CHEP

What’s New? What’s Still Really Important?

Canadian Recommendations for the Management of Hypertension

2013

Canadian Hypertension Education Program Programme Éducatif Canadien sur l’Hypertension

What’s Still Really Important? Are you and your patients armed with the latest hypertension management resources? Sign up at www. This can be done using lifestyle modification and. Prevention and Attaining Treatment Targets are Key Prevention is a key goal.. healthy diets and sodium restriction. there was concern that a lower threshold in frail elderly patients would result in treatment-related adverse effects.What’s New. 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. environmental and societal risk factors. the published literature indicates that. but the data are not as yet definitive for hypertensive individuals.ca for 2013 annual membership where they will receive email notices of updated and new educational resources. no detrimental effect on blood pressure is observed. Resistance training may even be associated with a net reduction in blood pressure. healthcare professionals should continue to assess blood pressure at all appropriate visits. Although many very elderly patients may potentially benefit from a lower (i. the CHEP Recommendations Task Force reviewed evidence examining hypertension treatment in the very elderly and initiated a <150 mmHg treatment target recommendation. What’s 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. all healthcare professionals should advocate for prevention of hypertension by modifying exposures to behavioural. Therefore. 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).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. Therefore. However. CHEP recommends that resistance training not be avoided for fear of raising blood pressure levels. In this regard. Many feel that resistance training should be avoided for fear of increasing blood pressure levels and/or causing surges in blood pressure.e. Your patients can also sign up at www. if necessary. patients should be followed annually. a <140/90 mmHg blood pressure target should be attained in most hypertensive patients (other than those at very low risk of events). As a whole. physical activity. <140 mmHg) treatment target threshold. Practitioners are advised to tailor this recommendation to individual patients’ circumstances and preferences. Healthcare providers are advised to encourage smoking cessation. Lifestyle modifications to achieve a healthy lifestyle and optimize weight can lower blood pressure and prevent the development of hypertension. . medication. In 2013.ca to be notified by email when new resources are developed or updated for you or your patients or to download current resources. CHEP reviewed data examining resistance training in patients with normal and high blood pressure levels. attaining blood pressure targets is vital to prevent cardiovascular and cerebrovascular complications. hypertension. the Task Force felt that a <150 mmHg more directly reflected published evidence. as long as recommended techniques are followed.hypertension. In persons with diabetes a blood pressure <130/80 mmHg is recommended. Furthermore. In patients with documented hypertension. Continuously update your knowledge with educational resources for the prevention and control of hypertension and also by registering at www. hypertension.

• Low doses of multiple drugs may be more effective and better tolerated than higher doses of fewer drugs. • Monitor creatinine and potassium when combining potassium sparing diuretics. • Replace multiple antihypertensive agents with fixeddose combination therapy. • The combination of ACE inhibitors and ARBs should not be used. Resistant Hypertension • Two-drug combinations of beta-blockers. an ACE inhibitor plus a long-acting dihydropyridine CCB is preferable to an ACE inhibitor plus a thiazide or thiazide-like diuretic. • If not used as first-line or second-line therapy. • In selected high-risk patients in whom combination therapy is being considered. post myocardial infarction. angiotensin receptor blockers and/or direct renin inhibitors. white coat effect and non-adherence. • 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. These potential drug combinations should not be used unless there is a compelling (non-blood pressure lowering) indication such as ischemic heart disease. especially in patients with type 2 diabetes. triple dose therapy should include a diuretic when not contraindicated. . 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.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. congestive heart failure or proteinuric renal disease. ACE inhibitors. • Reassess patients with uncontrolled blood pressure at least every 2 months. • Consider referral to a hypertension specialist if blood pressure is still not controlled after treatment with 3 antihypertensive medications. * Beta-blockers are not indicated as first line therapy for age 60 and above ACEI. ACE inhibitors and angiotensin receptor blockers have not been proven to have additive antihypertensive effect. • Consider white coat hypertension.

