Part 2: Recommendations for Hypertension Treatment

1
Part 2 Recommendations for Hypertension Treatment

• 2011 Canadian Hypertension Education Program
  Recommendations

2

• The full slide set of the 2011 CHEP
  Recommendations are available atwww.hypertension
  .ca

3
2011 Canadian Hypertension Education Program
(CHEP)

• A red flag has been posted where
  recommendations were updated for 2011.
• Slide kits for health care professional and
  public education can be downloaded (English and
  French versions) from www.hypertension.ca

4
2011 Canadian Hypertension Education Program
(CHEP)

• Treatment Approaches
• Lifestyle
• Pharmacological

5
Key CHEP Messages for the Management of
Hypertension

1. Assess blood pressure at all appropriate visits.
   
2. Promote a healthy lifestyle to lower blood
   pressure and reduce the risk of cardiovascular
   disease at each visit with interventions to
   reduce high dietary sodium, for smoking
   cessation, to reduce abdominal obesity, to
   promote a healthy weight, to increase physical
   activity and to manage dyslipidemia and
   dysglycemia.
3. 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
   using a combination of drugs and lifestyle
   modifications.
4. Advocate for healthy public policies to prevent
   hypertension and advance the health of patients
   and populations.
5. Keep up to date with resources for the prevention
   and control of hypertension by registering at
   www.htnupdate.ca and downloading and ordering
   tools at www.hypertension.ca/tools.

6
The Canadian Hypertension Education Program 2011
Recommendations

• Whats new?
• Increased emphasis on the use of single pill
  combinations (and more guidance on which
  combinations to use).
• In stroke patients avoid excessive blood pressure
  reductions, except in the setting of the most
  severe elevations
• The most important step in prescription of
  antihypertensive therapy is achieving patient
  buy-in new tips for improving adherence

7

• 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.htnupdate.ca for automatic updates and on
  current hypertension educational resources

8
The Canadian Hypertension Education Program 2011
Recommendations

• Whats old but still important?
• Out-of-office blood pressure measurements are
  important in both the diagnosis and management of
  hypertension
• Lifestyle changes are still a critical component
  of hypertension management (and prevention!)
• The management of hypertension is all about
  global risk management and vascular protection

9
Recommendations 2011Table of contents

1. Indications for drug therapy
2. Goals of therapy
3. Adherence
4. Lifestyle
5. Uncomplicated
6. CV IHD
7. CHF
8. Cerebrovascular / Stroke
9. LVH
10. Chronic kidney disease
11. Renovascular
12. Diabetes
13. Smoking
14. Overall risk reduction

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I. Indications for Pharmacotherapy

• 2011 Canadian Hypertension Education Program
  Recommendations

11
I. Indications for Pharmacotherapy

• Usual blood pressure threshold values for
  initiation of pharmacological treatment of
  hypertension

Condition Initiation
SBP or DBP mmHg
Systolic or Diastolic hypertension ?140/90
Diabetes Chronic Kidney Disease ?130/80
12
I. Indications for Pharmacotherapyafter
diagnosis of hypertension (1)

• Patients at low risk with stage 1 hypertension
  (140-159/90-99 mmHg)
• lifestyle modification can be the sole therapy.
• 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 130/80 mmHg

13
I. Indications for Pharmacotherapyafter
diagnosis of hypertension (2)

• 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.

14
II. Goals of Therapy

• 2011 Canadian Hypertension Education Program
  Recommendations

15
II. Goals of Therapy

• Blood pressure target values for treatment of
  hypertension

Condition Target
SBP and DBP mmHg
Isolated systolic hypertension lt140
Systolic/Diastolic Hypertension Systolic BP Diastolic BP lt140 lt90
Diabetes or Chronic Kidney Disease Systolic Diastolic lt130 lt80
16
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

17
Follow-up of blood pressure above targets

• Patients with blood pressure above 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

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III. Adherence

• 2011 Canadian Hypertension Education Program
  Recommendations

19
III. 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
• Replacing multiple pill antihypertensive
  combinations with single pill combinations!

