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Part 2: Recommendations for Hypertension Treatment. 2009 Canadian Hypertension Education Program (CHEP). A red flag has been posted where recommendations were updated for 2009.

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2009 canadian hypertension education program chep l.jpg
2009 Canadian Hypertension Education Program (CHEP)

  • A red flag has been posted where recommendations were updated for 2009.

  • Slide kits for health care professional and public education can be downloaded (English and French versions) from http://www.hypertension.ca


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2009 Canadian Hypertension Education Program (CHEP)

Treatment Approaches:

  • Lifestyle

  • Pharmacological


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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 antihypertensive drugs including 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 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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What’s 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 <130 systolic and <80 mmHg diastolic


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What’s New for 2009The Hypertensive Diabetic

  • 2/3rds of hypertensive diabetic patients have uncontrolled hypertension (> 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 <130 systolic and <80 mmHg diastolic


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What’s 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 2008;358:1887-98


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What’s 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 2008;358:1547-59

Lancet 2008; 372: 547–53


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What’s New for 2009

  • The use of combination of ACE inhibitor with an ARB should only be considered in selected and closely monitored people with advanced heart failure or proteinuric nephropathy.


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2009 Canadian Hypertension Education Program (CHEP)

Important messages from past recommendations

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.

Home measurement can help to confirm the diagnosis of hypertension, improve blood pressure control, reduce the need for medications, identify patients with white coat and masked hypertension and improve medication adherence


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2009 Canadian Hypertension Education Program (CHEP)

IMPORTANT ROLE FOR HOME MEASUREMENT OF BLOOD PRESSURE

  • An internet based toolkit for home blood pressure measurement including recording and tracking of blood pressures 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.

  • More information on home monitoring is in the CHEP diagnostic slide set and the BP measurement slide set


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2009 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 2300 mg/day to prevent and control hypertension


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TO REDUCE DIETARY SODIUM

Advise patients to

  • Buy and eat more fresh foods, especially fruit and vegetables

  • Choose processed foods look with low salt labels or brands with the lowest percentage of sodium on the food label

  • Wash canned foods or other salty foods in water before eating or cooking

  • If desired, use unsalted spices to make foods taste better

  • Eat less food at restaurants and fast food outlets and ask for less salt to be added in food orders

  • Use less sauces on food

  • Eat foods with less than 200 mg of sodium or less than 10% of the daily value per serving

    Advise patients not to

  • Buy or eat heavily salted foods (e.g. pickled foods, salted crackers or chips, processed meats, etc).

  • Add salt in cooking and at the table

  • Eat foods with more than 400 mg of sodium or more than 20% of the daily value per serving


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Recommendations 2009Table 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

Overall risk reduction


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I. Indications for Pharmacotherapy

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


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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.

  • In particular many younger hypertensive Canadians with multiple cardiovascular risks are currently not treated with pharmacotherapy. Health care professionals need to be alert to this important care gap and recommend pharmacotherapy.

  • 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 mmHg

  • Patients with diabetes or chronic kidney disease should be considered for pharmacotherapy if the blood pressure is equal or over 130/80 mmHg


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II. Goals of Therapy

Blood pressure target values for treatment of hypertension


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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


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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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Lifestyle Recommendations for Prevention and Treatment of Hypertension

To reduce the possibility of becoming hypertensive,

Reduce sodium intake to less than 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 sodium in accordance with Canada's Guide to Healthy Eating.

Regular physical activity:accumulation of 30-60 minutes of moderate intensity cardiorespiratory activity (e.g. a brisk walk)

4-7 days/week in addition to routine activities of daily living

Low risk alcohol consumption(≤2 standard drinks/dayandless 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 Men Women

- Europid, Sub-Saharan African, Middle Eastern <94 cm <80 cm

- South Asian, Chinese <90 cm <80 cm

- Smoke free environment


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Dietary Sodium

Less than 2300mg / day

(Most of the salt in food is ‘hidden’ and comes from processed food)