A global cardiovascular risk reduction strategy.5 kg weight loss -3. Standard 12-lead ECG Currently there is insufficient evidence. A smoke-free environment. for or against. glucose. tests (including electrolytes. triglycerides 5. • Reduce dietary sodium to 1500 mg/day in adults age 50 and under. to recommend routine testing of microalbuminuria in patients with hypertension but without diabetes or renal disease.1/-4. Urinalysis 2.7 mmHg with a 1800 mg/d sodium reduction For selected patients in whom stress plays a role in elevating BP. -7.24. Estimated BP Reduction -4. Abstinence from smoking. increased physical activity and behavior modification. and fasting lipids) should be repeated with a frequency reflecting the clinical situation. non-animal protein (e. 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. Follow-up investigations of patients with hypertension During the maintenance phase of hypertension management. sedentary lifestyle and poor dietary habits. Limited consumption: 0-2 standard drinks/day Men: < 14 drinks/week Women: < 9 drinks/week DASH-like diet: • High in fresh fruits. Comment Should be prescribed to both hypertensive and normotensive individuals for prevention and management of hypertension. Screen hypertensives with annual fasting plasma glucose testing and follow the screening recommendations. including dietary education.9/-3. soy) and low-fat dairy products.2/-5. the use of resistance or weight training exercise (such as free weight lifting. swimming) four to seven days per week in addition to the routine activities of daily living.4 mmHg -11.9 mmHg for every 4. to 1300 mg/day in adults age 51 to 70 and to 1200 mg/day in adults older than 70 years. impaired fasting glucose or impaired glucose tolerance. dyslipidemia.5 . 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. 2008. creatinine. dietary fibre. Diabetes develops in 1-3% per year of those with drug-treated hypertension. Fasting glucose 4. or hand grip exercise) does not adversely influence BP.g. fixed weight lifting. For diabetes management see: Can J Diabetes.5 mmHg for hypertensive patients on the DASH diet -5.7 mmHg Weight Reduction Moderation in Alcohol Intake Eating Healthier and Reducing Sodium Intake Reducing Stress Smoking Cessation Encourage multidisciplinary approach to weight loss. sodium and creatinine) 3. Higher intensities of exercise are no more effective at BP lowering but may produce other cardiovascular benefits. Fasting total cholesterol and high density lipoprotein cholesterol (HDL).3 mmHg n/a . Individualized cognitive behavior interventions are more likely to be effective when relaxation techniques are employed.Routine Lab Testing Preliminary Investigations of patients with hypertension 1.9 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. A healthy BMI (18. For non-hypertensive or stage 1 hypertensive Individuals. The risk is higher in those with one or more of the following: treated with a diuretic or beta-blocker. low density lipoprotein cholesterol (LDL). cycling.9/-2.1/-2. obesity (especially abdominal). vegetables. Blood chemistry (potassium.4 / -5. -6. Low in saturated fat and cholesterol.

ca • Clinical practice guidelines for dyslipidemia. even if they have multiple cardiovascular risks • Start pharmacotherapy for hypertensives with multiple cardiovascular risks factors immediately. Hypertension Canada www. It will help educate your patients about the importance of managing their blood pressure and provide ways to help them do so.ccsguidelineprograms.ca/BP • My Heart&Stroke Blood Pressure Action Plan™ Canadian Diabetes Association www.heartandstroke. or severe proteinuric nephropathy Hypertension Internet Resources The web page below shows the initial assessment screen of The Heart and Stroke Foundation’s online consumer education tool – My Heart&Stroke Blood Pressure Action Plan™.ca • Resources on hypertension and chronic disease prevention and management Canadian Cardiovascular Society www. 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.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.PHAC-ASPC.sodium101.ca • Patient and HCP resource on dietary sodium Public Health Agency of Canada www.gc. atrial fibrilliation.diabetes.ca cardiovascular illnesses • General lifestyle change information . in addition to lifestyle changes • In particular.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.hypertension. My Heart&Stroke Blood Pressure Action Plan™ www.ca • 2013 Clinical Practice Guidelines Canadian Stroke Network www. heart failure and many www.heartandstroke.

