CHEP

Whats New? Whats Still Really Important?

Canadian Recommendations for the Management of Hypertension

2013

Canadian Hypertension Education Program Programme ducatif Canadien sur lHypertension

Whats New, Whats Still Really Important?

Are you and your patients armed with the latest hypertension management resources? Sign up at www.hypertension.ca to be notified by email when new resources are developed or updated for you or your patients or to download current resources. Your patients can also sign up at www. hypertension.ca for 2013 annual membership where they will receive email notices of updated and new educational resources. Prevention and Attaining Treatment Targets are Key Prevention is a key goal. In this regard, healthcare professionals should continue to assess blood pressure at all appropriate visits. Lifestyle modifications to achieve a healthy lifestyle and optimize weight can lower blood pressure and prevent the development of hypertension. Healthcare providers are advised to encourage smoking cessation, physical activity, healthy diets and sodium restriction. In patients with documented hypertension, attaining blood pressure targets is vital to prevent cardiovascular and cerebrovascular complications. Therefore, a <140/90 mmHg blood pressure target should be attained in most hypertensive patients (other than those at very low risk of events). In persons with diabetes a blood pressure <130/80 mmHg is recommended. This can be done using lifestyle modification and, if necessary, medication. As a whole, all healthcare professionals should advocate for prevention of hypertension by modifying exposures to behavioural, environmental and societal risk factors. Continuously update your knowledge with educational resources for the prevention and control of hypertension and also by registering at www. hypertension.ca What is New in 2013?
The Effect of Resistance Training on Blood Pressure Hypertension Treatment Targets in the Very Elderly (Age 80 or Over)

In 2013, CHEP reviewed data examining resistance training in patients with normal and high blood pressure levels. Many feel that resistance training should be avoided for fear of increasing blood pressure levels and/or causing surges in blood pressure. However, the published literature indicates that, as long as recommended techniques are followed, no detrimental effect on blood pressure is observed. Resistance training may even be associated with a net reduction in blood pressure, but the data are not as yet definitive for hypertensive individuals. Therefore, CHEP recommends that resistance training not be avoided for fear of raising blood pressure levels.

In 2013, the CHEP Recommendations Task Force reviewed evidence examining hypertension treatment in the very elderly and initiated a <150 mmHg treatment target recommendation. Although many very elderly patients may potentially benefit from a lower (i.e., <140 mmHg) treatment target threshold, the Task Force felt that a <150 mmHg more directly reflected published evidence. Furthermore, there was concern that a lower threshold in frail elderly patients would result in treatment-related adverse effects. Practitioners are advised to tailor this recommendation to individual patients circumstances and preferences. Whats still really important in 2013? Key messages relating to the management of hypertension that continue to be important and relevant include: Lifestyle changes are a critical component of hypertension management and prevention The most important step in prescription of antihypertensive therapy is achieving patient buy-in Single pill combinations help achieve blood pressure control Global cardiovascular risk assessment and optimization is important in all hypertensive patients.

Measure Blood Pressure in All Adults at All Appropriate Visits

Elevated Out of the Office BP measurement Elevated Random Office BP measurement Hypertensive Urgency / Emergency Hypertension Visit 1 BP Measurement, History and Physical Diagnostic test ordering at visit 1 or 2

Hypertension Visit 2 within 1 month

BP 180/110 OR BP 140-179/90-109 with Target Organ Damage or Diabetes

YES

Diagnosis of HTN

NO
Home BPM = Home Blood Pressure Monitoring ABPM = Ambulatory Blood Pressure Monitoring

BP: 140-179 / 90-109 Clinic BPM Hypertension Visit 3 160 SBP or 100 DBP < 160/100 OR Diagnosis of HTN ABPM or Home BPM if available Diagnosis of HTN
Continue to follow-up

ABPM (If available) Awake BP <135/85 or 24-hour <130/80

Continue to follow-up

Home BPM (If available) OR <135/85

Repeat home BPM

Hypertension Visit 4-5 140 SBP or 90 DBP < 140/90

Awake BP 135 SBP or 85 DBP or 24-hour 130 SBP or 80 DBP

Diagnosis of HTN

135 SBP or 85 DBP

If <135/85
Continue to follow-up Diagnosis of HTN

If blood pressure is found to be high-normal (SBP 130-139 and or DBP 85-89), patients should be followed annually.

