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HYPERTENSION

Workshop

September, 2007

Information was produced and/or compiled by the Alberta Provincial Stroke Strategy and written permission is required prior to reprinting any of the material located within this document.

09/07:09/08[R]


High blood pressure get the low down
High Blood PressureGet the Low Down!


Average

Canadian


Who has hypertension
Who Has Hypertension?

  • What is the chance he has hypertension?

  • What is the chance he will get hypertension if not already?

  • If he has hypertension, what is the chance he knows his BP is high?

  • If he has hypertension, what is the chance he is treated and controlled?


The challenge in canada
The Challenge In Canada

  • Hypertension is a problem which increases with age

  • Hypertension is often unidentified

    • if identified - is poorly treated.

  • Recent data is showing that identification and management of hypertension in Canada has improved over the past few years.


We need to make a difference

We Need to Make a Difference!


What can be the result of hypertension hypertension increases the risk of what health problems

What can be the result of hypertension?Hypertension increases the risk of what health problems?


Hypertension is a major risk factor
Hypertension is a Major Risk Factor

  • Untreated high blood pressure increases risk of:

    • Stroke (4 times > risk hemorrhagic stroke)

    • Coronary Artery Disease

    • Congestive heart failure

    • Chronic Kidney Disease

    • Peripheral vascular disease

    • Dementia

    • Atrial Fibrillation

  • Effective treatment has been shown to reduce the risk of recurrent stroke and to reduce cognitive decline in patients with dementia

    Source: 2007 CHEP Recommendations


Hypertension
Hypertension

  • Stroke mortality doubles for every 20 mmHg increase in SBP or 10 mmHg increase in DBP

    • Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies.

      Lancet 2002;360:1903-13.


Benefits of treating hypertension
Benefits of Treating Hypertension

  • Younger than 60

    • reduces the risk of stroke by 42%

    • reduces the risk of coronary event by 14%

  • Older than 60

    • reduces overall mortality by 20%

    • reduces cardiovascular mortality by 33%

    • reduces incidence of stroke by 40%

    • reduces coronary artery disease by 15%

Source: 2007 CHEP Recommendations


What are the benefits of treating hypertension
What Are the Benefits of Treating Hypertension?

For a decrease of 10/5 mm Hg (one medication

or a change in lifestyle):

  • Heart attack by 15%

  • Heart failure by 50%

  • Stroke by 38%

  • Death by 10%

Source: 2007 CHEP Recommendations


Lets get the low down on hypertension
Lets get the Low Down on Hypertension

  • What is blood pressure?

  • Causes of hypertension

  • How to measure blood pressure

  • Diagnosis of hypertension

  • Types of hypertension

  • Lifestyle and Pharmaceutical treatment

  • BP target values

  • Review highlights of 2007 CHEP recommendations


What is blood pressure
What Is Blood Pressure?

  • Blood pressure is the amount of force on the walls of the arteries as the blood circulates around the body.


What is blood pressure1
What is Blood Pressure?

Systolic

Pressure in the blood vessels

as the heart beats or contracts

& fills them with blood (i.e. 130)

Diastolic

The pressure in the blood vessels as the heart relaxes in between beats. (i.e. 80)


What is blood pressure2
What is Blood Pressure?

  • Blood pressure goes up and down naturally throughout the day, and from one day to another.

  • A healthy blood pressure reading is

    less than 130/80 mmHg on a regular basis.

  • A client has high blood pressure if average or usual:

    • readings are ≥ 140/90

    • readings are ≥ 130/80 ( for those with diabetes or chronic kidney disease)

  • High blood pressure = hypertension


5 factors controlling blood pressure
5 Factors Controlling Blood Pressure

  • Cardiac output

  • Peripheral Vascular Resistance

  • Volume of circulating blood

  • Viscosity

  • Elasticity of vessel walls


Classification of hypertension
Classification of Hypertension

The category pertains to the highest risk blood pressure

*ISH=International Society of Hypertension. Chalmers J et al. J Hypertens 1999;17:151-85.

Source: 2007 CHEP Recommendations



What causes hypertension
What Causes HYPERTENSION ?

  • POOR LIFESTYLE!!

    - interaction between genetics and environment.

  • 1 in 20 people a diseasesuch as of the kidneys


Factors that affect blood pressure
Factors that affect Blood Pressure

  • Age

  • Sex

  • Race

  • Diurnal Rhythm

  • Genetics

  • Obesity

  • Exercise

  • Emotions

  • Stress

  • Diet

  • Alcohol


Symptoms of high blood pressure
Symptoms of High Blood Pressure

Called the “Silent Killer”

Usually no symptoms until initial event (Stroke or cardiac event)

If symptoms are present this may be due to secondary hypertension or complications of hypertension


Bp measurement technique

BP Measurement Technique

Demonstrate:

What is good technique?

What should have been done?


Bp measurement technique1
BP Measurement Technique:

1)Client should rest for 5 minutes in a quiet comfortable room prior to the measurement.

Should be in a sitting position with back supported and legs not crossed.

2) Select the appropriate cuff size as follows:


Bp measurement technique2
BP Measurement Technique:

3) Bare arm in a supported position, with antecubital fossa @ heart level.

4) Find brachial pulse (inner part of the arm near the elbow) using index & middle fingers.


Bp measurement technique3
BP Measurement Technique:

5)Apply the appropriate size cuff to the arm by positioning the center of the inflatable bladder directly over the brachial artery & secure snugly.

  • Ensure the lower edge of the cuff is 2cm above the elbow crease.

    NOTE: The bladder inside the cuff should encircle:

    • 80% of the arm in adults

    • 100% of the arm in children < 13years.


Bp measurement technique4
BP Measurement Technique:

6) Locate the client’s radial pulse on the thumb side of the wrist.


Bp measurement technique5
BP Measurement Technique:

7) Place manometer so center of the mercury column, or aneroid dial, is easily visible

- Ensure tubing is unobstructed.

