canadian hypertension guidelines 2010 - diagnosis assessment and follow up - ronal

7/26/2019 Canadian Hypertension Guidelines 2010 - Diagnosis Assessment and Follow Up - RONAL

1/61

2010 Canadian Hypertension Education Program Recommendations1

Key CHEP messages for themanagement of hypertension

Know the current blood pressure of all your patients.

Encourage the use of approved devices and proper technique tomeasure blood pressure at home.

Assess and manage CV risk in hypertensives including: highdietary sodium intake smoking dyslipidemia dysglycemiaabdominal obesity unhealthy eating and physical inactivity.

!ustained lifestyle modification is the cornerstone for theprevention and control of hypertension and the management of

CV disease. Encourage reducing sodium intake according to"ealth Canada#s recommendations.

$reat blood pressure to %&'()*( mm"g. +n people with diabetesor chronic kidney disease target to %&,()-( mm"g and morethan one drug is usually required including diuretics to achieve/ targets.

Keep up to date with evidence and resources for hypertensionmanagement go to: www.htnupdate.ca. 0ownload the latesttools at: www.hypertension.ca)tools. "ave your patients sign upat www.my/site.ca to access the latest hypertension resourcesfor patients.


2/61


2010 Canadian HypertensionEducation Program (CHEP)

Whats Od !ut "ti #mportant$O%E &O$ HO'E 'E"$E'E*+ O& ,%OO- P$E""$E

Encourage hypertensi.e patients to use an appro.ed!ood pressure measuring de.ice and use propertechni/ue to assess !ood pressure at home

'easuring !ood pressure at home has a strongerassociation ith cardio.ascuar prognosis thanoffice !ased readings

Home measurement can confirm the diagnosis of

hypertension impro.e !ood pressure controreduce the need for medications in some detectthose ith hite coat and mas3ed hypertensionand impro.e medication adherence in non adherentpatients


3/61


2010 Canadian Hypertension EducationProgram (CHEP)

"1/E2$E3!+43 0+A534!+! A!!E!!6E3$ A30 748849;/

+. Accurate 6easurement of blood pressure

++. Criteria for the diagnosis of hypertension and followup

+++. Assessment of overall cardiovascular risk in hypertensive patients

+V. 2outine and optional laboratory tests for the investigation of patients withhypertension

V. Assessment of renovascular hypertension

V+. Endocrine hypertension

V++. "ome measurement of blood pressure

V+++. Ambulatory blood pressure measurement

+


4/61


# ccurate 'easure of ,ood Pressure1) ssess !ood pressure at a appropriate .isits

9hen should blood pressure be measured=

"ealth care professionals should know the bloodpressure of all of their patients and clients. loodpressure of all adults should be measured whenever itis appropriate using standardi>ed techniques.

$o screen for hypertension

$o assess cardiovascular risk$o monitor antihypertensive treatment


5/61

2010 Canadian Hypertension Education Program Recommendations 5

2010 Canadian Hypertension EducationProgram (CHEP)

? Appro@imately *B of Canadians will develophypertension if they live an average lifespan

? 6ost overweight patients with high normalblood pressure &,(&,*)--* mm"gDdevelop hypertension within ' years andalmost &) within years. Annual followupof patients with high normal blood pressure is

recommended.


6/61


What percent of Canadians ha.ehypertension4

CCHS CMAJ 1992


7/61


%ife time ris3 of Hypertension in *ormotensi.e Women and'en aged 56 years

Risk 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


8/61


$e.ersi!e ris3s for de.eoping hypertension

4besity

/oor dietary habits

"igh sodium intake

!edentary lifestyle

"igh alcohol consumption


9/61


#ncidence of hypertension in those identified ith highnorma !ood pressure

FF subGects mean age '-.

3ot receiving treatment for "ypertension

Average of , blood pressures at baseline:

!/ &,(&,* and 0/ % -* 42!/ % &,* and 0/ --*

/rimary endpoint H new onset "ypertension

Iulius !. 3EI6 ((J,':&J-*F


10/61


*e onset hypertension in peope ith high norma!ood pressure

Iulius !. 3EI6 ((J,':&J-*F


11/61


-e.eopment of hypertension in those ith highnorma !ood pressure

&ramingham cohort Vasan. 8ancet ((&


12/61


High ris3 of de.eoping hypertension in those ith highnorma !ood pressure

Annual followup of patients with high normalblood pressure is recommended.


