/85-89 mmHg) will develop hypertension within 4 years and almost 1/2 within 2 years.
• Annual follow-up of patients with high normal blood pressure is recommended.
2007 Canadian Hypertension Education Program Recommendations 7
2007 Canadian Hypertension Education Program
What's New for 2007 • Up to 17% of hypertension can be
attributed to high sodium diets • Reduce sodium intake to less than
100 mmol in normotensive patients to prevent hypertension
2007 Canadian Hypertension Education Program Recommendations 8
Recommendations 2007Table of contents
I. Indications for drug therapyII. Goal for therapyIII. AdherenceIV. LifestyleV. UncomplicatedVI. CV – IHDVII. CHFVIII. Cerebrovascular / StrokeIX. LVHX. Chronic kidney diseaseXI. RenovascularXII. DiabetesXIII. SmokingXIV. Global risk reduction
2007 Canadian Hypertension Education Program Recommendations 9
Usual blood pressure threshold values for initiation of pharmacological treatment of hypertension
Condition Initiation
SBP or DBP mmHg
• Systolic or Diastolic hypertension 140/90
• Diabetes• Chronic Kidney Disease
130/80
I. Indications for Pharmacotherapy
2007 Canadian Hypertension Education Program Recommendations 10
I. Indications for Pharmacotherapy
• In low risk patients with stage 1 hypertension (140-159/90-99 mmHg) lifestyle modification can be the sole therapy.
• Over 90% of Canadians with hypertension have other risk factors and pharmacotherapy should be considered in these patients if blood pressure remains equal to or above 140/90 mmHg with lifestyle modification.
• Patients with target organ damage (e.g. left ventricular hypertrophy) are recommended to be treated with pharmacotherapy if blood pressure is equal to or above 140/90
• Patients with known atherosclerotic disease (e.g. past stroke) are recommended to be treated with pharmacotherapy even if the blood pressure is normal (see compelling indications)
• Patients with diabetes or chronic kidney disease should be considered for pharmacotherapy if the blood pressure is equal or over 130/80 mmHg
2007 Canadian Hypertension Education Program Recommendations 11
Blood pressure target values for treatment of hypertension
Condition Target
SBP and DBP mmHg
Isolated systolic hypertension <140
Systolic/Diastolic Hypertension• Systolic BP • Diastolic BP
<140<90
Diabetes• Systolic • Diastolic
<130<80
Chronic Kidney disease• Systolic • Diastolic
<130<80
II. Goals of Therapy
2007 Canadian Hypertension Education Program Recommendations 12
II. Goals of Therapy
• To optimally reduce cardiovascular risk reduce the blood pressure to specified targets.• This usually requires two or more drugs and
lifestyle changes• The systolic target is more difficult to
achieve however controlling systolic blood pressure is as important if not more important than controlling diastolic blood pressure
2007 Canadian Hypertension Education Program Recommendations 13
Follow-up of blood pressure above targets
• Patients with blood pressure at target are recommended to be followed at least every 2nd month
• Follow-up visits are used to increase the intensity of lifestyle and drug therapy, monitor the response to therapy and assess adherence
2007 Canadian Hypertension Education Program Recommendations 16
To reduce the possibility of becoming hypertensive,
Restriction of sodium intake to less than 100 mmol (2300 mg) / day
Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary and soluble fiber, whole grains and protein from plant sources, low in saturated fat, cholesterol and salt in accordance with Canada's Guide to Healthy Eating.
Regular physical activity: accumulation of 30-60 minutes of moderate intensity cardiorespiratory activity 4-7/week
Low risk alcohol consumption (≤2 standard drinks/day and less than 14/week for men and less than 9/week for women)
Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2)
Waist Circumference< 102 cm for men< 88 cm for women
Smoke free environment
Lifestyle Recommendations for Prevention of Hypertension for NON-Hypertensive Individuals.
2007 Canadian Hypertension Education Program Recommendations 17
Lifestyle Recommendations for the Treatment of Hypertension
Restriction of sodium intake to less than 100 mmol (2300 mg) / day
Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary and soluble fiber, whole grains and protein from plant sources, low in saturated fat, cholesterol and salt in accordance with Canada's Guide to Healthy Eating.
