2001 canadian hypertension education program recommendations 1 focus on the 2001 canadian...

2001 Canadian Hypertension Education Program Recommendations 1

Focus on the 2001 Canadian Recommendations for the

Management of Hypertension

Version: April 25, 2002


Recommendations for the Management and Treatment of

Hypertension

The Canadian Hypertension Education Program

April 25, 2002


2001 Canadian Recommendations for the Management of Hypertension

• Systematic review of the literature supplemented by personal files to Nov 2001

• Application of an evidence-based grading scheme• Use of a Central Review Committee comprised of methodologists to

improve consistency of grading• 1 day conference to discuss recommendations and evidence• National presentation• Voting with removal of recommendations that >30% disagree with


Office Measurement of BP: C Abbott (Chair), K Mann; Follow-up of BP: P Bolli; Risk Assessment: S GroverSelf-measurement of BP: D McKay (Chair), B Ens; Ambulatory BP Monitoring: M Myers, S Rabkin; Routine Laboratory Testing: T Wilson; Echocardiography: G Honos; Lifestyle Modification: E Burgess (Chair), R Petrella, R Touyz; Pharmacotherapy of Uncomplicated Hypertension: R Lewanczuk (Chair);

B Culleton, J Wright; sub group Hypertension in the Elderly: G. Fodor, P Hamet, R Herman

Pharmacotherapy for Hypertension in patients with Cardiovascular Disease:

F Leenen (Chair); S Rabkin, J Stone; Diabetes: J Mahon, P Larochelle, R Ogilvie, C Jones, S Tobe; Renal and Renovascular HTN: M Lebel (Chair), E Burgess, S Tobe; Endocrine forms of hypertension: E SchiffrinConcordance Strategies for Patients: RD Feldman (Chair), J Irvine

The Canadian Hypertension Recommendations Working Group:

Subgroups for the 2001 recommendations:




Working Group for slides development:

Dr. Norm Campbell, Dr. Denis Drouin,Dr. Ross Feldman,Dr. Alain Milot,Dr. Guy Tremblay.


Hypertension as a Risk Factor

• Hypertension is a significant risk factor for:– cerebrovascular disease– coronary artery disease– congestive heart failure– renal failure– peripheral vascular disease– dementia– atrial fibrillation


11.7%

6.0% 5.8% 5.3%

3.9%

0%

2%

4%

6%

8%

10%

12%

14%

Malnutrition Tobacco Use Hypertension Poor WaterSupply

PhysicalInactivity

% of Global

Disability

Murray et al. 1996

Proportion of Deaths Attributable to Leading Risk Factors

World Health Organization Global Burden of Disease Study


BrainStroke, TIA,

hypertensive encephalopathy,

etc.

EyesRetinal hemorrhage, exudate, optical disc

edema, arteriolar constriction, etc.

Blood vesselsAneurysm, arterial occlusive disease,

etc.

HeartAngina, MI, CHF,

LVH, etc.

KidneyESRF, etc.

Hypertension and Target Organ Damage


BP and Risk of CAD Mortality

0

5

10

15

20

25

30

35

40

75-79 80-89 90-99 100+ <120 120-139 140-159 160+

Blood pressure (mm Hg)

Ris

k o

f C

AD

mo

rta

lity

pe

r 1

0,0

00

p

ers

on

-ye

ars

Diastolic Systolic

Multiple Risk Factor Intervention Trial (MRFIT); n=347,978 men. Neaton et al. Arch Intern Med 1992;152:56-64


BP and Risk of Stroke Mortality

0

2

4

6

8

10

<85 85-89 90-99 100+ <130 130-139 140-159 160+

Blood pressure (mm Hg)

Ris

k o

f s

tro

ke

mo

rta

lity

pe

r 1

0,0

00

pe

rso

n-y

ea

rs

Diastolic Systolic

Multiple Risk Factor Intervention Trial (MRFIT); n=347,978 men. Neaton et al. In: Laragh et al (eds). Hypertension: Pathophysiology, Diagnosis, and Management.2 ed. NY: Raven, 1995:127


PP=Pulse Pressure. Adapted from : Third National Health and Nutrition. Examination Survey, Hypertension 1995;25:305-13