8) Take the clients pulse & rapidly increase the cuff pressure. Note the reading when the radialpulse disappears while deflating the cuff by releasing the valve all the way


Bp measurement technique6
BP Measurement Technique:

8) Locate brachial artery & place stethoscope gently but firmly over the artery,

just below the lower

edge of the cuff.

9) The column of mercury must be @ zero before the procedure begins, or the needle on the aneroid devise must be opposite zero when the cuff is deflated.


Bp measurement technique7
BP Measurement Technique:

10) Inflate the cuff rapidly to a pressure

20-30 mmHg above the previously

determined level (based on the disappearance

of the radial pulse).

11) Let the cuff deflate by slowly releasing the

valve and allowing the mercury or needle

to drop @ a rate of 2-3mmHg per second or

per pulse beat while listening for audible

Korotkoff sounds.


Bp measurement technique8
BP Measurement Technique:

  • Systolic: The 1st appearance of a clear tapping sound on the manometer (phase 1 Korotkoff). Note the reading on the manometer.

  • Diastolic: The point @ which the sound disappears on the manometer (phase V Korotkoff). Note the reading on the manometer.


Bp measurement technique9
BP Measurement Technique:

  • Once BP completed, record the Systolic & Diastolic numbers immediately.

  • Explain target values for BP to the client & provide education regarding the clients BP value and/or lifestyle modifications that may be helpful.

  • Contact the physician as required to report elevated BP values.


Tips to ensure an accurate bp measurement

Rest for 5 minutes prior to measurement

Calm, comfortable environment

No tight clothing on arm or forearm

No crossing of legs

No talking during measurement

No smoking 15-30 minutes prior

No caffeine 1 hour prior

No strenuous exercise

1 hour prior

Ensure bladder is empty

Appropriate cuff size

Tips to Ensure an Accurate BP Measurement:




Sources of potential errors in bp measurement1

No waiting time prior to measurement

Arm positioned inappropriately

Presence of background noise or conversation

Rounding figures up or down

Inappropriate cuff size or position of cuff

Inadequate deflation of the cuff (too quickly or slowly)

Instrument not calibrated

Sources of Potential Errors in BP Measurement:


Types of bp monitors
Types of BP Monitors:

1) Mercury Manometer: Usually fixed to a wall mount, or a portable unit on wheels.

2) Electronic Device: A portable unit which is most often used for home BP monitoring.


Types of bp monitors1
Types of BP Monitors:

3) Aneroid Manometer: Can be fixed to a wall mount, a portable hand held unit, or a portable unit on wheels.

  • Not Recommended:

  • May go out of calibration

  • 40% used are out of calibration

  • Require regular assessment of calibration every 6 - 12 months

  • A systematic process should be in place to ensure accuracy


2007 canadian hypertension education program recommendations
2007 Canadian Hypertension Education Program Recommendations

  • Annual process to develop and update evidence-based recommendations for HTN management

  • Incorporated all trials and meta-analyses published in the past year felt to have relevance for individuals with hypertension

  • The 2007 unabridged and “bottom line” reports available at www.hypertension.ca

  • CHEP is jointly sponsored by the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the Heart and Stroke Foundation of Canada, the College of Family Physicians of Canada, the Canadian Council of Cardiovascular Nurses, the Canadian Pharmacists Association


Treat hypertension in the context of overall cardiovascular risk
Treat Hypertension in the Context of Overall Cardiovascular Risk

  • Assess global cardiovascular risk

    • The management plan for patients with hypertension must be based on their global cardiovascular risk

  • Consider informing patients of their global risk to improve the effectiveness of risk modification

    • Shared decision-making may improve the effectiveness of preventive health interventions.

      Simply counting risk factors may be misleading

      Source: 2007 Canadian Hypertension Education Program Recommendations



Assess blood pressure at all appropriate visits
Assess blood pressure at all appropriate visits Risk

Blood pressure of all adults should be measured, whenever appropriate, by trained healthcare professionals using standardized techniques.

  • To screen for hypertension

  • To assess cardiovascular risk

  • To monitor antihypertensive treatment

    Assess blood pressure annually in those with high normal blood pressure.

Source: 2007 Canadian Hypertension Education Program Recommendations


Criteria for the diagnosis of hypertension and recommendations for follow up

Elevated Out of the Office BP measurement Risk

Elevated Random Office BP Measurement

Hypertensive

Urgency / Emergency

BP >140/90 mmHg and Target organ damage or Diabetes or Chronic Kidney Disease or BP >180/110?

Diagnosis

of HTN

Yes

No

BP: 140-179 / 90-109mmHg

Criteria for the diagnosis of hypertension and recommendations for follow-up

Hypertension Visit 1

BP Measurement,

History and Physical examination

Diagnostic tests ordering

at visit 1 or 2

Hypertension Visit 2

within 1 month

Source: 2007 CHEP Recommendations


Criteria for the diagnosis of hypertension and recommendations for follow up1

Clinic BP Risk

24-h ABPM (If available)

Home BPM(If available)

Hypertension visit 3

>160 SBP or

>100 DBP

Diagnosis

of HTN

>135/85

< 135/85

Awake BP

<135/85

and

24-hour

<130/80

Awake BP

>135 SBP or

>85 DBP or

24-hour

>130 SBP or

>80 DBP

ABPM or S/H BPM if available

<160 /100

or

or

Hypertension visit 4-5

>140 SBP or

>90 DBP

Diagnosis

of HTN

Continue to follow-up

Diagnosis

of HTN

Continue to follow-up

Diagnosis

of HTN

< 140 / 90

Continue to follow-up

Criteria for the diagnosis of hypertension and recommendations for follow-up

BP: 140-179 / 90-109

Patients with high normal blood pressure (clinic SBP 130-139 and/or DBP 85-89) should be followed annually.