Regular physical activity: accumulation of 30-60 minutes of moderate intensity cardiorespiratory activity 4-7/week
Low risk alcohol consumption (≤2 standard drinks/day and less than 14/week for men and less than 9/week for women)
Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2)
Weight loss (> 5 Kg) in those who are over weight (BMI>25)
Waist Circumference< 102 cm for men< 88 cm for women
Smoke free environment
2007 Canadian Hypertension Education Program Recommendations 18
Dietary Sodium
Restrict to target range of 65-100 mmol/day(Most of the salt in food is hidden and comes
from processed food)
Dietary PotassiumIf required, daily dietary intake
>80 mmol
Calcium supplementationNo conclusive studies for hypertension
Magnesium supplementationNo conclusive studies for hypertension
Lifestyle Recommendations for Hypertension: Dietary
• High in fresh fruits• High in vegetables• High in low fat
dairy products• High in dietary and
soluble fibre• High in plant
protein• Low in saturated
fat and cholesterol
http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_guide_rainbow_e.html
2007 Canadian Hypertension Education Program Recommendations 19
Recommendations for daily salt intake
Less than:• 100 mmol sodium (Na) • or 2,3 g sodium (Na) • or 5,8 g of salt (NaCl)• or 1 teaspoon of table salt
2,300 mg sodium = 1 teaspoon of table salt
2007 Canadian Hypertension Education Program Recommendations 20
Salt 2007: Meta-analyses
HypertensivesReduction of BP 5.1 / 2.7 mmHg with a average reduction of 78 mmol sodium/day (162 to 87mmol/day)
7.2/3.8 mmHg with a average reduction of 100 mmol sodium/day
Normotensives Reduction of BP 2.0 / 1.0 mmHg with a average reduction of sodium 74 mmol/day3.6/1.7 mmHg with a average reduction of 100 mol/day sodium
The Cochrane Library 2006;3:1-41;
2007 Canadian Hypertension Education Program Recommendations 21
Salt 2007: Meta analysis on different reduction in sodium on blood pressure
0
2
4
6
8
10
12
52 104 156
mmol reduction in sodium
BP
red
uct
ion
SBP hyper
DBP hyper
SBP normo
DBP normo
Hypertension 2003;42:1093-1099
2007 Canadian Hypertension Education Program Recommendations 22
Epidemiologic impact on mortality of blood pressure reduction in the population
Reduction in SBP
(mmHg)
% Reduction in Mortality
Stroke CHD Total
2 -6 -4 -3
3 -8 -5 -4
5 -14 -9 -7Adapted from Whelton, P. K. et al. JAMA 2002;288:1882-1888
AfterIntervention
BeforeIntervention
Reduction in BPP
revale
nce
%
2007 Canadian Hypertension Education Program Recommendations 23
Exercise should be prescribed as adjunctive to pharmacological therapy
Lifestyle Recommendations for Hypertension. Physical Activity
Should be prescribed to reduce blood pressure
Type cardiorespiratory activity- Walking, jogging- Cycling- Non-competitive swimming
Time - 30-60 minutes
Intensity - Moderate
Frequency - Four to seven days per weekF
I
T
T
2007 Canadian Hypertension Education Program Recommendations 24
Lifestyle Recommendations for Hypertension: Alcohol
Low risk alcohol consumption
• Women: maximum of 9 standard drinks/week
• Men: maximum of 14 standard drinks/week
• 0-2 standard drinks/day
A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or 12 oz of beer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).
2007 Canadian Hypertension Education Program Recommendations 25
Lifestyle Recommendations for Hypertension Stress Management
Hypertensive patientsin whom stress appears to be an important issue
Individualized cognitive behavioral interventions are more likely to be effective when relaxation techniques are employed.
Stress management
Behavior Modification
2007 Canadian Hypertension Education Program Recommendations 26
Lifestyle Recommendations for Hypertension Weight Loss
Height, weight, and waist circumference (WC) should be measured and body mass index (BMI) calculated for all adults.
