2007 part 1: recommendations for hypertension diagnosis assessment and follow up january, 2007

2007Part 1:

Recommendations for Hypertension

Diagnosis Assessment and

Follow up

January, 2007

2007 Canadian Hypertension Education Program Recommendations 2

The Canadian Hypertension Education Program (CHEP) is jointly sponsored by

• the Canadian Hypertension Society,

• Blood Pressure Canada,

• the Public Health Agency of Canada,

• the Heart and Stroke Foundation of Canada,

• the Canadian Council of Cardiovascular Nurses,

• the Canadian Pharmacists Association,

• the College of Family Physicians of Canada


• A red flag has been posted where recommendations were updated for 2007.

• This slide kit for medical education, health care professional, patient and public information can be downloaded (English and French versions) from the Canadian Hypertension Society website at:

http://www.hypertension.ca

The 2007 Canadian Hypertension Education Program


The 2007 Canadian Hypertension Education Program

What's New for 2007

• Approximately 95% of Canadians will develop hypertension if they live an average lifespan

• Most overweight patients with high normal blood pressure (130-139/85-89 mmHg) develop within 4 years and almost 1/2 within 2 years. Annual follow-up of patients with high normal blood pressure is recommended.


What percent of Canadians have hypertension?

0

10

20

30

40

50

60

18-24 25-34 35-44 44-55 56-65 65-74

age

% o

f C

an

ad

ian

s

CCHS CMAJ 1992


Life time risk of Hypertension in Normotensive Women and

Men aged 65 yearsRisk of Hypertension %

0 2 4 6 8 10 12 14 16 18 20

Years to Follow-up

Women

Risk of Hypertension %

Years to Follow-up

0 2 4 6 8 10 12 14 16 18 20

Men

JAMA 2002: Framingham data.

100

80

60

40

20

0

100

80

60

40

20

0


High risk of developing hypertension in those with high normal blood pressure

• 40% of patients with systolic 130-139 or diastolic 85-89 mmHg developed hypertension in 2 years and 63% in 4 years NEJM 2006;354:1685-97

• Annual follow-up of patients with high normal blood pressure is recommended.


Reversible risks for developing hypertension

• Obesity• Poor dietary habits• High sodium intake• Sedentary • High alcohol consumption• High stress• High normal blood pressure

2007The Canadian Hypertension

Education Program: 2007

Recommendations

What’s old but still important?


Assess blood pressure at all appropriate visits. Almost one half of those with blood pressure 130-139/85-89 will develop hypertension within 2 years. They require annual reassessment.Assess global cardiovascular risk in all hypertensive patients. Lifestyle modification is the cornerstone for the prevention and management of hypertension and CVD.

Key CHEP messages for the management of hypertension



Treat to target (<140/90 mmHg; <130/80 mmHg in patients with diabetes or chronic kidney disease). To achieve targets sustained lifestyle modification and more than one drug is usually required.Follow patients with uncontrolled blood pressure at least monthly until blood pressure targets are achieved.Strategies to improve patient adherence to lifestyle modifications and antihypertensive therapy need to be incorporated in every patients management


The 2007 Canadian Hypertension Education Program Table of contents

HYPERTENSION DIAGNOSIS, ASSESSMENT AND FOLLOW-UP

I. Assess blood pressure at all appropriate visits

II. Criteria for the diagnosis of hypertension and recommendations follow-up

III. Assessment of overall cardiovascular risk in hypertensive patients

IV. Routine and optional laboratory tests for the investigation of patients with hypertension

V. Assessment of renovascular hypertension

VI. Endocrine hypertension

VII. Home measurement of blood pressure

VIII. Ambulatory blood pressure measurement

IX. Role of Echocardiography



• More than 90% of Canadians are estimated to develop hypertension during adulthood

• Approximately one half of adult Canadians are hypertensive by age 60.

• Even normotensive 55 or 65 year olds have a 90% chance of developing hypertension over the next 20 years

• 60% of those who are overweight and have high normal blood pressure will develop hypertension in 4 years



Blood pressure of all adults should be measured whenever it is appropriate by trained healthcare professionals using standardized techniques.

