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The full slide set of the 2012 CHEP Recommendations is available at www.hypertension.ca
Whats new? Out-of-office blood pressure measurements are important in both the diagnosis and management of hypertension For patients with nondiabetic chronic kidney disease, target blood pressure should be < 140/90 mmHg For patients with systolic dysfunction and hypertension ACE inhibitors, beta-blockers and (for most) aldosterone antagonists are recommended
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.hypertension.ca for automatic updates and information on current hypertension educational resources
I. Lifestyle management
2012 Canadian Hypertension Education Program Recommendations
High in:
Fresh fruits Fresh vegetables Low fat dairy products Dietary and soluble fibre Plant protein
Less than 2300mg / day (Most of the salt in food is hidden and comes
from processed food)
Dietary Potassium
Daily dietary intake >80 mmol
Low in:
Saturated fat and cholesterol Sodium
Calcium supplementation
No conclusive studies for hypertension
Magnesium supplementation
No conclusive studies for hypertension
www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.
Age
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
Sodium: Meta-analyses
Average Reduction of sodium in mg/day 1800 mg/day 2300 mg/day Average Reduction of sodium in mg/day 1700 mg/day 2300 mg/day Hypertensives Reduction of BP 5.1 / 2.7 mmHg 7.2/3.8 mmHg Normotensives Reduction of BP 2.0 / 1.0 mmHg 3.6/1.7 mmHg
F I T T
Cardiorespiratory Activity
- Walking, jogging - Cycling - Non-competitive swimming
Waist Circumference
Men <102 cm Women <88 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
Intervention
Reduce sodium intake Weight loss Alcohol intake Aerobic exercise Dietary patterns
Intervention
-1800 mg/day sodium Hypertensive per kg lost -3.6 drinks/day 120-150 min/week DASH diet Hypertensive
SBP/DBP
-5.1 / -2.7 -1.1 / -0.9 -3.9 / -2.4 -4.9 / -3.7 -11.4 / -5.5
Intervention
Reduce foods with added sodium Weight loss Alcohol restriction Physical activity Dietary patterns Smoking cessation Waist circumference
Target
< 2300 mg /day BMI <25 kg/m2 < 2 drinks/day 30-60 minutes 4-7 days/week DASH diet Smoke free environment Men <102 cm Women <88 cm
Reduction in BP
Usual blood pressure threshold values for initiation of pharmacological treatment of hypertension
Condition Initiation SBP or DBP mmHg Systolic or Diastolic hypertension Diabetes Chronic Kidney Disease u140/90 u130/80 u140/90
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 140/90 mmHg
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.
Individualized Treatment
(and compelling indications)
III. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling Indications
TARGET <140/90 mmHg INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy
Thiazide
ACEI
ARB
Longacting CCB
Betablocker*
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
BBs are not indicated as first line therapy for age 60 and above
ACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential
III. Add-on Therapy for Systolic/Diastolic Hypertension without Other Compelling Indications
1. Add-on Therapy
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).
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
%
40 20 0 Baseline 6 mo 1y 3y 5y
<140/90 mm Hg
1.4 1.2 1 0.8 0.6 0.4 0.2 0 Thiazide -blocker ACE-I Combine Double CCB All 0.19 0.37 0.23 0.2 0.22 1.16 1.04 1 0.89 1.01
Wald et al, Combination Versus Monotherapy for Blood Pressure Reduction, The American Journal of Medicine, Vol 122, No 3, March 2009
Initial therapy
Thiazide diuretic
ACEI
ARB
Long-acting CCB
Betablocker*
CONSIDER Nonadherence Secondary HTN Interfering drugs or lifestyle White coat effect
Dual Combination
III. Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications
Thiazide diuretic
ARB
III. Add-on therapy for Isolated Systolic Hypertension without Other Compelling Indications
If partial response to monotherapy
Dual combination
Combine first line agents
Thiazide diuretic
ARB
CONSIDER Nonadherence Secondary HTN Interfering drugs or lifestyle White coat effect
Triple therapy
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).
III. Summary: Treatment of Isolated Systolic Hypertension without Other Compelling Indications
TARGET <140 mmHg
Lifestyle modification therapy
Thiazide diuretic
ARB
CONSIDER Nonadherence Secondary HTN Interfering drugs or lifestyle White coat effect
Dual therapy
Triple therapy
*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).
Diabetes Mellitus
With Nephropathy Without Nephropathy
V. Goals of Therapy
2012 Canadian Hypertension Education Program Recommendations
V. Goals of Therapy
Blood pressure target values for treatment of hypertension Condition Target SBP and DBP mmHg
Isolated systolic hypertension Systolic/Diastolic Hypertension Systolic BP Diastolic BP Diabetes Systolic Diastolic Non-DM CKD Systolic Diastolic <140 <140 <90 <130 <80 <140 <90
49
V. 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
Stable angina
ACEI are recommended for most patients with established CAD* ARBs are not inferior to ACEI in IHD
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
*Those at low risk with well controlled risk factors may not benefit from ACEI therapy
Short-acting nifedipine
VI. Treatment of Hypertension in Patients with Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI
Beta-blocker and ACEI or ARB
Heart Failure ?
YES
NO
Long-acting CCB
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)
Strongly consider blood pressure reduction in all patients after the acute phase of stroke or TIA .
Stroke TIA
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
Renovascular disease
Caution in the use of ACEI or ARB in bilateral renal artery stenosis or unilateral disease with solitary kidney
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.
without Nephropathy** Systolicdiastolic Hypertension Isolated Systolic 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
Addition of one or more of Long-acting CCB or Thiazide diuretic 3 - 4 drugs combination may be needed
If Creatinine over 150 mol/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
Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
DHP: dihydropyridine
IF ACE Inhibitor and ARB and DHP-CCB and Thiazide are contraindicated or not tolerated, SUBSTITUTE Cardioselective BB* or Long-acting NON DHP-CCB
Combinations of an ACE Inhibitor with an ARB are specifically not recommended in the absence of proteinuria * Cardioselective BB: Acebutolol, Atenolol, Bisoprolol , Metoprolol More than 3 drugs may be needed to reach target values for diabetic patients
without Nephropathy
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 More than 3 drugs may be needed to reach target values for diabetic patients If Creatinine over 150 mol/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
XIII. Adherence
2012 Canadian Hypertension Education Program Recommendations
Download at www.hypertension.ca
Download at www.hypertension.ca
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
Download at www.hypertension.ca
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.
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 Canadas 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 target BP is <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.hypertension.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.
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.hypertension.ca for automatic updates and on current hypertension educational resources