Hypertensive and all patientsBMI over 25 - Encourage weight reduction- Healthy BMI: 18.5-24.9 kg/m2
Waist Circumference< 102 cm for men< 88 cm for women
For patients prescribed pharmacological therapy: weight loss has additional antihypertensive effects. Weight loss strategies should employ a multidisciplinary approach and include dietary education, increased physical activity and behavioural modification
2007 Canadian Hypertension Education Program Recommendations 27
Courtesy J.P. Després 2006
Mid distance
Last rib margin
Iliac crest
Waist circumference measurement
2007 Canadian Hypertension Education Program Recommendations 28
Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults
Intervention Amount SBP/DBP
Reduce foods with added sodium 1.8g or 78 mmol/d -5.1 / -2.7
Weight loss per kg lost -1.1 / -0.9
Alcohol intake - 3.6 drinks/day -3.9 / -2.4
Aerobic exercise 120-150 min/week -4.9 / -3.7
Dietary patternsDASH diet
HypertensiveNormotensive
-11.4 / -5.5-3.6 / -1.8
Applying the 2005 Canadian Hypertension Education Program recommendations: 3. Lifestyle modifications to prevent and treat hypertension Padwal R. et al. CMAJ ・ SEPT. 27, 2005; 173 (7) 749-751
2007 Canadian Hypertension Education Program Recommendations 29
Lifestyle Therapies in Hypertensive Adults: Summary
Intervention Target
Reduce foods with added sodium < 100 mmol/day
Weight loss BMI <25 kg/m2
Alcohol restriction Less or equal to 2 drinks/day
Exercise at least 4 times/week
Dietary patterns DASH diet
Smoking cessation Smoke free environment
Waist Circumference< 102 cm for men< 88 cm for women
2007 Canadian Hypertension Education Program Recommendations 31
2007 Canadian Hypertension Education Program
I. Indications for drug therapyII. Goal for therapyIII. AdherenceIV. LifestyleV. UncomplicatedVI. CV – IHDVII. CHFVIII. Cerebrovascular / StrokeIX. LVHX. Chronic kidney diseaseXI. RenovascularXII. DiabetesXIII. SmokingXIV. Global risk reduction
Table of contents
2007 Canadian Hypertension Education Program Recommendations 32
V. Choice of Pharmacological Treatment Uncomplicated
Associated risk factors?or
Target organ damage/complications?or
Concomitant diseases/conditions?
IndividualizedTreatment
(and compelling indications)
YES
Treatment in theabsence of specific
indication
NO
2007 Canadian Hypertension Education Program Recommendations 33
V. Choice of Pharmacological Treatment
1. Treatment of Systolic/Diastolic hypertension without other compelling indications
2. Treatment of Isolated Systolic hypertension without other compelling indications
2007 Canadian Hypertension Education Program Recommendations 34
V. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling Indications
TARGET <140/90 mmHgINITIAL TREATMENT AND MONOTHERAPY
* BBs are not indicated as first line therapy for age 60 and above
Beta-blocker*
Long-actingCCB
Thiazide ACE-I ARB
Lifestyle modificationtherapy
ACEI and ARB are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential
2007 Canadian Hypertension Education Program Recommendations 35
V. Considerations Regarding the Choice of First-Line Therapy
• ACE inhibitors and ARBs are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential
• Beta adrenergic blockers are not recommended for patients age 60+ without another compelling indication
• Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agent
• ACE-I are not recommended (as monotherapy) for black patients without another compelling indication
2007 Canadian Hypertension Education Program Recommendations 36
Major Congenital Malformations after First Trimester Exposure to ACE
inhibitors• Cardiovascular and neurological defects• ACEI risk ratio 2.71 (1.72-4.27) vs. other
drugs 0.66 (0.25-1.75) vs. no drug
NEJM 2006;354:2443-51
2007 Canadian Hypertension Education Program Recommendations 37
V. Add-on Therapy for Systolic/Diastolic Hypertension without Other Compelling Indications
CONSIDER
• Nonadherence?• Secondary HTN?• Interfering drugs or lifestyle?• White coat effect?• Resistant Hypertension?
If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers or centrally acting agents).
2. Triple or Quadruple Therapy
1. Add-on Therapy
If partial response to monotherapy
2007 Canadian Hypertension Education Program Recommendations 38
Drug Combinations
• When combining drugs, use first-line therapies
• Two drug combinations of beta blockers, ACE inhibitors and angiotensin receptor blockers have not been proven to have additive hypotensive effects.
• Therefore these potential two drug combinations should not be used unless there is a compelling (non blood pressure lowering) indication such as ischemic heart disease, post myocardial infarction, congestive heart failure or chronic kidney disease with proteinuria.
2007 Canadian Hypertension Education Program Recommendations 39
Drug Combinations cont’d
• Caution should be exercised in combining a non dihydropyridine CCB and a beta blocker to reduce the risk of bradycardia or heart block.
• Monitor creatinine and potassium when combining K sparing diuretics, ACE inhibitors and/or angiotensin receptor blockers.
• If a diuretic is not used as first or second line therapy, triple dose therapy should include a diuretic, when not contraindicated.