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. Consider initiating therapy with a combination of first-line drugs if the blood pressure is ≥20 mmHg systolic or ≥10 mmHg diastolic above target. ARB and/or aldosterone antagonist. Combination of an ACEinhibitor with an ARB is not recommended. dihydropyridine CCBs or thiazide diuretics Combination of first-line drugs. Combinations of an ACE-inhibitor and ARB are not recommended in patients without proteinuria. ACE inhibitor/diuretic combinations Second-line Therapy Long-acting CCBs. Titrate doses of ACE inhibitors and ARBs to those used in clinical trials. ACE inhibitor. acute myocardial infarction. Hydralazine/ isosorbide dinitrate combination if ACE inhibitor and ARB contraindicated or not tolerated. Normal albumin to creatinine ratio [ACR] <2. If combination with ACE inhibitor is being considered. Combination of additional agents Combinations of additional agents Notes and/or Cautions Avoid short-acting nifedipine. ARBs. ARB. long acting CCB or thiazide diuretics.Systolic Hypertension (target BP <140/90 mmHg) Thiazide diuretics. Recent myocardial infarction Heart failure Left ventricular hypertrophy Past stroke or TIA Hydralazine and minoxidil should not be used.Considerations in the Individualization of Antihypertensive Therapy Initial Therapy Diastolic +/. Dihydropyridine CCB. or long-acting calcium channel blockers (consider ASA and statins in selected patients). a dihydropyridine CCB is preferable to thiazide diuretic. ACE inhibitors.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. Combination of an ACE inhibitor with an ARB is specifically not recommended Non-dihydropyridine CCBs should not be used with concomitant heart failure. Combination of an ACE inhibitor with an ARB is not recommended. Same as diastolic +/. 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. Thiazide diuretics. or NYHA Class II to IV symptoms. elevated BNP or NT-proBNP level. and caution is required if prescribing to women of child-bearing potential. an ACE inhibitor/ dihydropyridine CCB is preferred Long-acting CCBs if beta blocker contraindicated or not effective ACE inhibitor and ARB combined. Carefully monitor potassium and renal function if combining an ACE inhibitor. Treatment of hypertension should not be routinely undertaken in acute stroke unless extreme BP elevation. ARBs. beta-blockers. Carefully monitor renal function and potassium for those on an ACE inhibitor or ARB.0 mg/mmol in men and <2.intolerant) if there is proteinuria Does not affect initial treatment recommendations Combinations of additional agents. When combination therapy is being used for high risk patients. for age ≥80. ARBs and direct renin inhibitors are potential teratogens. 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. ACE inhibitors. the target SBP is <150 mmHg) Diabetes mellitus with microalbuminuria*. Hypokalemia should be avoided in those prescribed diuretics monotherapy. ACE inhibitors in blacks. Non-diabetic chronic kidney disease — Target <140/90 mmHg Non-diabetic chronic kidney disease with proteinuria† Renovascular disease ACE inhibitors (ARBs if ACEI. Aldosterone antagonists (mineralocorticoid receptor antagonists) may be added for patients with a recent cardiovascular hospitalization. cardiovascular disease. Thiazide or loop diuretics are recommended as additive therapy.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). Avoid ACE inhibitors or ARB if bilateral renal artery stenosis or unilateral disease with solitary kidney Combinations of additional agents . Beta-blockers in those > 60 years of age.

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. TIA Transient ischemic attack. assist your patient to adhere using a multi-pronged approach Tailor and simplify pill-taking to fit your patient’s daily habits. NYHA New York Heart Association. ** t he accumulated weight of placebo-controlled trial evidence supports the provision of ACE inhibitor therapy for this indication.0 mg/mmol in men and >2. For example. consider using a fixed dose combination or blister packaging (of several medications to be taken together). 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. ARB Angiotensin receptor blocker.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. CCB Calcium channel blocker. including working collaboratively with a pharmacist . ASA Acetylsalicylic acid. 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. 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.

