CARE GAPS NEW RECOMMENDATIONS

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CARE GAPSNEW RECOMMENDATIONS
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BPC 2009

• Blood Pressure Canada focuses on two major
  objectives
• Improve public and patient knowledge and
  awareness of hypertension
• Decrease the prevalence of hypertension through a
  reduction in dietary sodium

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BPC Organizational Chart
BPC Member organizations
Executive Committee
Public Education Task Force
Sodium Task Force
Topic subgroups
Topic subgroups
CHEP
HSFC
Sodium Strategic Planning Committee
PHAC
CHS
Hypertension Chair
Proposed Health Canada Dietary Sodium Working
Group
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The Canadian HypertensionEducation Program

• CHEP OBJECTIVETo improve the treatment and
  control of hypertension in Canada and hence
  reduce the burden of cardiovascular disease
• CHEP METHOD
• An evidence-based knowledge translation program
  aimed at primary health care professionals that
  started in 2000

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CHEP Organizational Chart
Steering Committee
Executive Committee
Evidence-Based Recommendations Task
Force ________________ Central Review Committee
Topic subgroups
Topic subgroups
Topic subgroups
Topic subgroups
Outcomes Research Task Force
Implementation Task Force
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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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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

N Engl J Med 20083581547-59 Lancet 2008 372
54753
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The Canadian Hypertension Education Program 2008
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.
• 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 in
  most people 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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Some Care Gaps
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Hypertensive Patients Not Receiving
Pharmacotherapy, CVD Risks
55 of aware hypertensive patients aged 20-39
years were not taking antihypertensive
medications while 17 of patients 40-59 and 5 of
patients gt60 years of age were not on
pharmacotherapy. There is no trend to increase
the use of antihypertensive pharmacotherapy with
increasing number of cardiovascular risk factors.
Can J Cardiol, 2008. 24 6 485-490.
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NPHS (1994-2002) More Lifestyle Changes After
Hypertension Diagnosis Are Needed
Small decreases in smoking and physical
inactivity along with increases in BMI were
observed of newly diagnosed patients in the
longitudinal National Population Health Survey
(NPHS). This trend was largely seen in patients
who were taking antihypertensive medication. A is
the survey cycle prior to diagnosis and B is the
survey cycle following hypertension diagnosis.
Can J Cardiol, 2008. 24 3 199-204.
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Educational points

• Need to risk stratify younger people with
  hypertension and use drug therapy in those at
  increased risk (note short term risk assessments
  are likely not appropriate in the young)
• Need for brief lifestyle interventions in
  hypertensive people

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CHEP Theme2009 Hypertension Management in
Peoplewith Diabetes
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Case of hypertension

• Think of a average Canadian with diabetes
• What are the chances that
• they have hypertension?
• if they have hypertension
• they are treated?
• their blood pressure is controlled?

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Case of hypertension

• Think of a average Canadian with diabetes
• Answers to case (Ontario 2006)
• What are the chances that
• they have hypertension?
• if they have hypertension
• they are treated?
• their blood pressure is controlled?

65
72
36
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Whats New for 2009The Hypertensive Diabetic

• People with diabetes are at high cardiovascular
  risk
• Up to 80 of people with diabetes die of
  cardiovascular disease
• Most people with diabetes have hypertension
• Between 35 and 75 of diabetic complications have
  been attributed to hypertension.
• Treatment of hypertension in people with diabetes
  reduces rates of total mortality, myocardial
  infarction, stroke, retinopathy and progressive
  renal failure.
• More intensive reduction in blood pressure
  reduces rates of 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 people with hypertension and diabetes
  have uncontrolled blood pressure (gt 130/80 mmHg)
• More intensive reduction in blood pressure in
  people with hypertension and diabetes is one a
  few medical interventions where the cost of
  treatment is less than the cost of the
  complications prevented
• A combination of lifestyle changes and 3 or more
  medications are often required.
• 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.

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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Proportion of diabetic complications attributable
to high blood pressure
Bild D et al Public Health Rep 1987102522-529
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SELECTEDHYPERTENSIONCLINICAL TRIALS IN PEOPLE
WITH DIADETES
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Clinical trials that assessed people with
hypertension and diabetes

• HOT trial
• 4/4 mmHg decrease in BP
• Major CVD 51 decrease
• MI 51 decrease
• CV death 66 decrease
• Syst Eur trial
• 9/4 mmHg decrease BP
• CVD decrease 69
• CAD decrease 63
• Stroke decrease 73
• CV death decrease 76
• Total death decrease 55

Hansson L. Lancet 19983511755-1762 Tuomilehto
J et al. N Eng J Med 1999340677-684
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Alberta Hypertension Initiative
www.hypertension.ca/tools/AB

• Contact Nicole Kelly
• nmkelly_at_ucalgary.ca
• 403-220-7103

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Project Sodium

• Purpose to provide an understanding of
  perceptions motivations to reduce dietary
  sodium across different contexts through
  ecological lens. Value to add to gaps in the
  literature for understanding the linkages, the
  relationships among different factors that may
  influence perceptions and motivations regarding
  sodium intake. To help inform and shape
  strategies aimed at reducing sodium intakes of
  Canadians, dietary guidance messages and product
  communications.
• Collaborative project between U of A, AHS, and
  Cdn. Council of Food Nutrition.
• Funded by Cdn. Foundation for Dietetic Research
  and BC Ministry of Healthy Living and Sport.
• PI Dr. Anna Farmer, PhD, RD, Asst. Professor,
  Community Nutrition, U of A.
• Calgary contact Sheila Tyminski, RD. Nutrition
  Manager, Healthy Living, AHS (Calgary).
• Seeking perspectives of consumers AND health
  professionals, including physicians.
• Wish to hear from 4-6 Calgary area physicians
  in a 45 minute focus group, hopefully in June
  2009.
• Suggested date of June 16 evening, but can
  arrange another time. Please indicate on sign-up
  sheet whether (1) interested in participating,
  and (2) whether available June 16 evening. Site
  to be determined.
• Many thanks for your interest!