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Part 2: Recommendations for Hypertension Treatment

Part 2: Recommendations for Hypertension Treatment. 2011 C anadian H ypertension E ducation P rogram Recommendations. The full slide set of the 2011 CHEP Recommendations are available at www.hypertension.ca. 2011 Canadian Hypertension Education Program (CHEP).

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Part 2: Recommendations for Hypertension Treatment

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  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 • Assess blood pressure at all appropriate visits. • 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. • 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. • Advocate for healthy public policies to prevent hypertension and advance the health of patients and populations. • 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 What’s 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 What’s 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 • Indications for drug therapy • Goals of therapy • Adherence • Lifestyle • Uncomplicated • CV – IHD • CHF • Cerebrovascular / Stroke • LVH • Chronic kidney disease • Renovascular • Diabetes • Smoking • Overall risk reduction

  10. 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

  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

  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

  18. 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

  21. 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 <102 cm <88 cm • South Asian, Chinese <90 cm <80 cm • Tobacco free environment

  23. 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 • Highin: • 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 • 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 REDUCTION IN AVERAGE DIETARY SODIUM FROM ABOUT 3500 MG TO 1700 MG Penz ED, Cdn J Cardiol 2008. Joffres MR_CJC_ 23(6) 2007.

  25. 2,300 mg sodium (Na) = 100 mmol sodium (Na) = 5.8 g of salt (NaCl) = 1 level teaspoon of table salt Recommendations for daily salt intake • 80% of average sodium intake is in processed foods • Only 10% is added at the table or in cooking Institute of Medicine, 2003

  26. Sodium: Meta-analyses The Cochrane Library 2006;3:1-41

  27. 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

  28. 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.

  29. 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

  30. 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.

  31. F Frequency - Four to seven days per week I Intensity - Moderate T Time - 30-60 minutes Type Cardiorespiratory Activity - Walking, jogging - Cycling - Non-competitive swimming T Lifestyle Recommendations for Hypertension: Physical Activity Should be prescribed to reduce blood pressure Exercise should be prescribed as an adjunctive to pharmacological therapy

  32. Hypertensive and all patients • 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 Loss Height, weight, and waist circumference (WC) should be measured and body mass index (BMI) calculated for all adults. CMAJ 2007;176:1103-6

  33. Measure here Iliac crest 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.

  36. Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults Padwal R. et al. CMAJ ･ SEPT. 27, 2005; 173 (7) 749-751

  37. Lifestyle Therapies in Hypertensive Adults: Summary

  38. 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

  39. V. Pharmacotherapy 2011 Canadian Hypertension Education Program Recommendations

  40. NO Treatment in the absence of compelling indications for specific therapies 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 • Treatment of Systolic/Diastolic hypertension without other compelling indications • Treatment of Isolated Systolic hypertension without other compelling indications

  42. ARB ACEI V. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling Indications TARGET <140/90 mmHg INITIAL TREATMENT AND MONOTHERAPY Lifestyle modification therapy Thiazide Long-acting CCB Beta-blocker* 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 • 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. 1. Add-on Therapy • 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).

  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 cont’d • 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  % <140/90 mm Hg Cushman et al. J Clin Hypertens 2002;4:393-404

  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. Long-acting CCB Beta-blocker* Thiazide diuretic ACEI ARB V. Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications 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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