Treatment of Adults with Systolic/Diastolic Hypertension Without Compelling Indications for a Specific Agent
Target <140/90 mmHg Initial Treatment and Monotherapy
Lifestyle modification therapy

Thiazide

ACEI

ARB

Long-acting CCB

Beta-blocker*

A combination of two first-line drugs may be considered as initial therapy if the blood pressure is 20 mmHg systolic or 10 mmHg diastolic above target.
* Beta-blockers are not indicated as first line therapy for age 60 and above

ACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential

Combination Therapy
To achieve optimal blood pressure targets: Multiple drugs are often required to reach target levels, especially in patients with type 2 diabetes. Replace multiple antihypertensive agents with fixeddose combination therapy. Low doses of multiple drugs may be more effective and better tolerated than higher doses of fewer drugs. Reassess patients with uncontrolled blood pressure at least every 2 months. A combination of two first-line agents may also be considered as initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. The combination of ACE inhibitors and ARBs should not be used. In selected high-risk patients in whom combination therapy is being considered, an ACE inhibitor plus a long-acting dihydropyridine CCB is preferable to an ACE inhibitor plus a thiazide or thiazide-like diuretic.

Resistant Hypertension
Two-drug combinations of beta-blockers, ACE inhibitors and angiotensin receptor blockers have not been proven to have additive antihypertensive effect. These potential 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 proteinuric renal disease. Consider white coat hypertension, white coat effect and non-adherence. Monitor creatinine and potassium when combining potassium sparing diuretics, ACE inhibitors, angiotensin receptor blockers and/or direct renin inhibitors. If not used as first-line or second-line therapy, triple dose therapy should include a diuretic when not contraindicated. Consider referral to a hypertension specialist if blood pressure is still not controlled after treatment with 3 antihypertensive medications.

Routine Lab Testing

Preliminary Investigations of patients with hypertension 1. Urinalysis 2. Blood chemistry (potassium, sodium and creatinine) 3. Fasting glucose 4. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides 5. Standard 12-lead ECG Currently there is insufficient evidence, for or against, to recommend routine testing of microalbuminuria in patients with hypertension but without diabetes or renal disease. Follow-up investigations of patients with hypertension During the maintenance phase of hypertension management, tests (including electrolytes, creatinine, glucose, and fasting lipids) should be repeated with a frequency reflecting the clinical situation. Diabetes develops in 1-3% per year of those with drug-treated hypertension. The risk is higher in those with one or more of the following: treated with a diuretic or beta-blocker, impaired fasting glucose or impaired glucose tolerance, obesity (especially abdominal), dyslipidemia, sedentary lifestyle and poor dietary habits. Screen hypertensives with annual fasting plasma glucose testing and follow the screening recommendations. For diabetes management see: Can J Diabetes. 2008; 32(suppl 1):S1-S201

Lifestyle Recommendations for Prevention and Treatment of Hypertension

Objective
Being More Physically Active

Recommendation
An accumulation of 30-60 minutes of dynamic exercise of moderate intensity (such as walking, cycling, swimming) four to seven days per week in addition to the routine activities of daily living. Higher intensities of exercise are no more effective at BP lowering but may produce other cardiovascular benefits. For non-hypertensive or stage 1 hypertensive Individuals, the use of resistance or weight training exercise (such as free weight lifting, fixed weight lifting, or hand grip exercise) does not adversely influence BP. A healthy BMI (18.5 - 24.9 kg/m2) and waist circumference (<102 cm for men and <88 cm for women) is recommended for non-hypertensive individuals to prevent hypertension and for hypertensive patients to reduce BP. Limited consumption: 0-2 standard drinks/day Men: < 14 drinks/week Women: < 9 drinks/week DASH-like diet: High in fresh fruits, vegetables, dietary fibre, non-animal protein (e.g. soy) and low-fat dairy products. Low in saturated fat and cholesterol. Reduce dietary sodium to 1500 mg/day in adults age 50 and under, to 1300 mg/day in adults age 51 to 70 and to 1200 mg/day in adults older than 70 years. Individualized cognitive behavior interventions are more likely to be effective when relaxation techniques are employed. Abstinence from smoking. A smoke-free environment.