30-39 40-49 50-59 60-69 70-79 80

70

80

110

130

150

Age

30-39 40-49 50-59 60-69 70-79 80

70

80

110

130

150

Age

Men Women

PPPP

Blood Pressure Distribution in the Population According to Age


Benefits of Treating Hypertension

• Younger than 60– reduces the risk of stroke by 42%– reduces the risk of coronary event by 14%

• Older than 60– reduces overall mortality by 20% – reduces cardiovascular mortality by 33%– reduces incidence of stroke by 40%– reduces coronary artery disease by 15%


Benefits of Treating to Target

• Older than 60 with isolated systolic hypertension(SBP 160 mm Hg and DBP <90 mm Hg)

– 36% reduction in the risk of stroke– 25% reduction in the risk of coronary events


Joffres et al. Am J Hyper 2001;14:1099 –1105

21%13%

43%22%

Hypertensive patients who are treated

but BP uncontrolled

Hypertensive patientswho are treated

and BP controlled

Hypertensive patients who are unaware

Patients who are awarebut remain untreatedand BP uncontrolled

22% of Canadians 18-70 years of age have hypertension50% of Canadians >65 years of age have hypertension

9%

Diabetic patientsWho are treated and

BP controlled

The Challenge In Canada


Results of a survey on awareness on hypertension (Canada)

67% of aware hypertensive patients believe that their BP was their own primary responsibility

HOWEVER two thirds of these patients stated that high BP was not a serious concern.

Thus the mandate to improve public awareness of the consequences of hypertension is clear.

R. Petrella MD, Perspective in Cardiology, March 2002.


A slide kit and clinical practice algorithms supporting the full recommendations can be downloaded from the CHS website at:

www.chs.md



DIAGNOSIS

AND FOLLOW-UP

OF HYPERTENSION



Classification of Hypertension According to WHO/ISH*

Category Systolic DiastolicOptimal <120 <80

Normal <130 <85

High-Normal 130-139 85-89

Grade 1 (mild hypertension ) 140-159 90-99

- Subgroup: borderline 140-149 90-94

Grade 2 (moderate hypertension) 160-179 100-109

Grade 3 (severe hypertension) 180 110

Isolated Systolic Hypertension (ISH) 140 <90

- Subgroup: borderline 140-149 <90

*ISH=International Society of Hypertension. Chalmers J et al. J Hypertens 1999;17:151-85.


Blood Pressure Assessment

• Patients should be assessed at all appropriate visits

– To determine cardiovascular risk– To monitor antihypertensive treatment


Recommended Technique for Measuring Blood Pressure

• Standardized technique:

– Have the patient rest for 5 minutes

– Use an appropriate cuff size

– Use a mercury manometer or a recently calibrated aneroid or electronic device


Recommended Technique for Measuring Blood Pressure (cont.)

– Position cuff appropriately

– Support arm with antecubital fossa at heart level

– Place stethoscope over the brachial artery


Recommended Technique for Measuring Blood Pressure (cont.)

– To exclude possibility of auscultatory gap, increase cuff pressure rapidly to 30 mmHg above level of disappearance of radial pulse

– Drop pressure by 2 mmHg / beat:• appearance of sound (phase I Korotkoff) = systolic

pressure• disappearance of sound (phase V Korotkoff) = diastolic

pressure

– Take 2 blood pressure measurements, 1 minute apart


Diagnosis of Hypertension: Summary

Visit 1

Visit 2

Visit 3

Visit 5

Blood pressuremeasurement

every year

- Hypertensive urgency?