•To screen for hypertension•To assess cardiovascular risk•To monitor antihypertensive treatment



• Assess blood pressure annually in those with high normal blood pressure.


Incidence of hypertension in those identified with borderline

hypertension

• 772 subjects, mean age 48.5 • Not receiving tx for HTN• Avg of 3 BPs at baseline:

SBP 130-139 and DBP < 89 ORSBP < 139 and DBP 85-89

• Primary endpoint – new onset HTN

NEJM 2006;354:1685-97


Kaplan-Meier Plot of New Onset HTN

NEJM 2006;354:1685-97


Other evidence from the Framingham cohort

Outcome: progression to HTN:– BP > 140/90 or – treatment for HTN

Vasan. Lancet 2001


Incidence rates of hypertension at 1, 2 and 3 yrs

Optimum < 120/80Normal 120-129/80-84High normal 130-139/85-89 Vasan. Lancet 2001


Impact of high-normal BP on risk of cardiovascular disease.

• Framingham cohort (n=6859)• High normal BP at baseline• 10-year cumulative incidence of CVD (CV

death, MI, stroke, CHF)

35-64 years 65-90 years

Men8% (6% - 10%) 25% (17% - 34%)

Women4% (2% - 5%) 18% (12% - 23%)

NEJM 2001;345:1291-7


II. Criteria for the diagnosis of hypertension and recommendations for follow-up

BP: 140-179 / 90-109BP: 140-179 / 90-109

ABPM (If available)ABPM (If available)Clinic BPMClinic BPM Home BPM (If available)Home BPM (If available)

Yes

Hypertension Visit 2Target Organ Damage

or Diabetesor Chronic Kidney Disease

or BP >180/110?

Hypertension Visit 2Target Organ Damage

or Diabetesor Chronic Kidney Disease

or BP >180/110?

Hypertension Visit 1BP Measurement,

History and Physical examination



HypertensiveUrgency /

Emergency


Emergency

Diagnosisof HTN

Diagnosisof HTN

No







Hypertension Visit 2within 1 month

Yes

BP >140/90 mmHg and Target organ damage or

Diabetes or Chronic Kidney Disease or BP >180/110?

BP >140/90 mmHg and Target organ damage or

Diabetes or Chronic Kidney Disease or BP >180/110?

Diagnostic tests orderingat visit 1 or 2

Diagnostic tests orderingat visit 1 or 2


Emergency


Emergency

Diagnosisof HTN

Diagnosisof HTN

BP: 140-179 / 90-109mmHgBP: 140-179 / 90-109mmHg

No

Elevated Out of the Office BP measurement

Elevated Out of the Office BP measurement

Elevated Random Office BP

Measurement

Elevated Random Office BP

Measurement



BP: 140-179 / 90-109BP: 140-179 / 90-109

24-h ABPM (If available)24-h ABPM (If available)

Diagnosisof HTN

Awake BP>135 SBP or>85 DBP or

24-hour>130 SBP or

>80 DBP

Awake BP>135 SBP or>85 DBP or

24-hour>130 SBP or

>80 DBP

Awake BP<135/85

and24-hour<130/80

Awake BP<135/85

and24-hour<130/80

Continue to follow-up

Clinic BPClinic BP

Diagnosisof HTN

Hypertension visit 3 >160 SBP or >100 DBP

>140 SBP or>90 DBP

< 140 / 90

Diagnosisof HTN

Continue to follow-up

<160 / 100

Hypertension visit 4-5

ABPM or S/H BPM if

availableor

Home BPM (If available)Home BPM (If available)

>135/85>135/85 < 135/85 < 135/85

Diagnosisof HTN

Continue to follow-

up

or

Patients with high normal blood pressure (clinic SBP 130-139 and/or DBP 85-89) should be followed annually.


The concept of masked hypertension

From Pickering, Hypertension 1992

Office SBP mmHg

Am

bula

tory

SB

P m

mH

g

Truehypertensive

TrueNormotensive White Coat HTN

Masked HTN

White Coat HTNTrueNormotensive

Masked HTNTruehypertensive

200

180

160

140

120

100

100 120 140 160 180 200

135


The prognosis of masked hypertension

Prevalence is approximately 10% in hypertensive patients.

