2009 part 2: recommendations for hypertension treatment

2009Part 2:

Recommendations for

Hypertension Treatment

2009 Canadian Hypertension Education Program Recommendations 2

• A red flag has been posted where recommendations were updated for 2009.

• Slide kits for health care professional and public education can be downloaded (English and French versions) from http://www.hypertension.ca

2009 Canadian Hypertension Education Program (CHEP)


Treatment Approaches:• Lifestyle• Pharmacological



Assess blood pressure at all appropriate visits. Encourage people with hypertension to use approved devices and proper technique to measure blood pressure at home. Ensure people with hypertension are screened for diabetes (and vice versa). Treat hypertension in people with diabetes with a combination of lifestyle changes and pharmacotherapy to control blood pressure to less than 130/80 mmHg. Many require use of three or more antihypertensive drugs including diuretics to achieve blood pressure targets. Assess and manage overall cardiovascular risk in all people with hypertension including: smoking, dyslipidemia, dysglycemia, abdominal obesity, unhealthy eating and physical inactivity. Sustained lifestyle modification is the cornerstone for the prevention and management of hypertension and cardiovascular disease (CVD).Treat blood pressure to less than 140/90 mmHg in most people and to less than 130/80 mmHg in people with diabetes or chronic kidney disease. More than one drug is usually required.

Key CHEP messages for the management of hypertension


What’s New for 2009The Hypertensive Diabetic

• Patients with diabetes are at high cardiovascular risk • Up to 80% of diabetic patients die of cardiovascular

disease• Most patients with diabetes have hypertension• Between 35 and 75% of diabetic complications have

been attributed to hypertension. • Treatment of hypertension in patients with diabetes

reduces total mortality, myocardial infarction, stroke, retinopathy and progressive renal failure rates.

• More intensive reduction in blood pressure reduces major cardiovascular events and total mortality by 25%

Treating hypertension in the diabetic patient reduces death and disability and reduces health care system costs

TARGET <130 systolic and <80 mmHg diastolic


What’s New for 2009The Hypertensive Diabetic

• 2/3rds of hypertensive diabetic patients have uncontrolled hypertension (> 130/80 mmHg)

• There is underutilization of diuretic therapy in treating hypertension in diabetic patients. In general a diuretic is required for blood pressure control in multi drug regimes.

• A combination of lifestyle changes and 3 or more medications are often required.

• More intensive reduction in blood pressure in the hypertensive diabetic is one a few medical interventions where the cost of treatment is less than the cost of the complications prevented

Treating hypertension in the diabetic patient reduces death and disability and reduces health care system costs

TARGET <130 systolic and <80 mmHg diastolic


What’s New for 2009

Increased age on its own should not be a consideration in determining the need for antihypertensive drug therapy. Drug therapy for the elderly should be based on the same criteria as in younger adults however caution should be exercised in elderly patients who are frail or have postural hypotension.

N Engl J Med 2008;358:1887-98



The combination of an ACE inhibitor with an ARB is not recommended in patients with

• hypertension without compelling indications, • coronary artery disease who do not have heart

failure, • prior stroke,• non proteinuric chronic kidney disease or• diabetes mellitus without micro albuminuria

N Engl J Med 2008;358:1547-59Lancet 2008; 372: 547–53



• The use of combination of ACE inhibitor with an ARB should only be considered in selected and closely monitored people with advanced heart failure or proteinuric nephropathy.



Important messages from past recommendations

IMPORTANT ROLE FOR HOME MEASUREMENT OF BLOOD PRESSURE

Encourage hypertensive patients to use an approved blood pressure measuring device and use proper technique to assess blood pressure at home.

Home measurement can help to confirm the diagnosis of hypertension, improve blood pressure control, reduce the need for medications, identify patients with white coat and masked hypertension and improve medication adherence



IMPORTANT ROLE FOR HOME MEASUREMENT OF BLOOD PRESSURE

• An internet based toolkit for home blood pressure measurement including recording and tracking of blood pressures can be found at www.heartandstroke.ca/BP.