Dietary Potassium

Daily dietary intake >80 mmol

Calcium supplementation

No conclusive studies for hypertension

Magnesium supplementation

No conclusive studies for hypertension

Lifestyle Recommendations for Hypertension: Dietary

  • • High in fresh fruits

  • • High in fresh vegetables

  • • High in low fat dairy products

  • High in dietary and soluble fibre

  • High in plant protein

  • • Low in saturated fat and cholesterol

  • Low in sodium

www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php


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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


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Recommendations for daily salt intake Sodium in Canada

Less than:

  • 2,300 mg sodium (Na)

  • 100 mmol sodium (Na)

  • 5.8 g of salt (NaCl)

  • 1 teaspoon of table salt

2,300 mg sodium = 1 level teaspoon of table salt however, 80% of average sodium intake is in processed foods and only 10% is added at the table or in cooking


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Sodium: Meta-analyses Sodium in Canada

Hypertensives

Reduction of BP

5.1 / 2.7 mmHg with a average reduction of 1800 mg sodium/day

7.2/3.8 mmHg with a average reduction of 2300 mg sodium/day

Normotensives

Reduction of BP

2.0 / 1.0 mmHg with a average reduction of sodium 1700 mg/day

3.6/1.7 mmHg with a average reduction of 2300 mg/day sodium

The Cochrane Library 2006;3:1-41


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Meta analysis on different reductions in dietary sodium intake on blood pressure

Hypertension 2003;42:1093-1099


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F intake on blood pressure

I

Intensity - Moderate

T

Time - 30-60 minutes

T

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


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  • Hypertensive and all patients intake on blood pressure

  • BMI over 25

  • - Encourage weight reduction

  • Healthy BMI: 18.5-24.9 kg/m2

  • Waist Circumference Men Women

  • - Europid, Sub-Saharan African, Middle Eastern <94 cm <80 cm

  • - South Asian, Chinese, Japanese <90 cm <80 cm

  • For patients prescribed pharmacological therapy: weight loss has additional antihypertensive effects. Weight loss strategies should employ a multidisciplinary approach and include dietary education, increased physical activity and behaviour modification

Lifestyle Recommendations for Hypertension: Weight LossHeight, weight, and waist circumference (WC) should be measured and body mass index (BMI) calculated for all adults.

CMAJ 2007;176:1103-6


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Waist Circumference Measurement intake on blood pressure

Last rib margin

Mid distance

Iliac crest

Courtesy J.P. Després 2006


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Lifestyle Recommendations for Hypertension: Alcohol intake on blood pressure

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).


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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

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


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Lifestyle Therapies in Hypertensive Hypertensive AdultsAdults: Summary


Slide34 l.jpg

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 2002;288:1882-1888


Pharmacotherapy l.jpg

Pharmacotherapy reduction in the population


V choice of pharmacological treatment uncomplicated l.jpg

NO reduction in the population

YES

Treatment in the

absence of compelling

indications for specific therapies

Individualized

Treatment

(and compelling indications)

V. Choice of Pharmacological Treatment Uncomplicated

Associated risk factors?

or

Target organ damage/complications?

or

Concomitant diseases/conditions?


V choice of pharmacological treatment l.jpg

V. Choice of Pharmacological Treatment reduction in the population

1. Treatment of Systolic/Diastolic hypertension without other compelling indications

2. Treatment of Isolated Systolic hypertension without other compelling indications


V treatment of adults with systolic diastolic hypertension without other compelling indications l.jpg

ARB reduction in the population

ACEI

V. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling Indications

TARGET <140/90 mmHg

INITIAL TREATMENT AND MONOTHERAPY

Lifestyle modification

therapy

A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target

Thiazide

Long-acting

CCB

Beta-blocker*

  • 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


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V. reduction in the populationConsiderations 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 agent if required.

  • The use of combination of ACE inhibitor with a ARB should only be considered in selected and closely monitored people with advanced heart failure or proteinuric nephropathy.

  • ACE-I are not recommended (as monotherapy)for black patients without another compelling indication.


V add on therapy for systolic diastolic hypertension without other compelling indications l.jpg

1. Add-on Therapy reduction in the population

  • IF BLOOD PRESSURE IS NOT CONTROLLED CONSIDER

  • Nonadherence

  • Secondary HTN

  • Interfering drugs or lifestyle

  • White coat effect

2. Triple or Quadruple Therapy

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).