Source: 2007 CHEP Recommendations


Case 1
Case #1 Risk

  • Mr. W. is a 58 year old Sr. Administrator for a Health Region in Alberta. Seen in clinic to follow-up on BP 164/92 taken at a pharmacy

  • BPs during this visit 156/90 & 160/92

  • Interview and review of the medical chart reveals:

    • Height 6 ’1” and weight 215 lbs (BMI 28.4 kg/m2)

    • Review of systems normal

    • Social drinker (~4 glasses of wine/week)

    • Quit smoking 10 years ago

    • No routine physical activity

    • Family history of CVD (father died at age 50 from MI)

    • Married, four children

      Is he hypertensive?


Diagnostic work up
Diagnostic Work-Up Risk

  • Check BP at all appropriate visits

  • Use standardized measurement technique:

    • Have patient rest for 5 minutes

    • Use a validated & calibrated device

    • Cuff encircles 80% of upper arm

    • Measure both arms at initial visit

    • Thereafter take 2 measurements on the side where BP is higher


Diagnostic work up cont
Diagnostic Work-Up, cont… Risk

  • History and physical

    • Review for CV risk factors, evidence of Target Organ Damage and HTN, monitor treatment

  • Routine laboratory tests

    • Urinalysis

    • blood chemistry (potassium, sodium, creatinine), fasting glucose, fasting TC, HDL, LDL, triglycerides

    • Standard 12-lead ECG

  • Lab tests for specific subgroups

    • Diabetes & renal disease: urinary albumin excretion

    • increased creatinine, hx of renal disease or proteinuria - renal ultrasound


Search for cardiovascular risk factors

Hypertension Risk

Male

Increasing age

Peripheral arterial disease

Previous stroke or TIA

Microalbuminuria or proteinuria

Diabetes mellitus

Smoking

Family history of premature CVD

Chronic kidney disease

Abnormal lipid profile

Sedentary lifestyle

Left ventricular hypertrophy

Abdominal obesity

Coronary Artery Disease

Search for Cardiovascular Risk Factors

Source: 2007 CHEP Recommendations


Search for target organ damage
Search for Target Organ Damage Risk

Cerebrovascular

TIA

Ischemic or Hemorrhagic Stroke

Hypertensive retinopathy

Left ventricular dysfunction

Coronary artery disease

Angina or prior MI

CHF

Chronic kidney disease

Peripheral arterial disease

Source: 2007 CHEP Recommendations


Case 11

Case #1 Risk

Visit 2


Case 1 visit 2

LDL=3.1 mmol/L Risk

TC = 4.85 mmol/L

TG=2.2 mmol/L

HDL =1.32 mmol/L

Normal 12 lead ECG

Weight 7.5 lbs since first visit

No routine physical activity

BP 158/100 mmHg

No evidence of Target Organ Damage

Normal urinalysis

Serum potassium=4.5 mmol/L (3.5-5.0)

Serum creatinine 97 mmol/L (50-120)

Fasting glucose=5.1 mmol/L

Case #1: Visit 2

  • Is he hypertensive?

  • What are the treatment and management options?


Use any of three validated technologies to diagnose hypertension office ambulatory and home

Use any of three validated technologies to diagnose hypertensionoffice,ambulatory and home


Ambulatory bp monitoring who
Ambulatory BP Monitoring: Who? hypertension

  • Role in diagnosis and management of patients with HTN

    • Patients with suspected office-induced elevations in BP

    • Untreated patients with mild to moderate clinic BP elevation and no target organ damage

    • Treated patients with:

      • BP not below target values despite receiving appropriate chronic hypertensive therapy

      • Symptoms that may be suggestive of hypotension

      • Fluctuating office readings


Ambulatory bp monitoring
Ambulatory BP Monitoring hypertension

  • BP is monitored during daily activities and during sleep

  • Mean daytime BP ≥ 135/85 or mean nocturnal BP ≥ 125/75 is considered elevated

  • Mean 24 hour ambulatory BP ≥ 130/80 mmHg is considered elevated

  • A drop in nocturnal BP <10% is associated with an increased risk of cardiovascular events

Source: 2007 CHEP Recommendations


Follow up algorithm for high blood pressure ambulatory blood pressure measurement
Follow up algorithm for hypertensionhigh Blood Pressure: Ambulatory Blood Pressure Measurement

24-h ABPM

Awake BP

>135 SBP or

>85 DBP

or

24-hour

>130 SBP or

>80 DBP

Awake BP

< 135/85

and

24-hour

< 130/80

Consistent with HTN

Continue

to follow-up

Patients with high normal blood pressure should be followed annually.

Source: 2007 CHEP Recommendations


Home blood pressure monitoring
Home Blood Pressure Monitoring hypertension

  • Patients who

    • May wish to take an active role in BP management

    • May need help with adherence

    • Are not adherent with treatment

    • Have hypertension and diabetes

    • May have office induced (“white coat”) hypertension

    • Target <135/85 mmHg (unless diabetes, renal disease, or proteinuria)

    • A blood pressure contract and BP monitoring tools are available from the BP Action Plan

    • Have chronic kidney disease

    • Have masked hypertension


Home blood pressure monitoring protocol
Home Blood Pressure Monitoring Protocol hypertension

  • Assessment of white coat or sustained hypertension based on the following protocol

    • Two daily measures

    • Morning and evening

    • An initial 7-day period

  • Do not consider single and first day home BP values

  • Ask patient to bring device and BP record to appointment

  • Demonstrate/review how to measure and record BP (arm, position, time of day).

  • Refer to the BP ACTION Plan for monitoring tools

  • Review treatment goals and personal BP targets with patient at visits (daytime average BP135/85 considered elevated)


Do you have white coat hypertension

Do You Have White Coat Hypertension? hypertension

Demonstration?