• Patient information on selecting an approved device, and how to measure and track home blood pressure can be found at www.hypertension.ca.

• More information on home monitoring is in the CHEP diagnostic slide set and the BP measurement slide set



Important messages from past recommendations

• High dietary sodium is estimated to increase blood pressure in the Canadian population to the extent that 1,000,000 Canadians meet the diagnostic criteria for hypertension who would otherwise have ‘normal’ blood pressure

• Most of the sodium in Canadian diets comes from processed foods and restaurants.

• Pizza, breads, soups and sauces usually have high amounts of sodium

• Patient information on how to achieve a reduced sodium diet can be found at www.hypertension.ca

• Aim to reduce sodium intake to less than 2300 mg/day to prevent and control hypertension


TO REDUCE DIETARY SODIUMAdvise patients to • Buy and eat more fresh foods, especially fruit and vegetables• Choose processed foods look with low salt labels or brands with the

lowest percentage of sodium on the food label• Wash canned foods or other salty foods in water before eating or

cooking• If desired, use unsalted spices to make foods taste better• Eat less food at restaurants and fast food outlets and ask for less

salt to be added in food orders• Use less sauces on food• Eat foods with less than 200 mg of sodium or less than 10% of the

daily value per serving

Advise patients not to • Buy or eat heavily salted foods (e.g. pickled foods, salted crackers

or chips, processed meats, etc). • Add salt in cooking and at the table• Eat foods with more than 400 mg of sodium or more than 20% of

the daily value per serving


Recommendations 2009Table of contents

I. Indications for drug therapyII. Goal for therapyIII. AdherenceIV. LifestyleV. UncomplicatedVI. CV – IHDVII. CHFVIII. Cerebrovascular / StrokeIX. LVHX. Chronic kidney diseaseXI. RenovascularXII. DiabetesXIII. SmokingXIV. Overall risk reduction


Usual blood pressure threshold values for initiation of pharmacological treatment of hypertension

Condition Initiation

SBP or DBP mmHg

• Systolic or Diastolic hypertension 140/90

• Diabetes• Chronic Kidney Disease

130/80

I. Indications for Pharmacotherapy


I. Indications for Pharmacotherapy• In low risk patients with stage 1 hypertension (140-159/90-99 mmHg) lifestyle

modification can be the sole therapy.

• Over 90% of Canadians with hypertension have other risk factors and pharmacotherapy should be considered in these patients if blood pressure remains equal to or above 140/90 mmHg with lifestyle modification.

• In particular many younger hypertensive Canadians with multiple cardiovascular risks are currently not treated with pharmacotherapy. Health care professionals need to be alert to this important care gap and recommend pharmacotherapy.

• Patients with target organ damage (e.g. left ventricular hypertrophy) are recommended to be treated with pharmacotherapy if blood pressure is equal to or above 140/90 mmHg

• Patients with diabetes or chronic kidney disease should be considered for pharmacotherapy if the blood pressure is equal or over 130/80 mmHg


Blood pressure target values for treatment of hypertension

Condition Target

SBP and DBP mmHg

Isolated systolic hypertension <140

Systolic/Diastolic Hypertension• Systolic BP • Diastolic BP

<140<90

Diabetes or Chronic Kidney Disease• Systolic • Diastolic

<130<80

II. Goals of Therapy


II. Goals of Therapy

• To optimally reduce cardiovascular risk reduce the blood pressure to specified targets.• This usually requires two or more drugs and

lifestyle changes• The systolic target is more difficult to

achieve however controlling systolic blood pressure is as important if not more important than controlling diastolic blood pressure


Follow-up of blood pressure above targets

• Patients with blood pressure above target are recommended to be followed at least every 2nd month

• Follow-up visits are used to increase the intensity of lifestyle and drug therapy, monitor the response to therapy and assess adherence

2009

IV. Lifestyle management


To reduce the possibility of becoming hypertensive,Reduce sodium intake to less than 2300 mg / day

Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary and soluble fiber, whole grains and protein from plant sources, low in saturated fat, cholesterol and sodium in accordance with Canada's Guide to Healthy Eating.

