Part 2: Recommendations for Hypertension Treatment

1
Part 2 Recommendations for Hypertension Treatment

• January 2007

2
Key CHEP messages for the management of
hypertension

• Assess blood pressure at all appropriate visits.
• Almost one half of those with blood pressure
  130-139/85-89 will develop hypertension within 2
  years. They require annual reassessment.
• Assess global cardiovascular risk in all
  hypertensive patients.
• Lifestyle modification is the cornerstone for the
  prevention and management of hypertension and CVD.

3
Key CHEP messages for the management of
hypertension

• Treat to target (lt140/90 mmHg lt130/80 mmHg in
  patients with diabetes or chronic kidney
  disease).
• To achieve targets sustained lifestyle
  modification and more than one drug is usually
  required.
• Follow patients with uncontrolled blood pressure
  at least monthly until blood pressure targets are
  achieved.
• Strategies to improve patient adherence to
  lifestyle modifications and antihypertensive
  therapy need to be incorporated in every patients
  management

4
2007 Canadian Hypertension Education Program

• A red flaghas been posted where recommendations
  were updated for 2007.
• A slide kit for medical education can be
  downloaded (English and French versions) from
• http//www.hypertension.ca

5
2007 Canadian Hypertension Education Program

• Treatment Approaches
• Lifestyle
• Pharmacological

6
2007 Canadian Hypertension Education Program

• What's New for 2007
• 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) will develop
  hypertension within 4 years and almost 1/2 within
  2 years.
• Annual follow-up of patients with high normal
  blood pressure is recommended.

7
2007 Canadian Hypertension Education Program

• What's New for 2007
• Up to 17 of hypertension can be attributed to
  high sodium diets
• Reduce sodium intake to less than 100 mmol in
  normotensive patients to prevent hypertension

8
Recommendations 2007Table of contents

• Indications for drug therapy
• Goal for therapy
• Adherence
• Lifestyle
• Uncomplicated
• CV IHD
• CHF
• Cerebrovascular / Stroke
• LVH
• X. Chronic kidney disease
• Renovascular
• Diabetes
• Smoking
• Global risk reduction

9
Usual blood pressure threshold values for
initiation of pharmacological treatment of
hypertension
I. Indications for Pharmacotherapy
10
I. Indications for Pharmacotherapy

• In low risk patients with stage 1 hypertension
  (140-159/90-99 mmHg) lifestyle modification can
  be the sole therapy.
• Over 90 of Canadians with hypertension have
  other risk factors and pharmacotherapy should be
  considered in these patients if blood pressure
  remains equal to or above 140/90 mmHg with
  lifestyle modification.
• Patients with target organ damage (e.g. left
  ventricular hypertrophy) are recommended to be
  treated with pharmacotherapy if blood pressure is
  equal to or above 140/90
• Patients with known atherosclerotic disease (e.g.
  past stroke) are recommended to be treated with
  pharmacotherapy even if the blood pressure is
  normal (see compelling indications)
• Patients with diabetes or chronic kidney disease
  should be considered for pharmacotherapy if the
  blood pressure is equal or over 130/80 mmHg

11
Blood pressure target values for treatment of
hypertension
II. Goals of Therapy
12
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

13
Follow-up of blood pressure above targets

• Patients with blood pressure at 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

14
Part 2 Recommendations for Hypertension Treatment
January, 2007
15
IV. Lifestyle management
16
Lifestyle Recommendations for Prevention of
Hypertension for NON-Hypertensive Individuals.

• To reduce the possibility of becoming
  hypertensive,
• Restriction of sodium intake to less than 100
  mmol (2300 mg) / day
• Healthy diet high in fresh fruits, vegetables,
  low fat dairy products, dietary and soluble
  fiber, 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 cardiorespiratory
  activity 4-7/week
• Low risk alcohol consumption (2 standard
  drinks/day and less than 14/week for men and less
  than 9/week for women)
• Maintenance of ideal body weight (BMI 18.5-24.9
  kg/m2)
• Waist Circumference
• lt 102 cm for men
• lt 88 cm for women
• Smoke free environment

17
Lifestyle Recommendations for the Treatment of
Hypertension

• Restriction of sodium intake to less than 100
  mmol (2300 mg) / day
• Healthy diet high in fresh fruits, vegetables,
  low fat dairy products, dietary and soluble
  fiber, 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 cardiorespiratory
  activity 4-7/week
• Low risk alcohol consumption (2 standard
  drinks/day and less than 14/week for men and less
  than 9/week for women)
• Maintenance of ideal body weight (BMI 18.5-24.9
  kg/m2)
• Weight loss (gt 5 Kg) in those who are over weight
  (BMIgt25)
• Waist Circumference
• lt 102 cm for men
• lt 88 cm for women
• Smoke free environment

