Part 1: Recommendations for Hypertension Diagnosis Assessment and Follow up

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Part 1 Recommendations for Hypertension
Diagnosis Assessment and Follow up
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Overseeing organizations and partners

• Overseeing organizations
• Blood Pressure Canada
• Canadian Council of Cardiovascular Nurses
• Canadian Hypertension Society
• Canadian Pharmacists Association
• College of Family Physicians of Canada
• Heart and Stroke Foundation of Canada
• Public Health Agency of Canada
• Partner organizations
• Canadian Cardiovascular Society
• Canadian Diabetes Association
• Canadian Society of Nephrology
• Canadian Stroke Network
• Canadian Society of Internal Medicine
• Kidney Foundation of Canada
• Volunteers (gt100)

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Whats New for 2009The Hypertensive Diabetic

• Patients with diabetes are at high cardiovascular
  risk
• Up to 80 of diabetic patients die of
  cardiovascular disease
• Most patients with diabetes have hypertension
• Between 35 and 75 of diabetic complications have
  been attributed to hypertension.
• Treatment of hypertension in patients with
  diabetes reduces total mortality, myocardial
  infarction, stroke, retinopathy and progressive
  renal failure rates.
• More intensive reduction in blood pressure
  reduces major cardiovascular events and total
  mortality by 25

Treating hypertension in the diabetic patient
reduces death and disability and reduces health
care system costs TARGET lt130 systolic and lt80
mmHg diastolic
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Whats New for 2009The Hypertensive Diabetic

• 2/3rds of hypertensive diabetic patients have
  uncontrolled hypertension (gt 130/80 mmHg)
• There is underutilization of diuretic therapy in
  treating hypertension in diabetic patients. In
  general a diuretic is required for blood pressure
  control in multi drug regimes.
• A combination of lifestyle changes and 3 or more
  medications are often required.
• More intensive reduction in blood pressure in the
  hypertensive diabetic is one a few medical
  interventions where the cost of treatment is less
  than the cost of the complications prevented

Treating hypertension in the diabetic patient
reduces death and disability and reduces health
care system costs TARGET lt130 systolic and lt80
mmHg diastolic
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Whats New for 2009

• The combination of an ACE inhibitor with an ARB
  is not recommended in patients with
• hypertension without compelling indications,
• coronary artery disease who do not have heart
  failure,
• prior stroke,
• non proteinuric chronic kidney disease or
• diabetes mellitus without micro albuminuria

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Whats New for 2009

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

N Engl J Med 20083581887-98.
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2009 Canadian Hypertension Education Program
(CHEP)

• A red flag has been posted where
  recommendations were updated for 2009.
• Slide kits for medical education and health care
  professional, patient and public information can
  be downloaded (English and French versions)
  from the Canadian Hypertension Society website
  at
• www.hypertension.ca

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The Canadian Hypertension Education Program 2009
Recommendations Whats old but still important?
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Key CHEP messages for the management of
hypertension

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

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2009 Canadian Hypertension Education Program
(CHEP)

• IMPORTANT ROLE FOR HOME MEASUREMENT OF BLOOD
  PRESSURE
• Encourage hypertensive patients to use an
  approved blood pressure measuring device and use
  proper technique to assess blood pressure at
  home.
• Measuring blood pressure at home has a stronger
  association with cardiovascular prognosis than
  office based readings.
• Home measurement can confirm the diagnosis of
  hypertension, improve blood pressure control,
  reduce the need for medications in some, detect
  those with white coat and masked hypertension and
  improve medication adherence in non adherent
  patients.

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2009 Canadian Hypertension Education Program
(CHEP)

• IMPORTANT ROLE FOR HOME MEASUREMENT OF BLOOD
  PRESSURE
• An internet-based tool kit for home blood
  pressure measurement including recording and
  tracking of blood pressure can be found at
  www.heartandstroke.ca/bp
• Patient information on selecting an approved
  device, and how to measure and track home blood
  pressure can be found at www.hypertension.ca/bpc

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2009 Canadian Hypertension Education Program
(CHEP)
Table of contents

• HYPERTENSION DIAGNOSIS, ASSESSMENT AND FOLLOW-UP
• Assess blood pressure at all appropriate visits
• Criteria for the diagnosis of hypertension and
  follow-up
• Assessment of overall cardiovascular risk in
  hypertensive patients
• Routine and optional laboratory tests for the
  investigation of patients with hypertension
• Assessment of renovascular hypertension
• Endocrine hypertension
• Home measurement of blood pressure
• Ambulatory blood pressure measurement
• Role of Echocardiography

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2009 Canadian Hypertension Education Program
(CHEP)

• Approximately 95 of Canadians will develop
  hypertension if they live an average lifespan
• Most overweight patients with high normal blood
  pressure (130-139/85-89 mmHg) develop
  hypertension within 4 years and almost 1/2 within
  2 years. Annual follow-up of patients with high
  normal blood pressure is recommended.