- Target organ damage or BP >180/105? (Visit 3) Hypertension

diagnosisconfirmed

BP >threshold for initiation of

treatment

Yes

No Validated technique andBP measurement device

Visit 4

History-taking,physical examination

BP

140

/90

180

/10

5


Blood Pressure Threshold Values for Initiation of Pharmacological Treatment of Hypertension

Condition Initiation

SBP / DBP mmHg

Diastolic ± systolic hypertension 140/90

Isolated systolic hypertension 160

Diabetes 130/80

Renal disease 130/80

Proteinuria >1 g/day 125/75


Target Values for Blood Pressure

Condition Target

SBP / DBP mmHg

Diastolic ± systolic hypertension

Isolated systolic hypertension

<140/90

<140

Home BP measurement

(No diabetes, renal disease or proteinuria) <135/85

Diabetes <130/80

Renal disease <130/80

Proteinuria >1 g/day <125/75


Threshold for Initiation of Treatment and Target Values

Condition Initiation Target

SBP / DBP mmHg SBP / DBP mmHg

Diastolic ± systolic hypertension >140/90 <140/90

Isolated systolic hypertension SBP >160 <140

Home BP measurement (no diabetes, renal disease or proteinuria)

>135/85 <135/85

Diabetes >130/80 <130/80

Renal disease >130/80 <130/80

Proteinuria >1 g/day >125/75 <125/75


Routine and Optional Laboratory Tests

1. Urinalysis

2. Complete blood count

3. Blood chemistry (Potassium, Sodium and creatinine)

4. Fasting glucose

5. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides

6. Standard 12 leads ECG

Investigation of all patients with hypertension

New recommendations for investigation of endocrine and renal hypertension syndromes


Screening for Renovascular Hypertension

• Should be considered for patients with the following characteristics: – Patients who are candidates for angioplasty or

revascularization and who have• Uncontrolled hypertension despite therapy with 3 drugs• Or deteriorating renal function• Or recurrent episodes of flash pulmonary edema

Screening should include a post captopril renogram


Screening for Hyperaldosteronism

• Spontaneous hypokalemia

• Profound diuretic-induced hypokalemia (<3.0 mmol/L)

• Hypertension refractory to treatment with 3 or more drugs

• Incidental adrenal adenomas.

should be considered for patients with the following characteristics:


Screening for Hyperaldosteronism

• Screening for hyperaldosteronism should include a plasma aldosterone and plasma renin activity

measured in morning samples taken from patients in a sitting position after resting at least 15 minutes. Antihypertensive drugs with the exception of aldosterone antagonists may be continued prior to testing.


Screening for Pheochromocytoma

• Paroxysmal and/or severe sustained hypertension refractory to usual antihypertensive therapy;

• Hypertension and symptoms suggestive of catacholamine excess (two or more of headaches, palpitations, sweating, etc);

• Hypertension triggered by beta-blockers, monoamine oxidase inhibitors, micturition, or changes in abdominal pressure;

• Incidentally discovered adrenal adenoma;

• Multiple endocrine neoplasia (MEN) 2A or 2B; von Recklinghausen’s neurofibromatosis, or von Hippel-Lindau disease.

should be considered for patients with the following characteristics:


Screening for Pheochromocytoma

Screening for pheochromocytoma should include a 24 hour urine for metanephrines and creatinine

Assessment of urinary VMA is inadequate


WHO/ISH Recommendations forRisk Assessment

Stratification of risk to quantify prognosis

Grade 1 Grade 2 Grade 3

–Other Risk Factors & Disease History

–SBP 140-159 orDBP 90-99

(mild hypertension)

–SBP 160-179 or DBP 100-109

(moderate hypertension)

–SBP ≥ 180 or DBP ≥ 110

(severe hypertension)

I. No other risk factors

–Low risk Medium risk High risk

II. 1-2 risk factors Medium risk Medium risk V high risk

III. 3 risk factors or TOD or diabetes High risk High risk V high risk

IV. ACC V high risk V high risk V high risk

Risk strata (typical 10 year risk of stroke, myocardial infarction and cardiovascular mortality)

Chalmers J et al. J Hyper 1999;17:151-85.


Hypertension anddiabetes

Non adherence

Which patients?

Further assessusing

ambulatoryblood pressure

monitoring

Normal

Home BP?Office-induced blood

pressure elevation

BP >135/85 mm Hg should be considered elevated

Home (Self) Measurement of BP:Specific Role in Selected Patients


Home (Self) Measurement of BP:Patient Education

Values over135 / 85 mm Hg

should beconsidered elevated

How to?

