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Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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Page 1: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Part 2: Recommendations for Hypertension Treatment

2011 Canadian Hypertension Education Program Recommendations

Page 2: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

The full slide set of the 2011 CHEP Recommendations

are available atwww.hypertension.ca

Page 3: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

2011 Canadian Hypertension Education Program (CHEP)

• A red flag has been posted where recommendations were updated for 2011.

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

Page 4: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

2011 Canadian Hypertension Education Program (CHEP)

Treatment Approaches:– Lifestyle– Pharmacological

Page 5: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Key CHEP Messages for the Management of Hypertension

1. Assess blood pressure at all appropriate visits. 2. Promote a healthy lifestyle to lower blood pressure and reduce

the risk of cardiovascular disease at each visit with interventions to reduce high dietary sodium, for smoking cessation, to reduce abdominal obesity, to promote a healthy weight, to increase physical activity and to manage dyslipidemia and dysglycemia.

3. 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 using a combination of drugs and lifestyle modifications.

4. Advocate for healthy public policies to prevent hypertension and advance the health of patients and populations.

5. Keep up to date with resources for the prevention and control of hypertension by registering at www.htnupdate.ca and downloading and ordering tools at www.hypertension.ca/tools.

Page 6: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

The Canadian Hypertension Education Program: 2011 Recommendations

What’s new?• Increased emphasis on the use of single pill

combinations (and more guidance on which combinations to use).

• In stroke patients avoid excessive blood pressure reductions, except in the setting of the most severe elevations

• The most important step in prescription of antihypertensive therapy is achieving patient “buy-in”: new tips for improving adherence

Page 7: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

• For your patients – ask them to sign up at www.myBPsite.ca for free access to the latest information & resources on high blood pressure

• For health care professionals – sign up at www.htnupdate.ca for automatic updates and on current hypertension educational resources

Page 8: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

The Canadian Hypertension Education Program: 2011 Recommendations

What’s old but still important?

• Out-of-office blood pressure measurements are important in both the diagnosis and management of hypertension

• Lifestyle changes are still a critical component of hypertension management (and prevention!)

• The management of hypertension is all about global risk management and vascular protection

Page 9: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Recommendations 2011Table of contents

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

Page 10: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

I. Indications for Pharmacotherapy

2011 Canadian Hypertension Education Program Recommendations

Page 11: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

I. Indications for Pharmacotherapy

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 Disease130/80

Page 12: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

I. Indications for Pharmacotherapyafter diagnosis of hypertension (1)

• Patients at low risk with stage 1 hypertension (140-159/90-99 mmHg)– lifestyle modification can be the sole therapy.

• Patients with target organ damage (e.g. left ventricular hypertrophy) (140-159/90-99 mmHg)– Treat with pharmacotherapy

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

Page 13: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

I. Indications for Pharmacotherapyafter diagnosis of hypertension (2)

• Patients with other risk factors (over 90% of Canadians with hypertension have other risk factors) (140-159/90-99 mmHg despite lifestyle modification) – Treat with pharmacotherapy

• Treatment Gap Alert: Many younger hypertensive Canadians with multiple cardiovascular risks are currently not treated with pharmacotherapy. Health care professionals need to be aware of this important care gap and recommend pharmacotherapy.

Page 14: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

II. Goals of Therapy

2011 Canadian Hypertension Education Program Recommendations

Page 15: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

II. Goals of Therapy

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

Page 16: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Page 17: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Page 18: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

III. Adherence

2011 Canadian Hypertension Education Program Recommendations

Page 19: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

III. 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

• Replacing multiple pill antihypertensive combinations with single pill combinations!

Page 20: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

III. 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 coordinating with work-site health care givers and pharmacists if available

Page 21: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

IV. Lifestyle management

2011 Canadian Hypertension Education Program Recommendations

Page 22: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Lifestyle Recommendations for Prevention and Treatment of Hypertension

To reduce the possibility of becoming hypertensive,Reduce sodium intake to less than 1500 mg/day • Healthy diet: high in fresh fruits, vegetables, low fat dairy products,

dietary and soluble fibre, whole grains and protein from plant sources, low in saturated fat, cholesterol and salt in accordance with Canada's Guide to Healthy Eating.

