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Canadian Journal of Cardiology 27 (2011) 407– 414

Position Statement
Canadian Hypertension Education Program: The Science
Supporting New 2011 CHEP Recommendations With an
Emphasis on Health Advocacy and Knowledge
Translation
Norman R. C. Campbell, MD,a Luc Poirier, BPharm, MSc,b Guy Tremblay, MD,c
Patrice Lindsay, PhD,d Deb Reid, PhD,e and Sheldon W. Tobe, MD;f on behalf of the Canadian
Hypertension Education Program
a
Department of Medicine, Faculty of Medicine, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada;
b
Département de pharmacie et Unité d’hypertension, Centre Hospitalier Universitaire de Québec (CHUL), Québec, Québec, Canada;
c
Service de Cardiologie, CHAuQ, Hopital St Sacrement, Québec, Québec, Canada;
d
Canadian Stroke Network, Toronto, Ontario, Canada;
e
Dietitians of Canada, Toronto, Ontario, Canada;
f
Division of Nephrology, University of Toronto, Toronto, Ontario, Canada

ABSTRACT RÉSUMÉ
This is a summary of the theme, key new recommendations, and Cet article est un résumé du thème, des principales nouvelles recom-
supporting science of the 2011 Canadian Hypertension Education Pro- mandations, et de la littérature sous-jacente du Programme éducatif
gram (CHEP). In 2011, the ACCORD trial challenged current blood canadien sur l’hypertension (PECH) 2011. En 2011, l’étude ACCORD a
pressure treatment targets for people with diabetes. After consider- remis en question les cibles tensionnelles couramment utilisées dans
ation of multiple factors relating to the ACCORD trial design and its le traitement de l’hypertension artérielle chez les personnes diabé-
reporting, the current treatment target of ⬍130/80 mm Hg was not tiques. Après avoir considéré les multiples facteurs relatifs à la con-
changed. A meta-analysis implicated angiotensin receptor blockers in ception de l’étude ACCORD et suite à la lecture de l’article, la cible de
causing cancer; however, weaknesses in the meta-analysis and ongo- pression artérielle a été maintenue à ⬍130/80 mmHg. Une métaanal-
ing close scrutiny of the issue by the U.S. Food and Drug Administration yse a relié les antagonistes des récepteurs de l’angiotensine au cancer;
precluded any changes in current CHEP recommendations. New expert cependant, les lacunes de cette métaanalyse ainsi que l’examen
opinion– based recommendations were added to assist the manage- minutieux en cours de cette situation par la Food and Drug Adminis-
ment of hypertension in the setting of acute stroke. To promote health- tration des États-Unis n’ont résulté en aucun changement dans les
ier blood pressure in Canadians, CHEP emphasizes the need for all recommandations actuelles du PECH. De nouvelles recommandations
Canadians—in particular, health care professionals and their organi- basées sur des opinions d’experts ont été ajoutées pour aider à la prise
zations—to more actively work with different levels of government to en charge de l’hypertension dans la phase aigue d’un accident vascu-

This year is the 12th year that the Canadian Hypertension for improvement. On the success front, a national survey con-
Education Program (CHEP) has annually updated recommen- ducted by Statistics Canada in 2007 found that Canada had the
dations for the management of hypertension. New surveillance highest reported national rates of awareness, treatment, and
data have indicated tremendous success in controlling hyper- control.1-3 The treatment and control rate was 66% (a 5-fold
tension in Canada but also important gaps and opportunities improvement since the prior survey in 1985–1992), whereas
most developed countries have rates of control ⬍30%.1,2 Fur-
Received for publication February 22, 2011. Accepted March 1, 2011. ther, ⬎95% of adult Canadians who are aware of having hy-
Corresponding author: Dr Norman R. C. Campbell, Department of Med- pertension reported taking antihypertensive drug therapy.1
icine, Faculty of Medicine, Libin Cardiovascular Institute of Alberta, Univer- However, the survey also found that 1 in 5 adult Canadians had
sity of Calgary, 3330 Hospital Dr NW, Calgary, Alberta T2N 4N1, Canada.
E-mail: ncampbel@ucalgary.ca hypertension, 1 in 5 adult Canadians with hypertension was
See page 413 for disclosure information. unaware of his or her “hypertension status,” and at least 1 in 3