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What percent of Canadians have hypertension?
CCHS CMAJ 1992
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Life time risk of Hypertension in Normotensive
Women and Men aged 65 years
Risk of Hypertension
Risk of Hypertension
100
100
Women
Men
80
80
60
60
40
40
20
20
0
0
Years to Follow-up
Years to Follow-up
JAMA 2002 Framingham data.
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Reversible risks for developing hypertension

• Obesity
• Poor dietary habits
• High sodium intake
• Sedentary lifestyle
• High alcohol consumption

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Incidence of hypertension in those identified
with high normal blood pressure

• 772 subjects, mean age 48.5
• Not receiving treatment for Hypertension
• Average of 3 blood pressures at baseline
• SBP 130-139 and DBP lt 89 OR
• SBP lt 139 and DBP 85-89
• Primary endpoint new onset Hypertension

NEJM 20063541685-97
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New onset hypertension in people with high normal
blood pressure
NEJM 20063541685-97
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Development of hypertension in those with high
normal blood pressure
Framingham cohort Vasan. Lancet 2001
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High risk of developing hypertension in those
with high normal blood pressure

• Annual follow-up of patients with high normal
  blood pressure is recommended.

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I. Assess blood pressure at all appropriate
visits

• Blood pressure of all adults should be measured
  whenever it is appropriate by healthcare
  professionals using standardized techniques.
• To screen for hypertension
• To assess cardiovascular risk
• To monitor antihypertensive treatment

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II. Criteria for the diagnosis of hypertension
and recommendations for follow-up
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II. Criteria for the diagnosis of hypertension
and recommendations for follow-up
Hypertension Visit 1 BP Measurement, History and
Physical examination
Diagnostic tests ordering at visit 1 or 2
Hypertension Visit 2 within 1 month
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II. Criteria for the diagnosis of hypertension
and recommendations for follow-up
BP 140-179 / 90-109
Patients with high normal blood pressure (clinic
SBP 130-139 and/or DBP 85-89) should be followed
annually.
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II. Criteria for the diagnosis of hypertension
and recommendations for follow-up
Diagnosis of hypertension
Non Pharmacological treatment With or without
Pharmacological treatment
Are BP readings below target during 2 consecutive
visits?
No
Yes
Symptoms, Severe hypertension, Intolerance to
anti-hypertensive treatment or Target Organ Damage
Follow-up at 3-6 month intervals
Yes
No
Visits every 1 to 2 months
More frequentvisits
Consider Home blood pressure measurement in
hypertension management, to assess for the
presence of masked hypertension or white coat
effect and to enhance adherence.
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The concept of masked hypertension
140
True hypertensive
Masked HTN
Home or Daytime ABPM SBP mmHg
135
True Normotensive
White Coat HTN
140
Office SBP mmHg
Derived from Pickering et al. Hypertension 2002
40 795-796.
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The prognosis of masked hypertension
Prevalence of masked hypertension is
approximately 10 in the general population but
is higher in patients with diabetes
J Hypertension 2007252193-98
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Search for target organ damage
III. Assessment of the overall cardiovascular risk
Cerebrovascular disease - transient ischemic
attacks - ischemic or hemorrhagic stroke -
vascular dementia Hypertensive retinopathy Left
ventricular dysfunction Left ventricular
hypertrophy Coronary artery disease -
myocardial infarction - angina pectoris -
congestive heart failure Chronic kidney
disease - hypertensive nephropathy (GFR lt 60
ml/min/1.73 m2) - albuminuria Peripheral
artery disease - intermittent claudication -
ankle brachial index lt 0.9
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Search for exogenous potentially modifiable
factors that can induce/aggravate hypertension
III. Assessment of the overall cardiovascular risk

• Prescription Drugs
• NSAIDs, including COXIBS (e.g. celecoxib)
• Corticosteroids and anabolic steroids
• Oral contraceptive and sex hormones
• Vasoconstricting/sympathomimetic decongestants
• Calcineurin inhibitors (cyclosporin, tacrolimus)
• Erythropoietin and analogues
• Monoamine oxidase inhibitors (MAOIs)
• Other sympathomemetics e.g. Midodrine
• Other
• Licorice root
• Stimulants including cocaine
• Salt
• Excessive alcohol use
• Sleep apnea