Comment
Should be prescribed to both hypertensive and normotensive individuals for prevention and management of hypertension.

Estimated BP Reduction
-4.9/-3.7 mmHg

Weight Reduction Moderation in Alcohol Intake Eating Healthier and Reducing Sodium Intake Reducing Stress Smoking Cessation

Encourage multidisciplinary approach to weight loss, including dietary education, increased physical activity and behavior modification. Should be prescribed to both hypertensive and normotensive individuals for prevention and management of hypertension Should be prescribed to both hypertensive and normotensive individuals for prevention/ management of hypertension.

-7.2/-5.9 mmHg for every 4.5 kg weight loss -3.9/-2.4 mmHg

-11.4 / -5.5 mmHg for hypertensive patients on the DASH diet -5.1/-2.7 mmHg with a 1800 mg/d sodium reduction

For selected patients in whom stress plays a role in elevating BP. A global cardiovascular risk reduction strategy.

-6.1/-4.3 mmHg n/a

Hypertension Care Pearls

Interprofessional team care Involvement of an interprofessional team improves adherence Lifestyle changes are important to make Frequent brief interventions double the rate of lifestyle changes All hypertensives require lifestyle assessment and ongoing support to initiate and maintain lifestyle changes 50% of hypertensives < 45 years old are not treated with antihypertensives, even if they have multiple cardiovascular risks Start pharmacotherapy for hypertensives with multiple cardiovascular risks factors immediately, in addition to lifestyle changes In particular, reduce risk factors in smokers who cannot quit Combination therapy of ACE inhibitor with ARB Reassess all patients on this combination Consider other combinations Should only be considered in selected and closely monitored patients with advanced heart failure, or severe proteinuric nephropathy

Hypertension Internet Resources

The web page below shows the initial assessment screen of The Heart and Stroke Foundations online consumer education tool My Heart&Stroke Blood Pressure Action Plan. It will help educate your patients about the importance of managing their blood pressure and provide ways to help them do so.
Hypertension Canada www.hypertension.ca Complete Canadian Hypertension Education Program (CHEP) recommendations and slide decks Sign up now for regular Hypertension Canada resource updates Patient and HCP Resources Instructions for purchasing and using home blood pressure measurement devices Have your patients sign up to access the latest hypertension resources Heart and Stroke Foundation, My Heart&Stroke Blood Pressure Action Plan www.heartandstroke.ca/BP My Heart&Stroke Blood Pressure Action Plan Canadian Diabetes Association www.diabetes.ca 2013 Clinical Practice Guidelines Canadian Stroke Network www.sodium101.ca Patient and HCP resource on dietary sodium Public Health Agency of Canada www.PHAC-ASPC.gc.ca Resources on hypertension and chronic disease prevention and management Canadian Cardiovascular Society

www.ccsguidelineprograms.ca Clinical practice guidelines for dyslipidemia, atrial fibrilliation, heart failure and many www.heartandstroke.ca cardiovascular illnesses General lifestyle change information

Considerations in the Individualization of Antihypertensive Therapy

Initial Therapy
Diastolic +/- Systolic Hypertension (target BP <140/90 mmHg) Thiazide diuretics, beta-blockers, ACE inhibitors, ARBs, or long-acting calcium channel blockers (consider ASA and statins in selected patients). Consider initiating therapy with a combination of first-line drugs if the blood pressure is 20 mmHg systolic or 10 mmHg diastolic above target. Thiazide diuretics, ARBs or long-acting dihydropyridine calcium channel blockers

Second-line Therapy
Combinations of first-line drugs

Notes and/or Cautions

Not recommended for monotherapy: Alpha blockers, Beta-blockers in those > 60 years of age, ACE inhibitors in blacks. Hypokalemia should be avoided in those prescribed diuretics monotherapy. ACE inhibitors, ARBs and direct renin inhibitors are potential teratogens, and caution is required if prescribing to women of child-bearing potential. Combination of an ACE inhibitor with an ARB is not recommended. Same as diastolic +/- systolic hypertension