0828-282X/$ – see front matter © 2011 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.cjca.2011.03.004
408 Canadian Journal of Cardiology
Volume 27 2011

implement healthy public policies. These should build community ca- laire cérébral. Pour promouvoir une pression artérielle plus santé chez
pacity to promote healthy behaviours with the goal of the prevention of les Canadiens, le PECH met désormais l’accent sur la nécessité pour
hypertension and its consequences. To aid a substantive knowledge tous les Canadiens - particulièrement, les professionnels de la santé et
translation gap, health care professionals and people with hyperten- leurs organisations - de travailler plus étroitement avec les différents
sion can now receive regular CHEP updates by signing up at the Web paliers de gouvernement pour implanter des politiques de santé pub-
sites htnupdate.ca and www.myBPsite.ca. lique. Ceci devrait permettre de renforcer la capacité communautaire
à promouvoir des comportements sains dans le dessein de prévenir
l’hypertension et ses conséquences. Afin de combler les lacunes dans
le transfert des connaissances, les professionnels des soins de santé
et les personnes atteintes d’hypertension peuvent maintenant recevoir
les mises à jour régulières du PECH en s’inscrivant sur les sites Web à
htnupdate.ca et www.myBPsite.ca.

adult Canadians who have hypertension remain “uncon- Ischemic stroke eligible for thrombolytic therapy. Very
trolled” and at high risk of complications.1 While CHEP will high BP (⬎185/110 mm Hg) should be treated concurrently
continue to increase the dissemination of knowledge on hyper- in patients receiving thrombolytic therapy for acute ischemic
tension to the public and health care professionals, in 2011 stroke to reduce the risk of secondary intracranial hemorrhage.
CHEP’s major goal will be to lead the charge in a call to action,
to mobilize and empower Canadians, health care professional-
s,and scientists to become active in advocating for healthy pub- Ischemic stroke patients not eligible for thrombolytic
lic policies, health services policies, and community capacity therapy. Treatment of hypertension in the setting of acute
building to prevent and control hypertension. ischemic stroke should not be routinely undertaken. Ex-
This is a short scientific summary of the hypertension evi- treme BP elevation (eg, systolic BP [SBP] ⬎220 mm Hg or
dence that supports the 2011 CHEP recommendations as well diastolic BP [DBP] ⬎120 mm Hg) may be treated to reduce
as opinions from the CHEP executive on important issues in the BP by ⬃15%, and not more than 25%, over the first 24
hypertension management in Canada. Table 1 contains the hours, with gradual reduction thereafter. Avoid excessive
updated recommendations for pharmacologically managing lowering of BP as this may exacerbate existing ischemia or
hypertension in different clinical scenarios. The full CHEP induce ischemia, particularly in the setting of intracranial
recommendations are available at www.hypertension.ca and arterial occlusion or extracranial carotid or vertebral artery
are published in this issue of the Canadian Journal of Cardiology occlusion.8
(see page 415). Importantly, in the next few years, clinical trials will pro-
duce more information to guide therapy in this important clin-
ical area.6,9 Controlling BP so it is consistently below 140/90
New Evidence and CHEP Recommendations mm Hg ⬎72 hours after the acute event is one of the most
important interventions to preventing a recurrent stroke or
Management of hypertension in the setting of acute transient ischemic attack (TIA).10
stroke
Most commonly, elevated blood pressure (BP) is a reac- Assessment and review of recent concern about a
tion to acute stroke, rather than an acute cause. Elevated BP possible association between angiotensin receptor
typically subsides spontaneously to baseline levels over the blockers and cancer
first 24-72 hours.4,5 The rapid changes in BP related to
stroke make the prescription of antihypertensive drugs chal- Many antihypertensive drugs have been associated with
lenging and the diagnosis of chronic hypertension in the cancer only to have follow-up studies provide evidence that the
acute setting tenuous. There is a U-shaped prognostic value drugs do not cause cancer.11 A post-hoc meta-analysis of 8
of acute BP, with very low or very high BP associated with randomized controlled trials examining the association be-
poorer clinical outcome.4 tween angiotensin II receptor blockers (ARBs) and cancer was
In the setting of intracerebral hemorrhage, high BP is asso- reviewed.12 The analysis had several weaknesses and hence was
ciated with hematoma expansion.6,7 In contrast, in an acute not viewed to provide adequate causal evidence for an increased
intracranial arterial occlusion with cerebral infarction, hyper- risk of malignancy with ARB therapy. The task force noted that
tension may be either beneficial or harmful.4,5 Induced hyper- the U.S. Food and Drug Administration has an ongoing active
tension reduces neurologic deficit by increasing perfusion in review in progress and has not concluded that ARBs increase
zones where maximally dilated arteries have pressure-depen- the risk of cancer but currently has indicated the benefits of
dent flow; as a corollary, hypotension has negative effects in the ARBs continue to outweigh their potential risks pending the
same situation. Hypertension is also associated with hemor- results of their safety review (http://www.fda.gov/Drugs/
rhagic conversion of infarction, particularly when associated DrugSafety/PostmarketDrugSafetyInformationforPatients
with thrombolysis. There have been no large randomized con- andProviders/ucm218845.htm#Additional_Information_
trolled clinical trials to indicate treatment thresholds or targets for_Healthcare_Professionals). Given the potential that in-
for BP in acute stroke. Several consensus guidelines have been creased cardiovascular events may result from the sudden dis-
developed, and the guidelines of the Canadian Stroke Network continuation of antihypertensive therapy, the task force viewed
are now recommended by CHEP.8 These provide the follow- the stance of the FDA as prudent and plans to revisit this issue
ing guidance. as forthcoming data become available.
Campbell et al. 409
The 2011 Canadian Hypertension Education Program Recommendations