2007 Canadian Hypertension Education Program Recommendations 40
Most HTN Pts need more than 1 drug (data from ALLHAT)
2007 Canadian Hypertension Education Program Recommendations 41
Most HTN Pts need more than 1 drug
0
1
2
3
4
5
UKPDS
ABCD
MDRD
HOT
AASKID
NT
ALLHAT
Nu
mb
er o
f d
rug
s
2007 Canadian Hypertension Education Program Recommendations 42
BP Effects from antihypertensive therapy
Law. BMJ 2003 (SR of 354 RCTs)• Dose response curves for efficacy
are relatively flat
• 80% of the BP lowering efficacy is achieved at half-standard dose
• Combinations of high standard dose have additive blood pressure lowering effects
2007 Canadian Hypertension Education Program Recommendations 43
V. Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications
CONSIDER
• Nonadherence?• Secondary HTN?• Interfering drugs or
lifestyle?• White coat effect?
Dual Combination
Triple or Quadruple Therapy
Lifestyle modificationtherapy
Thiazidediuretic ACE-I Long-acting
CCBBeta-
blocker*
TARGET <140/90 mmHg
ARB
* Not indicated as first line therapy over 60
ACEI and ARB are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential
2007 Canadian Hypertension Education Program Recommendations 44
V. Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications
INITIAL TREATMENT AND MONOTHERAPY
Thiazide diuretic
Long-actingDHP CCB
Lifestyle modificationtherapy
ARB
TARGET <140 mmHg
2007 Canadian Hypertension Education Program Recommendations 45
V. Add-on therapy for Isolated Systolic Hypertension without Other Compelling Indications
CONSIDER
• Nonadherence?• Secondary HTN?• Interfering drugs or
lifestyle?• White coat effect?
If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha adrenergic blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).
If partial response to monotherapy
Long-actingDHP CCB
Triple therapy
Thiazide diuretic
ARB
Dual combinationCombine first line agents
2007 Canadian Hypertension Education Program Recommendations 46
V. Summary: Treatment of Isolated Systolic Hypertension without Other Compelling Indications
CONSIDER
• Nonadherence?• Secondary HTN?• Interfering drugs or
lifestyle?• White coat effect?
Thiazide diuretic
Long-actingDHP CCB
Dual therapy
Triple therapy
Lifestyle modificationtherapy
ARB
TARGET <140 mmHg
*If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).
2007 Canadian Hypertension Education Program Recommendations 47
V. Choice of Pharmacological Treatment
1. Treatment of systolic-diastolic hypertension without other compelling indications
2. Treatment of isolated systolic hypertension without other compelling indications
2007 Canadian Hypertension Education Program Recommendations 48
Choice of Pharmacological Treatment for Hypertension
Individualized treatment
• 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
• Global Vascular Protection for Hypertensive Patients• Statins if 3 or more additional cardiovascular risks• Aspirin once blood pressure is controlled
2007 Canadian Hypertension Education Program Recommendations 49
VI. Treatment of Hypertension in Patients with Ischemic Heart Disease
• Caution should be exercised when combining a non DHP-CCB and a beta-blocker• If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or
Diltiazem)
1. Beta-blocker2. Long-acting CCBStable angina
ACE-I are recommended for most patients with established CAD*
Short-actingnifedipine
Those at low risk with well controlled risk factors may not benefit from ACEI therapy
2007 Canadian Hypertension Education Program Recommendations 50
VI. Treatment of Hypertension in Patients with Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI
Long-actingDHP CCB
(Amlodipine, Felodipine)
Beta-blocker and ACE-I
Recentmyocardialinfarction
Heart Failure
?
NO
YES
Long-acting CCB
If beta-blocker contraindicated or not effective
An ARB can be used if the patient is intolerant to ACE-I
2007 Canadian Hypertension Education Program Recommendations 51
VII. Treatment of Hypertension with Left Ventricular Systolic Dysfunction
Beta-blockers used in clinical trials were bisoprolol, carvedilol and metoprolol. Physicians who are not yet experienced in the use of beta-blockers should consider initiation of treatment in conjunction with a physician experienced in heart failure management particularly for NYHA Class III-IV patients
If additional therapy is needed:• Diuretic* • for CHF class III-IV: Aldosterone Antagonist
Systoliccardiac
dysfunction
• ACE-I• if ACE-I intolerant: ARB
If ACE-I and ARB are contraindicated: Hydralazine and Isosorbide dinitrate in combination
If additional antihypertensive therapy is needed: • ACE-I / ARB Combination • Long-acting DHP-CCB (Amlodipine or Felodipine)
Non dihydropyridine
CCB
and Beta-Blocker
2007 Canadian Hypertension Education Program Recommendations 52
VIII. Treatment of Hypertensionfor Patients with Cerebrovascular Disease
Strongly consider blood pressure reduction in all patients after the acute phase of non disabling stroke or TIA .