The concept of masked hypertension

True hypertension

hypertensive

Masked HTN

135

True

Normotensive

White Coat HTN

The Concept of Masked Hypertension

200

180

True

hypertensive

Masked HTN

160

Ambulatory SBP mmHg

140

True

Normotensive

120

White Coat HTN

100

100

120

140

160

180

200

Office SBP mmHg

From Pickering, Hypertension 1992


The prognosis of masked hypertension
The prognosis of masked hypertension hypertension

Prevalence is approximately 10% in hypertensive patients.

35

CV Events

30

25

20

CV events per 1000 patient-year

15

10

5

0

Normal

White coat

Uncontrolled

Masked

23/685

24/656

41/462

236/3125

Bobrie et al. JAMA 2004;291:1342-9


Some recommended electronic blood pressure monitors for home blood pressure measurement
Some recommended electronic blood pressure monitors for home blood pressure measurement

Monitors A&D® or LifeSource®

Models: 767*, 767PAC*, 774AC*, 779, 787AC*

Monitor Omron®

Models: HEM-705 PC*, HEM-711*, HEM-741CINT*

Monitor Microlife®

Model: BP 3BTO-A

* Models with memory are preferred

Source: 2007 CHEP Recommendations


Clinic home ambulatory abp blood pressure measurement equivalence numbers
Clinic, Home, Ambulatory (ABP) Blood Pressure Measurement equivalence numbers

A clinic blood pressure of 140/90 mmHg

has a similar risk of a:

Source: 2007 CHEP Recommendations


Criteria for the diagnosis of hypertension and recommendations for follow up2

Hypertension Visit 1 equivalence numbers

BP Measurement,

History and Physical examination

Hypertensive

Urgency / Emergency

Hypertension Visit 2

Target Organ Damage

or Diabetes

or Chronic Kidney Disease

or BP >180/110?

Diagnosis

of HTN

Yes

No

BP: 140-179 / 90-109

Clinic BPM

ABPM (If available)

Home BPM (If available)

Criteria for the diagnosis of hypertension and recommendations for follow-up

Source: 2007 CHEP Recommendations


Criteria for the diagnosis of hypertension and recommendations for follow up3

Clinic BP equivalence numbers

24-h ABPM (If available)

Home BPM(If available)

Hypertension visit 3

>160 SBP or

>100 DBP

Diagnosis

of HTN

>135/85

< 135/85

Awake BP

<135/85

and

24-hour

<130/80

Awake BP

>135 SBP or

>85 DBP or

24-hour

>130 SBP or

>80 DBP

ABPM or S/H BPM if available

<160 /100

or

or

Hypertension visit 4-5

>140 SBP or

>90 DBP

Diagnosis

of HTN

Continue to follow-up

Diagnosis

of HTN

Continue to follow-up

Diagnosis

of HTN

< 140 / 90

Continue to follow-up

Criteria for the diagnosis of hypertension and recommendations for follow-up

BP: 140-179 / 90-109

Patients with high normal blood pressure (clinic SBP 130-139 and/or DBP 85-89) should be followed annually.

Source: 2007 CHEP Recommendations


Criteria for the diagnosis of hypertension and recommendations for follow up4
Criteria for the diagnosis of hypertension and recommendations for follow-up

Diagnosis of hypertension

Non Pharmacological treatment

With or without Pharmacological treatment

Are BP readings below target during 2 consecutive visits?

Yes

No

Symptoms, Severe hypertension, Intolerance to anti-hypertensive treatment or Target Organ Damage

Follow-up at 3-6 month intervals *

Yes

No

Visits every 1 to 2 months*

More frequentvisits *

* Consider Home measurement in hypertension management, to rule out masked hypertension or white coat effect and to enhance adherence.


Key chep messages for the management of hypertension
Key CHEP messages for the recommendations for follow-upmanagement of hypertension

  • Assess blood pressure at all appropriate visits.

  • Almost one half of those with blood pressure 130-139/85-89 will develop hypertension within 2 years. They require annual reassessment.

  • Assess global cardiovascular risk in all hypertensive patients.

  • Lifestyle modification is the cornerstone for the prevention and management of hypertension and CVD.


Key chep messages for the management of hypertension1
Key CHEP messages for the recommendations for follow-upmanagement of hypertension

  • Treat to target (<140/90 mmHg; <130/80 mmHg in patients with diabetes or chronic kidney disease).

  • To achieve targets sustained lifestyle modification and more than one drug is usually required.

  • Follow patients with uncontrolled blood pressure at least every 2 months until blood pressure targets are achieved.

  • Strategies to improve patient adherence to lifestyle modifications and antihypertensive therapy need to be incorporated in every patients management


Lifestyle management recommendations

Lifestyle Management Recommendations recommendations for follow-up

Case #2


Reversible risks for developing hypertension
Reversible risks for developing hypertension recommendations for follow-up

  • Obesity

  • Poor dietary habits

  • High sodium intake

  • Sedentary

  • High alcohol consumption

  • High stress

  • High normal blood pressure

Source: 2007 CHEP Recommendations


Case 2
Case # 2 recommendations for follow-up

  • Mr. J is a 45 year old mechanic

  • Several recent office visits pre/post inguinal hernia repair

  • BP range 140/90-154/90 mmHg at recent office visits

  • Previous documented BP 122/70 mmHg

  • Nonsmoker

  • Drinks 3-4 beers/day (more on W/E)

  • Saturday night hockey league, no other exercise

  • Weight increased 20 lbs over past 5 years (BMI 28 kg/m2 )

  • Eats fast food for lunch 3-4 times/week


Lifestyle strategies

Prevent HTN recommendations for follow-up

Eat a healthy diet: Canada’s Guide to Healthy Eating

High in fresh fruits, vegetables, low fat dairy products, low in saturated fat and cholesterol

Restrict sodium (<100 mmol/day)

Physical activity: 30-60 min moderate intensity 4-7x/week

Maintain healthy body weight (BMI 18.5-24.9 kg/m2) & WC<102cm men, <88 cm women

Alcohol consumption (2 drinks /day)