Hypertension in diabetes Hg in the standard arm vs 119.3 mm Hg in the intensive arm.


The main result of the BP study showed no significant benefit
This year, new data from the long-awaited Action to Con- for intensive BP lowering on the main composite outcome
trol Cardiovascular Risk in Diabetes Blood Pressure Interven- measure (nonfatal myocardial infarction, nonfatal stroke, and
tion Trial (ACCORD-BP) became available with the hope that cardiovascular death). Furthermore, a higher rate of adverse
it would clarify the target SBP for people with diabetes. Also, effects resulted from the additional antihypertensive therapy
the Avoiding Cardiovascular Events through Combination given to these patients. Stroke, one of the predefined secondary
Therapy in Patients Living with Systolic Hypertension (AC- outcomes however, was reduced by 42% (P ⫽ 0.01) in the
COMPLISH) diabetes subgroup analysis was published. Hy- intensive arm.
pertension contributes to both microvascular and macrovascu- The CHEP task force thought that 3 major issues relating to
lar disease in diabetes and the primary cause of premature death the ACCORD trial precluded accurate application of the study
in patients with diabetes is cardiovascular disease.13,14 For per- results to inform optimal target SBPs at this time. First, because
sons with diabetes, a BP target of ⬍130/80 mm Hg has previ- study patients did better than predicted based on the event
ously been recommended. The target DBP is based on a rates of older studies (there were 50% fewer cardiovascular
prespecified secondary analysis of the diabetic subgroup of the events in the ACCORD trial than expected), the study’s power
Hypertension Optimal Treatment (HOT) trial.15 In this sub- was reduced, limiting the trial’s ability to assess the clinical
group analysis, 1501 diabetic patients were randomized to 3 questions it was designed to address. Second, there was evi-
different target DBP thresholds: ⬍90 mm Hg, ⬍85 mm Hg, dence of a statistical interaction in ACCORD, which may af-
and ⬍80 mm Hg. The group assigned to DBP ⬍80 mm Hg fect interpretation of the study. There was a difference in the
had a ⬎50% reduction in major cardiovascular events and primary BP outcome in the 2 different glycemic target arms. In
cardiovascular mortality than the group assigned to the con- the usual glycemic control arm (now the standard of care),
ventional target of ⬍90 mm Hg. The current target SBP of there appeared to be a statistically significant 24% relative de-
⬍130 mm Hg is based on less rigourous clinical trial evidence crease in the ACCORD trial’s primary composite outcome in
(specifically, extrapolation of data from the normotensive Ap- the intensive BP treatment arm compared to the standard treat-
propriate Blood Pressure Control in Diabetes [ABCD] trial) ment arm. In the intensive glucose-lowering arm of the study,
than the target DBP; however, a series of randomized con- there appeared to be no benefit to intensive BP control. Over-
trolled trials in a meta-analysis provides convincing evidence of all, further information regarding the presence of interactions
reductions in cardiovascular and total mortality with more in- will be needed to properly interpret the results of the study.
tensive therapy.14,16 This ABCD trial examined the impact of Third, the ACCORD trial did not directly include a compar-
a 10 mm Hg greater DBP reduction in the intensive versus the ison arm of ⬍130 mm Hg, which is the threshold currently