20
III. Adherence to anti-hypertensive management
can be improved by a multi-pronged approach

• Encourage greater patient responsibility/autonomy
  in regular monitoring of their blood pressure
• Educate patients and patients' families about
  their disease/treatment regimens verbally and in
  writing
• Use an interdisciplinary care approach
  coordinating with work-site health care givers
  and pharmacists if available

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IV. Lifestyle management

• 2011 Canadian Hypertension Education Program
  Recommendations

22
Lifestyle Recommendations for Prevention and
Treatment of Hypertension

• To reduce the possibility of becoming
  hypertensive,
• Reduce sodium intake to less than 1500 mg/day
• Healthy diet high in fresh fruits, vegetables,
  low fat dairy products, dietary and soluble
  fibre, 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 dynamic exercise
  4-7 days per week in addition to daily activities
• Low risk alcohol consumption (2 standard
  drinks/day and less than 14/week for men and less
  than 9/week for women)
• Attaining and maintaining ideal body weight (BMI
  18.5-24.9 kg/m2)
• Waist Circumference
  Men Women
• Europid, Sub-Saharan African, Middle Eastern
  lt102 cm lt88 cm
• South Asian, Chinese lt90
  cm lt80 cm
• Tobacco free environment

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Lifestyle Recommendations for Hypertension
Dietary

• High in
• Fresh fruits
• Fresh vegetables
• Low fat dairy products
• Dietary and soluble fibre
• Plant protein
• Low in
• Saturated fat and cholesterol
• Sodium

www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng
.php.
24
Potential Benefits of a Wide Spread Reduction in
Dietary Sodium in Canada
REDUCTION IN AVERAGE DIETARY SODIUM FROM ABOUT
3500 MG TO 1700 MG

• 1 million fewer hypertensives
• 5 million fewer physicians visits a year for
  hypertension
• Health care cost savings of 430 to 540 million
  per year related to fewer office visits, drugs
  and laboratory costs for hypertension
• Improvement of the hypertension treatment and
  control rate
• 13 reduction in CVD
• Total health care cost savings of over 1.3
  billion/year

Penz ED, Cdn J Cardiol 2008. Joffres MR_CJC_
23(6) 2007.
25
Recommendations for daily salt intake

• 2,300 mg sodium (Na)
• 100 mmol sodium (Na)
• 5.8 g of salt (NaCl)
• 1 level teaspoon of table salt

Age Recommended Intake
19-50 1500
51-70 1300
71 and over 1200

• 80 of average sodium intake is in processed
  foods
• Only 10 is added at the table or in cooking

Institute of Medicine, 2003
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Sodium Meta-analyses
Average Reduction of sodium in mg/day 1800 mg/day 2300 mg/day Hypertensives Reduction of BP 5.1 / 2.7 mmHg 7.2/3.8 mmHg
Average Reduction of sodium in mg/day 1700 mg/day 2300 mg/day Normotensives Reduction of BP 2.0 / 1.0 mmHg 3.6/1.7 mmHg
The Cochrane Library 200631-41
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2011 Canadian Hypertension Education Program
(CHEP)

• Important messages from past recommendations
• High dietary sodium is estimated to increase
  blood pressure in the Canadian population to the
  extent that 1,000,000 Canadians meet the
  diagnostic criteria for hypertension who would
  otherwise have normal blood pressure
• Most of the sodium in Canadian diets comes from
  processed foods and restaurants.
• Pizza, breads, soups and sauces usually have high
  amounts of sodium
• Patient information on how to achieve a reduced
  sodium diet can be found at www.hypertension.ca
• Aim to reduce sodium intake to less than 1500
  mg/day to prevent and control hypertension

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Reduce Your Sodium Intake

• At home
• Plan meals at least a day in advance.
• Make more meals from unprocessed foods.
• Gradually decrease the amount of salt used in
  cooking and at the table (this includes sea
  salt).
• Use condiments sparingly.
• Flavour food with lemon juice, fresh garlic,
  spices, herbs and flavoured vinegars.
• Try low-sodium seasoning mixes.
• Cook and bake with vegetable oil rather than
  butter or margarine.
• Use tomato paste instead of tomato sauce or soup
  in recipes.