13/61


ccurate 'easurement of ,ood Pressure

Automated office blood pressure measurementscan be used in the assessment of office bloodpressureL.

9hen used under proper conditions automatedoffice !/ of &, mm"g or higher or 0/ values of- mm"g or higher should be consideredanalogous to mean awake ambulatory !/ of &,mm"g or higher or 0/ of - mm"g or higherL.

Lsee notes


14/61


se of standardi7ed measurement techni/ues isrecommended hen assessing !ood pressure

9hen using automated office oscillometricdevices such as the p$2; the patient shouldbe seated in a quiet room alone. 9ith the

device set to take measures at & or minuteintervals the first measurement is taken by ahealth professional to verify cuff position andvalidity of the measurement. $he patient isleft alone after the first measurement while

the device automatically takes subsequentreadings.


15/61


## Criteria for the diagnosis of hypertension andrecommendations for foo8up

,P9 1:081;< =


16/61



Hypertension ?isit 1,P 'easurement

History and Physicae@amination

Hypertension ?isit 1,P 'easurement

History and Physicae@amination

Hypertension ?isit 2ithin 1 month

>es

,P A1:0=


17/61



,P9 1:081;< =


18/61



L Consider "ome blood pressuremeasurement in hypertensionmanagement to assess for thepresence of masked hypertension orwhite coat effect and to enhanceadherence.

!ymptoms !everehypertension +ntolerance

to antihypertensivetreatment or $arget 4rgan

0amage

Are / readings below target during consecutive visits=

3on /harmacological treatment

9ith or without /harmacological treatment

-iagnosis of hypertension

7ollowup at ,Jmonth intervals L

*o>es

>es

'ore fre/uent.isits

?isits e.ery 1to 2 months

*o


19/61


+he concept of mas3ed hypertension

Office SBP mmHg

HomeorDaytim

eABPM

SBPmmH

g

True

hypertensive

True

Normotensive White Coat HTN

Maske HTN

!"#

!$%

!"#

!$%

Derived from Pickering et al. Hypertension 2002: 40: 795-7


20/61


+he prognosisof mas3ed hypertension

I "ypertension ((F:&*,*-

/revalence of masked hypertension is appro@imately &(B in the general population but ishigher in patients with diabetes


21/61


"earch for target organ damage

Cere!ro.ascuar disease transient ischemic attacks

ischemic or hemorrhagic stroke

vascular dementia

Hypertensi.e retinopathy

%eft .entricuar dysfunction

%eft .entricuar hypertrophy

Coronary artery disease

myocardial infarction

angina pectoris

congestive heart failure

Chronic 3idney disease

hypertensive nephropathy 572 % J(

ml)min)&.F, mD albuminuria

Periphera artery disease

intermittent claudication

ankle brachial inde@ % (.*

### ssessment of the o.era cardio.ascuar ris3


22/61


"earch for e@ogenous potentiay modifia!e factors thatcan induce=aggra.ate hypertension

Prescription -rugs9 3!A+0s including co@ibs Corticosteroids and anabolic steroids 4ral contraceptive and se@ hormones Vasoconstricting)sympathomimetic decongestants Calcineurin inhibitors cyclosporin tacrolimusD Erythropoietin and analogues Antidepressants: 6onoamine o@idase inhibitors 6A4+sD

!32+s !!2+s 6idodrine

Other9 8icorice root !timulants including cocaine !alt E@cessive alcohol use



23/61


4ver *(B of hypertensive Canadians have othercardiovascular risks

Assess and manage hypertensive patients fordyslipidemia dysglycemia e.g. impaired fastingglucose diabetesD abdominal obesity unhealthy

eating and physical inactivity



24/61


+reat Hypertension in the Conte@t of O.eraCardio.ascuar $is3

&. 4verall cardiovascular risk should be assessed. +nhypertensive patients consider using calculations thatinclude cerebrovascular events

. +n the absence of Canadian data to determine the accuracyof risk calculations avoid using absolute levels of risk tosupport treatment decisions at specific risk thresholds.