standard arm in patients with a pretrial DBP of 80-89 mm Hg. recommended, and so it does not directly inform whether this
The achieved BP was 128/75 mm Hg in the intensive treat- threshold should be maintained.
ment group vs 137/81 mm Hg in the standard treatment Given the lack of analysis provided and the lack of data to
group. Although there was no difference between groups in the support a change in the target BP for people with diabetes,
primary endpoint, which was change in 24-hour creatinine CHEP was not able to come to a consensus to move the target
clearance, there were reductions in the progression of retinop- in either direction and has left the target BP at ⬍130/80 mm
athy and a 71% reduction in stroke in the intensively treated Hg for 2011. The task force plans to follow this issue closely
patients. and issue further guidance as new data become available.
In 2010, the ACCORD trial data became available, which Also new this year is a recommendation supporting angio-
examined whether a lower target SBP of ⬍120 mm Hg might tensin-converting enzyme inhibitor (ACEI)– calcium channel
be preferable to a current target of ⬍140 mm Hg.17 Based on blocker (CCB) combination therapy over ACEI-diuretic com-
the largely neutral results of this study, some have called for a bination therapy in patients with type 2 diabetes who are pre-
higher target SBP (⬍140 mm Hg); however, CHEP recom- scribed an ACEI and need combination therapy. This is based
mends no change to the current target SBP of ⬍130/80 mm on the ACCOMPLISH trial, which compared amlodipine/
Hg, largely because clear consensus could not be reached and benazepril versus thiazide/benazepril as combination treat-
because further information is required to assist with proper ment. The primary endpoint was a composite of myocardial
interpretation of the ACCORD trial. infarction, stroke, cardiovascular death, hospitalization for an-
A number of different conclusions can be reached from the gina, resuscitated cardiac arrest, and coronary revasculariza-
data available so far from the ACCORD-BP study, which may tion. The trial enrolled 6946 high-risk subjects with type 2
indicate that the question of the best target SBP for people with diabetes. With virtually equal BP control, the amlodipine/
diabetes is more complex than previously thought. ACCORD benazepril arm reduced occurrence of the primary event com-
had a complex double 2 ⫻ 3 factorial design.17 It examined the pared to thiazide/benazepril by a statistically significant 21%
effect of intensive versus standard glucose control in the entire (absolute risk reduction 8.8% vs 11%).
population of 10,251 patients. It also assessed the effect of
Pharmacists and improved blood pressure control
intensive versus standard BP control in a subgroup of 4733
patients and the effect of fibrate-based lipid-lowering therapy Team-based health care is advocated for the management of
(on a background of statin-based lipid-lowering therapy) in the chronic diseases18 and has been advocated as routine clinical
remaining 5518 patients who were not in the intensive BP part care of hypertension in Canada.19 In 2010, CHEP reviewed a
of the study. It was anticipated that the ACCORD study would meta-analysis and several clinical trials that indicate that in-
clarify the optimal SBP treatment target in diabetes. Achieved volvement of pharmacists in hypertension care improved ad-
SBP levels in the BP arm of the ACCORD trial were 133.5 mm herence and BP control.17,20-25 Table 2 outlines the steps that
410 Canadian Journal of Cardiology
Volume 27 2011