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Reduce Your Sodium Intake

• At the grocery store
• Buy pre-prepared, convenience foods that are low
  in sodium such as frozen vegetables, frozen
  shrimp, skinless boneless chicken breasts and
  pre-cut salads and fruit.
• Choose unsalted snack foods such as pretzels,
  nuts, seeds and crackers.
• Read food labels and compare sodium content
  between similar foods
• Look for foods labelled salt-free, no added salt,
  low in sodium, or reduced in sodium.
• Always check the Nutrition Facts table

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Reduce Your Sodium Intake

• When eating or taking out
• Choose salads and meals made with foods low in
  sodium
• Ask for no salt or MSG to be added during cooking
• Ask for sauces, spreads or dressings on the side
  and use sparingly
• Limit fast foods and take-out meals.

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Lifestyle Recommendations for Hypertension
Physical Activity
Should be prescribed to reduce blood pressure
Exercise should be prescribed as an adjunctive to
pharmacological therapy
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Lifestyle Recommendations for Hypertension
Weight Loss

• Height, weight, and waist circumference (WC)
  should be measured and body mass index (BMI)
  calculated for all adults.

CMAJ 20071761103-6
33
Waist Circumference Measurement
Courtesy J.P. Després 2006
34
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).
35
Lifestyle Recommendations for Hypertension
Stress Management
Stress management
Hypertensive patients in whom stress appears to
be an important issue
Behaviour Modification
Individualized cognitive behavioural
interventions are more likely to be effective
when relaxation techniques are employed.
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Impact of Lifestyle Therapies on Blood Pressure
in Hypertensive Adults
Intervention Intervention SBP/DBP
Reduce sodium intake -1800 mg/day sodium Hypertensive -5.1 / -2.7
Weight loss per kg lost -1.1 / -0.9
Alcohol intake -3.6 drinks/day -3.9 / -2.4
Aerobic exercise 120-150 min/week -4.9 / -3.7
Dietary patterns DASH diet Hypertensive -11.4 / -5.5
Padwal R. et al. CMAJ ? SEPT. 27, 2005 173 (7)
749-751
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Lifestyle Therapies in Hypertensive Adults
Summary
Intervention Target
Reduce foods with added sodium lt 2300 mg /day
Weight loss BMI lt25 kg/m2
Alcohol restriction lt 2 drinks/day
Physical activity 30-60 minutes 4-7 days/week
Dietary patterns DASH diet
Smoking cessation Smoke free environment
Waist Circumference Europid South Asian, Chinese Men Women lt94 cm lt80 cm lt90 cm lt80 cm
38
Epidemiologic impact on mortality of blood
pressure reduction in the population
After Intervention
Before Intervention
Prevalence
Reduction in BP
Reduction in SBP (mmHg) Reduction in Mortality Reduction in Mortality Reduction in Mortality
Reduction in SBP (mmHg) Stroke CHD Total
2 -6 -4 -3
3 -8 -5 -4
5 -14 -9 -7
Adapted from Whelton, P. K. et al. JAMA
20022881882-1888
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V. Pharmacotherapy

• 2011 Canadian Hypertension Education Program
  Recommendations

40
V. Choice of Pharmacological Treatment
Uncomplicated
Associated risk factors? or Target organ
damage/complications? or Concomitant
diseases/conditions?
YES
Individualized Treatment (and compelling
indications)
41
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