Adequate patient training in:- measuring their BP- interpreting these readings

Regular verifications- accuracy of the device- measuring techniques

Use devices:- appropriate for the individual (cuff size)- have met the standards of the AAMI and/or the BHS

AAMI=Association for the Advancement of Medical Instrumentation; BHS=British Hypertension Society

Self measurement can help to improve patient adherence


Ambulatory BP Monitoring: Specific Role in Selected Patients*

Untreated- Mild (Grade 1) to moderate (Grade 2) clinic BP elevation and

without target organ damage

Treated patients- Apparent resistance to drug therapy

- Symptoms suggestive of hypotension

- Fluctuating office blood pressure readings

Which patients?Those with suspected office-induced BP elevation

* When available


Ambulatory BP Monitoring Specific Role in Selected Patients

How to interpret?

Mean daytime ambulatory blood pressure

>135/85 mm Hg

is considered elevated

Use validated devices

* A drop in nocturnal BP of <10% is associated with increased risk of CV events

How to ?


The Role of Echocardiography: Specific Role in Selected Patients

Presence of

Coronary artery disease

Routine Evaluation

Tracking of thetherapeutic regression

Assessment ofLeft ventricular

dysfunction

Most antihypertensives regress LVH over 6 months treatment period except arterial vasodilators (eg. Hydralazine)


Recommendations for Follow-up

Are BP readings below target during 2 consecutive visits*?

Non Pharmacological treatment

With or without Pharmacological treatment

Diagnosis of hypertension

Follow-up at 3-6 month intervals

Symptoms, Severe hypertension, Intolerance to anti-hypertensive treatment or Target Organ Damage

NoYes

NoYes

More frequentvisits

Monthly visits


LIFESTYLE MANAGEMENT



Healthy diet; High in fresh fruits, vegetables and low fat dairy products, low in saturated fat, and salt in accordance with Canada's Guide to Healthy Eating

Regular physical activity: optimum 45-60 minutes of moderate cardiorespiratory activity 4-5/week

Reduction in alcohol consumption in those who drink excessively (<2 drinks/ day

Weight loss (> 5 Kg) in those who are over weight (BMI>25)

Smoke free environment

Lifestyle Recommendations for Hypertension


Dietary Potassium

Dietary Sodium

Magnesium supplementation

Calcium supplementation

Restrict to target range of 90-130 mmol/day (Limitation of salt additives and foods with

excessive added salt)

Daily dietary intake >60 mmol

Fresh fruits,

Vegetables,

Low fat dairy products,

Low fat diet,

in accordance with

Canada's Guide

to Healthy EatingNo conclusive studies for hypertension

No conclusive studies for hypertension

Lifestyle Recommendations for Hypertension: Dietary


Should be prescribed to reduce blood pressure

For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapy

Lifestyle Recommendations for Hypertension: Physical Activity

Type Dynamic exercise- Walking- Cycling- Non-competitive swimming

Time - 45-60 minutes

Intensity - Moderate

Frequency - Four or five times per weekF

I

T

T


Low risk alcohol consumption

• Women: <9 drinks/week

• Men: <14 drinks/week

• 0-2 drinks/day

Lifestyle Recommendations for Hypertension: Alcohol


Lifestyle Recommendations for Hypertension: Stress Management

Hypertensive patientsin whom stress appears to be an important issue

- Individualized - Cognitive

Stress management

Behaviour Modification


Hypertensive and all patients

BMI over 25

- Encourage weight reduction- Lose a minimum of 4.5 kg

For patients prescribed pharmacological therapy: weight loss has additional antihypertensive effects

Lifestyle Recommendations for Hypertension: Weight Loss


Impact of Lifestyle Therapies on BP in Hypertensive Adults

Intervention Targeted change SBP/DBP

Sodium reduction 100 mmol/day -5.8 / -2.5

Weight loss -4.5 kg -7.2 / -5.9

Alcohol reduction -2.7 drinks/day -4.6 / -2.3

Exercise 3 times/week -10.3 / -7.5

Dietary patterns DASH diet -11.4 / -5.5

Potassium increase 75 mmol/day -4.4 / -2.5

Result of aggregate and metaanalyses of short term trials. Miller ER et al. J Clin Hyper 1999:Nov/Dec:191-8.