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III. Assessment of the overall cardiovascular risk

• Over 90 of hypertensive Canadians have other
  cardiovascular risks
• Assess and manage hypertensive patients for
  dyslipidemia, dysglycemia (e.g. impaired fasting
  glucose, diabetes) abdominal obesity, unhealthy
  eating and physical inactivity

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Treat Hypertension in the Context of Overall
Cardiovascular Risk
III. Assessment of the overall cardiovascular risk

• 1. Overall cardiovascular risk should be
  assessed. In hypertensive patients consider
  using calculations that include cerebrovascular
  events.
• 2. In the absence of Canadian data to determine
  the accuracy of risk calculations, avoid using
  absolute levels of risk to support treatment
  decisions at specific risk thresholds.

Simply counting risk factors may underestimate
risk
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Cardiovascular Risk Factors
III. Assessment of the overall cardiovascular risk

• Presence of Risk Factors
• - Increasing age
• Male gender
• Smoking
• Family history of premature cardiovascular
  disease (agelt 55 in men and lt 65 in women)
• Dyslipidemia
• Sedentary lifestyle
• Unhealthy eating
• Abdominal obesity
• Dysglycemia (diabetes, impaired glucose
  tolerance, impaired fasting glucose)
• Presence of Target Organ Damage
• Microalbuminuria or proteinuria
• Left ventricular hypertrophy
• Chronic kidney disease (glomerular filtration
  rate lt 60 ml/min/1.73 m2)
• Presence of atherosclerotic vascular disease
• Previous stroke or TIA
• Coronary Heart Disease
• Peripheral arterial disease

CV Risk Factors that may alter thresholds and
targets in the treatment of HTN
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Methods of Risk Assessment
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SCORE 10 year Fatal Cardiovascular Risk
Evaluation in Canada
Find the cell nearest to the persons risk
factors values Age Sex Smoking Status Systolic
Blood Pressure Total-Chol. / HDL-C. Ratio
Systematic Coronary Risk Evaluation
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SCORE Canada Relative Risk Evaluationfor use in
those less than 40 years old
n times risk at same age
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SCORE Canada Caveats to estimating Fatal CVD
Risk

• Person approaches next age category
• Pre-clinical evidence of atherosclerosis (CT
  scan, ultrasonography, )
• Strong family history of premature CVD Multiply
  risk by 1.4
• Obesity BMI gt 30 kg/m2, Waist circumference gt
  102 cm (men) and gt 88 cm (woman)
• Sedentary lifestyle
• Diabetes multiply risk by 2 for men and by 4 for
  women
• Raised serum triglycerides level
• Raised level of C-reactive prot., Fibrinogen,
  Homocysteine, Apolipoprotein B or Lp(a)

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IV. Routine Laboratory Tests
Preliminary Investigations of patients with
hypertension 1. Urinalysis 2. Blood chemistry
(potassium, sodium and creatinine) 3. Fasting
glucose 4. Fasting total cholesterol and high
density lipoprotein cholesterol (HDL), low
density lipoprotein cholesterol (LDL),
triglycerides 5. Standard 12-leads ECG Currently
there is insufficient evidence to recommend
routine testing of microalbuminuria in people
with hypertension who do not have diabetes
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IV. Routine Laboratory Tests
Follow-up investigations of patients with
hypertension During the maintenance phase of
hypertension management, tests (including
electrolytes, creatinine, glucose, and fasting
lipids) should be repeated with a frequency
reflecting the clinical situation. Diabetes
develops in 1-3/year of those with drug treated
hypertension. The risk is higher in those
treated with a diuretic or beta blocker, in the
obese, sedentary, with higher fasting glucose and
who have unhealthy eating patterns. Assess for
diabetes more frequently in these patients.
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IV. Optional Laboratory Tests
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Abnormal Urinary Albumin levels
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V. Screening for Renovascular Hypertension

• Patients presenting with two or more of the
  following clinical clues listed below suggesting
  renovascular hypertension should be investigated.
• sudden onset or worsening of hypertension and gt
  age 55 or lt age 30
• the presence of an abdominal bruit
• hypertension resistant to 3 or more drugs
• a rise in creatinine of 30 or more associated
  with use of an angiotensin converting enzyme
  inhibitor or angiotensin II receptor blocker
• other atherosclerotic vascular disease,
  particularly in patients who smoke or have
  dyslipidemia
• recurrent pulmonary edema associated with
  hypertensive surges