An ACE-I / diuretic combination is preferred
StrokeTIA
2007 Canadian Hypertension Education Program Recommendations 53
IX. Treatment of Hypertension in Patients with Left Ventricular Hypertrophy
Vasodilators:Hydralazine, Minoxidil can increase LVH
Left ventricularhypertrophy
Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events.
- ACE-I- ARB,- CCB- Thiazide Diuretic- BB (if age below 60)*
2007 Canadian Hypertension Education Program Recommendations 54
X. Treatment of Hypertension in Patients with Non Diabetic Chronic Kidney Disease
Chronic kidney disease and proteinuria *
ACE-I/ARB: Bilateral renal artery stenosis
1. ACE-I2. Alternate if ACE-I not tolerated: ARB
Combination with other agents
Additive therapy: Thiazide diuretic.Alternate: If volume overload: loop diuretic
Target BP: Nondiabetic: < 130/80 mmHg
* albumin:creatinine ratio [ACR] > 30 mg/mmol or urinary protein > 500 mg/24hr
Monitor potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
2007 Canadian Hypertension Education Program Recommendations 55
XI. Treatment of Hypertension in Patients with Renovascular Disease
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, or deteriorating renal function, or bilateral atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a single kidney), or recurrent episodes of flash pulmonary edema.
Does not imply specific treatment choice
Renovascular disease
Caution in the use of ACE-I/ARB in bilateral renal artery stenosis or unilateral disease with solitary kidney
2007 Canadian Hypertension Education Program Recommendations 57
XII. Treatment of Hypertension in association with Diabetes Mellitus
Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg
withNephropathy*
*Urinary albumin to creatinine ration > 2.0 mg/mmol in men or > 2.8mg/mmol in women or chronic kidney disease*
Diabetes
withoutNephropathy**
IsolatedSystolic
Hypertension
Systolic- diastolic
Hypertension
**Urinary albumin to creatinine ratio <2.0 mg/mmol in men or <2.8mg/mmol in women
* based on at least 2 of 3 measurements
2007 Canadian Hypertension Education Program Recommendations 58
XII. Treatment of Hypertension in association with Diabetic Nephropathy
THRESHOLD equal or over 130/80 mmHg and TARGET below 130/80 mmHg
If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired
DIABETESwith
Nephropathy
ACE Inhibitoror ARB
IF ACE-I and ARB are contraindicated or not tolerated, SUBSTITUTE• Long-acting CCB or• Thiazide diuretic
Addition of one or more ofThiazide diuretic orLong-acting CCB
3 - 4 drugs combination may be needed
Monitor potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
2007 Canadian Hypertension Education Program Recommendations 59
XII. Treatment of Systolic-Diastolic Hypertension without Diabetic Nephropathy
1. ACE-Inhibitor or ARB or
2. Thiazide diuretic or Dihydropyridine CCB
IF ACE-I and ARB and DHP-CCB or Thiazide are contraindicated or not tolerated, SUBSTITUTE• Cardioselective BB* or• Long-acting NON DHP-CCB
More than 3 drugs may be needed to reach target values for diabetic patients
* Cardioselective BB: Acebutolol, Atenolol, Bisoprolol , Metoprolol
Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg
Combination of first line agents
Addition of one or more of:Cardioselective BB orLong-acting CCB
Diabeteswithout
Nephropathy
DHP: dihydropyridine
2007 Canadian Hypertension Education Program Recommendations 60
XII. Treatment of Hypertension in association with Diabetes Mellitus: Summary
More than 3 drugs may be needed to reach target values for diabetic patients
If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired
Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg
Diabetes
withNephropathy
Combination(Effective
2-drug combination)
ACE Inhibitoror ARB
withoutNephropathy
1. ACE-Inhibitor or ARB
or
2. Thiazide diuretic or DHP-CCB
Monitor potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
2007 Canadian Hypertension Education Program Recommendations 61
The benefits of treating smokers with beta-blockersremain uncertain in the absence of a specific
indications like angina or post-MI
Smoking Beta-blocker
XIII. Treatment of Hypertension for Patients Who Use Tobacco
2007 Canadian Hypertension Education Program Recommendations 63
XIV. Vascular Protection for Hypertensive Patients: Statins
In addition to current Canadian recommendations on management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria:
• Male• Age 55 or older• Smoking• Type 2 Diabetes• Total-C/HDL-C ratio of 6
mmol/L or higher
• Family History of Premature CV disease
• LVH• ECG abnormalities• Microalbuminuria or
Proteinuria
ASCOT-LLA Lancet 2003;361:1149-58
2007 Canadian Hypertension Education Program Recommendations 64
XIV. Vascular Protection for Hypertensive Patients: ASA
Consider low dose ASA
Caution should be exercised if BP is not controlled.