Simply counting risk factors may underestimate risk



25/61


Cardio.ascuar $is3 &actors

Presence of $is3 &actors +ncreasing age

6ale gender !moking 7amily history of premature cardiovascular disease age% in men and

% J in womenD 0yslipidemia !edentary lifestyle

;nhealthy eating Abdominal obesity 0ysglycemia diabetes impaired glucose tolerance impaired fasting

glucoseDPresence of +arget Organ -amage 6icroalbuminuria or proteinuria 8eft ventricular hypertrophy

Chronic kidney disease glomerular filtration rate % J( ml)min)&.F, mDPresence of atheroscerotic .ascuar disease /revious stroke or $+A Coronary "eart 0isease /eripheral arterial disease

CV Risk Factors tat may a!ter treso!"s an" tar#ets in te treatment of H$



26/61


'ethods of $is3 ssessment

Clinical impression

2isk factor counting

2isk calculation or equation tools

7ramingham hard coronary heart disease C"0D

http:))hp(&(.nhlbihin.net)atpiii)calculator.asp=usertypeNprof

!C42E Canada H !ystematic Cerebrovascular and Coronary2isk Evaluation

www.scorecanada.ca

Cardiovascular Age$6

www.myhealthcheckup.com

4thers: see notes


27/61


"CO$E 10 year &ata Cardio.ascuar$is3 E.auation in Canada

* Systematic Coronary Risk Evaluation

Find the cell nearest to the persons

risk factors values :

Age

Se

S!oking Status

S"stolic #lood $ressure%otal&Chol' ( H)*&C' +atio

SC,+- Canada : S"ste!aticCere.rovascular and c,ronar"

+isk -valuation


28/61


SystolicBP

Total Cholesterol (mmol/L)

SmokerNon smoker

"CO$E Canada9 $eati.e $is3 E.auationfor use in those ess than :0 years od

/ nti!es risk

at sa!e age


29/61


&actors to ta3e into account using "CO$ECanada to estimate ris3 of &ata C?-

/erson approaching ne@t age category

/reclinical evidence of atherosclerosis imaging testD

!trong family history of premature CV0: 6ultiply risk by &.'

4besity 6+ M ,( kg)m 9aist circumference M &( cm menD

and M -- cm womanD

!edentary lifestyle

0iabetes: multiply risk by for men and by ' for women

2aised serum triglycerides level

2aised level of Creactive prot. 7ibrinogen "omocysteine

Apolipoprotein or 8paD


30/61


#? $outine %a!oratory +ests

Preiminary #n.estigations of patients ith hypertension

&. ;rinalysis

. lood chemistry potassium sodium and creatinineD

,. 7asting glucose'. 7asting total cholesterol and high density lipoproteincholesterol "08D low density lipoprotein cholesterol 808Dtriglycerides

. !tandard &leads EC5

Currently there is insufficient evidence to recommendroutine testing of microalbuminuria in people withhypertension who do not have diabetes


31/61


#? $outine %a!oratory +ests

&oo8up in.estigations of patients ith hypertension

0uring the maintenance phase of hypertension managementtests including electrolytes creatinine glucose and fasting

lipidsD should be repeated with a frequency reflecting the clinicalsituation.

0iabetes develops in &,B)year of those with drug treated

hypertension. $he risk is higher in those treated with a diureticor beta blocker in the obese sedentary with higher fastingglucose and who have unhealthy eating patterns. Assess fordiabetes more frequently in these patients.


32/61


#? Optiona %a!oratory +ests

#n.estigation in specific patient su!groups

? 7or those with diabetes or chronic kidney disease: assessurinary albumin e@cretion since therapeutic

recommendations differ if proteinuria is present.? 7or those suspected of having an endocrine cause for the

high blood pressure or renovascular hypertension seefollowing slides.

? 4ther secondary forms of hypertension require specifictesting.