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V. Screening for Renovascular Hypertension

• The following tests are recommended, when
• available, to screen for renal vascular disease
• captopril-enhanced radioisotope renal scan
• doppler sonography
• magnetic resonance angiography
• CT-angiography (for those with normal renal
  function
• captopril-enhanced radioisotope renal scan is
  not recommended for those with glomerular
  filtration rates lt60 mL/min)

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VI. Screening for Hyperaldosteronism
Should be considered for patients with the
following characteristics

• Spontaneous hypokalemia (lt3.5 mmol/L).
• Profound diuretic-induced hypokalemia (lt3.0
  mmol/L).
• Hypertension refractory to treatment with 3 or
  more drugs.
• Incidental adrenal adenomas.

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VI. Screening for hyperaldosteronism

• Screening for hyperaldosteronism should include
  plasma aldosterone and renin activity (or renin
  concentration)
• - measured in morning samples.
• - taken from patients in a sitting position
  after
• resting at least 15 minutes.
• Aldosterone antagonists, ARBs, beta-blockers and
  clonidine should be discontinued prior to
  testing.
• A positive screening test should lead to referral
  or further testing.

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Renin, Aldosterone and Ratio Conversion factors
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VI. Screening for Pheochromocytoma
Should be considered for patients with the
following characteristics

• Paroxysmal and/or severe sustained hypertension
  refractory to usual antihypertensive therapy
• Hypertension and symptoms suggestive of
  catecholamine excess (two or more of headaches,
  palpitations, sweating, etc)
• Hypertension triggered by beta-blockers,
  monoamine oxidase inhibitors, micturition, or
  changes in abdominal pressure
• Incidentally discovered adrenal mass
• Multiple endocrine neoplasia (MEN) 2A or 2B von
  Recklinghausens neurofibromatosis, or von
  Hippel-Lindau disease. 

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VI. Screening for Pheochromocytoma

• Screening for pheochromocytoma should include a
  24 hour urine for metanephrines and creatinine.
• Assessment of urinary VMA is inadequate.
• A normal plasma metanephrine level can be used to
  exclude pheochromocytoma in low risk patients but
  the test is performed by few laboratories.

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VII. Home measurement of blood pressure
Home BP measurement should be encouraged to
increase patient involvement in care
Which patients?

• Uncomplicated hypertension
• Suspected non adherence
• Office-induced blood pressure elevation (white
  coat effect)
• Masked hypertension

Average BP gt 135/85 mm Hg should be considered
elevated
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Potential advantages of home blood pressure
measurement

• More rapid confirmation of the diagnosis of
  hypertension
• Improved ability to predict cardiovascular
  prognosis
• Improved blood pressure control
• Can be used to assess patients for white coat
  hypertension (WCH) and masked hypertension
• Reduced medication use in some (WCH)
• Improved adherence to drug therapy

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Not all patients are suited to home measurement

• Undue anxiety in response to high blood pressure
  readings
• Physical or mental disability prevents accurate
  technique or recording
• Arm not suited to blood pressure cuff (e.g.
  conical shaped arm)
• Irregular pulse or arrhythmias prevent accurate
  readings
• Lack of interest

Most patients can be trained to measure blood
pressure. Periodic reassessment of technique and
retraining is desirable
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VII. Suggested Protocol for Home Measurement of
Blood Pressure for the diagnosis of hypertension

• Home blood pressure values should be based on
• duplicate measures,
• morning and evening,
• for an initial 7-day period.
• First day home BP values should not be
  considered.
• The following six days blood pressure readings
  should be averaged
• Average BP equal to or over 135/85
• mmHg should be considered elevated.

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Recommended electronic blood pressure monitors
for home blood pressure measurement
-Monitors that have been validated as accurate
and available in Canada are listed at
www.hypertension.ca/chs in the device
endorsements section -The boxes containing the
device are also be marked with
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VII. Home Measurement of BP Patient Education
Assist patients select a model with the correct
size of cuff Measure and record the patients mid
arm circumference so they can match it to cuff
size. Recommend devices listed at
www.hypertension.ca or marked with this symbol
Ask patients to carefully follow the
instructions with device and to record only those
blood pressures where they have followed
recommended procedure Advise patients that
average readings equal to or over 135/85 mmHg are
high In patients with diabetes or chronic kidney
disease, lower therapeutic targets and diagnostic
criteria are likely required
Home measurement can help to improve patient
adherence
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Web based home monitoring

• Website resources are available
  www.heartandstroke.ca/bp
• Individualized automated counseling and tracking
  to assist patients home monitor and to enhance
  self management of lifestyle.