Table 1. Considerations in the individualization of antihypertensive therapy


Initial therapy Second-line therapy Notes and/or cautions
Hypertension without other compelling indications (target blood pressure < 140/90 mm Hg)
Diastolic ⫾ systolic hypertension Thiazide diuretics, ␤-blockers, ACEIs, Combinations of first-line ␤-blockers are not recommended as initial
ARBs, or long-acting calcium drugs therapy in those older than 60 years of age.
channel blockers (consider ASA Hypokalemia should be avoided by using
and statins in selected patients). potassium-sparing agents in those who are
Consider initiating therapy with a prescribed diuretics as monotherapy.
combination of first-line drugs if ACEIs are not recommended in blacks.
the blood pressure is ⱖ20 mm Hg ACEIs, ARBs, and direct renin inhibitors
systolic or ⱖ10 mm Hg diastolic are potential teratogens, and caution is
above target required if prescribing to women of child-
bearing potential. Combination of an
ACEI with an ARB is not recommended.
Isolated systolic hypertension Thiazide diuretics, ARBs, or long- Combinations of first-line Same as diastolic ⫾ systolic hypertension
without other compelling acting dihydropyridine calcium drugs
indications channel blockers
Diabetes mellitus (target blood pressure < 130/80 mm Hg)
Diabetes mellitus with albuminuria,* ACEIs or ARBs Addition of dihydropyridine A loop diuretic could be considered in
cardiovascular disease, renal CCB is preferred over hypertensive CKD patients with
disease or additional thiazide extracellular fluid volume overload
cardiovascular risk factors,
Diabetes mellitus not included in the ACEIs, ARBs, dihydropyridine CCBs, Combination of first-line Combination of an ACEI with an ARB is
above category or thiazide diuretics drugs or, if first-line specifically not recommended.
agents are not tolerated,
addition of cardioselective
␤-blockers and/or long-
acting
nondihydropyridine
CCBs
Cardiovascular disease (target blood pressure < 140/90 mm Hg)
Coronary artery disease ACEIs or ARBs (except in low-risk Long-acting CCBs. When Avoid short-acting nifedipine. Combination of
patients); ␤-blockers for patients combination therapy is an ACEI with an ARB is specifically not
with stable angina being used for high-risk recommended
patients, an ACEI/
dihydropyridine CCB is
preferred
Prior myocardial infarction ␤-blockers, ACEIs (ARBs if ACEI Long-acting CCBs Combination of an ACEI with an ARB is
intolerant) specifically not recommended
Heart failure ACEIs (ARBs if ACEI-intolerant) and ARB in addition to ACEI. Titrate doses of ACEIs and ARBs to those used
␤-blockers. Spironolactone in Hydralazine/isosorbide in clinical trials. Avoid nondihydropyridine
patients with NYHA class III or dinitrate combination CCBs (diltiazem, verapamil). Monitor
IV symptoms. Thiazide or loop diuretics are potassium and renal function if combining
recommended as additive an ACEI with ARB
therapy
Left ventricular hypertrophy Does not affect initial treatment Combination of additional Hydralazine and minoxidil can increase left
recommendations agents ventricular hypertrophy
Past stroke or TIA ACEI/diuretic combinations Combination of additional This does not apply to acute stroke. Blood
agents pressure reduction reduces recurrent
strokes in stable patients. Combination of
an ACEI with an ARB is specifically not
recommended.
Nondiabetic chronic kidney disease (target blood pressure < 130/80 mm Hg)
Nondiabetic chronic kidney disease ACEIs (ARBs if ACEI-intolerant) if Combinations of additional Avoid ACEIs or ARBs if bilateral renal artery
with proteinuria† there is proteinuria agents stenosis or unilateral disease with solitary
Diuretics as additive therapy kidney. Patients placed on an ACEI or an
ARB should have their serum creatinine
and potassium carefully monitored.
Combinations of an ACEI and ARB are
specifically not recommended in patients
with chronic kidney disease without
proteinuria
Renovascular disease Does not affect initial treatment Combinations of additional Avoid ACEIs or ARB if bilateral renal artery
recommendations agents stenosis or unilateral disease with solitary
kidney
Other conditions (target blood pressure < 140/90 mm Hg)
Peripheral arterial disease Does not affect initial treatment Combinations of additional Avoid ␤-blockers with severe disease
recommendations agents
Dyslipidemia Does not affect initial treatment Combinations of additional –
recommendations agents
Campbell et al. 411
The 2011 Canadian Hypertension Education Program Recommendations

Table 1. Continued
Initial therapy Second-line therapy Notes and/or cautions
Overall vascular protection Statin therapy for patients with 3 or – Caution should be exercised with the ASA
more cardiovascular risk factors or recommendation if blood pressure is not
atherosclerotic disease controlled.
Low-dose ASA in patients with
controlled blood pressure
Table provided by the Canadian Hypertension Education Program.
ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; ASA, aspirin; CKD, chronic kidney disease; NYHA, New York Heart
Association; TIA, transient ischemic attack.
* Albuminuria is defined as a persistent albumin to creatinine ratio of ⬎ 2.0 mg/mmol in men and ⬎ 2.8 mg/mmol in women.