0

5

10

15

20

25

30

35

Normal23/685

White coat24/656

Uncontrolled41/462

Masked236/3125

Bobrie et al. JAMA 2004;291:1342-9

CV

even

ts p

er

10

00

pati

en

t-year

CV Events


Symptoms, Severe hypertension, Intolerance

to anti-hypertensive treatment or Target Organ

Damage


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 *

NoYes

Yes

More frequentvisits *

Visits every 1 to 2 months*

* Consider Home measurement in hypertension management, to rule out masked hypertension or white coat effect and to enhance adherence.

No


Search for target organ damageCerebrovascular disease

- transient ischemic attacks- ischemic or hemorrhagic stroke- vascular dementia

Hypertensive retinopathyLeft ventricular dysfunctionCoronary artery disease

- myocardial infarction- angina pectoris- congestive heart failure

Chronic kidney disease- hypertensive nephropathy (GFR < 60

ml/min/1.73 m2)

- albuminuriaPeripheral artery disease

- intermittent claudication

III. Assessment of the overall cardiovascular risk


Search for exogenous potentially modifiable factors that can induce/aggravate hypertension

• Presription Drugs:– NSAIDs, including Coxibs– Corticosteroids and anabolic steroids– Oral contraceptive and sex hormones– Vasoconstricting/sympathomimetic decongestants– Calcineurin inhibitors (cyclosporin, tacrolimus)– Erythropoietin and analogues– Monoamine oxidase inhibitors (MAOIs)– Midodrine

• Other:– Licorice root– Stimulants including cocaine– Salt– Excessive alcohol use– Sleep apnea



Treat Hypertension in the Context of Overall Cardiovascular Risk

1. Global cardiovascular risk should be assessed. In hypertensive patients consider using calculations that include cerebrovascular events

2. In the absence of Canadian data to determine the accuracy of risk calculations, avoid using absolute levels of risk to support treatment decisions at specific risk thresholds.

Simply counting risk factors may be misleading



Cardiovascular Risk FactorsPresence of Risk Factors- Increasing age- Male gender- Smoking- Family history of premature cardiovascular disease (age< 55 in men and

< 65 in women)- Dyslipidemia- Sedentary lifestyle- Abdominal obesityPresence of DiabetesPresence of Target Organ Damage- Microalbuminuria or proteinuria- Left ventricular hypertrophy- Chronic kidney disease (glomerular filtration rate < 60 ml/min/1.73 m2)Presence of atherosclerotic vascular disease- Previous stroke or TIA- CHD- Peripheral arterial disease

CV Risk Factors that may alter thresholds and targets in the treatment of HTN



Systematic Coronary Risk Evaluation10-Year Risk of Fatal CVD

in High-Risk Regions like Canada

Adapted from De Backer et al. Eur Heart J.

2003;24:1601-1610.