• Regular physical activity: accumulation of 30-60 minutes of moderate intensity dynamic exercise 4-7 days per week in addition to daily activities

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

• Attaining and maintaining ideal body weight (BMI 18.5-24.9 kg/m2)• Waist Circumference Men Women

– Europid, Sub-Saharan African, Middle Eastern <102 cm <88 cm– South Asian, Chinese <90 cm

<80 cm

• Tobacco free environment

Page 23: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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• Fresh vegetables• Low fat dairy products• Dietary and soluble fibre• Plant protein

Low in:• Saturated fat and cholesterol• Sodium

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

Page 24: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

• 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

Penz ED, Cdn J Cardiol 2008.Joffres MR_CJC_ 23(6) 2007.

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

Page 25: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Recommendations for daily salt intake

2,300 mg sodium (Na)

= 100 mmol sodium (Na)

= 5.8 g of salt (NaCl)

= 1 level teaspoon of table salt

• 80% of average sodium intake is in processed foods

• Only 10% is added at the table or in cooking

Age Recommended Intake

19-50 1500

51-70 1300

71 and over 1200

Institute of Medicine, 2003

Page 26: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Sodium: Meta-analyses

The Cochrane Library 2006;3:1-41

Average Reduction of sodium in mg/day

1800 mg/day

2300 mg/day

Hypertensives Reduction of BP

5.1 / 2.7 mmHg

7.2/3.8 mmHg

Average Reduction of sodium in mg/day

1700 mg/day

2300 mg/day

Normotensives Reduction of BP

2.0 / 1.0 mmHg

3.6/1.7 mmHg

Page 27: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

2011 Canadian Hypertension Education Program (CHEP)

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 1500 mg/day to prevent and control hypertension

Page 28: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Reduce Your Sodium Intake

At home

• Plan meals at least a day in advance.

• Make more meals from unprocessed foods.

• Gradually decrease the amount of salt used in cooking and at the table (this includes sea salt).

• Use condiments sparingly.

• Flavour food with lemon juice, fresh garlic, spices, herbs and flavoured vinegars.

• Try low-sodium seasoning mixes.

• Cook and bake with vegetable oil rather than butter or margarine.

• Use tomato paste instead of tomato sauce or soup in recipes.

Page 29: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Reduce Your Sodium Intake

At the grocery store

• Buy pre-prepared, convenience foods that are low in sodium such as frozen vegetables, frozen shrimp, skinless & boneless chicken breasts and pre-cut salads and fruit.

• Choose unsalted snack foods such as pretzels, nuts, seeds and crackers.

• Read food labels and compare sodium content between similar foods

• Look for foods labelled salt-free, no added salt, low in sodium, or reduced in sodium.

• Always check the Nutrition Facts table

Page 30: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Reduce Your Sodium Intake

When eating or “taking” out

• Choose salads and meals made with foods low in sodium

• Ask for no salt or MSG to be added during cooking

• Ask for sauces, spreads or dressings on the side and use sparingly

• Limit fast foods and take-out meals.

Page 31: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Exercise should be prescribed as an adjunctive to pharmacological therapy

Lifestyle Recommendations for Hypertension: Physical Activity

Should be prescribed to reduce blood pressure

Frequency - Four to seven days per weekFIntensity - ModerateI

Time - 30-60 minutesTType Cardiorespiratory Activity

- Walking, jogging- Cycling- Non-competitive swimming

T

Page 32: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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 patients

BMI 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

Page 33: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Courtesy J.P. Després 2006

Measure here

Iliac crest

Waist Circumference Measurement

Page 34: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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).

Page 35: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Page 36: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults

Intervention Intervention SBP/DBP

Reduce sodium intake-1800 mg/day sodium

Hypertensive-5.1 / -2.7

Weight loss per kg lost -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

Hypertensive -11.4 / -5.5

Padwal R. et al. CMAJ ・ SEPT. 27, 2005; 173 (7) 749-751

Page 37: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Page 38: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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 -7

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

AfterIntervention

BeforeIntervention

Reduction in BPPre

vale

nce

%

Page 39: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

V. Pharmacotherapy

2011 Canadian Hypertension Education Program Recommendations

Page 40: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Page 41: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Page 42: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Page 43: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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 agents if required.

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

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

Page 44: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Page 45: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Page 46: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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.

Page 47: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

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

<140/90 mm Hg

%

Page 48: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Ratio of Incremental SBP lowering effect at “standard dose”– Combine or Double?