Regular physical activity: accumulation of 30-60 minutes of moderate intensity cardiorespiratory activity (e.g. a brisk walk) 4-7 days/week in addition to routine activities of daily living

Low risk alcohol consumption (≤2 standard drinks/day and less than 14/week for men and less than 9/week for women)

Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2)

Waist Circumference Men Women- Europid, Sub-Saharan African, Middle Eastern <94 cm <80 cm- South Asian, Chinese <90 cm <80 cm- Smoke free environment

Lifestyle Recommendations for Prevention and Treatment of Hypertension


Dietary Sodium

Less than 2300mg / day(Most of the salt in food is ‘hidden’ and comes

from processed food)

Dietary Potassium

Daily dietary intake >80 mmol

Calcium supplementationNo conclusive studies for hypertension

Magnesium supplementationNo conclusive studies for hypertension

Lifestyle Recommendations for Hypertension: Dietary

• High in fresh fruits• High in fresh

vegetables• High in low fat

dairy products• High in dietary and

soluble fibre• High in plant

protein• Low in saturated

fat and cholesterol• Low in sodium

www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php


Potential Benefits of a Wide Spread Reduction in Dietary Sodium in Canada

REDUCTION IN AVERAGE DIETARY SODIUM FROM ABOUT 3500 MG TO 1700 MG

• 1 million fewer hypertensives• 5 million fewer physicians visits a year for

hypertension• Health care cost savings of $430 to 540 million per

year related to fewer office visits, drugs and laboratory costs for hypertension

• Improvement of the hypertension treatment and control rate

• 13% reduction in CVD

• Total health care cost savings of over $1.3 billion/year


Recommendations for daily salt intake

Less than:• 2,300 mg sodium (Na) • 100 mmol sodium (Na)• 5.8 g of salt (NaCl)• 1 teaspoon of table salt

2,300 mg sodium = 1 level teaspoon of table salt however, 80% of average sodium intake is in processed foods and only 10% is added at the table or in cooking


Sodium: Meta-analysesHypertensivesReduction of BP 5.1 / 2.7 mmHg with a average reduction of 1800 mg sodium/day

7.2/3.8 mmHg with a average reduction of 2300 mg sodium/day

Normotensives Reduction of BP 2.0 / 1.0 mmHg with a average reduction of sodium 1700 mg/day3.6/1.7 mmHg with a average reduction of 2300 mg/day sodium

The Cochrane Library 2006;3:1-41


Meta analysis on different reductions in dietary sodium intake on blood pressure

Hypertension 2003;42:1093-1099

0

2

4

6

8

10

12

1200 2400 3600

mg/day reduction in sodium

BP

red

ucti

on

SBP hyper

DBP hyper

SBP normo

DBP normo


Exercise should be prescribed as adjunctive to pharmacological therapy

Lifestyle Recommendations for Hypertension: Physical Activity

Should be prescribed to reduce blood pressure

Type cardiorespiratory activity- Walking, jogging- Cycling- Non-competitive swimming

Time - 30-60 minutes

Intensity - Moderate

Frequency - Four to seven days per weekF

I

T

T


Lifestyle Recommendations for Hypertension: Weight Loss

Height, weight, and waist circumference (WC) should be measured and body mass index (BMI) calculated for all adults.