18
Lifestyle Recommendations for Hypertension
Dietary

• High in fresh fruits
• High in vegetables
• High in low fat dairy products
• High in dietary and soluble fibre
• High in plant protein
• Low in saturated fat and cholesterol

http//www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_g
uide_rainbow_e.html
19
Recommendations for daily salt intake

• Less than
• 100 mmol sodium (Na)
• or 2,3 g sodium (Na)
• or 5,8 g of salt (NaCl)
• or 1 teaspoon of table salt

2,300 mg sodium 1 teaspoon of table salt
20
Salt 2007 Meta-analyses

• Hypertensives
• Reduction of BP
• 5.1 / 2.7 mmHg with a average reduction of 78
  mmol sodium/day (162 to 87mmol/day)
• 7.2/3.8 mmHg with a average reduction of 100 mmol
  sodium/day
• Normotensives
• Reduction of BP
• 2.0 / 1.0 mmHg with a average reduction of sodium
  74 mmol/day
• 3.6/1.7 mmHg with a average reduction of 100
  mol/day sodium

The Cochrane Library 200631-41
21
Salt 2007 Meta analysis on different reduction
in sodium on blood pressure
Hypertension 2003421093-1099
22
Epidemiologic impact on mortality of blood
pressure reduction in the population
After Intervention
Before Intervention
Prevalence
Reduction in BP
Adapted from Whelton, P. K. et al. JAMA
20022881882-1888
23
Lifestyle Recommendations for Hypertension.
Physical Activity
Should be prescribed to reduce blood pressure
Frequency - Four to seven days per week
Type cardiorespiratory activity - Walking,
jogging - Cycling - Non-competitive swimming
Exercise should be prescribed as adjunctive to
pharmacological therapy
24
Lifestyle Recommendations for Hypertension
Alcohol
Low risk alcohol consumption
0-2 standard drinks/day
Men maximum of 14 standard drinks/week
Women maximum of 9 standard drinks/week
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).
25
Lifestyle Recommendations for Hypertension Stress
Management
Stress management
Hypertensive patients in whom stress appears to
be an important issue
Behavior Modification
Individualized cognitive behavioral interventions
are more likely to be effective when relaxation
techniques are employed.
26
Lifestyle Recommendations for Hypertension Weight
LossHeight, weight, and waist circumference
(WC) should be measured and body mass index (BMI)
calculated for all adults.
27
Waist circumference measurement
Last rib margin
Mid distance
Iliac crest
Courtesy J.P. Després 2006
28
Impact of Lifestyle Therapies on Blood Pressure
in Hypertensive Adults
Applying the 2005 Canadian Hypertension Education
Program recommendations 3. Lifestyle
modifications to prevent and treat hypertension
Padwal R. et al. CMAJ ? SEPT. 27, 2005 173 (7)
749-751
29
Lifestyle Therapies in Hypertensive Adults
Summary
30
Pharmacotherapy
31
2007 Canadian Hypertension Education Program
Table of contents

• Indications for drug therapy
• Goal for therapy
• Adherence
• Lifestyle
• Uncomplicated
• CV IHD
• CHF
• Cerebrovascular / Stroke
• LVH
• X. Chronic kidney disease
• Renovascular
• Diabetes
• Smoking
• Global risk reduction

32
V. Choice of Pharmacological Treatment
Uncomplicated
Associated risk factors? or Target organ
damage/complications? or Concomitant
diseases/conditions?
33
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

34
V. Treatment of Adults with Systolic/Diastolic
Hypertension without Other Compelling Indications
TARGET lt140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy
Beta-blocker
Long-acting CCB
Thiazide
BBs are not indicated as first line therapy for
age 60 and above
ACEI and ARB are contraindicated in pregnancy and
caution is required in prescribing to women of
child bearing potential
35
V. Considerations Regarding the Choice of
First-Line Therapy

• ACE 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 without another compelling
  indication
• Diuretic-induced hypokalemia should be avoided
  through the use of potassium sparing agent
• ACE-I are not recommended (as monotherapy) for
  black patients without another compelling
  indication

36
Major Congenital Malformations after First
Trimester Exposure to ACE inhibitors

• Cardiovascular and neurological defects
• ACEI risk ratio 2.71 (1.72-4.27) vs. other drugs
  0.66 (0.25-1.75) vs. no drug

NEJM 20063542443-51
37
V. Add-on Therapy for Systolic/Diastolic
Hypertension without Other Compelling Indications
If partial response to monotherapy
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).
38
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 such as
  ischemic heart disease, post myocardial
  infarction, congestive heart failure or chronic
  kidney disease with proteinuria.