33/61


!norma rinary !umin e.es

!etting ;rinary albumin: creatinine

level mg)mmolD

6en 9omen

Chronickidney

0isease

M,(

0iabetes M M.-


34/61


? "creening for $eno.ascuar Hypertension

/atients presenting with two or more of the following

clinical clues listed below suggesting renovascularhypertension should be investigated.

iD sudden onset or worsening of hypertension and Mage or % age ,(

iiD the presence of an abdominal bruit

iiiD hypertension resistant to , or more drugsivDa rise in creatinine of ,(B or more associated with

use of an angiotensin converting en>yme inhibitor orangiotensin ++ receptor blocker

vD other atherosclerotic vascular disease particularly in

patients who smoke or have dyslipidemiaviDrecurrent pulmonary edema associated with

hypertensive surges


35/61


? "creening for $eno.ascuar Hypertension

$he following tests are recommended when

available to screen for renal vascular disease:

captoprilenhanced radioisotope renal scanL

doppler sonography

magnetic resonance angiography

C$angiography for those with normal renalfunction

L captoprilenhanced radioisotope renal scan is notrecommended for those with glomerular filtration

rates %J( m8)minD


36/61


?# "creening for Hyperadosteronism

!pontaneous hypokalemia %,. mmol)8D.

/rofound diureticinduced hypokalemia %,.(mmol)8D.

"ypertension refractory to treatment with , or moredrugs.

+ncidental adrenal adenomas.

!hould be considered for patients with thefollowing characteristics:


37/61


?# "creening for hyperadosteronism

"creening for hyperadosteronism shoud incudepasma adosterone and renin acti.ity (or reninconcentration)

measured in morning samples.

taken from patients in a sitting position after

resting at least & minutes.

Aldosterone antagonists A2s betablockers andclonidine should be discontinued prior to testing.

A positive screening test should lead to referral or

further testing.


38/61


?# $enin dosterone and $atioCon.ersion factors

+o

estimate9, &rom9

'utipy (,)

!y9

Renin

Concentration(ng/mL)

Plasma Renin

Actiit!(ng/mL/"r) 0#206

Plasma ReninActiit!(g/L/sec)

Plasma ReninActiit!(ng/mL/"r)

0#278

Al$osteroneconcentration(%mol/L)

Al$osteroneconcentration(ng/$L)

28

?# "creening for Pheochromocytoma


39/61



/aro@ysmal and)or severe sustained hypertension refractoryto usual antihypertensive therapy

"ypertension and symptoms suggestive of catecholamine

e@cess two or more of headaches palpitations sweatingetcD

"ypertension triggered by betablockers monoamineo@idase inhibitors micturition or changes in abdominalpressure

+ncidentally discovered adrenal mass 6ultiple endocrine neoplasia 6E3D A or von

2ecklinghausenOs neurofibromatosis or von "ippel8indaudisease.

"houd !e considered for patients ith thefooing characteristics9



40/61



!creening for pheochromocytoma should include a 'hour urine for metanephrines and creatinine.

Assessment of urinary V6A is inade/uate.

A normal plasma metanephrine level can be used to

e@clude pheochromocytoma in low risk patients butthe test is performed by few laboratories.


41/61


?## Home measurement of !ood pressure

ncompicated hypertension "uspected non adherence Office8induced !ood pressure ee.ation (hite coat

effect)

'as3ed hypertension

Whichpatients4

Average / M &,)- mm "g should be considered elevated

Home ,P measurement shoud !e encouraged to

increase patient in.o.ement in care


42/61


Potentia ad.antages of home !oodpressure measurement

6ore rapid confirmation of the diagnosis ofhypertension

+mproved ability to predict cardiovascular prognosis +mproved blood pressure control

Can be used to assess patients for white coathypertension 9C"D and masked hypertension

2educed medication use in some 9C"D +mproved adherence to drug therapy


43/61


*ot a patients are suited to homemeasurement

;ndue an@iety in response to high blood pressurereadings

/hysical or mental disability prevents accuratetechnique or recording

Arm not suited to blood pressure cuff e.g. conical

shaped armD +rregular pulse or arrhythmias prevent accurate

readings

8ack of interest

'ost patients can !e trained to measure !ood pressure

Periodic reassessment of techni/ue and retraining is desira!e


44/61


?## "uggested Protoco for Home 'easurement of,ood Pressure for the diagnosis of hypertension

"ome blood pressure values should be based on: duplicate measures morning and evening for an initial Fday period.