Smoke free environment

Treat HTN

Eat healthy: DASH diet

High in fresh fruits, vegetables, low fat dairy products, low in saturated fat

Restrict sodium (<100 mmol/day)

Physical activity: 30-60 min moderate intensity 4x/week or more

Weight loss (>5 Kg) in those who are overweight (BMI 25) and WC<102cm men, <88 cm women

Reduce alcohol consumption in those who drink excessively

Smoke free environment

Lifestyle Strategies

Source: 2007 CHEP Recommendations


Dietary approaches to stop hypertension dash diet
Dietary Approaches to Stop Hypertension: recommendations for follow-upDASH Diet

  • Rich in fruits, vegetables, low fat dairy foods, and low in fat, total fat, cholesterol and salt

  • The low sodium DASH diet evaluated the effect of reducing sodium intake in combination with a DASH diet. BP fell 11.4/5.5 mmHg in hypertensive persons compared to 3.5/2.1 in normotensives

    Source: Appel et al. N Engl J Med 1997;336:1117.

  • The DASH eating plan is available at www.nhlbi.nih.gov/health/public/heart/hbp/dash


Lifestyle recommendations for hypertension dietary

Dietary Sodium recommendations for follow-up

Restrict to target range of 65-100 mmol/day

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

Dietary Potassium

If required, 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 vegetables

  • • High in low fat dairy products

  • High in dietary and soluble fibre

  • High in plant protein

  • • Low in saturated fat and cholesterol

http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_guide_rainbow_e.html

Source: 2007 CHEP Recommendations


Sodium reduction
Sodium Reduction recommendations for follow-up

  • For hypertensive patients

    • Ask patients how much fresh foods and unprocessed foods they consume

    • Ask about processed and fast foods

    •  dietary sodium to target range:

      65-100mmol/day (2/3-1 tsp table salt/day).

  • Counsel all patients to avoid excessive salt intake

    • Avoid fast and processed foods and minimize use of salt at the table and during cooking


2007 canadian hypertension education program
2007 Canadian Hypertension Education Program recommendations for follow-up

What's New for 2007

  • Up to 30% of hypertension can be attributed to high sodium diets

  • Reduce sodium intake to less than 100 mmol in normotensive patients to prevent hypertension


Physical activity
Physical Activity recommendations for follow-up

  • Evidence that mild hypertension can be treated with moderate physical activity alone

  • Of particular note:

    • Significant  BP after 4 to 5 wks

    • Effect persisted as long as patient exercised, reversible if training stopped

    • Daily physical activity not essential to get antihypertensive effect

    • Age, race, sex has no effect on the benefit derived


Physical activity1
Physical Activity recommendations for follow-up

  • The Heart and Stroke Foundation recommends that clients be prescribed exercise to reduce blood pressure

  • Think FITT

    • Frequent (4 or more days of the week)

    • Intensity (moderate)

    • Time (optimum 30-60 minutes)

    • Type (dynamic – walking, cycling, swimming)

  • Physical activity should be prescribed as adjunctive therapy for those patients prescribed pharmacotherapy


Weight loss
Weight Loss recommendations for follow-up

  • Healthy BMI: 18.5-24.9 kg/m2

  • Waist circumference:

    <102 cm for men, <88 cm for women

  • Encourage weight reduction for hypertensive and all patients with BMI >25

  • Additional anti-hypertensive effects for patients prescribed pharmacological therapy

  • Weight loss strategies should use a multidisciplinary approach and include dietary education, increased physical activity and behavior modification


Waist circumference measurement
Waist circumference measurement recommendations for follow-up

Last rib margin

Mid distance

Iliac crest

Courtesy J.P. Després 2006

Source: 2007 CHEP Recommendations


Alcohol consumption
Alcohol Consumption recommendations for follow-up

  • Ask how much alcohol clients drink

  • For those who choose to drink:

    • Limit to  2 standard drinks/day as per low risk drinking guidelines (www.lrdg.net)

      • 14 standard drinks/wk for men

      • 9 standard drinks/week for women 1 standard drink = 1 can beer or 1.5 oz liquor or spirits or 5 oz of wine

  • Advise hypertensive patients to limit alcohol


Stress management
Stress Management recommendations for follow-up

  • “There is no evidence that stress management prevents hypertension, but there is some evidence that stress management can reduce BP in hypertensive patients.”

  • Consider how stress contributes to hypertension (e.g., unhealthy lifestyle choices such as smoking, drinking and binge eating)

  • Consider exercise as a treatment for stress management

  • In patients whom stress is an important issue, individualized cognitive behavioural interventions are more likely to be effective when relaxation techniques are employed

CMAJ 1999;160 (9 Suppl):S47 & S48.


Smoking cessation
Smoking Cessation recommendations for follow-up


Health professionals role in smoking cessation
Health Professionals’ Role in Smoking Cessation recommendations for follow-up

  • Ask – systematically identify all tobacco users

    • Implement an office wide system that ensures that tobacco use is queried and documented at every visit

  • Advise – strongly urge all tobacco users to quit

    • In a clear and personalized manner, urge every tobacco user to quit

  • Assess – determine willingness to make a quit attempt

    • Ask every tobacco user if he/she is willing to make a quit attempt at this time (based on the Stages of Change)

  • Assist – aid the patient in quitting

    • Provide a quit plan

  • Arrange – follow up & support with links to the local community

Adapted from Anderson et al, Chest 2002;121:932-941.


Suggested smoking cessation approach using the stages of change
Suggested Smoking Cessation Approach: recommendations for follow-upUsing the Stages of Change

  • Pre-contemplation

    • Not thinking seriously about quitting

    • Goal: Encourage smoker to think about the personal impact of smoking

  • Contemplation

    • Thinking about quitting in the next six months

    • Goal: Discuss health effects of smoking and benefits of quitting. Offer follow-up and set date for next appointment.