Hypertensive and all patientsBMI over 25 - Encourage weight reduction- Healthy BMI: 18.5-24.9 kg/m2

Waist Circumference Men Women- Europid, Sub-Saharan African, Middle Eastern <94 cm <80 cm- South Asian, Chinese, Japanese <90 cm <80 cm

For patients prescribed pharmacological therapy: weight loss has additional antihypertensive effects. Weight loss strategies should employ a multidisciplinary approach and include dietary education, increased physical activity and behaviour modification

CMAJ 2007;176:1103-6


Courtesy J.P. Després 2006

Mid distance

Last rib margin

Iliac crest

Waist Circumference Measurement


Lifestyle Recommendations for Hypertension: Alcohol

Low risk alcohol consumption

• Women: maximum of 9 standard drinks/week

• Men: maximum of 14 standard drinks/week

• 0-2 standard drinks/day

A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or 12 oz of beer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).


Lifestyle Recommendations for Hypertension: Stress Management

Hypertensive patientsin whom stress appears to be an important issue

Individualized cognitive behavioural interventions are more likely to be effective when relaxation techniques are employed.

Stress management

Behaviour Modification


Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults

Intervention Intervention SBP/DBP

Reduce foods with added sodium

-1800 mg/day sodium

Hypertensive-5.1 / -2.7

Weight loss -1 kg -1.1 / -0.9

Alcohol intake -3.6 drinks/day -3.9 / -2.4

Aerobic exercise 120-150 min/week -4.9 / -3.7

Dietary patternsDASH diet

HypertensiveNormotensive

-11.4 / -5.5-3.6 / -1.8

Applying the 2005 Canadian Hypertension Education Program recommendations: 3. Lifestyle modifications to prevent and treat hypertension Padwal R. et al. CMAJ ･ SEPT. 27, 2005; 173 (7) 749-751


Lifestyle Therapies in Hypertensive Adults: Summary

Intervention Target

Reduce foods with added sodium < 2300 mg /day

Weight loss BMI <25 kg/m2

Alcohol restriction < 2 drinks/day

Physical activity 30-60 minutes 4-7 days/week

Dietary patterns DASH diet

Smoking cessation Smoke free environment

Waist Circumference- Europid- South Asian, Chinese

Men Women <94 cm <80 cm <90 cm <80 cm


Epidemiologic impact on mortality of blood pressure reduction in the population

Reduction in SBP

(mmHg)

% Reduction in Mortality

Stroke CHD Total

2 -6 -4 -3

3 -8 -5 -4

5 -14 -9 -7Adapted from Whelton, P. K. et al. JAMA 2002;288:1882-1888

AfterIntervention

BeforeIntervention

Reduction in BPP

revale

nce

%

2009

Pharmacotherapy


V. Choice of Pharmacological Treatment Uncomplicated

Associated risk factors?or

Target organ damage/complications?or

Concomitant diseases/conditions?

IndividualizedTreatment

(and compelling indications)

YES

Treatment in theabsence of compelling indications for specific

therapies

NO


V. Choice of Pharmacological Treatment

1. Treatment of Systolic/Diastolic hypertension without other compelling indications

2. Treatment of Isolated Systolic hypertension without other compelling indications


V. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling

Indications

TARGET <140/90 mmHg

INITIAL TREATMENT AND MONOTHERAPY

• BBs are not indicated as first line therapy for age 60 and above

Beta-blocker*

Long-actingCCB

Thiazide ACEI ARB

Lifestyle modificationtherapy

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

A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target


V. Considerations Regarding the Choice of First-Line Therapy

• Use caution in initiating therapy with 2 drugs in whom adverse events are more likely (e.g. frail elderly, those with postural hypotension or who are dehydrated).

• ACE inhibitors, renin inhibitors and ARBs are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential.

• Beta adrenergic blockers are not recommended for patients age 60 and over without another compelling indication.

• Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agent if required.

• The use of combination of ACE inhibitor with a ARB should only be considered in selected and closely monitored people with advanced heart failure or proteinuric nephropathy.

• ACE-I are not recommended (as monotherapy) for black patients without another compelling indication.


V. Add-on Therapy for Systolic/Diastolic Hypertension without Other Compelling

Indications

IF BLOOD PRESSURE IS NOT CONTROLLED CONSIDER

• Nonadherence• Secondary HTN• Interfering drugs or lifestyle• White coat effect

If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers or centrally acting agents).