Proteinuria is defined as urinary protein ⬎ 500 mg in 24 h or albumin to creatinine ratio ⬎ 30 mg/mmol.

are recommended to assist people with hypertension adhere to have been shown to improve risk perception by patients and
their therapy, including a new recommendation for health care risk factor management by physicians and can be accessed at
teams to incorporate pharmacists to improve monitoring of the Web sites www.myhealthcheckup.com and www.monbi-
adherence with pharmacologic and lifestyle-modification pre- lansante.com. The SCORE risk calculation has been updated
scriptions. using Canadian data and is now available at www.SCORE-
Canada.ca.
Cardiovascular age and cardiovascular risk
CHEP recommends assessment of cardiovascular risk in Hypertension and blood pressure measurement in
people with hypertension. Many people may, however, have population surveys
difficulty in interpreting cardiovascular risk when presented in Hypertension is the leading risk for premature death and is
a traditional fashion.26 Assessing risk over 5-10 years may result a leading risk for disability; hence, measurement of BP is com-
in the undertreatment of the young and target older individuals mon in health measures surveys. The BP information is used to
for medical therapy based on a high absolute risk in the absence track relative changes over time in the population’s BP and
of significantly elevated risk factors. Recent clinical trials have estimates of hypertension prevalence, awareness, treatment,
shown the utility of presenting cardiovascular risk as the pa- and control. Although there are several limitations, the survey
tient’s age based on their cardiovascular risk.27-29 CHEP has data are also used to estimate the clinical diagnosis, treatment,
therefore recommended consideration of using an individual’s and control rates. As outlined in CHEP recommendations, the
calculated risk compared to the average risk of Canadians of the diagnosis of hypertension and assessment of BP is complex and
same age and sex. Programs that compare risk by using terms requires multiple visits and BP measures, especially to accu-
such as “cardiovascular age,” “vascular age,” and “heart age” rately classify those with BPs of 140-159/90-99 mm Hg.30 In
2005, a committee of 19 Canadian experts developed mini-
mum criteria to use in surveys that assess BP to enhance their
Table 2. Strategies to improve patient adherence accuracy.31 Automated BP monitors that operate in the ab-
Assist your patient to adhere by:
sence of survey personal were recommended to be used. These
● Tailoring pill-taking to fit patients’ daily habits devices are less influenced by study personal (and hence have
● Simplifying medication regimens to once-daily dosing lower rates of “white coat hypertension” and “white coat ef-
● Replacing 2 antihypertensive agents with a fixed-dose combination fect”), do not have terminal digit preference, and reduce many
(where available and appropriate), provided it is the same combination of the technical issues associated with BP measurement.31 Both
the patient is already taking
● Using unit-of-use packaging (of several medications to be taken the recent population surveys in Ontario (ONBP) and Canada
together) (Canadian Health Measures Survey) used the same fully auto-
● Identifying potential barriers to adherence mated device (BPtru; BpTRU Medical Devices, Coquitlam,
Assist your patient in getting more involved in their treatment by: British Columbia, Canada).1,32
● Encouraging greater patient responsibility/autonomy in monitoring
their blood pressure and adjusting their prescriptions
The use of fully automated BP devices may result in read-
● Educating patients and patients’ families about their disease/treatment ings that are lower than those obtained by standardized office
regimens measurements using mercury-based devices. In the ONBP
Improve your management in the office and beyond by: trial, 10% of those surveyed had readings obtained from both
● Assessing adherence to pharmacologic and nonpharmacologicl therapy the automated BP device and single standardized measure-
at every visit
● Reassess patients at least every 2 months for those patients with a blood ments using mercury-based devices, and a calibration equation
pressure above target was developed to allow comparison of the 2 methods.32 Use of
● Encouraging adherence with therapy via out-of-office contact (by either the calibration equation indicates automated office readings are
telephone or mail), particularly over the first 3 months of therapy 1.6/0.3 mm Hg lower than standardized readings at the ther-
● Coordinating with pharmacists and work-site health care providers to
improve monitoring of adherence with pharmacologic and lifestyle
apeutic cutpoint of 140/90 mm Hg. Adjustment of the Cana-
modification prescriptions dian Health Measures Survey using the regression equation has
● Using electronic medication compliance aids little impact on the prevalence, awareness, treatment, or con-
● Adherence to an antihypertensive prescription can be improved by a trol rate of hypertension in Canada (eg, ⬃2% difference in
multidisciplinary team approach control rate, N. Campbell, unpublished observation). Further,
Table provided by the Canadian Hypertension Education Program. single-visit readings with the fully automated device used in the
412 Canadian Journal of Cardiology
Volume 27 2011