This can damage your arteries and cause health problems. the more damage there is to your blood vessels. Hypertension recommendations designed for the public have been developed.ca. heart failure and kidney failure. It is also related to dementia and sexual problems. 124/79 mmHg). If home blood pressure readings are done properly they may reflect your true pressure more than those done in the doctor’s office. the more damage to your blood vessels.ca for a 2013 annual membership. Blood to people with diabetesat home pressure of 135/85 mmHg or more measured or 140/90 mmHg or higher measured in a doctor’s Having diabetes increases your risk of developing high office is considered high. heart disease and stroke. treating and keeping it in the normal range can reduce your risk of developing many Canadian Hypertension Education Program complications of diabetes. and it occurs when your heart relaxes and fills with blood. high blood pressure. 5. 4. It causes strokes. Hypertension recommendations for patients with diabetes are also available. The high pressure damages the arteries causing health problems. These summaries are available electronically at www. They will receive email notices of updated and new educational resources. The higher your systolic or diastolic pressure. Know what your blood pressure is and remember that both numbers are important. Hypertension also Know what your blood pressure is and remember that increases the risk many complications of diabetes. and medications taken consistently if prescribed. If either the of systolic or such as high. Dietary sodium is an important contributor to high blood pressure.g. and the longer it stays high. The first number is called the systolic pressure and the second is called the diastolic pressure. and the longer it stays high. visit www. 3. 2. Blood pressure is the force of blood against your blood vessels as it circulates through your body.ca/resources.hypertension. High Blood Pressure and Diabetes Your heart pumps blood around your body giving it oxygen and nutrients. 124/84 millimetres of mercury).hypertension. Regular monitoring helps ensure that high blood pressure is diagnosed and controlled before it leads to serious health problems. means there is too much pressure in your arteries. Nine out of 10 Canadians will develop hypertension during their lifetime. This force is necessary to make the blood flow.hypertension. it is important to have your blood pressure checked regularly. High blood pressure has no warning signs or symptoms – which is why it is often called a ‘silent killer. High blood pressure is one of the leading health problems in Canada.ca/resources. Systolic pressure occurs when your heart contracts and is the higher of the two numbers. Systolic pressure is your highest blood pressure measurement. both numbers are important. Once high blood pressure develops. This website will also post opportunities to be trained as a hypertension community leader. Two thirds of Canadians with hypertension and diabetes have uncontrolled blood pressure. You can also check your blood pressure at home. Have your blood pressure checked at every visit by a health care provider. but it becomes more common as you get older and requires even more aggressive management if you also have been diagnosed with diabetes. Finding high blood pressure early. blood pressure and other cardiovascular problems. Lowering sodium intake is good for public health. . 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. How is it measured? We describe blood pressure with two numbers (e. If either the systolic or diastolic number is usually high.The Role of Sodium 13% of CV events in Canada are attributed to excess dietary sodium.You need further Increased blood pressure represents a major health risk blood pressure checks and drug treatment. because diabetes leads to hardening of your arteries. interactive tool to optimize self-management and track home blood pressure measurement and lifestyle change. heart attacks. Hypertension is defined as blood pressure that is consistently above the normal range. Guidelines for sodium intake Age Adequate Intake (mg) 19-50 51-70 71 and over 1500 1300 1200 Sign up at www. also called hypertension. Canadian sodium intake is well above recommended levels. However. Blood pressure is the force that pushes blood through your blood vessels. Most diastolic number is consistently people withmay diabetes also have high blood pressure. Canadian Hypertension Education Program CHEP For an internet-based. Bulk orders of 25 or more copies can be ordered at www. make changes in your lifestyle.ca to be notified by email when new resources are developed or updated for you and your patients. You should also monitor your blood pressure more often at home. Hypertension in Diabetes Should you monitor your blood pressure? Whether or not you have high blood pressure. The higher your systolic or diastolic pressure.hypertension. When blood pressure is too high it is called hypertension. delivering nutrients and oxygen throughout your body. CHEP How is blood pressure measured? We measure blood pressure with two numbers (e. CANADA Hypertension How to Manage Your Blood Pressure What is high blood pressure? Your heart pumps blood around your body. Having diabetes increases your risk of having high blood pressure. If home blood pressure readings are done properly they may reflect your usual pressure more than those done in the doctor’s office. diabetic eye disease you need to and kidney disease.heartandstroke. it usually lasts for life unless lifestyle changes are made. Download current resources at www.hypertension. you probably have high blood pressure. Diastolic pressure is the lower number and it occurs when your heart relaxes and fills with blood. it is important to have your blood pressure checked regularly. Should I monitor my blood pressure? Whether or not you have high blood pressure.ca/bp. Processed foods are our main source of dietary sodium. It occurs when your heart contracts. Millimetres of mercury is a standardized measurement of pressure.g. The first number is called the systolic pressure and the second is called the diastolic pressure. Your patients can also sign up at www. Regular blood pressure checks help make sure that high blood Hypertension pressure is diagnosed and controlled before it leads CANADA to serious health problems. Healthcare professionals can play a key role. Beyond the Salt Shaker: Key Messages for Healthcare Professionals 1.’ People with diabetes are twice as likely to develop high blood pressure as those without diabetes. Nine out of 10 Canadians will develop high blood pressure during their lifetime. Finding and treating high blood pressure early helps prevent these problems. Anyone can develop high blood pressure. a regular newsletter and lectures. Diastolic pressure is your lowest measurement.

ca www. Home BP monitoring is an important tool in self-monitoring and self-management. Treat to target. Lifestyle modifications are effective in preventing hypertension. This booklet is published by Hypertension Canada and the Canadian Hypertension Education Program as a professional service. treating hypertension and reducing cardiovascular risk. Hypertension Canada 3780 14th Avenue.hypertension. Suite 211 Markham ON L3R 9Y5 Tel : 905-943-9400 Fax : 905-943-9401 Email : admin@hypertension. Optimum management of BP requires assessment of overall cardiovascular risk.2013 Key Messages All Canadian adults should have their blood pressure assessed at all appropriate clinical visits.ca CHEP . For the complete version of the 2013 CHEP Recommendations please refer to our website at www. Combinations of both lifestyle changes and drugs are generally necessary to achieve target blood pressures. with unrestricted support from Forest Laboratories Canada Inc.ca This booklet was developed by Luc Poirier and Raj Padwal with the CHEP Executive. Focus on adherence.hypertension.