  • Preparation

    • Preparing to quit in next month and has tried to quit in the past year

    • Goal: Assist the patient to select the best plan to be smoke free. Set date for next appointment.


Suggested approach cont
Suggested Approach, cont… recommendations for follow-up

  • Action

    • Receptive to cessation advice. Actively trying to quit.

    • Goal: Assist the patient in efforts to quit. Discuss relapse prevention and replacing smoking with other behaviours (physical activity, hobbies, etc.) Set date for next appointment.

  • Maintenance

    • Continues to remain smoke free for more than six months. May “slip” and have occasional cigarette.

    • Goal: Congratulate patient. Assist patient to find strategies to prevent relapse.

      Source: Prochaska JO, Diclemente CC. Understanding and using the stages of change. Program Training & Consultation Centre, Ontario Tobacco Strategy, 1995.


Smoking cessation pharmacotherapy
Smoking Cessation: Pharmacotherapy recommendations for follow-up

  • Effective pharmacotherapies exist for smoking cessation.

  • Except in the presence of contraindications these should be considered as part of the quit plan for all patients willing to quit smoking

  • Nicotine replacement therapy

    • Nicotine patch (Habitrol™, Nicoderm™, Nicotrol™)

    • Nicotine gum (Nicorette™)

  • Bupropion SR (Zyban™)

  • Varenicline (Champix)

  • Combined use of the Nicotine patch and Bupropion SR are more effective than either alone in patients who are willing to quit


Impact of lifestyle therapies on blood pressure in hypertensive adults
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

Source: 2007 CHEP Recommendations


Lifestyle therapies in hypertensive adults summary
Lifestyle Therapies in Hypertensive Hypertensive AdultsAdults: Summary

Source: 2007 CHEP Recommendations


BP ACTION PLAN™ Hypertensive Adults

  • The BP ACTION PLAN is a free, confidential, customized action plan for healthy living.

  • This plan will give your patients access to practical tips, tools and other resources that are relevant to them. Then they can take the next steps to reducing their risks and improving their health.

  • Self-administered, evidence-based, health risk assessment questionnaire

  • Patients receive customized tips, resources and information links to help them reduce their risks.

  • www.heartandstroke.ca or 1-888-HSF-INFO


Your Risks Hypertensive Adults

Sex (male)

Activity level

Weight (BMI >25)

Alcohol (>2 drinks per day)

Fat (diet high in fat)

Salt (diet high in salt)

Blood pressure (elevated blood pressure)

Your Plan

Activity –think about ↑ activity

see Health Goals Chart and Physical Activity Log

Weight –think about losing weight

Salt –  dietary salt

Alcohol –think about alcohol

Fat –  dietary fat

 Blood Pressure

BP ACTION PLAN™ for Mr. J.


BP ACTION PLAN™ for Mr. J. Hypertensive Adults

  • Blood Pressure

    • Set goals and a start date for changing your lifestyle

    • See your doctor if you have a lot of weight to lose or haven’t been active for a while

    • Bring your Health Action Report to your next visit and discuss risk factors.

    • You may want to print and fill out a Blood Pressure Management Contract

    • Check out resources

      • Heart and Stroke HeartWalk Workout and Healthy Weight program

      • Health Canada’s Physical Activity site www.hcsc.gc.ca/english/healthy_living/physical_activty.html


2007 canadian hypertension education program1
2007 Canadian Hypertension Education Program Hypertensive Adults

  • What's New for 2007

  • Approximately 95% of Canadians will develop hypertension if they live an average lifespan

  • Most overweight patients with high normal blood pressure (130-139/85-89 mmHg) will develop hypertension within 4 years and almost 1/2 within 2 years.

  • Annual follow-up of patients with high normal blood pressure is recommended.


Integrating c anadian h ypertension e ducation p rogram recommendations into practice

Integrating Hypertensive AdultsCanadian Hypertension Education Program RecommendationsintoPractice


When to consider pharmacotherapy

Systolic-Diastolic Hypertension in the Absence of Specific Disease**No other compelling indications such as associated risk factors, target organ damage or co-morbid conditions/diseases

When to Consider Pharmacotherapy


Strongly consider pharmacotherapy if
Strongly Consider Pharmacotherapy If : Disease*

  • BP remains  140/90 mmHg with lifestyle modification

  • Client has Target Organ Damage (e.g. LVH) and BP  140/90 mmHg

  • Client has Diabetes or chronic kidney disease and BP is  130/80 mmHg

  • Patient has known atherosclerotic disease

    (e.g. past stroke) even if BP is normal

    Source: 2007 CHEP Recommendations


Blood pressure target values for treatment of hypertension1

Goals of Therapy Disease*

Blood pressure target values for treatment of hypertension


Goals of therapy
Goals of Therapy Disease*

  • To optimally reduce cardiovascular risk reduce the blood pressure to specified targets.

    • This usually requires two or more drugs and lifestyle changes

    • Systolic target is more difficult to achieve however controlling systolic blood pressure is as important if not more important than controlling diastolic blood pressure


Treatment of adults with systolic diastolic hypertension without other compelling indications

ARB Disease*

ACE-I

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*

* BBs are not indicated as first line therapy for age 60 and above

ACEI and ARB are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential


Combination therapy for systolic diastolic hypertension with no other compelling indications
Combination Therapy for Systolic-Diastolic Hypertension With No Other Compelling Indications

  • If partial response to dual combination therapy

    • May be necessary to try triple or quadruple therapy

  • Consider possibility of one or more of the following:

    • Nonadherence

    • Secondary hypertension

    • Interfering drugs or lifestyle

    • White coat hypertension

    • Resistant hypertension

Source: 2007 CHEP Recommendations


Factors that induce and or aggravate htn
Factors That Induce and/or Aggravate HTN No Other Compelling Indications

  • Alcohol

  • Recreation drugs (e.g., cocaine)

  • Some herbal remedies

  • Non steroidal anti-inflammatory drugs

  • Oral contraceptive pill

  • Corticosteroids

  • Anabolic steroids

  • Erythropoietin

  • Calcineurin inhibitors (Cyclosporin, Tacrolimus)

  • Ephedrine/pseudo-ephedrine

  • licorice

  • Sleep apnea

    Source: CHEP 2005 Recommendations


Summary treatment of systolic diastolic hypertension without other compelling indications

Long-acting No Other Compelling Indications

CCB

Beta-blocker*

Thiazide

diuretic

ACE-I

ARB

Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications

TARGET <140/90 mmHg

Lifestyle modification

therapy

* Not indicated as first line therapy over 60

Dual Combination

  • CONSIDER

  • Nonadherence?