SCRE

10-year risk of fatal CVD in populations at high

CVD risk

Calibrated according to the 2002 Canadian

mortality data

15% and over10%–14%5%–9%3%–4%2%1%<1%

(Total Cholesterol / HDL-Cholesterol) Ratio

Sys

tolic

blo

od

pre

ssu

re (

mm

Hg

) Women Men

180 5 7 8 10 11 10 13 15 18 20 9 12 14 17 19 17 22 26 30 33

160 4 5 6 7 8 7 9 11 13 14 7 9 10 12 14 13 16 19 22 25

140 3 3 4 5 6 5 7 8 9 10 5 6 7 9 10 9 12 14 16 18

120 2 2 3 3 4 4 5 6 7 8 3 4 5 6 7 6 8 10 12 13

180 3 4 5 5 6 6 7 9 10 12 6 7 9 10 12 11 13 16 19 21

160 2 3 3 4 4 4 5 6 7 8 4 5 6 7 8 8 10 12 14 16

140 1 2 2 3 3 3 4 4 5 6 3 4 4 5 6 5 7 8 10 11

120 1 1 2 2 2 2 3 3 4 4 2 3 3 4 4 4 5 6 7 8

180 2 2 3 3 3 3 4 5 6 6 3 4 5 6 7 6 8 10 12 13

160 1 1 2 2 2 2 3 3 4 5 2 3 4 4 5 5 6 7 8 9

140 1 1 1 2 2 2 2 2 3 3 2 2 3 3 4 3 4 5 6 7

120 1 1 1 1 1 1 1 2 2 2 1 2 2 2 3 2 3 4 4 5

180 1 1 1 2 2 2 2 3 3 4 2 3 3 4 4 4 5 6 7 8

160 1 1 1 1 1 1 2 2 2 3 1 2 2 3 3 3 4 4 5 6

140 0 1 1 1 1 1 1 1 2 2 1 1 2 2 2 2 3 3 4 4

120 0 0 0 1 1 1 1 1 1 1 1 1 1 1 2 1 2 2 3 3

180 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 3

160 0 0 0 0 0 0 0 1 1 1 0 1 1 1 1 1 1 1 2 2

140 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 1 1 1 1

120 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1

3 4 5 6 7 3 4 5 6 7 3 4 5 6 7 3 4 5 6 7

60

SmokersNon-smokers

55

50

40

AGE

65

SmokersNon-smokers

Canada


IV. Routine Laboratory Tests

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-leads ECG

Investigation of all 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.

Deleted routine CBC as a recommendation


IV. Optional Laboratory Tests

Investigation for specific patient subgroups

• For those with diabetes or chronic kidney disease: assess urinary albumin excretion, since therapeutic recommendations differ if proteinuria is present.

For those suspected of having an endocrine cause for the high blood pressure, or renovascular hypertension, see following slides.

• Other secondary forms of hypertension require specific testing.

albumin:creatinine ratio [ACR] > 30 mg/mmol is abnormal


V. Screening for Renovascular HypertensionPatients presenting with two or more of the following clinical clues

listed below suggesting renovascular hypertension should be investigated.

i) sudden onset or worsening of hypertension and > age 55 or < age 30

ii) the presence of an abdominal bruitiii)hypertension resistant to 3 or more drugsiv)a rise in creatinine of 30% or more associated with use of an

angiotensin converting enzyme inhibitor or angiotensin II receptor blocker

v) other atherosclerotic vascular disease, particularly in patients who smoke or have dyslipidemia

vi)recurrent pulmonary edema associated with hypertensive surges


V. Screening for Renovascular Hypertension

The following tests are recommended, when available, to aid in the usual screening for renal vascular disease:

• captopril-enhanced radioisotope renal scan*• Doppler sonography• magnetic resonance angiography• CT-angiography (for those with normal renal

function

* captopril-enhanced radioisotope renal scan is not recommended for those with glomerular filtration rates <60 mL/min)


VI. Screening for Hyperaldosteronism

• Spontaneous hypokalemia (<3.5 mmol/L).

• 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:


VI. Screening for hyperaldosteronism

Screening for hyperaldosteronism should include plasma aldosterone and plasma renin activity (or renin concentration)- measured in morning samples.- taken from patients in a sitting position after resting at least 15 minutes.

Aldosterone antagonists, ARBs, beta-blockers and clonidine should be discontinued prior to testing.

A positive screening test should lead to referral or further testing.


VI. Renin, Aldosterone and Ratio Conversion factors

A. To estimate:

B. From:Multiply (B) by:

Renin Concentration(ng/mL)

Plasma Renin Activity(ng/mL/hr)

0.206

Plasma Renin Activity(g/L/sec)

Plasma Renin Activity(ng/mL/hr)

0.278

Aldosterone concentration (pmol/L)

Aldosterone concentration (ng/dL)

28


VI. Screening for Pheochromocytoma

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

• Hypertension and symptoms suggestive of catecholamine 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 mass;

• 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:


VI. Screening for Pheochromocytoma

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

• Assessment of urinary VMA is inadequate.

• A normal plasma metanephrine level can be used to exclude pheochromocytoma in low risk patients but the test is performed by few laboratories.