2. Triple or Quadruple Therapy

1. Add-on Therapy

If partial response to monotherapy


Drug Combinations

When combining drugs, use first-line therapies.

• Two drug combinations of beta blockers, ACE inhibitors and angiotensin receptor blockers have not been proven to have additive hypotensive effects. Therefore these potential two drug combinations should not be used unless there is a compelling (non blood pressure lowering) indication

• Combinations of an ACEI with an ARB do not reduce cardiovascular events more than the ACEI alone and have more adverse effects therefore are not generally recommended


Drug Combinations cont’d

• Caution should be exercised in combining a non dihydropyridine CCB and a beta blocker to reduce the risk of bradycardia or heart block.

• Monitor serum creatinine and potassium when combining K sparing diuretics, ACE inhibitors and/or angiotensin receptor blockers.

• If a diuretic is not used as first or second line therapy, triple dose therapy should include a diuretic, when not contraindicated.


Medication Use and BP Control in ALLHAT

0

20

40

60

80

100

Baseline 6 mo 1 y 3 y 5 y

%

3 Drugs

2 Drugs

1 drug

% controlled-Canadian sites

% controlled-All

Cushman et al. J Clin Hypertens 2002;4:393-404.

<140/90 mm Hg


Most HTN Pts need more than 1 drug

0

1

2

3

4

5

UKPDS

ABCD

MDRD

HOT

AASKID

NT

ALLHAT

Nu

mb

er o

f d

rug

s


BP lowering effects from antihypertensive drugs

• Dose response curves for efficacy are relatively flat

• 80% of the BP lowering efficacy is achieved at half-standard dose

• Combinations of standard doses have additive blood pressure lowering effects

Law. BMJ 2003


V. Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling

Indications

CONSIDER

• Nonadherence• Secondary HTN• Interfering drugs or

lifestyle• White coat effect

Dual Combination

Triple or Quadruple Therapy

Lifestyle modification

Thiazidediuretic ACEI Long-acting

CCBBeta-

blocker*

TARGET <140/90 mmHg

ARB

*Not indicated as first line therapy over 60 y

Initial therapy



V. Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling

Indications

INITIAL TREATMENT AND MONOTHERAPY

Thiazide diuretic

Long-actingDHP CCB


ARB

TARGET <140 mmHg


V. Add-on therapy for Isolated Systolic Hypertension without Other Compelling Indications

CONSIDER



If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha adrenergic blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).

If partial response to monotherapy

Long-actingDHP CCB

Triple therapy

Thiazide diuretic

ARB

Dual combinationCombine first line agents


V. Summary: Treatment of Isolated Systolic Hypertension without Other Compelling Indications

CONSIDER



Thiazide diuretic

Long-actingDHP CCB

Dual therapy

Triple therapy


ARB

TARGET <140 mmHg

*If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).


Choice of Pharmacological Treatment for Hypertension

Individualized treatment

• Compelling indications:• Ischemic Heart Disease• Recent ST Segment Elevation-MI or non-ST Segment

Elevation-MI• Left Ventricular Systolic Dysfunction• Cerebrovascular Disease• Left Ventricular Hypertrophy• Non Diabetic Chronic Kidney Disease• Renovascular Disease• Smoking

• Diabetes Mellitus• With Diabetic Nephropathy• Without Diabetic Nephropathy

• Global Vascular Protection for Hypertensive Patients• Statins if 3 or more additional cardiovascular risks• Aspirin once blood pressure is controlled


VI. Treatment of Hypertension in Patients with Ischemic Heart Disease

• Caution should be exercised when combining a non DHP-CCB and a beta-blocker• If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or

Diltiazem)• Combinations of an ACEI with an ARB are not recommended in the absence of

heart failure

1. Beta-blocker2. Long-acting CCBStable angina

ACEI are recommended for most patients with established CAD*

Short-actingnifedipine

*Those at low risk with well controlled risk factors may not benefit from ACEI therapy


VI. Treatment of Hypertension in Patients with Recent ST Segment Elevation-MI or

non-ST Segment Elevation-MI

Long-actingDihydropyridine

CCB*(e.g. Amlodipine)

Beta-blocker and ACEI or ARB (if ACEI not tolerated)

Recentmyocardialinfarction

Heart Failure

?