42
V. Treatment of Adults with Systolic/Diastolic
Hypertension without Other Compelling Indications
TARGET lt140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy
Thiazide
Beta-blocker
Long-acting CCB
A combination of 2 first line drugs may be
considered as initial therapy if the blood
pressure is gt20 mmHg systolic or gt10 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
43
V. Considerations Regarding the Choice of
First-Line Therapy

• Use caution in initiating therapy with 2 drugs in
  whom adverse events are more likely (e.g. frail
  elderly, those with postural hypotension or who
  are dehydrated).
• ACE inhibitors, renin 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 and over without another
  compelling indication.
• Diuretic-induced hypokalemia should be avoided
  through the use of potassium sparing agents if
  required.
• The use of dual therapy with an ACE inhibitor and
  an ARB should only be considered in selected and
  closely monitored people with advanced heart
  failure or proteinuric nephropathy.
• ACE-inhibitors are not recommended (as
  monotherapy) for black patients without another
  compelling indication.

44
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).
45
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

46
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 serum 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.

47
Medication Use and BP Control in ALLHAT
?

lt140/90 mm Hg
Cushman et al. J Clin Hypertens 20024393-404
48
Ratio of Incremental SBP lowering effect at
standard dose Combine or Double?
Incremenal SBP reduction ratio Observed/Expected
(additive)
Wald et al, Combination Versus Monotherapy for
Blood Pressure Reduction, The American Journal
of Medicine, Vol 122, No 3, March 2009
49
BP lowering effects from antihypertensive drugs

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

Law. BMJ 2003
50
V. Summary Treatment of Systolic-Diastolic
Hypertension without Other Compelling Indications
TARGET lt140/90 mmHg
Lifestyle modification
A combination of 2 first line drugs may be
considered as initial therapy if the blood
pressure is gt20 mmHg systolic or gt10 mmHg
diastolic above target
Initial therapy
Dual Combination

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

Not indicated as first line therapy over 60 y
Triple or Quadruple Therapy
51
V. 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
52
V. Add-on therapy for Isolated Systolic
Hypertension without Other Compelling Indications
If partial response to monotherapy
Dual combination Combine first line agents
Long-acting DHP CCB
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).
53
V. Summary Treatment of Isolated Systolic
Hypertension without Other Compelling Indications
TARGET lt140 mmHg
Lifestyle modification therapy
Thiazide diuretic
Long-acting DHP CCB
ARB
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).
Dual therapy

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

Triple therapy
54
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 Nephropathy
• Without Nephropathy
• Global Vascular Protection for Hypertensive
  Patients
• Statins if 3 or more additional cardiovascular
  risks
• Aspirin once blood pressure is controlled

55
VI. Treatment of Hypertension in Patients with
Ischemic Heart Disease
1. Beta-blocker 2. Long-acting CCB
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
56
VI. Treatment of Hypertension in Patients with
Recent ST Segment Elevation-MI or non-ST Segment
Elevation-MI
Beta-blocker and ACEI or ARB
Recent myocardial infarction
If beta-blocker contraindicated or not effective
Long-acting Dihydropyridine CCB
Heart Failure?
YES
NO
Long-acting CCB
Avoid non dihydropyridine CCBs (diltiazem,
verapamil)
57
VII. Treatment of Hypertension with Left
Ventricular Systolic Dysfunction
ACEI and Beta blocker if ACEI intolerant
ARB Titrate doses of ACEI or ARB to those used in
clinical trials
Systolic cardiac dysfunction

• If additional therapy is needed
• Diuretic (Thiazide for hypertension Loop for
  volume control)
• for CHF class III-IV or post MI Aldosterone
  Antagonist

If ACEI and ARB are contraindicated Hydralazine
and Isosorbide dinitrate in combination
If additional antihypertensive therapy is
needed ACEI / ARB Combination
Long-acting DHP-CCB (Amlodipine)
Beta-blockers used in clinical trials were
bisoprolol, carvedilol and metoprolol.
58
Viii. Treatment of Hypertension in Association
With StrokeAcute Stroke Onset to 72 Hours