PHARMACOLOGICAL

TREATMENT



Indications for Pharmacotherapy

• Strongly consider prescription if:– Sustained DBP >90 mm Hg and:

• Target-organ damage or CVD• OR concomitant diseases such as diabetes mellitus• OR other cardiovascular risk factors

• if no other risk factors, prescribe if:DBP >100 mm Hg and/or SBP >160 mm Hg


Associated risk factors?or

Target organ damage/complications?or

Concomitant diseases/conditions?

Individualizedtreatment

Standardizedtreatment

YESNO

Choice of Treatment


Recommendations for Improving Adherence to Antihypertensive Prescription

• Adherence can be improved by a multi-pronged approach– Simplify medication regimens to once daily dosing– Tailor pill-taking to fit patients’ daily habits– Encourage greater patient responsibility/autonomy in

monitoring their BP and adjusting their prescriptions– Coordinate with worksite health care givers to improve

monitoring of adherence with pharmacological and lifestyle modification prescriptions

– Educate patients and patients’ families about their disease/treatment regimens


Suggestions: Improving Adherence to Antihypertensive Prescription

• Provide quality information on the consequences of hypertension and the benefits of lifestyle and drug therapy

• Ask about side effects and record any that occur • Tailor pill taking into a usual daily routine (same

time/place/situation)• Simplify drug and lifestyle regime• Ensure regime is affordable• Involve family and friends in lifestyle and medication adherence• Maintain regular BP follow-up• Consider Dosett® or other adherence aids• Consider self measurement of blood pressure• Record prescription refill dates on calendar and consider self

monitoring pill countsCampbell 2002


ACE-I Beta-blockers

Low-dosethiazides

CombinationCombine adjacent classes

Lifestyle modificationtherapy

Long-actingDHP-CCB

Alpha-blockeras initial

monotherapy

Triple or quadruple therapy

Treatment Algorithmfor Systolic-Diastolic Hypertension

TARGET <140/90 mmHg

CONSIDER

• Nonadherence?• Secondary HTN?• Interfering drugs or

lifestyle?• White coat effect?


Low-doseThiazide

Long-actingDHP CCB

CONSIDER



CombinationEffective 2-drug combination(Add ACE-I or beta blocker)

Alpha-blockers and beta-blockers as

initial monotherapy

Combination


Treatment algorithmfor Isolated Systolic Hypertension

TARGET <140 mmHg



ACE-I * Beta-blockers **

Low-dosethiazides

CombinationCombine adjacent classes


Long-actingDHP-CCB

Alpha-blockeras initial

monotherapy

*Not recommended for ISH; **Not recommended for patients >60 years or ISH


Global Treatment Algorithmfor HypertensionTARGET <140/90 mm Hg

CONSIDER




Rationale for Drug Combination Therapy

• Even higher proportion of hypertensive patients with diabetes require multi-drug therapy

• Low doses of multiple drugs may be more effective and better tolerated than higher doses of fewer drugs

Many patients require multiple drugs to achieve BP targets

33%

3 Drugs

50%

2 Drugs1 Drug

50%


Useful Combinations

Column 1 Column 2

• Low dose thiazide diuretics

• Long-acting dihydropyridine calcium channel blocker

• Beta-blocker

• ACE Inhibitor

For additive hypotensive effect in dual therapy combine an agent from

Column 1 with any in Column 2


Dyslipidemia

Treatment of uncomplicated hypertension,

hypertension associated with other conditions or

concomitant risk factors.