39
Drug Combinations contd

• Caution should be exercised in combining a non
  dihydropyridine CCB and a beta blocker to reduce
  the risk of bradycardia or heart block.
• Monitor 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.

40
Most HTN Pts need more than 1 drug (data from
ALLHAT)
41
Most HTN Pts need more than 1 drug
5
4
3
Number of drugs
2
1
0
HOT
IDNT
AASK
ABCD
MDRD
UKPDS
ALLHAT
42
BP Effects from antihypertensive therapy Law.
BMJ 2003 (SR of 354 RCTs)

• Dose response curves for efficacy are relatively
  flat
• 80 of the BP lowering efficacy is achieved at
  half-standard dose
• Combinations of high standard dose have additive
  blood pressure lowering effects

43
V. Summary Treatment of Systolic-Diastolic
Hypertension without Other Compelling Indications
TARGET lt140/90 mmHg
Lifestyle modification therapy
Not indicated as first line therapy over 60
Dual Combination

• CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?

ACEI and ARB are contraindicated in pregnancy and
caution is required in prescribing to women of
child bearing potential
Triple or Quadruple Therapy
44
Treatment Algorithm for Isolated Systolic
Hypertension without Other Compelling Indications
TARGET lt140 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy
Thiazide diuretic
ARB
Long-acting DHP CCB
45
V. 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
Long-acting DHP CCB

• 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).
46
V. Summary Treatment of Isolated Systolic
Hypertension without Other Compelling Indications
TARGET lt140 mmHg
Lifestyle modification therapy
Thiazide diuretic
ARB
Long-acting DHP CCB
Dual therapy

• 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 blockers, centrally acting
agents, or nondihydropyridine calcium channel
blocker).
Triple therapy
47
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

48
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 Diabetic Nephropathy
• Without Diabetic Nephropathy
• Global Vascular Protection for Hypertensive
  Patients
• Statins if 3 or more additional cardiovascular
  risks
• Aspirin once blood pressure is controlled

49
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)
Those at low risk with well controlled risk
factors may not benefit from ACEI therapy
50
VI. Treatment of Hypertension in Patients with
Recent ST Segment Elevation-MI or non-ST Segment
Elevation-MI
An ARB can be used if the patient is intolerant
to ACE-I
Beta-blocker and ACE-I
Recent myocardial infarction
If beta-blocker contraindicated or not effective
Long-acting DHP CCB (Amlodipine, Felodipine)
YES
Heart Failure ?
NO
Long-acting CCB
51
VII. Treatment of Hypertension with Left
Ventricular Systolic Dysfunction
Systolic cardiac dysfunction
ACE-I if ACE-I intolerant ARB
and Beta-Blocker

• If additional therapy is needed
• Diuretic
• for CHF class III-IV Aldosterone Antagonist

If ACE-I and ARB are contraindicated Hydralazine
and Isosorbide dinitrate in combination
If additional antihypertensive therapy is
needed ACE-I / ARB Combination
Long-acting DHP-CCB (Amlodipine or Felodipine)
Beta-blockers used in clinical trials were
bisoprolol, carvedilol and metoprolol. Physicians
who are not yet experienced in the use of
beta-blockers should consider initiation of
treatment in conjunction with a physician
experienced in heart failure management
particularly for NYHA Class III-IV patients
52
VIII. Treatment of Hypertensionfor Patients
with Cerebrovascular Disease
53
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.

• ACE-I
• ARB,
• CCB
• Thiazide Diuretic
• - BB (if age below 60)