• Treat extreme BP elevation (systolic gt 220 mmHg,
  diastolic gt 120 mmHg) by 15-25 over the first 24
  hour with gradual reduction after.
• If eligible for thrombolytic therapy treat very
  high BP (gt185/110 mmHg)

Acute ischemic Stroke
Avoid excessive lowering of BP which can
exacerbate ischemia
59
VIII. Treatment of Hypertension in Association
With Stroke After the acute Phase of Stroke or
TIA

• Strongly consider blood pressure reduction in all
  patients after the acute phase of stroke or TIA .

Combinations of an ACEI with an ARB are not
recommended
60
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

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

61
X. Treatment of Hypertension in Patients with Non
Diabetic Chronic Kidney Disease
Target BP lt 130/80 mmHg
Chronic kidney disease and proteinuria
ACEI or ARB (if ACEI tolerated)
Additive therapy Thiazide diuretic. Alternate
If volume overload loop diuretic
Combination with other agents
ACEI/ARB Bilateral renal artery stenosis
albumincreatinine ratio ACR gt 30 mg/mmol or
urinary protein gt 500 mg/24hr
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
62
XI. Treatment of Hypertension in Patients with
Renovascular Disease
Does not imply specific treatment choice
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.

63
XII. Treatment of Hypertension in association
with Diabetes Mellitus

• 2011 Canadian Hypertension Education Program
  Recommendations

64
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 ratio gt 2.0
mg/mmol in men or gt 2.8mg/mmol in women
with Nephropathy
A combination of 2 first line drugs may be
considered as initial therapy if the blood
pressure is gt20 mmHg systolic or gt10 mmHg
diastolic above target
Combinations of an ACEI with an ARB are
specifically not recommended in the absence of
proteinuria
based on at least 2 of 3 measurements
65
XII. Treatment of Hypertension in association
with Diabetic Nephropathy
THRESHOLD equal or over 130/80 mmHg and TARGET
below 130/80 mmHg
Addition of one or more of Long-acting CCB or
Thiazide diuretic
DIABETES with Nephropathy
3 - 4 drugs combination may be needed

• 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

Monitor serum potassium and creatinine carefully
in patients with CKD prescribed an ACEI or ARB
66
2011 Canadian Hypertension Education Program
(CHEP)

• Important messages from past recommendations
• Patients with diabetes are at high cardiovascular
  risk
• Most patients with diabetes have hypertension
• Treatment of hypertension in patients with
  diabetes reduces total mortality, myocardial
  infarction, stroke, retinopathy and progressive
  renal failure rates.
• Treating hypertension in patients with diabetes
  reduces death and disability and reduces health
  care system costs
• In diabetes, TARGET lt130 systolic and lt80 mmHg
  diastolic
• The use of the combination of ACE inhibitor with
  an ARB should only be considered in selected and
  closely monitored people with advanced heart
  failure or proteinuric nephropathy.

67
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. Dihydropyridine
CCB or Thiazide diuretic
Diabetes without Nephropathy
Combination of first line agents
IF ACE Inhibitor and ARB and DHP-CCB and Thiazide
are contraindicated or not tolerated,
SUBSTITUTE Cardioselective BB or
Long-acting NON DHP-CCB
DHP dihydropyridine
Addition of one or more of Cardioselective BB
or Long-acting 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
68
ACCORD Study Results and rational for lack of
impact on BP recommendations

• Overall BP study was neutral with no benefit of
  systolic target lt 120 mmHg vs lt 140 mmHg for
  primary outcome, yet
• Power issue Annual rate of primary outcome 1.87
  in the intensive arm versus 2.09 in the standard
  arm vs 4/year event rate projected during sample
  size calculations
• Significant interaction between BP and glycaemia
  control studies such that those in usual care
  glycaemia group (A1c 7) had a significant
  improvement in primary outcome with lower BP
  target
• Secondary outcome for stroke reduction showed a
  benefit for lower BP target
• Therefore no clear evidence supporting a change
  in BP targets for people with diabetes at this
  point