Canadian survey produce average values similar to averages food procurement. A substantial amount of food purchased
using standardized measurements with mercury-based devices using public funds or sold in public buildings is inconsistent
after 3 visits; hence, readings with fully automated devices are with Canada’s Guide to Healthy Eating. Standardized healthy
more like BP values recommended to be used to clinically di- food procurement policies used by all levels of government
agnose hypertension using current recommendations.33,34 would be likely to contribute to healthy eating patterns. New
The improvement in control of hypertension in the recent York City is an example of a jurisdiction that has been active in
surveys may be even greater than current analyses suggest. The developing such a food procurement policy (http://www.
Canadian Heart Health Survey (1985–1992) that produced cspinet.org/new/pdf/nyc_agency_food_standards.pdf). Another
the baseline BP control levels for Canada used readings from 2 potential policy example is exposure of children to an almost
visits and the home setting was used for one of the visits; both unending advertizing of “junk” foods. Although a ban in ad-
factors are known to result in lower readings than single visits in vertizing to children has been strongly advocated by many
a clinic setting.35 Unfortunately, there has been no validation international and national groups, only Québec has imple-
work preformed to allow more direct comparison of the BP mented such a policy in Canada.46 The lack of clear, easy-to-
values from the different surveys. understand warnings on foods containing high quantities of
Some authors have suggested that a more appropriate ad- sodium, saturated fats, simple sugars, and calories is another
justment of the Canadian survey data would be reducing the area where thoughtful public policy change could help Cana-
values by 5/5 mm Hg, citing a CHEP recommendation that dians avoid unhealthy foods. Warning labels for high-sodium
readings with fully automated office devices of 135/85 mm Hg products was believed to be one of the success factors for the
are similar to daytime ambulatory BP readings of 135/85 mm program to reduce dietary sodium in Finland.48
Hg.36 Data linking precise daytime ambulatory BP s with stan- In 2011, CHEP calls to action all Canadians to become
dardized office readings using mercury-based devices on which active in advocating for healthy public policies. A major new
therapeutic cut points (140/90 mm Hg) are based are still un- effort by Hypertension Canada is to develop a Public Policy
clear. In contrast to the CHEP recommendation that Committee to work with government and nongovernment or-
“rounded” the estimate of abnormal daytime ambulatory BP ganizations to promote policies to prevent and control hyper-
readings to 135/85 mm Hg, both European and American tension. By aligning health care professionals, their organiza-
Heart Association recommendations equated “rounded” day- tions, and various levels of government to work on a common
time ambulatory BP readings of 140/90 mm Hg with being policy agenda, it is believed substantive progress can be made to
abnormal.30,37-39 To the CHEP executive’s knowledge, there further prevent and control hypertension.
have been no national survey studies using ambulatory BP and
there is inadequate clinical trial data using ambulatory or au-
Hypertension Canada
tomated BP from which accurate therapeutic thresholds or tar-
Hypertension Canada was formed in 2010 by integrating 3
gets could be derived. The lack of clarity is also reflected by
existing national hypertension organizations (Blood Pressure
almost uniform disagreement in selecting treatment thresholds
Canada, the Canadian Hypertension Society, and Canadian
among world experts when using ambulatory BP monitor-
Hypertension Education Program), thereby providing sub-
ing.37 The new technologies for automated office BP measure-
stantive opportunities for developing more synergistic interac-
ment are appropriately generating interest and debate as well as
tions across education, health care, policy and research. The
stimulating new research in the area but should not take away
mission of Hypertension Canada is: “Advancing health by the
from the fact that while BP awareness treatment and control
prevention and control of high BP through research, advocacy,
rates have improved in Canada, these rates are far from ideal
education and knowledge development and translation.” For
and have not yet been demonstrated to be sustainable.
more information, visit the Hypertension Canada Web site at
The importance of becoming more active in health www.hypertension.ca. The CHEP program will continue to
policy advocacy function within Hypertension Canada.
Hypertension is largely preventable.40,41 Unhealthy diets
high in sodium, physical inactivity, and weight gain coupled Hypertension Knowledge Translation
with excess alcohol consumption and stress in some are major A key CHEP knowledge translation effort has been to pro-
contributors.40,42 Most hypertensive Canadians want to have a vide regular updates and multiple resources to suit the differing
healthier lifestyle and are trying to make appropriate lifestyle needs of individual health care providers and Canadians with
changes, but change is very difficult in the current social envi- hypertension. However, a survey conducted by the Heart and
ronment. Extensive reviews outline the policies that are likely Stroke Foundation (unpublished) found many primary health
to improve our environment to make healthy changes easier care providers remained unaware of CHEP recommendations
but these policies are rarely implemented.43-47 Lack of engage- and many faced challenges in accessing CHEP updates. In re-
ment of the public, scientists, and health care professionals has sponse, CHEP has developed new Internet methods for health
impeded the political will to bring about the healthy public care professionals and people with hypertension to stay up to
policies that can substantively reduce the estimate that 95% of date. At www.htnupdate.ca, health care professionals can sign
Canadians will develop hypertension over an average life span. up and be updated electronically when new resources are de-
Hence, CHEP has selected the need for health care profession- veloped or old ones are updated and they can download current
als and the public to engage in advocacy for health policy as the resources. Similarly, people at risk or with hypertension can
theme for 2011. sign up at www.myBPsite.ca for public updates and current
One area that Hypertension Canada is exploring is the po- resources. To aid knowledge translation at the community
tential benefit that government policy would have for healthy level, CHEP also hosts training sessions for health care profes-
Campbell et al. 413
The 2011 Canadian Hypertension Education Program Recommendations