NO

YES

Long-acting CCB

If beta-blocker contraindicated or not effective

*Avoid non dihydropyridine CCBs (diltiazem, verapamil)


VII. Treatment of Hypertension with Left Ventricular Systolic Dysfunction

Beta-blockers used in clinical trials were bisoprolol, carvedilol and metoprolol.

If additional therapy is needed:• Diuretic (Thiazide for hypertension; Loop for volume control) • for CHF class III-IV or post MI: Aldosterone Antagonist

Systoliccardiac

dysfunction

• ACEI and Beta blocker• if ACEI intolerant: ARBTitrate doses of ACEI or ARB to those used in clinical trials

If ACEI and ARB are contraindicated: Hydralazine and Isosorbide dinitrate in combination

If additional antihypertensive therapy is needed: • ACEI / ARB Combination • Long-acting DHP-CCB (Amlodipine)

Non dihydropyridine

CCB


VIII. Treatment of Hypertensionfor Patients with Cerebrovascular Disease

Strongly consider blood pressure reduction in all patients after the acute phase of stroke or TIA .

An ACEI / diuretic combination is preferred

StrokeTIA

Combinations of an ACEI with an ARB are not recommended


IX. Treatment of Hypertension in Patients with Left Ventricular Hypertrophy

Vasodilators:Hydralazine, Minoxidil can increase LVH

Left ventricularhypertrophy

Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events.

- ACEI- ARB,- CCB- Thiazide Diuretic- BB (if age below 60)*


X. Treatment of Hypertension in Patients with Non Diabetic Chronic Kidney Disease

Chronic kidney disease and proteinuria *

ACEI/ARB: Bilateral renal artery stenosis

ACEI or ARB (if ACEI tolerated)

Combination with other agents

Additive therapy: Thiazide diuretic.Alternate: If volume overload: loop diuretic

Target BP: < 130/80 mmHg

* albumin:creatinine ratio [ACR] > 30 mg/mmol or urinary protein > 500 mg/24hr

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB

Combinations of a ACEI and a ARB are specifically not recommended in the absence of proteinuria


XI. Treatment of Hypertension in Patients with Renovascular Disease

Close follow-up and intervention (angioplasty and stenting or surgery) should be considered for patients with: uncontrolled hypertension despite therapy with three or more drugs, or deteriorating renal function, or bilateral atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a single kidney), or recurrent episodes of flash pulmonary edema.

Does not imply specific treatment choice

Renovascular disease

Caution in the use of ACEI or ARB in bilateral renal artery stenosis or unilateral disease with solitary kidney

2009 XII. Treatment

of Hypertension in association with Diabetes

Mellitus


XII. Treatment of Hypertension in association with Diabetes Mellitus

Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg

withNephropathy*

*Urinary albumin to creatinine ratio > 2.0 mg/mmol in men or > 2.8mg/mmol in women or chronic kidney disease*

Diabetes

withoutNephropathy**

IsolatedSystolic

Hypertension

Systolic- diastolic

Hypertension

* based on at least 2 of 3 measurements


Combinations of an ACEI with an ARB are specifically

not recommended in the absence of proteinuria


XII. Treatment of Hypertension in association with Diabetic Nephropathy

THRESHOLD equal or over 130/80 mmHg and TARGET below 130/80 mmHg

If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired

DIABETESwith

Nephropathy

ACE Inhibitoror ARB

IF ACEI and ARB are contraindicated or not tolerated, SUBSTITUTE• Long-acting CCB or• Thiazide diuretic