Hypertension Without Other Compelling Indications for a Specific Agent

Isolated systolic hypertension without other compelling indications (target BP for age <80 is <140/90 mmHg; for age 80, the target SBP is <150 mmHg) Diabetes mellitus with microalbuminuria*, cardiovascular disease, renal disease or additional cardiovascular risk factors Diabetes mellitus not included in the above category

Combinations of first-line drugs

Diabetes Mellitus Target <130/80 mmHg

ACE inhibitors or ARBs Addition of dihydropyridine CCB is preferred over thiazide A loop diuretic could be considered in hypertensive CKD patients with extracellular fluid volume overload

ACE inhibitors, ARBs, dihydropyridine CCBs or thiazide diuretics

Combination of first-line drugs. If combination with ACE inhibitor is being considered, a dihydropyridine CCB is preferable to thiazide diuretic.

Normal albumin to creatinine ratio [ACR] <2.0 mg/mmol in men and <2.8 mg/mmol in women Combination of an ACE inhibitor with an ARB is specifically not recommended

Initial Therapy Cardiovascular Disease Target <140/90 mmHg

Coronary artery disease** ACE inhibitors or ARBs (except in low-risk patients); beta blockers for patients with stable angina Beta-blockers and ACE inhibitors (ARBs if ACE inhibitor intolerant) ACE inhibitors (ARBs if ACE inhibitorintolerant) and beta-blockers. Aldosterone antagonists (mineralocorticoid receptor antagonists) may be added for patients with a recent cardiovascular hospitalization, acute myocardial infarction, elevated BNP or NT-proBNP level, or NYHA Class II to IV symptoms. ACE inhibitor, ARB, long acting CCB or thiazide diuretics. ACE inhibitor/diuretic combinations

Second-line Therapy
Long-acting CCBs. When combination therapy is being used for high risk patients, an ACE inhibitor/ dihydropyridine CCB is preferred Long-acting CCBs if beta blocker contraindicated or not effective ACE inhibitor and ARB combined. Hydralazine/ isosorbide dinitrate combination if ACE inhibitor and ARB contraindicated or not tolerated. Thiazide or loop diuretics are recommended as additive therapy. Dihydropyridine CCB. Combination of additional agents Combinations of additional agents

Notes and/or Cautions

Avoid short-acting nifedipine. Combination of an ACE inhibitor with an ARB is specifically not recommended Non-dihydropyridine CCBs should not be used with concomitant heart failure. Titrate doses of ACE inhibitors and ARBs to those used in clinical trials. Carefully monitor potassium and renal function if combining an ACE inhibitor, ARB and/or aldosterone antagonist.

Recent myocardial infarction Heart failure

Left ventricular hypertrophy Past stroke or TIA

Hydralazine and minoxidil should not be used. Treatment of hypertension should not be routinely undertaken in acute stroke unless extreme BP elevation. Combination of an ACEinhibitor with an ARB is not recommended.

Non-diabetic chronic kidney disease Target <140/90 mmHg

Non-diabetic chronic kidney disease with proteinuria Renovascular disease ACE inhibitors (ARBs if ACEI- intolerant) if there is proteinuria Does not affect initial treatment recommendations Combinations of additional agents. Carefully monitor renal function and potassium for those on an ACE inhibitor or ARB. Combinations of an ACE-inhibitor and ARB are not recommended in patients without proteinuria. Avoid ACE inhibitors or ARB if bilateral renal artery stenosis or unilateral disease with solitary kidney

Combinations of additional agents

Considerations in the Individualization of Antihypertensive Therapy*

Initial Therapy Other Conditions Target <140/90 mmHg
Peripheral arterial disease Dyslipidemia Overall vascular protection Does not affect initial treatment recommendations Does not affect initial treatment recommendations Statin therapy for people with 3 or more cardiovascular risk factors or with atherosclerotic disease Low dose ASA in people with controlled blood pressure Combinations of additional agents Combinations of additional agents Avoid beta-blockers with severe disease

(continued)