54
X. Treatment of Hypertension in Patients with Non
Diabetic Chronic Kidney Disease
albumincreatinine ratio ACR gt 30 mg/mmol or
urinary protein gt 500 mg/24hr
Monitor potassium and creatinine carefully in
patients with CKD prescribed an ACEI or ARB
55
XI. Treatment of Hypertension in Patients with
Renovascular Disease
56
XII. Treatment of Hypertension in association
with Diabetes Mellitus
57
XII. Treatment of Hypertension in association
with Diabetes Mellitus
Threshold equal or over 130/80 mmHg and Target
below 130/80 mmHg
Urinary albumin to creatinine ration gt 2.0
mg/mmol in men or gt 2.8mg/mmol in women or
chronic kidney disease
Urinary albumin to creatinine ratio lt2.0
mg/mmol in men or lt2.8mg/mmol in women
based on at least 2 of 3 measurements
58
XII. Treatment of Hypertension in association
with Diabetic Nephropathy
Monitor potassium and creatinine carefully in
patients with CKD prescribed an ACEI or ARB
59
XII. Treatment of Systolic-Diastolic Hypertension
without Diabetic Nephropathy
Threshold equal or over 130/80 mmHg and TARGET
below 130/80 mmHg
1. ACE-Inhibitor or ARB or 2. Thiazide diuretic
or Dihydropyridine CCB
Combination of first line agents
Diabetes without Nephropathy
IF ACE-I and ARB and DHP-CCB or Thiazide are
contraindicated or not tolerated, SUBSTITUTE
Cardioselective BB or Long-acting NON DHP-CCB
Addition of one or more of Cardioselective BB
or Long-acting CCB
DHP dihydropyridine
Cardioselective BB Acebutolol, Atenolol,
Bisoprolol , Metoprolol
More than 3 drugs may be needed to reach target
values for diabetic patients
60
XII. Treatment of Hypertension in association
with Diabetes Mellitus Summary
Threshold equal or over 130/80 mmHg and TARGET
below 130/80 mmHg
ACE Inhibitor or ARB
1. ACE-Inhibitor or ARB or 2. Thiazide diuretic
or DHP-CCB
Combination (Effective 2-drug combination)
without Nephropathy
Monitor potassium and creatinine carefully in
patients with CKD prescribed an ACEI or ARB
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
61
XIII. Treatment of Hypertension for Patients Who
Use Tobacco
62
XIV. Global Vascular Protection for Patients
with Hypertension
63
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

ASCOT-LLA Lancet 20033611149-58
64
XIV. Vascular Protection for Hypertensive
Patients ASA
Consider low dose ASA
Caution should be exercised if BP is not
controlled.
65
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

66
Adherence to anti-hypertensive management can be
improved by a multi-pronged approach

• Encourage greater patient responsibility/autonomy
  in regular monitoring their blood pressure
• Educate patients and patients' families about
  their disease/treatment regimens verbally and in
  writing

67
Public translation of CHEP recommendations
Download at www.hypertension.ca
68
Educate patients and patients' families about
their disease/treatment regimens verbally and in
writing
Useful patient information can be obtained in
recent publications from the Canadian
Hypertension Society.
Available by order from CHS Secretariat?Canadian
Hypertension Society? Tel [phone], Fax
613-533-6927 E mail HYPERTENSION_at_QUEENSU.CA? .
Coming soon to bookstores near you.
69
Encourage greater patient responsibility/autonomy
70
Summary I

• Regarding the treatment of hypertension, the
  recommendations endorse
• ASSESSMENT OF BLOOD PRESSURE AT ALL APPROPRIATE
  VISITS
• Most Canadians will develop hypertension during
  their lives. Routine assessment of blood pressure
  is required for early detection and risk
  management
• ANNUAL FOLLOW-UP OF PATIENTS WITH HIGH NORMAL
  BLOOD PRESSURE
• Most overweight patients with high normal blood
  pressure (130-139/85-89 mmHg) will develop within
  4 years and almost 1/2 within 2 years.

71
Summary II

• Regarding the treatment of hypertension, the
  recommendations endorse
• INDIVIDUALIZING THERAPY
• consider concomitant risk factors and/or
  concurrent diseases, other patient
  characteristics and preferences (e.g. age,
  diabetes, CVD) and other considerations e.g.
  costs
• LIFESTYLE MODIFICATION
• To prevent hypertension
• In those with hypertension alone if effective to
  reach the goal value or in combination with
  pharmacological treatment

72
Summary III

• Regarding the treatment of hypertension, the
  recommendations endorse
• TREATING TO TARGET BP
• treat aggressively using combinations of drugs
  and lifestyle modification to achieve
  individualized target
• PROMOTING ADHERENCE
• a multi-faceted approach should be used to
  improve adherence with both non pharmacological
  and pharmacological strategies

73
Key CHEP messages for the management of
hypertension

• Assess blood pressure at all appropriate visits.
• Almost one half of those with blood pressure
  130-139/85-89 will develop hypertension within 2
  years. They require annual reassessment.
• Assess global cardiovascular risk in all
  hypertensive patients.
• Lifestyle modification is the cornerstone for the
  prevention and management of hypertension and CVD.

74
Key CHEP messages for the management of
hypertension

• Treat to target (lt140/90 mmHg lt130/80 mmHg in
  patients with diabetes or chronic kidney
  disease).
• To achieve targets sustained lifestyle
  modification and more than one drug is usually
  required.
• Follow patients with uncontrolled blood pressure
  at least monthly until blood pressure targets are
  achieved.
• Strategies to improve patient adherence to
  lifestyle modifications and antihypertensive
  therapy need to be incorporated in every patients
  management