Addition of one or more ofThiazide diuretic orLong-acting CCB

3 - 4 drugs combination may be needed



XII. Treatment of Systolic-Diastolic Hypertension without Diabetic

Nephropathy

1. ACE Inhibitor or ARB or

2. Thiazide diuretic or Dihydropyridine CCB

IF ACE Inhibitor and ARB and DHP-CCB and Thiazide are contraindicated or not tolerated, SUBSTITUTE• Cardioselective BB* or• Long-acting NON DHP-CCB

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

* Cardioselective BB: Acebutolol, Atenolol, Bisoprolol , Metoprolol

Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg

Combination of first line agents

Addition of one or more of:Cardioselective BB orLong-acting CCB

Diabeteswithout

Nephropathy

DHP: dihydropyridine

Combinations of an ACE Inhibitor with an ARB are specifically not recommended in the absence of proteinuria


XII. Treatment of Hypertension in association with Diabetes Mellitus: Summary

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

If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired

Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg

Diabetes

withNephropathy

> 2-drug combinations

ACE Inhibitoror ARB

withoutNephropathy

1. ACEInhibitor or ARB

or

2. Thiazide diuretic or DHP-CCB


Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria



The benefits of treating smokers with beta-blockersremain uncertain in the absence of a specific indication

like angina or post-MI

Smoking Beta-blocker

XIII. Treatment of Hypertension for Patients Who Use Tobacco

2009 XIV. Overall

Vascular Protection for Patients with Hypertension


Most hypertensive Canadians have other cardiovascular risks

• Assess and manage hypertensive patients for smoking, dyslipidemia and dysglycemia (impaired fasting glucose or diabetes) abdominal obesity, unhealthy eating and physical inactivity.


XIV. Vascular Protection for Hypertensive Patients: Statins

In addition to current Canadian recommendations on management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria:

• Male• Age 55 or older• Smoking• Total-C/HDL-C ratio of 6

mmol/L or higher

• Family History of Premature CV disease

• LVH• ECG abnormalities• Microalbuminuria or

Proteinuria

ASCOT-LLA Lancet 2003;361:1149-58


XIV. Vascular Protection for Hypertensive Patients: ASA

Consider low dose ASA

Caution should be exercised if BP is not controlled.


Adherence to anti-hypertensive management can be improved by a multi-pronged approach

• Assess adherence to pharmacological and non-pharmacological therapy at every visit

• Teach patients to take their pills on a regular schedule associated with a routine daily activity e.g. brushing teeth.

• Simplify medication regimens using long-acting once-daily dosing

• Utilize fixed-dose combination pills • Utilize unit-of-use packaging e.g. blister

packaging


Adherence to anti-hypertensive management can be improved by a multi-pronged approach

• Encourage greater patient responsibility/autonomy in regular monitoring of their blood pressure

• Educate patients and patients' families about their disease/treatment regimens verbally and in writing

• Use an interdisciplinary care approach if available to improve adherence to therapy


Focusing on care gapsCHEP utilizes several different surveillance

mechanisms to look for areas where patient care can be improved.

In 2009 we highlight 3 important care gaps

1)Lifestyle change after a diagnosis of hypertension

2)Pharmacotherapy in younger patients who have multiple cardiovascular risk factors

3)Achieving blood pressure targets in people with diabetes


NPHS (1994-2002): More Lifestyle Changes After Hypertension Diagnosis Are Needed

Small decreases in smoking and physical inactivity along with increases in BMI were observed in newly diagnosed patients in the longitudinal National Population Health Survey (NPHS). This trend was largely seen in patients who were taking antihypertensive medication. A is the survey cycle prior to diagnosis and B is the survey cycle following hypertension diagnosis.

Can J Cardiol, 2008. 24; 3: 199-204.