Second-line Therapy

Notes and/or Cautions

Caution should be exercised with the ASA recommendation if blood pressure is not controlled

*  Albuminuria is defined as persistent albumin to creatinine ratio [ACR] >2.0 mg/mmol in men and >2.8 mg/mmol in women. P  roteinuria is defined as urinary protein >500 mg/24hr or albumin to creatinine ratio [ACR] >30 mg/mmol. ACE Angiotensin-converting enzyme; ARB Angiotensin receptor blocker; ASA Acetylsalicylic acid; CCB Calcium channel blocker; NYHA New York Heart Association; TIA Transient ischemic attack. ** t he accumulated weight of placebo-controlled trial evidence supports the provision of ACE inhibitor therapy for this indication.

Diagnostic Thresholds for Hypertension

Setting
Home: Office:

Location or Condition
Home blood pressure and daytime ABPM* Diastolic systolic hypertension Isolated systolic hypertension Diabetes Non-DM Chronic kidney disease

Target

(SBP/DBP mmHg)

<135/85 <140/90 <140 <130/80 <140/90

Interventions That Can Help Improve Medication Adherence

Adherence can be improved by a multi-pronged approach:

1) At every visit, assist your patient to adhere using a multi-pronged approach Tailor and simplify pill-taking to fit your patients daily habits. For example, consider using a fixed dose combination or blister packaging (of several medications to be taken together). 2) Assist your patient in getting more involved in his/her treatment Encourage greater responsibility/autonomy in monitoring his/her blood pressure and reporting the results, so you may adjust his/her prescriptions as needed

3) Improve your management in the office and beyond a) Educate your patient and his/her family about hypertension and its treatment b) Inform your patient of their global risk to improve the effectiveness of risk factor modification using vascular or cardiovascular age c) Adherence to an antihypertensive prescription can be improved by an interprofessional team approach, including working collaboratively with a pharmacist

The Role of Sodium

13%

of CV events in Canada are attributed to excess dietary sodium.

Beyond the Salt Shaker: Key Messages for Healthcare Professionals 1. Dietary sodium is an important contributor to high blood pressure. 2. Canadian sodium intake is well above recommended levels. 3. Lowering sodium intake is good for public health. 4. Processed foods are our main source of dietary sodium. 5. Healthcare professionals can play a key role. Guidelines for sodium intake

Age

Adequate Intake (mg)

19-50 51-70 71 and over

1500 1300 1200

Sign up at www.hypertension.ca to be notified by email when new resources are developed or updated for you and your patients. Download current resources at www.hypertension.ca/resources. This website will also post opportunities to be trained as a hypertension community leader. Your patients can also sign up at www.hypertension.ca for a 2013 annual membership. They will receive email notices of updated and new educational resources, a regular newsletter and lectures.

CANADA

Hypertension

How to Manage Your Blood Pressure

What is high blood pressure? Your heart pumps blood around your body. Blood pressure is the force of blood against your blood vessels as it circulates through your body. This force is necessary to make the blood flow, delivering nutrients and oxygen throughout your body. However, high blood pressure, also called hypertension, means there is too much pressure in your arteries. This can damage your arteries and cause health problems. Hypertension is defined as blood pressure that is consistently above the normal range. Anyone can develop high blood pressure, but it becomes more common as you get older and requires even more aggressive management if you also have been diagnosed with diabetes. Once high blood pressure develops, it usually lasts for life unless lifestyle changes are made, and medications taken consistently if prescribed. High blood pressure is one of the leading health problems in Canada. It causes strokes, heart attacks, heart failure and kidney failure. It is also related to dementia and sexual problems. Finding and treating high blood pressure early helps prevent these problems. How is it measured? We describe blood pressure with two numbers (e.g. 124/84 millimetres of mercury). Millimetres of mercury is a standardized measurement of pressure. The first number is called the systolic pressure and the second is called the diastolic pressure. Systolic pressure occurs when your heart contracts and is the higher of the two numbers. Diastolic pressure is the lower number and it occurs when your heart relaxes and fills with blood. The higher your systolic or diastolic pressure, and the longer it stays high, the more damage there is to your blood vessels.