Treatment of Hypertension With Associated Risk Factors


Smoking Beta-blocker

The benefits of treatingsmokers with beta-blockers

remain uncertainin the absence

of a specific indicationlike angina or post-MI

Treatment of Hypertension With Associated Risk Factors


Diabetes

withNephropathy

withoutNephropathy

1. ACE Inhibitor2. ARB

ACE-Inhibitor

ACE-Inhibitor

Long-acting dihydropyridine

CCB

Low-dose thiazide

More than 3 drugs may be needed to reach target values for diabetic patients

Alpha-blockers

COMBINATION

Cardioselective BBLong-acting CCBLow-dose thiazide diuretic

Treatment of Hypertension with DiabetesTARGET <130/80 mmHg

Combination

Effective 2-drug combination

IsolatedSystolic

Hypertension


Ischemiccardiopathy

Stableangina

Priormyocardialinfarction

Normal systolicleft ventricular

function

1. Beta-blocker2. Long-acting CCB

CombinationBeta-blocker

and long-actingDihydropyridine CCB

ACE-I,Beta-blocker

or both

Verapamilor

Diltiazem

Alternate

Short-actingnifedipine

Treatment of Hypertension with Ischemic Heart Disease

ACE-I should be strongly considered in all patients with CAD


ACE-I/ARB(use with caution)

Peripheralvasculardisease

AtheroscleroticPVD

Renal artery stenosis

Raynaud’ssyndrome

Treatment of uncomplicated hypertension,hypertension associated with other

conditions or concomitant risk factors.

Beta-blocker

Vasodilators:Alpha-blockers, CCB,

ACE-I, ARB

May aggravatesymptoms

May induce renalinsufficiency

May havebeneficial effects

severe

mild

Beta-blocker

± ACE-I ?

Treatment of Hypertension with Peripheral Vascular Diseases


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

* Diuretics:

- Thiazides- Loop diuretics

Systoliccardiac

dysfunction

ACE-I+

Additional therapy, if abnormal water

retention: Diuretic*

If ACE-I are contraindicated or not tolerated:

Hydralazine and Isosorbide dinitrate in combination

Or ARB

AddBisoprolol, Carvedilol,

Metoprolol

Additionaltherapy

Amlodipine or

Felodipine

NYHA class II - IV

Non dihydropyridine

CCB or nifedipineAdd Spironolactone

Treatment of Hypertension with Systolic Dysfunction

NYHA class III - IV


Arrhythmiaand

conductionproblems

Atrial fibrillation andsupraventricular

tachycardia

Sinoatrial node dysfunction and atrioventricular

conduction problems

Beta-blockerVerapamilDiltiazem

Beta-blockerVerapamilDiltiazemClonidine

Methyldopa

May inhibitventricular response

* Caution is recommended when diuretics are used with class 1A, 1C or III antiarrythmic drugs

Caution if systolic dysfunction is

present

Treatment of Hypertension with Arrhythmia*


Left ventricularhypertrophy

Vasodilators:Hydralazine, Minoxidil

Mostantihypertensives

Can IncreaseLVH

Most antihypertensives regress LVH over 6 months treatment period except arterial vasodilators (eg. hydralazine)

Can reduce LVH over a 6 months treatment period

Treatment of Hypertension with Left Ventricular Hypertrophy


ACE-I

Additive therapy:Diuretic

Renaldisease

Combination with other agents

Nondiabetic: < 130/80

Proteinuria > 1 g/day: < 125/ 85Target BP

ACE-I: Bilateral renal artery

stenosis

Treatment of Hypertension with Nondiabetic Renal Disease


Treatment of Hypertension After the Acute Phase of Nondisabling Stroke or TIA

Stroke,TIA

Strongly consider blood pressure reduction after

the acute phase

An ACE-I should be strongly considered in all patients with stroke and TIA


Summary I

• Regarding the treatment of hypertension, the recommendations endorse: – Individualizing therapy

• consider concomitant risk factors and/or concurrent diseases (i.e., diabetes, CVD, renal disease)

– Treating to target BP • treat aggressively to achieve individualized targets

– Using nonpharmacological strategies• lifestyle modifications


Summary II

• Regarding the treatment of hypertension, the recommendations endorse: – Using combination therapy

• addition of medications in combination to achieve BP targets is preferred to maximal dose titration or serially switching drugs

– Promoting adherence• a multi-pronged approach should be used to improve

adherence with both non pharmacological and pharmacological strategies


Summary III

Regarding the treatment of hypertension, the recommendations endorse:

Hypertension is a major factor responsible for progression of atherosclerotic disease.

Therefore, a comprehensive treatment of hypertension should include all associated risk factors.

2001 canadian hypertension education program recommendations 1 focus on the 2001 canadian...

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