2007 Canadian Hypertension Education Program Recommendations 65
Adherence to anti-hypertensive management can be improved by a multi-pronged approach
• Assess adherence to pharmacological and non-pharmacological therapy 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 fixed-dose combination pills • Utilize unit-of-use packaging e.g. blister
packaging
2007 Canadian Hypertension Education Program Recommendations 66
Adherence to anti-hypertensive management can be improved by a multi-pronged approach
• Encourage greater patient responsibility/autonomy in regular monitoring their blood pressure
• Educate patients and patients' families about their disease/treatment regimens verbally and in writing
2007 Canadian Hypertension Education Program Recommendations 67
Public translation of CHEP recommendations
Download at www.hypertension.ca
2007 Canadian Hypertension Education Program Recommendations 68
Useful patient information can be obtained in recent publications from the Canadian Hypertension Society.
Available by order from CHS SecretariatCanadian Hypertension Society
Tel: 613-533-3299, Fax: 613-533-6927
E mail: HYPERTENSION@QUEENSU.CA .
Coming soon to bookstores near you.
Educate patients and patients' families about their disease/treatment regimens verbally and in writing
2007 Canadian Hypertension Education Program Recommendations 69
Encourage greater patient responsibility/autonomy
2007 Canadian Hypertension Education Program Recommendations 70
Summary I
Regarding the treatment of hypertension, the recommendations endorse: • ASSESSMENT OF BLOOD PRESSURE AT ALL
APPROPRIATE VISITS• Most Canadians will develop hypertension during
their lives. Routine assessment of blood pressure is required for early detection and risk management
• ANNUAL FOLLOW-UP OF PATIENTS WITH HIGH NORMAL BLOOD PRESSURE
• Most overweight patients with high normal blood pressure (130-139/85-89 mmHg) will develop within 4 years and almost 1/2 within 2 years.
2007 Canadian Hypertension Education Program Recommendations 71
Summary II
Regarding the treatment of hypertension, the recommendations endorse:• INDIVIDUALIZING THERAPY
• consider concomitant risk factors and/or concurrent diseases, other patient characteristics and preferences (e.g. age, diabetes, CVD) and other considerations e.g. costs
• LIFESTYLE MODIFICATION• To prevent hypertension• In those with hypertension alone if effective to reach
the goal value or in combination with pharmacological treatment
2007 Canadian Hypertension Education Program Recommendations 72
Summary III
Regarding the treatment of hypertension, the recommendations endorse:
• TREATING TO TARGET BP • treat aggressively using combinations of drugs
and lifestyle modification to achieve individualized target
• PROMOTING ADHERENCE• a multi-faceted approach should be used to
improve adherence with both non pharmacological and pharmacological strategies
2007 Canadian Hypertension Education Program Recommendations 73
Assess blood pressure at all appropriate visits. Almost one half of those with blood pressure 130-139/85-89 will develop hypertension within 2 years. They require annual reassessment.Assess global cardiovascular risk in all hypertensive patients. Lifestyle modification is the cornerstone for the prevention and management of hypertension and CVD.
Key CHEP messages for the management of hypertension
2007 Canadian Hypertension Education Program Recommendations 74
Key CHEP messages for the management of hypertension
Treat to target (<140/90 mmHg; <130/80 mmHg in patients with diabetes or chronic kidney disease). To achieve targets sustained lifestyle modification and more than one drug is usually required.Follow patients with uncontrolled blood pressure at least monthly until blood pressure targets are achieved.Strategies to improve patient adherence to lifestyle modifications and antihypertensive therapy need to be incorporated in every patients management