Should I monitor my blood pressure? Whether or not you have high blood pressure, it is important to have your blood pressure checked regularly. Nine out of 10 Canadians will develop high blood pressure during their lifetime. High blood pressure has no warning signs or symptoms which is why it is often called a silent killer. Have your blood pressure checked at least once every two years by a health care provider or more often if your blood pressure is high. You can also check your blood pressure at home. If home blood pressure readings are done properly they may reflect your usual pressure more than those done in the doctors office. Regular blood pressure checks help make sure that high blood Hypertension pressure is diagnosed and controlled before it leads CANADA to serious health problems.

Hypertension in Diabetes
Should you monitor your blood pressure?
Whether or not you have high blood pressure, it is important to have your blood pressure checked regularly. Nine out of 10 Canadians will develop hypertension during their lifetime. High blood pressure has no warning signs or symptoms which is why it is often called a silent killer. People with diabetes are twice as likely to develop high blood pressure as those without diabetes. Have your blood pressure checked at every visit by a health care provider. You should also monitor your blood pressure more often at home. If home blood pressure readings are done properly they may reflect your true pressure more than those done in the doctors office. Regular monitoring helps ensure that high blood pressure is diagnosed and controlled before it leads to serious health problems. Know what your blood pressure is and remember that both numbers are important. If either the systolic or diastolic number is usually high, you probably have high blood pressure.

High Blood Pressure and Diabetes

Your heart pumps blood around your body giving it oxygen and nutrients. Blood pressure is the force that pushes blood through your blood vessels. When blood pressure is too high it is called hypertension. The high pressure damages the arteries causing health problems. Having diabetes increases your risk of having high blood pressure, heart disease and stroke. Hypertension also Know what your blood pressure is and remember that increases the risk many complications of diabetes, both numbers are important. If either the of systolic or such as high, diabetic eye disease you need to and kidney disease. Most diastolic number is consistently people withmay diabetes also have high blood pressure. make changes in your lifestyle.You need further Increased blood pressure represents a major health risk blood pressure checks and drug treatment. Blood to people with diabetesat home pressure of 135/85 mmHg or more measured or 140/90 mmHg or higher measured in a doctors Having diabetes increases your risk of developing high office is considered high. blood pressure and other cardiovascular problems, because diabetes leads to hardening of your arteries. Two thirds of Canadians with hypertension and diabetes have uncontrolled blood pressure. Finding high blood pressure early, treating and keeping it in the normal range can reduce your risk of developing many Canadian Hypertension Education Program complications of diabetes.

CHEP

How is blood pressure measured?

We measure blood pressure with two numbers (e.g. 124/79 mmHg). The first number is called the systolic pressure and the second is called the diastolic pressure. Systolic pressure is your highest blood pressure measurement. It occurs when your heart contracts. Diastolic pressure is your lowest measurement, and it occurs when your heart relaxes and fills with blood. The higher your systolic or diastolic pressure, and the longer it stays high, the more damage to your blood vessels.

Hypertension recommendations designed for the public have been developed. Bulk orders of 25 or more copies can be ordered at www.hypertension.ca/resources. Hypertension recommendations for patients with diabetes are also available. These summaries are available electronically at www.hypertension.ca.

Canadian Hypertension Education Program

CHEP

For an internet-based, interactive tool to optimize self-management and track home blood pressure measurement and lifestyle change, visit www.heartandstroke.ca/bp.

2013 Key Messages

All Canadian adults should have their blood pressure assessed at all appropriate clinical visits. Optimum management of BP requires assessment of overall cardiovascular risk. Home BP monitoring is an important tool in self-monitoring and self-management. Treat to target. Lifestyle modifications are effective in preventing hypertension, treating hypertension and reducing cardiovascular risk. Combinations of both lifestyle changes and drugs are generally necessary to achieve target blood pressures. Focus on adherence.
For the complete version of the 2013 CHEP Recommendations please refer to our website at www.hypertension.ca This booklet was developed by Luc Poirier and Raj Padwal with the CHEP Executive. This booklet is published by Hypertension Canada and the Canadian Hypertension Education Program as a professional service, with unrestricted support from Forest Laboratories Canada Inc.
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