Age Standardized Rates of Lifestyle Change After a Hypertension Diagnosis

0

20

40

60

80

Smoking BMI 25+ Inactive Alcohol 9+

Per

cen

t

A B

-1.6%

+1.4%-2.4%

-0.1%


Lifestyle change

• Single lifestyle changes can have a similar blood pressure lowering effect as an antihypertensive drug and most lifestyle changes also reduce other cardiovascular risk factors

• Brief health care professional interventions are effective in promoting lifestyle change

• More extensive interdisciplinary team approaches are more effective in promoting lifestyle change.


Treating younger patients with pharmacotherapy

• Most patients with hypertension have other cardiovascular risks.

• Multiple risk factors can dramatically increase the probability of an adverse cardiovascular outcome


The Proportion of Aware Adult Hypertensive Canadians Not Receiving Antihypertensive Treatment by Number of

Cardiovascular Disease (CVD) Risk Factors

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5

Number of CVD Risk Factors

Per

cent

age(

%)

of H

yper

tens

ives

Not

Rec

eivi

ng

Ant

ihyp

erte

nsiv

e T

reat

men

t

20-39 40-59 60+

(risks include male, smoking, obese (BMI >30), diabetes, and physically inactive)

Can J Cardiol 2008;24:485-90


Treating younger patients with pharmacotherapy

• Be aware that many young hypertensive patients are not currently prescribed antihypertensive therapy

• Those with additional cardiovascular risk factors are recommended for pharmacotherapy

• In particular, hypertensive patients who smoke and are unable to stop should be prescribed antihypertensive therapy.


Hypertension in the Diabetic patient

• Two thirds of Ontarians with hypertension and diabetes have blood pressure above target.• Only 25% were prescribed a thiazide like diuretic.

• Very large reductions in cardiovascular disease and death occur from treating hypertension in diabetic patients.

• Many require lifestyle change and three or more drugs

CMAJ 2008;178:1441-9, Am J Hypertens 2008;21:1210-5.


NEW PATIENT RESOURCES FOR HYPERTENSION ON LINE

• www.heartandstroke.ca/BP• To monitor home blood pressure and

encourage self management of lifestyle

• www.hypertension.ca• To access up to date downloadable patient

information on hypertension


Public translation of CHEP recommendations

Download at www.hypertension.ca/bpc


Useful patient information can be obtained in recent publications from the Canadian Hypertension Society.

Available by order from CHS Secretariat-Canadian Hypertension Society.

Tel: 613-533-3299, Fax: 613-533-6927

Email: [email protected]

Educate patients and patients' families about their disease/treatment regimens verbally and in writing


Encourage greater patient responsibility/autonomy

Can be ordered at: www.hypertension.qc.ca


Summary I Regarding the treatment of hypertension, the

recommendations endorse: • ASSESSMENT OF BLOOD PRESSURE AT ALL

APPROPRIATE VISITS• Most Canadians will develop hypertension during

their lives. Routine assessment of blood pressure is required for early detection and risk management

• Encourage appropriate patients to properly measure blood pressure at home

• Most can assess blood pressure at home. Home measurement can confirm a diagnosis of hypertension, improve adherence to drug treatment, improve control rates and detect patients with white coat hypertension and masked hypertension.


Summary II

Regarding the treatment of hypertension, the recommendations endorse:• INDIVIDUALIZING THERAPY

• consider concomitant risk factors and/or concurrent diseases, other patient characteristics and preferences (e.g. age, diabetes, CVD) and other considerations e.g. costs

• LIFESTYLE MODIFICATION• To prevent hypertension• In those with hypertension alone if effective to reach

the treatment target or in combination with pharmacological treatment


Summary III

Regarding the treatment of hypertension, the recommendations endorse:

• TREATING TO TARGET BP • treat aggressively using combinations of drugs

and lifestyle modification to achieve individualized target

• PROMOTING ADHERENCE• a multi-faceted approach should be used to

improve adherence with both non pharmacological and pharmacological strategies

2009 part 2: recommendations for hypertension treatment

Documents