1.04 1

1.16

0.891.01

0.19 0.23 0.2

0.37

0.22

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Thiazide β-blocker ACE-I CCB All

Combine Double

Incr

emen

al S

BP

red

uct

ion

ra

tio

Ob

serv

ed/E

xpec

ted

(ad

dit

ive)

Wald et al, Combination Versus Monotherapy for Blood Pressure Reduction, The American Journal of Medicine, Vol 122, No 3, March 2009

Page 49: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Page 50: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

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

Page 51: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

V. Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications

INITIAL TREATMENT AND MONOTHERAPY

Thiazide diuretic

Long-actingDHP CCB

Lifestyle modificationtherapy

ARB

TARGET <140 mmHg

Page 52: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

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 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

Page 53: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

CONSIDER

• Nonadherence• Secondary HTN• Interfering drugs or

lifestyle• White coat effect

Thiazide diuretic

Long-actingDHP CCB

Dual therapy

Triple therapy

Lifestyle modificationtherapy

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).

Page 54: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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 Nephropathy– Without Nephropathy

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

Page 55: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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)• Dual therapy with an ACEI and an ARB are not recommended in the absence of

refractory heart failure• The combination of an ACEi and CCB is preferred

1. Beta-blocker2. Long-acting CCBStable angina

ACEI are recommended for most patients with established CAD*

ARBs are not inferior to ACEI in IHD

Short-actingnifedipine

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

Page 56: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Long-actingDihydropyridine

CCB*

Beta-blocker and ACEI or ARB

Recentmyocardialinfarction

Heart Failure

?

NO

YES

Long-acting CCB

If beta-blocker contraindicated or not effective

*Avoid non dihydropyridine CCBs (diltiazem, verapamil)

Page 57: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Page 58: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Viii. Treatment of Hypertension in Association With StrokeAcute Stroke: Onset to 72 Hours

Treat extreme BP elevation (systolic > 220 mmHg, diastolic > 120 mmHg)

by 15-25% over the first 24 hour with gradual reduction after.

•If eligible for thrombolytic therapy treat very high BP (>185/110 mmHg)

Acute ischemic

Stroke

Avoid excessive lowering of BP which can exacerbate ischemia

Page 59: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

VIII. Treatment of Hypertension in Association With Stroke After the acute Phase of Stroke or TIA

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

Target BP < 140/90 mmHg

An ACEI / diuretic combination is preferred

StrokeTIA

Combinations of an ACEI with an ARB are not recommended

Page 60: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

IX. Treatment of Hypertension in Patients with Left Ventricular Hypertrophy

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

subsequent cardiovascular events

Vasodilators:Hydralazine, Minoxidil can increase LVH

Left ventricularhypertrophy

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

Page 61: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Page 62: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Page 63: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

XII. Treatment of Hypertension in association

with Diabetes Mellitus2011 Canadian Hypertension

Education Program Recommendations

Page 64: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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*

Diabetes

withoutNephropathy**

IsolatedSystolic

Hypertension

Systolic- diastolic

Hypertension

* based on at least 2 of 3 measurements

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

Combinations of an ACEI with an ARB are specifically

not recommended in the absence of proteinuria

Page 65: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

XII. Treatment of Hypertension in association with Diabetic Nephropathy

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

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 ofLong-acting CCB or Thiazide diuretic

3 - 4 drugs combination may be needed

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

Page 66: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

2011 Canadian Hypertension Education Program (CHEP)

Important messages from past recommendations

• Patients with diabetes are at high cardiovascular risk

• Most patients with diabetes have hypertension

• Treatment of hypertension in patients with diabetes reduces total mortality, myocardial infarction, stroke, retinopathy and progressive renal failure rates.

• Treating hypertension in patients with diabetes reduces death and disability and reduces health care system costs

• In diabetes, TARGET <130 systolic and <80 mmHg diastolic

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

Page 67: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

XII. Treatment of Systolic-Diastolic Hypertension without Diabetic Nephropathy

1. ACE Inhibitor or ARB or

2. Dihydropyridine CCB or Thiazide diuretic

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

Page 68: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

ACCORD Study: Results and rational for lack of impact on BP recommendations

• Overall BP study was neutral with no benefit of systolic target < 120 mmHg vs < 140 mmHg for primary outcome, yet:

• Power issue: Annual rate of primary outcome 1.87% in the intensive arm versus 2.09% in the standard arm vs 4%/year event rate projected during sample size calculations

• Significant interaction between BP and glycaemia control studies such that those in usual care glycaemia group (A1c 7%+) had a significant improvement in primary outcome with lower BP target

• Secondary outcome for stroke reduction showed a benefit for lower BP target

• Therefore no clear evidence supporting a change in BP targets for people with diabetes at this point

ACCORD study NEJM 2010

Page 69: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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. ACE Inhibitor or ARB

or2. DHP-CCB or

Thiazide diuretic

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

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

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. Combining an ACEi and a DHP-CCB is recommended.

