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”

CHEP 2015 Recommendations

2015

Population SBP > DBP >

Diabetes 130 80High risk (TOD or CV risk factors) 140 90Low 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 andheightened 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 80All 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 pressureif diastolic blood pressures are < 60mmHg

2015

What’s still important?• Know the BP threshold and treat to the 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”

CHEP 2015 Recommendations

2015

Impact of health behaviour managementon 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/weekDietary patterns DASH diet

Smoking cessation Smoke free environment

Waist circumference Men <102 cm Women <88 cm

2015

What’s still important?• Know the BP threshold and treat to the 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”

CHEP 2015 Recommendations

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

CHEP 2015 Recommendations

What’s new? • Monitor blood pressures in clinic using an electronic (oscillometric)

device• 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

Criteria for the diagnosis of hypertension and recommendations for follow-up: overview

Measurement using electronic (oscillometric) upper arm devices is preferred over auscultationABPM: Ambulatory Blood Pressure MeasurementAOBP: Automated Office Blood PressureHBPM: Home Blood Pressure measurementOBPM: 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

BP measurement methods

Office (attended, OBPM)Auscultatory (mercury, aneroid) Oscillometric (electronic)

http://www.dableducational.org/sphygmomanometers.htmlhttp://www.bhsoc.org/bp-monitors/bp-monitors/

2015

BP measurement methods

Office Automated (unattended, AOBP) Oscillometric (electronic)

http://www.dableducational.org/sphygmomanometers.html

http://www.bhsoc.org/bp-monitors/bp-monitors/

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)

http://www.dableducational.org/sphygmomanometers.htmlhttp://www.bhsoc.org/bp-monitors/bp-monitors/

2015

Out of office BP measurement methods:Home (HBPM)

http://www.dableducational.org/sphygmomanometers.htmlhttp://www.bhsoc.org/bp-monitors/bp-monitors/

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

Ambu

lato

ry B

P m

mHg True

Hypertension

Normotension White Coat Hypertension

Masked Hypertension

200

180

160

140

120

100100 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

Normal23/685

White coat24/656

Uncontrolled41/462

Masked236/3125

CV e

vent

s per

100

0 pa

tient

-yea

r

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;62:982-7Lovibond 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;29:1880-88Barochiner 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 auscultationABPM: Ambulatory Blood Pressure MeasurementAOBP: Automated Office Blood PressureHBPM: Home Blood Pressure measurementOBPM: Office Blood Pressure measurement

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

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 riskGee 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

20152015

Effect of advice on smoking cessation rates

Cochrane Database Syst Rev. 2013 May 31;5:CD000165. doi: 10.1002/14651858.CD000165.pub4

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 2014Kate 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

CHEP 2015 RecommendationsWhat’s new? • Clinic blood pressures should be 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 supporting smoking cessation

• Treatment of atherosclerotic renal artery stenosis is primarily 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

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 the target• Adopting health behaviours is integral to the

management of hypertension• The most important step in prescription of

antihypertensive therapy is achieving patient “buy-in”

CHEP 2015 Recommendations

2015

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