VII. Home measurement of blood pressure

• Uncomplicated hypertension• Diabetes mellitus• Chronic kidney disease• Suspected nonadherence• Hypertension and diabetes

• Office-induced blood pressure elevation (white coat effect)

• Masked hypertension

Which patients?

Further assessusing

24-h ambulatoryblood pressure

monitoring

If office BP measurementis elevated and Home BP

is normal

Daytime average BP equal to or over 135/85 mm Hg should be considered elevated

Home BP measurement should be encouraged to increase patient involvement in care


VII. Suggested Protocol for Home Measurement of Blood Pressure

Home blood pressure values should be based on:- duplicate measures,- morning and evening,- for an initial 7-day period.

Singular and first day home BP values should not be considered.

Daytime average BP equal to or over 135/85 mmHg should be considered elevated


Some recommended electronic blood pressure monitors for home blood pressure

measurement

Monitors A&D® or LifeSource® Models: 767*, 767PAC*, 774AC*, 779, 787AC*

Monitor Omron® Models: HEM-705 PC*, HEM-711*, HEM-741CINT*

Monitor Microlife®Model: BP 3BTO-A * Models with memory are preferred


VII. Home Measurement of BP:Patient Education

AAMI=Association for the Advancement of Medical Instrumentation;BHS=British Hypertension Society; IP: International Protocol.

Use devices:• appropriate for the individual (cuff size)• have met the standards of the AAMI and

or the BHS and or IP

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

Regular verifications• accuracy of the device• measuring techniques

How to?

Home measurement can help to improve patient adherence

Values equal to or over135 / 85 mm Hgshould beconsidered elevated


VIII. Ambulatory BP Monitoring:

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

without target organ damage.

Treated patients- Blood pressure that is not below target values despite

receiving appropriate chronic antihypertensive therapy.- Symptoms suggestive of hypotension.- Fluctuating office blood pressure readings.

Which patients?

Beyond the diagnosis of hypertension, ABPM measurement may also be considered for selected patients for the management of HTN


VIII. Ambulatory BP MonitoringSpecific Role in Selected Patients

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

Use validated devices

How to interpret?Mean daytime ambulatory blood pressure >135/85 mmHgis considered elevated.Mean 24 h ambulatory blood pressure >130/80 mmHgis considered elevated.

How to ?


Description Blood Pressure mmHg

Home pressure average 135 / 85

Daytime average ABP 135 / 85

24-hour average ABP 130 / 80

A clinic blood pressure of 140/90 mmHg

has a similar risk of a:

Clinic, Home, Ambulatory (ABP) Blood Pressure Measurement equivalence

numbers


Follow up algorithm for high Blood Pressure

using Ambulatory Blood Pressure Measurement

24-h ABPM24-h ABPM

Consistent with HTN

Awake BP>135 SBP or

>85 DBPor

24-hour>130 SBP or

>80 DBP

Awake BP>135 SBP or

>85 DBPor

24-hour>130 SBP or

>80 DBP

Awake BP< 135/85

and 24-hour< 130/80

Awake BP< 135/85

and 24-hour< 130/80

Continueto follow-up

Patients with high normal blood pressure should be followed annually.


IX. The Role of Echocardiography: Specific Roles

Echocardiography is not useful for routine evaluation

Echocardiography is useful for: Assessment of Left ventricular dysfunctionPresence of left ventricular hypertrophy may influence management


Assess blood pressure at all appropriate visits. Almost one half of those with blood pressure 130-139/85-89 will develop hypertension within 2 years. They require annual reassessment.Assess global cardiovascular risk in all hypertensive patients. Lifestyle modification is the cornerstone for the prevention and management of hypertension and CVD.




Treat to target (<140/90 mmHg; <130/80 mmHg in patients with diabetes or chronic kidney disease). To achieve targets sustained lifestyle modification and more than one drug is usually required. Follow patients with uncontrolled blood pressure at least monthly until blood pressure targets are achieved.Strategies to improve patient adherence to lifestyle modifications and antihypertensive therapy need to be incorporated in every patients management

2007 part 1: recommendations for hypertension diagnosis assessment and follow up january, 2007

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