Page 70: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

The benefits of treating smokers with beta-blockers remain 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

MRC Working Party. MRC trial of treatment of mild hypertension: 1985 Jul 13;291(6488):97-104.

Page 71: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

XIV. Overall Vascular Protection for Patients with

Hypertension2011 Canadian Hypertension

Education Program Recommendations

Page 72: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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.

• Discuss global risk using analogies that describe comparative risk such as “Cardiovascular Age”, “Vascular Age” or “Heart Age” to inform patients of their risk status and to improve the effectiveness of risk factor modification.

Page 73: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

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

Page 74: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

XIV. Vascular Protection for Hypertensive Patients: ASA

Consider low dose ASA

Caution should be exercised if BP is not controlled.

Page 75: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

New Patient Resources For Hypertension On Line

• www.hypertension.ca/tools - Download current resources for the prevention and control of hypertension

• www.htnupdate.ca -To keep up to date with the latest evidence and resources

• www.myBPsite.ca - Have your patients sign up to access the latest hypertension resources

• www.lowersodium.ca - Tools and resources for healthcare professionals to use in educating other healthcare professionals, the public or patients about the risks of high dietary sodium in Canada.

• www.sodium101.ca -To access a simple to use demonstration of food sodium content for your patients

• www.heartandstroke.ca/BP -To monitor home blood pressure and encourage self management of lifestyle

• http://www.hypertension.qc.ca/ - Société Québécoise d’hypertension artérielle

Page 76: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Public translation of CHEP recommendations

• Hypertension recommendations for the public • Translated into 4 Indo-Asian languages (2007)• Based on CHEP guidelines (annually updated)

Download at www.hypertension.ca

Page 77: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Sodium Slide Kit

• Tool used to educate the public and patients on dietary sodium.

• Annually updated.

Download at www.hypertension.ca

Page 78: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Brief Hypertension Action Tool

Can by used by a healthcare provider to better inform and engage a hypertensive patient to ultimately become more active in their

care.

Involves 3 Action Tools:

Action Tool # 1 – Explains High BP

Action Tool # 2 – Self-management of lifestyle

Action Tool # 3 – Proper home measurement & information about medication

Download at www.hypertension.ca

Page 79: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Measuring Blood Pressure the Right Way – Poster

• Posters (24’’ by 36’’) can be ordered from our website.

• Brief highlights: 1. Preparing to taking your

blood pressure

2. Using endorsed BP devices.

Download at www.hypertension.ca

Page 80: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Summary I

Regarding the treatment of hypertension, the recommendations endorse:

– Know the current blood pressure of all your patients

• Most Canadians will develop hypertension during their lives. Routine assessment of blood pressure is required for early detection and risk management

– Encourage the use of approved devices and proper technique to measure blood pressure at home.

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

Page 81: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Summary II

Regarding the treatment of hypertension, the recommendations endorse:

– Assess and manage CV risk in hypertensives• high dietary sodium intake, smoking, dyslipidemia,

dysglycemia, abdominal obesity, unhealthy eating, and physical inactivity.

– LIFESTYLE MODIFICATION• Sustained lifestyle modification is the cornerstone for the

prevention and control of hypertension and the management of cardiovascular disease. Encourage patients to reduce their sodium intake according to Health Canada’s recommendations.

Page 82: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

Summary III

Regarding the treatment of hypertension, the recommendations endorse:

– TREATING TO TARGET BP • Treat blood pressure to less than <140/90 mmHg. In people

with diabetes or chronic kidney disease target to <130/80 mmHg and more than one drug is usually required including diuretics to achieve BP targets

– KEEP UP TO DATE• To keep up to date with the latest evidence and resources for

the prevention and control of hypertension, go to: www.htnupdate.ca

• Download current resources at: www.hypertension.ca/tools. • Have your patients sign up at www.myBPsite.ca to access the

latest hypertension resources for patients.

Page 83: Part 2: Recommendations for Hypertension Treatment 2011 Canadian Hypertension Education Program Recommendations

• For your patients – ask them to sign up at www.myBPsite.ca for free access to the latest information & resources on high blood pressure

• For health care professionals – sign up at www.htnupdate.ca for automatic updates and on current hypertension educational resources