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Drug Combinations reduction in the population

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


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Drug Combinations cont’d reduction in the population

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.


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Medication Use and BP Control in ALLHAT reduction in the population

<140/90 mm Hg

Cushman et al. J Clin Hypertens 2002;4:393-404.


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Most HTN Pts need more than 1 drug reduction in the population

5

4

3

Number of drugs

2

1

0

HOT

IDNT

AASK

ABCD

MDRD

UKPDS

ALLHAT


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BP lowering effects from antihypertensive drugs reduction in the population

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


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V. Summary: Treatment of reduction in the populationSystolic-Diastolic Hypertension without Other Compelling Indications

Long-acting

CCB

Beta-blocker*

Thiazide

diuretic

ACEI

ARB

TARGET <140/90 mmHg

Lifestyle modification

A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target

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


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Treatment Algorithm for Isolated Systolic Hypertension reduction in the populationwithout Other Compelling Indications

TARGET <140 mmHg

INITIAL TREATMENT AND MONOTHERAPY

Lifestyle modification

therapy

Thiazide diuretic

ARB

Long-acting

DHP CCB


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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).


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V. Summary: Treatment of Isolated Systolic Hypertension without Other without Other Compelling Indications

TARGET <140 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


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Choice of Pharmacological Treatment without Other 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


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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*

Short-acting

nifedipine

  • • 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)

  • Combinations of an ACEI with an ARB are not recommended in the absence of heart failure

*Those at low risk with well controlled risk factors may not benefit from ACEI therapy


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VI. Treatment of Hypertension in Patients Heart Diseasewith Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI

Beta-blocker and ACEI or ARB (if ACEI not tolerated)

Recent

myocardial

infarction

If beta-blocker contraindicated or not effective

Long-acting

Dihydropyridine CCB*

(e.g. Amlodipine)

YES

Heart Failure ?

NO

Long-acting CCB

*Avoid non dihydropyridine CCBs (diltiazem, verapamil)


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VII. Treatment of Hypertension with Left Ventricular Systolic Dysfunction

Non dihydropyridine CCB

• 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.


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VIII. Treatment of Hypertension Systolic Dysfunctionfor Patients with Cerebrovascular Disease

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

An ACEI / diuretic combination is preferred

Stroke

TIA

Combinations of an ACEI with an ARB are not recommended


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IX. Treatment of Hypertension in Patients with Left Ventricular Hypertrophy

Left ventricular

hypertrophy

Vasodilators:

Hydralazine, Minoxidil can increase LVH

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)*


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X. Treatment of Hypertension in Patients with Non Diabetic Chronic Kidney Disease

Target BP: < 130/80 mmHg

ACEI/ARB: Bilateral renal artery stenosis

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

* albumin:creatinine ratio [ACR] > 30 mg/mmol

or urinary protein > 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


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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.



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XII. Treatment of Hypertension in association with Diabetes Mellitus

with

Nephropathy*

Diabetes

without

Nephropathy**

Systolic- diastolic

Hypertension

Isolated

Systolic

Hypertension

Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg

*Urinary albumin to creatinine ratio > 2.0 mg/mmol in men or > 2.8mg/mmol in women or chronic kidney disease*

A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target

Combinations of an ACEI with an ARB are specifically

not recommended in the absence of proteinuria

* based on at least 2 of 3 measurements


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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

Thiazide diuretic or

Long-acting CCB

DIABETES

with

Nephropathy

ACE Inhibitor

or ARB

IF ACEI and ARB are contraindicated or not tolerated,

SUBSTITUTE

• Long-acting CCB or

• Thiazide diuretic

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


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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

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


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XII. Treatment of Hypertension in association with Diabetes Mellitus: Summary

with

Nephropathy

Diabetes

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 >20 mmHg systolic or >10 mmHg diastolic above target

ACE Inhibitor

or ARB

1. ACEInhibitor or ARB

or

2. Thiazide diuretic or DHP-CCB

without

Nephropathy

> 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


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XIII. Treatment of Hypertension for Patients Who Use Tobacco

Smoking

Beta-blocker

The benefits of treating smokers with beta-blockers

remain uncertain in the absence of a specific indication like angina or post-MI



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Most hypertensive Canadians have other cardiovascular risks Hypertension

Assess and manage hypertensive patients for smoking, dyslipidemia and dysglycemia (impaired fasting glucose or diabetes) abdominal obesity, unhealthy eating and physical inactivity.