  • Secondary HTN?

  • Interfering drugs or lifestyle?

  • White coat effect?

ACEI and ARB are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential

Triple or Quadruple Therapy

Source: 2007 CHEP Recommendations


Isolated systolic hypertension with no other compelling indication

Isolated Systolic Hypertension with No Other Compelling Indication

Case # 1b

How would you treat Mr. W if his SBP was consistently higher than 160 mmHg?


Isolated systolic hypertension with no other compelling indication1
Isolated Systolic Hypertension with No Other Compelling Indication

Initial Treatment

Lifestyle

Modification

Therapy

Target BP <140 mmHg

Monotherapywith:

Thiazide

Diuretics

Long acting

DHP-CCB

ARB

or

or

Dual therapy: Combine agents from adjacent classes

Source: Adapted from CHEP 2007 Recommendations


Add on therapy for isolated systolic hypertension without other compelling indications
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?

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).

Source: Adapted from CHEP 2007 Recommendations


Summary treatment of isolated systolic hypertension without other compelling indications
Summary: Treatment of Isolated Systolic Hypertension Other without Other Compelling Indications

TARGET <140 mmHg

Initial Treatment

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

Source: Adapted from CHEP 2007 Recommendations


Barriers
Barriers Other



Barriers to htn diagnosis and treatment1
Barriers to HTN Diagnosis and Treatment Other

  • Patient related factors

    • Low level of awareness about diagnosis

    • Lack of compliance/adherence to therapy

    • Belief that HTN is self limiting (don’t know that they need to stay on the medication)

    • Cost of medications

    • Lack of knowledge about seriousness of uncontrolled BP

    • Side effects of the medications

    • “White coat” hypertension

      Source: Clinical problem-solving based on the 1999 Canadian recommendations for the

      management of hypertension. CMAJ 1999;161 (12 Suppl):S18-22.


Barriers cont
Barriers, cont… Other

  • System related factors

    • Time constraints in practice settings

    • Complexity of prescribing and/or monitoring existing drug regimens

    • Drug adverse effects

    • Lack of awareness of new lower BP target values

    • Practice patterns

    • Lack of awareness of up-to-date guidelines

      Source: Clinical problem-solving based on the 1999 Canadian recommendations for the

      management of hypertension. CMAJ 1999;161 (12 Suppl):S18-22.


Economic considerations
Economic Considerations Other

  • 2007 CHEP recommendations are based solely on efficacy data

  • Individual patient/physician preferences and costs of different drug classes have not been a part of the process

  • Pharmaceutical costs are a significant barrier for many Albertans without drug coverage

  • Cost may be a deciding factor when choosing an anti-hypertensive pharmaceutical treatment


Adherence
Adherence Other

  • Adherence is the single most important modifiable factor that compromises treatment outcome (WHO)

  • Defined as the extent to which a patient’s behaviour corresponds with recommendations from the health care provider

  • The term adherence is intended to be non judgemental, a statement of fact rather than of blame of the prescriber, patient or treatment

  • Level 1a evidence exists to support a number of methods to promote adherence



Suggestions for improving adherence1
Suggestions for Improving Adherence Other

Health professionals can encourage adherence using a number of approaches:

  • Provide quality information about the risks of increased BP and the benefits of lifestyle and pharmaceutical treatment

  • Explain that more than one drug may be necessary

  • Explain that will probably take medication for life

  • Counsel on side effects of treatment

  • Take BP and talk about targets at every available visit

  • Maintain regular BP follow up

  • Refer to BP ACTION PLAN™ to encourage greater awareness, responsibility and involvement in BP and health management

    Adapted from 2005 CHEP Recommendations, JNC 7, and the Heart and Stroke BP Action Plan


Suggestions for improving adherence cont
Suggestions for Improving Adherence, cont… Other

  • Assess adherence at every visit

  • Encourage responsibility/autonomy in monitoring BP and prescriptions

  • Write prescriptions for exercise

  • Simplify medication dosing

  • Tailor pill taking to fit daily habits (same place/time/situation)

  • Ask patient to bring pill vials (including OTCs) to medical visits

  • Record medications and side effects

  • Explore options for patients who have no drug coverage

  • Work with worksite to improve monitoring of adherence to medications & lifestyle changes

Adapted from WHO, CHEP 2007, JNC 7, and the Heart and Stroke BP Action Plan


Treatment of systolic diastolic hypertension with other compelling indications

Treatment of Systolic-Diastolic Hypertension with other compelling Indications

Case Studies


Treatment of systolic diastolic hypertension in a diabetic patient

Treatment of Systolic-Diastolic Hypertension compelling Indicationsin a Diabetic Patient

Case #3


Case 3
Case #3 compelling Indications

  • Mr. M is a 57 year old labourer with NIDDM and mild hypertension that is untreated

  • New patient to the area

  • Smokes 1½ ppd

  • Weight has increased over past 5 years (BMI 27.4 kg/m2)