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More resources for home monitoring

• www.hypertension.ca/bpc
• Information to assist you in training patients to
  measure blood pressure at home
• Brief action tool for Health Care professionals
  under resources in the Education tools for health
  care professionals section
• Information for patients on how to purchase a
  device for home measurement and how to measure
  blood pressure at home
• Learn how to measure your blood pressure at home
  and Home measurement of blood pressure under
  resources in the Education tools for health care
  professionals section).
• In 2009, a training DVD on home measurement of
  blood pressure will become available for
  download

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Advice for patients on when to contact a health
care professional based on high average home
blood pressure readings
Patients with diabetes, chronic kidney disease
or who are at high risk of cardiovascular events
require individualized advice.
( resource available at www.hypertension.ca in
the 3 Minute Hypertension Action Tool or
www.heartandstroke.ca/BP)
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Home measurement Doing it right

• EQUIPMENT
• Validated device
• Look for the logo or go to
  www.hypertenion.ca/chs for a list of validated
  devices available in Canada
• Ensure the cuff size is appropriate
• Ensure the device is accurate in the patient at
  purchase and annually

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Home measurement Doing it right

• PREPARATION
• DO
• Read and carefully follow the instructions
  provided with the device
• Relax in a comfortable chair with back support
  for 5 minutes
• Sit quietly without talking or distractions (e.g.
  TV)
• DONT
• Measure if stressed, cold, in pain or if your
  bowel or bladder are uncomfortable
• Measure within 1 hour of heavy physical activity
• Measure within 30 minutes of smoking or drinking
  coffee

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Home measurement Doing it right

• PREPARATION
• DO
• Put the cuff on a bare arm or one with a light
  sleeve
• Support the arm on a table so it is at heart
  level
• Record two readings in the morning and evening
  daily for seven days (discarding the first days
  readings) to help diagnose hypertension
• Measure and record your blood pressure (as above)
  for several days before an appointment with a
  health care professional

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Home measurement Doing it right

• Posters and handouts providing recommendations
  to patients on how to measure blood pressure can
  be found at www.hypertension.ca (Learn how to
  measure your blood pressure at home and Home
  measurement of blood pressure in the Education
  tools for health care professionals section)

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VII. Home Measurement of BP Confirm
contradictory home measurement readings
If office BP measurement is elevated and home
BP is normal or vice versa
Consider further assess using 24-h
ambulatory blood pressure monitoring
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VIII. Ambulatory BP Monitoring
Beyond the diagnosis of hypertension, ABPM
measurement may also be considered for selected
patients for the management of HTN
Which patients?

• Untreated
• - Mild (Grade 1) to moderate (Grade 2) clinic BP
  elevation and without target organ damage.
• Treated patients
• - Blood pressure that is not below target values
  despite receiving appropriate antihypertensive
  therapy.
• - Symptoms suggestive of hypotension.
• Fluctuating office blood pressure readings.

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VIII. Ambulatory BP Monitoring
How to ?
Use validated devices How to interpret? Mean
daytime ambulatory blood pressure gt135/85 mmHg is
considered elevated. Mean 24 h ambulatory blood
pressure gt130/80 mmHg is considered elevated.
A drop in nocturnal BP of lt10 is associated with
increased risk of CV events
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Clinic, Home, Ambulatory (ABP) Blood Pressure
Measurement Equivalence Numbers
A clinic blood pressure of 140/90 mmHg has a
similar risk of a
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Follow Up Algorithm For High Blood Pressure
Using Ambulatory Blood Pressure Measurement
24-h ABPM
Awake BP gt135 SBP or gt85 DBP or 24-hour gt130 SBP
or gt80 DBP
Awake BP lt 135/85 and 24-hour lt 130/80
Continue to follow-up
Consistent with HTN
Patients with high normal blood pressure should
be followed annually.
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Follow Up Algorithm For High Blood Pressure Using
Ambulatory Blood Pressure Measurement

• 30-40 of patients with white coat hypertension
  diagnosed based on a single ABPM session will
  have true hypertension on retesting.
• Some patients with white coat hypertension
  develop sustained hypertension.
• Patients with white coat hypertension may be
  followed with home BP measurement or repeat ABPM
  could be considered every 1-2 years

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IX. The Role of Echocardiography
Echocardiography is not useful for routine
evaluation of hypertensive patients