7irst day home / values should not be considered.

$he following si@ days blood pressure readings should beaveraged

Average / equal to or over &,)-mm"g should be considered elevated.


45/61


$ecommended eectronic !ood pressure monitors for home!ood pressure measurement

8'onitors that ha.e !een .aidated as accurate and

a.aia!e in Canada are isted at hypertensionca=chs

in the Fde.ice endorsements section

8+he !o@es containing the de.ice are aso !e mar3ed ith


46/61


?## Home 'easurement of ,P9 Patient Education

ssist patients seect a mode ith thecorrect si7e of cuff

'easure and record the patients mid armcircumference so they can match it to cuffsi7e

$ecommend de.ices isted athypertensionca or mar3ed ith thissym!o

s3 patients to carefuy foo theinstructions ith de.ice and to recordony those !ood pressures here theyha.e fooed recommended procedure

d.ise patients that a.erage readings e/uato or o.er 16=B6 mmHg are high

#n patients ith dia!etes or chronic 3idneydisease oer therapeutic targets anddiagnostic criteria are i3ey re/uired


47/61


We! !ased home monitoring

We!site resources are a.aia!eheartandstro3eca=!p

#ndi.iduai7ed automatedcounseing and trac3ing to assistpatients home monitor and to

enhance sef management ofifestye


48/61

2010 Canadian Hypertension Education Program Recommendations 482010 Canadian Hypertension Education Program Recommendations

'ore resources for home monitoring

hypertensionca=!pc

#nformation to assist you in training patients tomeasure !ood pressure at home ,rief action too for Heath Care professionas

under resources in the Education toos for heathcare professionas section

#nformation for patients on ho to purchase a de.icefor home measurement and ho to measure !oodpressure at home %earn ho to measure your !ood pressure at

homeand Home measurement of !ood pressureunder resources in the Education toos for heathcare professionas section)

training -?- on home measurement of !oodpressure is a.aia!e for donoad athypertensionca

d i f i h h h


49/61


d.ice for patients on hen to contact a heath careprofessiona !ased on high a.erage home !ood pressure

readings

Systolic BP (mmHg) Diastolic BP reading

Less than 13 Less than !" #s$al %ollo&'$

13'1*+ !"'1*+ Check reading again $sing the correct techni,$e- .%the readings remain high disc$ss &ith yo$rhealthcare ro0ider at yo$r net reg$larlysched$led aointment

1! 2 1**+ 11'11* Check reading again $sing the correct techni,$e- .%the readings remain high sched$le anaointment &ith yo$r doctor to disc$ss yo$rtreatment lan-

ore than 4+ ore than 14 Check reading again $sing the correct techni,$e- .%the readings remain high sched$le an $rgentaointment &ith yo$r doctor to disc$ss yo$rtreatment lan-

( resource a.aia!e at hypertensionca in the 'inuteHypertension ction +oo or heartandstro3eca=,P)

L/atients with diabetes chronic kidney disease or who are at high

risk of cardiovascular events require individuali>ed advice.

H t - i it i ht


50/61


Home measurement9 -oing it right

EP;+/6E3$

Validated device

8ook for the logo or go towww.hypertenion.ca for a list

of validated devices available inCanada

Ensure the cuff si>e is appropriate

Ensure the device is accurate inthe patient at purchase and

annually


51/61



/2E/A2A$+43

042ead and carefully follow the

instructions provided with thedevice

2ela@ in a comfortable chair with backsupport for minutes

!it quietly without talking ordistractions e.g. $VD

043O$6easure if stressed cold in pain or if

your bowel or bladder are

uncomfortable6easure within & hour of heavyphysical activity

6easure within ,( minutes of smokingor drinking coffee



52/61



/2E/A2A$+4304/ut the cuff on a bare arm or

one with a light sleeve!upport the arm on a table so

it is at heart level

2ecord two readings in themorning and evening dailyfor seven days discardingthe first days readingsD tohelp diagnose hypertension

6easure and record your blood

pressure as aboveD forseveral days before anappointment with a healthcare professional

H t - i it i ht


53/61



/osters and handouts

providing recommendationsto patients on how tomeasure blood pressure canbe found atwww.hypertension.ca

8earn how to measure yourblood pressure at home and"ome measurement of bloodpressure in the Educationtools for health careprofessionals sectionD


54/61


?## Home 'easurement of ,P9 Confirm contradictoryhome measurement readings

+f office / measurementis elevated and home /is normal or vice versa

Consider further assessusing 'h ambulatoryblood pressure monitoring

?### m!uatory ,P 'onitoring9


55/61


?### m!uatory ,P 'onitoring9

ntreated 6ild 5rade &D to moderate 5rade D clinic / elevation and

without target organ damage.