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XIV. Vascular Protection for Hypertensive HypertensionPatients: 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 2003;361:1149-58


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XIV. Vascular Protection for Hypertensive HypertensionPatients: ASA

Consider low dose ASA

Caution should be exercised if BP is not controlled.


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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

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


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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 if available to improve adherence to therapy

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


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Focusing on care gaps monitoring of their blood pressure

CHEP utilizes several different surveillance mechanisms to look for areas where patient care can be improved.

In 2009 we highlight 3 important care gaps

Lifestyle change after a diagnosis of hypertension

Pharmacotherapy in younger patients who have multiple cardiovascular risk factors

Achieving blood pressure targets in people with diabetes


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NPHS (1994-2002): More Lifestyle Changes After monitoring of their blood pressure Hypertension Diagnosis Are Needed

Small decreases in smoking and physical inactivity along with increases in BMI were observed in 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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Lifestyle change monitoring of their blood pressure

Single lifestyle changes can have a similar blood pressure lowering effect as an antihypertensive drug and most lifestyle changes also reduce other cardiovascular risk factors

Brief health care professional interventions are effective in promoting lifestyle change

More extensive interdisciplinary team approaches are more effective in promoting lifestyle change.


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Treating younger patients with pharmacotherapy monitoring of their blood pressure

Most patients with hypertension have other cardiovascular risks.

Multiple risk factors can dramatically increase the probability of an adverse cardiovascular outcome


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The Proportion of Aware Adult Hypertensive Canadians Not Receiving Antihypertensive Treatment by Number of Cardiovascular Disease (CVD) Risk Factors

(risks include male, smoking, obese (BMI >30), diabetes, and physically inactive)

Can J Cardiol 2008;24:485-90


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Treating younger patients with pharmacotherapy Receiving Antihypertensive Treatment by Number of Cardiovascular Disease (CVD) Risk Factors

Be aware that many young hypertensive patients are not currently prescribed antihypertensive therapy

Those with additional cardiovascular risk factors are recommended for pharmacotherapy

In particular, hypertensive patients who smoke and are unable to stop should be prescribed antihypertensive therapy.


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Hypertension in the Diabetic patient Receiving Antihypertensive Treatment by Number of Cardiovascular Disease (CVD) Risk Factors

Two thirds of Ontarians with hypertension and diabetes have blood pressure above target.

Only 25% were prescribed a thiazide like diuretic.

Very large reductions in cardiovascular disease and death occur from treating hypertension in diabetic patients.

Many require lifestyle change and three or more drugs

CMAJ 2008;178:1441-9, Am J Hypertens 2008;21:1210-5.


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NEW Receiving Antihypertensive Treatment by Number of Cardiovascular Disease (CVD) Risk FactorsPATIENT RESOURCES FOR HYPERTENSION ON LINE

www.heartandstroke.ca/BP

To monitor home blood pressure and encourage self management of lifestyle

www.hypertension.ca

To access up to date downloadable patient information on hypertension


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Public translation of CHEP recommendations Receiving Antihypertensive Treatment by Number of Cardiovascular Disease (CVD) Risk Factors

Download at www.hypertension.ca/bpc


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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: 613-533-3299, Fax: 613-533-6927

Email: [email protected]


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Encourage greater patient responsibility/autonomy disease/treatment regimens verbally and in writing

Can be ordered at: www.hypertension.qc.ca


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Summary I disease/treatment regimens verbally and in writing

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

Encourage appropriate patients to properly measure blood pressure at home

Most can assess blood pressure at home. Home measurement can confirm a diagnosis of hypertension, improve adherence to drug treatment, improve control rates and detect patients with white coat hypertension and masked hypertension.


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Summary II disease/treatment regimens verbally and in writing

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 treatment target or in combination with pharmacological treatment


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Summary III disease/treatment regimens verbally and in writing

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


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