ACCORD study NEJM 2010
69
XII. Treatment of Hypertension in association
with Diabetes Mellitus Summary
Threshold equal or over 130/80 mmHg and TARGET
below 130/80 mmHg
A combination of 2 first line drugs may be
considered as initial therapy if the blood
pressure is gt20 mmHg systolic or gt10 mmHg
diastolic above target. Combining an ACEi and a
DHP-CCB is recommended.
ACE Inhibitor or ARB
1. ACE Inhibitor or ARB or 2. DHP-CCB or Thiazide
diuretic
without Nephropathy
gt 2-drug combinations
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 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
70
XIII. Treatment of Hypertension for Patients Who
Use Tobacco
MRC Working Party. MRC trial of treatment of mild
hypertension 1985 Jul 13291(6488)97-104.
71
XIV. Overall Vascular Protection for Patients
with Hypertension

• 2011 Canadian Hypertension Education Program
  Recommendations

72
Most hypertensive Canadians have other
cardiovascular risks

• Assess and manage hypertensive patients for
  smoking, dyslipidemia and dysglycemia (impaired
  fasting glucose or diabetes) abdominal obesity,
  unhealthy eating and physical inactivity.
• Discuss global risk using analogies that
  describe comparative risk such as Cardiovascular
  Age, Vascular Age or Heart Age to inform
  patients of their risk status and to improve the
  effectiveness of risk factor modification.

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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

Male Age 55 or older Smoking
Total-C/HDL-C ratio of 6 mmol/L or higher
Family History of Premature CV disease LVH
ECG abnormalities Microalbuminuria or
Proteinuria
ASCOT-LLA Lancet 20033611149-58
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XIV. Vascular Protection for Hypertensive
Patients ASA
Consider low dose ASA
Caution should be exercised if BP is not
controlled.
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New Patient Resources For Hypertension On Line

• www.hypertension.ca/tools - Download current
  resources for the prevention and control of
  hypertension
• www.htnupdate.ca -To keep up to date with the
  latest evidence and resources
• www.myBPsite.ca - Have your patients sign up to
  access the latest hypertension resources
• www.lowersodium.ca - Tools and resources for
  healthcare professionals to use in educating
  other healthcare professionals, the public or
  patients about the risks of high dietary sodium
  in Canada.
• www.sodium101.ca -To access a simple to use
  demonstration of food sodium content for your
  patients
• www.heartandstroke.ca/BP -To monitor home blood
  pressure and encourage self management of
  lifestyle
• http//www.hypertension.qc.ca/ - Société
  Québécoise dhypertension artérielle

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Public translation of CHEP recommendations

• Hypertension recommendations for the public
• Translated into 4 Indo-Asian languages (2007)
• Based on CHEP guidelines (annually updated)

Download at www.hypertension.ca
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Sodium Slide Kit

• Tool used to educate the public and patients on
  dietary sodium.
• Annually updated.

Download at www.hypertension.ca
78
Brief Hypertension Action Tool

• Can by used by a healthcare provider to better
  inform and engage a hypertensive patient to
  ultimately become more active in their care.

Download at www.hypertension.ca
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Measuring Blood Pressure the Right Way Poster

• Posters (24 by 36) can be ordered from our
  website.
• Brief highlights
• Preparing to taking your blood pressure
• Using endorsed BP devices.

Download at www.hypertension.ca
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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.

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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.

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Summary III

• Regarding the treatment of hypertension, the
  recommendations endorse
• TREATING TO TARGET BP
• Treat blood pressure to less than lt140/90 mmHg.
  In people with diabetes or chronic kidney disease
  target to lt130/80 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.htnupdate.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.

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• 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.htnupdate.ca for automatic updates and on
  current hypertension educational resources