sionals to enable them to become leaders for hypertension 9. Delcourt C, Huang Y, Wang J, et al. The second (main) phase of an
education in their communities, or “Hypertension Champions.” open, randomised, multicentre study to investigate the effectiveness of
These sessions are held throughout the year in different regions an intensive blood pressure reduction in acute cerebral haemorrhage
trial (INTERACT2). Int J Stroke 2010;5:110-6.
of the country in association with national or regional meetings.
Those interested can either sign up for updates at www. 10. Hackam DG, Khan NA, Hemmelgarn BR, et al. The 2010 Canadian
htnupdate.ca or periodically visit www.hypertension.ca. Hypertension Education Program recommendations for the management
of hypertension: part 2, therapy. Can J Cardiol 2010;26:249-58.

Acknowledgements 11. Grossman E, Messerli FH, Goldbourt U. Antihypertensive therapy and


The CHEP executive would like to acknowledge contribu- the risk of malignancies. Eur Heart J 2001;22:1343-52.
tions of Drs M. Hill, R. Padwal, T. Campbell, and S. Grover to 12. Sipahi I, Debanne S, Rowland D, Simon DI, Fang JC. Angiotensin-
sections of this summary and the more than 150 health care receptor blockade and risk of cancer: meta-analysis of randomised con-
professional volunteers who contribute to the CHEP program. trolled trials. Lancet Oncol 2010;11:627-36.

13. Campbell NR, Leiter LA, Larochelle P, et al. Hypertension in diabetes: a


Disclosures call to action. Can J Cardiol 2009;25:299-302.
Norman R. C. Campbell received a travel grant and hon-
14. Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of
ouraria for chairing a session sponsored by Boehringer-Ingel-
different blood pressure-lowering regimens on major cardiovascular
heim. Luc Poirier has received honouraria for presentations events in individuals with and without diabetes mellitus: results of pro-
sponsored by many different pharmaceutical companies and is spectively designed overviews of randomized trials. Arch Intern Med
on the advisory board of Novartis Canada. Sheldon W. Tobe 2005;165:1410-9.
receives honouraria for academic talks from most of the ethical
pharmaceutical manufacturers of CV medicines including: 15. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-
pressure lowering and low-dose aspirin in patients with hypertension:
Pfizer, Bristol-Myers, sanofi-aventis, Amgen, Roche, Merck,
principal results of the Hypertension Optimal Treatment (HOT) ran-
and Boehringer-Ingelheim. He has been and continues to be
domised trial. Lancet 1998;351:1755-62.
involved as an investigator on several research projects both
contract and investigator initiated with Abbott, Astra Zeneca, 16. Schrier RW, Estacio RO, Esler A, et al. Effects of aggressive blood pressure
Janssen Ortho, Novartis, Bristol-Myers, sanofi-aventis, Am- control in normotensive type 2 diabetic patients on albuminuria, retinop-
gen, Roche, Merck, and Boehringer-Ingelheim. He is also a athy and strokes. Kidney Int 2002;61:1086-97.
member of the advisory boards for Pfizer, Merck, Abbott, Bris- 17. The ACCORD Study Group, Cushman WC, Evans GW, et al. Effects of
tol-Myers, and sanofi-aventis. Guy Tremblay, Patrice Lindsay, intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med
and Deb Reid have no conflicts of interest to disclose. 2010;362:1575-85.

18. Lewanczuk R. Hypertension as a chronic disease: what can be done at a


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