  • Total cholesterol elevated at 6.25 mmol/L

  • HDL cholesterol =0.97 mmol/L

  • Fasting serum glucose 7.3 mmol/L

  • Urinalysis, serum electrolytes, creatinine normal

  • BP ranges from 140/90-150/96 mmHg


Treatment of hypertension in association with diabetes mellitus

with compelling Indications

Nephropathy*

Diabetes

without

Nephropathy**

Systolic- diastolic

Hypertension

Isolated

Systolic

Hypertension

Treatment of Hypertension in association with Diabetes Mellitus

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

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

**Urinary albumin to creatinine ratio <2.0 mg/mmol in men or <2.8mg/mmol in women

* based on at least 2 of 3 measurements

Source: Adapted from CHEP 2007 Recommendations


Treatment of hypertension in association with diabetes mellitus summary

with compelling Indications

Nephropathy

Diabetes

Treatment of Hypertension in association with Diabetes Mellitus: Summary

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

ACE Inhibitor

or ARB

1. ACE-Inhibitor or ARB

or

2. Thiazide diuretic or DHP-CCB

Combination

(Effective

2-drug combination)

without

Nephropathy

Monitor potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB

More than 3 drugs may be needed to reach target values for diabetic patients

If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired

Source: Adapted from CHEP 2007 Recommendations


Treatment of systolic diastolic hypertension with other compelling indications1

Treatment of Systolic-Diastolic Hypertension with other compelling Indications

Case Studies


Treatment of Hypertension in Patients compelling Indicationswith Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI

An ARB can be used if the patient is intolerant to ACE-I

Beta-blocker and ACE-I

Recent

myocardial

infarction

If beta-blocker contraindicated or not effective

Long-acting

DHP CCB

(Amlodipine, Felodipine)

YES

Heart Failure ?

NO

Long-acting CCB

Source: Adapted from CHEP 2007 Recommendations


Treatment of hypertension for patients with cerebrovascular disease

Strongly consider blood pressure reduction compelling Indicationsin all patients after the acute phase of non disabling stroke or TIA .

An ACE-I / diuretic combination is preferred

Stroke

TIA

Treatment of Hypertensionfor Patients with Cerebrovascular Disease

Source: Adapted from CHEP 2007 Recommendations


Treatment of hypertension for patients who use tobacco

Smoking compelling Indications

Beta-blocker

The benefits of treating smokers with beta-blockers

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

Treatment of Hypertension for Patients Who Use Tobacco

Source: Adapted from CHEP 2007 Recommendations


Vascular protection with hypertension

Vascular Protection with compelling IndicationsHypertension


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

• Type 2 Diabetes

• Total-C/HDL-C ratio of 6 mmol/L or higher

• Family History of Premature CV disease

• LVH

• ECG abnormalities

• Microalbuminuria or Proteinuria

Vascular Protection for Hypertensive Patients: Statins

ASCOT-LLA Lancet 2003;361:1149-58

ASCOT-LLA Lancet 2003;361:1149


Vascular protection for hypertensive patients asa
Vascular Protection for Hypertensive management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria:Patients: ASA

Consider low dose ASA

Caution should be exercised if BP is not controlled.

Source: Adapted from CHEP 2007 Recommendations


Summary i
Summary I management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria:

Regarding the treatment of hypertension, the recommendations endorse:

  • ASSESSMENT OF BLOOD PRESSURE AT ALL APPROPRIATE VISITS

    • Most Canadians will develop hypertension during their lives. Routine assessment of blood pressure is required for early detection and risk management

  • ANNUAL FOLLOW-UP OF PATIENTS WITH HIGH NORMAL BLOOD PRESSURE

  • Most overweight patients with high normal blood pressure (130-139/85-89 mmHg) will develop within 4 years and almost 1/2 within 2 years.

Source: CHEP 2007 Recommendations


Summary ii
Summary II management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria:

Regarding the treatment of hypertension, the recommendations endorse:

  • INDIVIDUALIZING THERAPY

    • consider concomitant risk factors and/or concurrent diseases, other patient characteristics and preferences (e.g. age, diabetes, CVD) and other considerations e.g. costs

  • LIFESTYLE MODIFICATION

    • To prevent hypertension

    • In those with hypertension alone if effective to reach the goal value or in combination with pharmacological treatment

Source: CHEP 2007 Recommendations


Summary iii
Summary III management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria:

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

Source: CHEP 2007 Recommendations


Key chep messages
Key CHEP messages management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria:

  • Assess blood pressure at all appropriate visits.

  • Almost one half of those with blood pressure 130-139/85-89 will develop hypertension within 2 years. They require annual reassessment.

  • Assess global cardiovascular risk in all hypertensive patients.

  • Lifestyle modification is the cornerstone for the prevention and management of hypertension and CVD.

Source: CHEP 2007 Recommendations


Key chep messages1
Key CHEP messages management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria:

  • Treat to target (<140/90 mmHg; <130/80 mmHg in patients with diabetes or chronic kidney disease).

  • To achieve targets sustained lifestyle modification and more than one drug is usually required.

  • Follow patients with uncontrolled blood pressure at least monthly until blood pressure targets are achieved.

  • Strategies to improve patient adherence to lifestyle modifications and antihypertensive therapy need to be incorporated in every patients management

Source: CHEP 2007 Recommendations


Impending doom

Impending Doom! management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria:


High blood pressure get the low down1
High Blood Pressure management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria:Get the Low Down!


Hypertension1
HYPERTENSION management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria:

Prepared by

Carolyn Walker, RN, BN

Education Coordinator

Alberta Provincial Stroke Strategy

September 2007

Reviewers

Dr. Norm Campbell, MD, FRCPCF

Professor of Medicine, Community Health Sciences and Pharmacology and Therapeutics at the University of Calgary

CIHR Canadian Chair in Hypertension Prevention and Control

Chair of the Canadian Hypertension Education Program (CHEP) Steering Committee and the CHEP Executive Committee

President of Blood Pressure Canada.

Recognition of the Canadian Stroke Strategy for information utilized in the development of this presentation


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