+reated patients

lood pressure that is not below target values despite

receiving appropriate antihypertensive therapy. !ymptoms suggestive of hypotension.

7luctuating office blood pressure readings.

Which patients4

eyond the diagnosis of hypertension A/6 measurementmay also be considered for selected patients for the

management of "$3

?### ! t ,P ' i i


56/61


?### m!uatory,P 'onitoring

A drop in nocturnal / of %&(B is associated with increased risk of CVevents

se .aidated de.ices

Ho to interpret46ean daytime ambulatory !ood pressure A16=B6 mmHgis considered elevated.6ean ' h ambulatory !ood pressure A10=B0 mmHgis considered elevated.

Ho to 4


57/61


-escription ,ood Pressure mmHg

"ome pressure average &, ) -

0aytime average A/ &, ) -

'hour average A/ &,( ) -(

A clinic blood pressure of &'()*( mm"g

has a similar risk of a:

Cinic Home m!uatory (,P) ,ood Pressure'easurement E/ui.aence *um!ers

&oo p gorithm &or High ,ood Pressure


58/61


&oo p gorithm &or High ,ood Pressuresing m!uatory ,ood Pressure 'easurement

2:8h ,P'2:8h ,P'

Consistent ith H+*

a3e ,PA&, !/ or

A- 0/

or2:8hour

A&,( !/ orA-( 0/

a3e ,PA&, !/ or

A- 0/

or2:8hour

A&,( !/ orA-( 0/

a3e ,P% &,)-

and

2:8hour% &,()-(

a3e ,P% &,)-

and

2:8hour% &,()-(

Continueto foo8up

/atients with high normal blood pressure should be followed annually.


59/61


&oo p gorithm &or High ,ood Pressure singm!uatory ,ood Pressure 'easurement

,('(B of patients with white coat hypertensiondiagnosed based on a single A/6 session will havetrue hypertension on retesting.

!ome patients with white coat hypertension developsustained hypertension.

/atients with white coat hypertension may befollowed with home / measurement or repeat A/6could be considered every & years

#G +he $oe of Echocardiography


60/61


#G +he $oe of Echocardiography

Echocardiography is not usefu for routinee.auation of hypertensi.e patients

Echocardiography is usefu for9ssessment of eft .entricuar dysfunction and thepresence of eft .entricuar hypertrophy

Key CHEP messages for the


61/61

y gmanagement of hypertension

Know the current blood pressure of all your patients. Encourage people with hypertension to use approved devices and

proper technique to measure blood pressure at home. Assess and manage cardiovascular risk in all people with

hypertension: high dietary sodium smoking dyslipidemiadysglycemia abdominal obesity unhealthy eating and physicalinactivity.

!ustained lifestyle modification is the cornerstone for the preventionand control of hypertension and the management of cardiovascular

disease. Encourage patients to reduce their intake according to"ealth Canada recommendations.

$reat blood pressure to %&'()*( mm"g in most people and to%&,()-( mm"g in people with diabetes or chronic kidney disease.6ore than one drug is usually required. 6an people with diabetesor chronic kidney disease require three or more antihypertensivedrugs including diuretics to achieve blood pressure targets.

$o keep up to date with the latest evidence and resources for theprevention and control of hypertension go to: www."t3update.ca.0ownload current resources at: www.hypertension.ca)tools. +n(&( look for an interactive casebased internet lecture seriesfeaturing top Canadian hypertension e@perts. "ave your patientssign up at www.my/site.ca to access the latest hypertensionresources

canadian hypertension guidelines 2010 - diagnosis assessment and follow up - ronal

Documents