2010 Canadian Hypertension Education Program Recommendations The by vhb13605


									2010 Canadian Hypertension Education Program Recommendations:
         The Short Clinical Summary - An Annual Update

        On behalf of the Canadian Hypertension Education Program

    Acknowledgement: This manuscript was written by Dr Norm Campbell with the
                CHEP Executive and Margaret Moy Lum Kwong

                         Sign up at www.htnupdate.ca to be notified by email when
                         new resources are developed or updated for you and your
                         patients or download current resources at
                         www.hypertension.ca/tools. In 2010, an interactive internet-
                         based lecture series on clinically important hypertension
                         topics will be launched so you can learn and interact with top
                         national hypertension experts. Also be notified of
                         opportunities to be trained to be a hypertension community

                         Your patients can also sign up at www.myBPsite.ca for 2010
                         Annual membership in myBP where they will receive email
                         notices of updated and new educational resources, a regular
                         newsletter, discount coupons to assist with lifestyle change,
                         lectures and possibly in the future personalized health care
                         professional advice.

                         Hypertension recommendations designed for public education
                         have been developed in 2010. Bulk orders of 25 or more
                         copies can be obtained by contacting hyperten@ucalgary.ca.
                         Hypertension recommendations for patients with diabetes,
                         developed in 2009, are also available. These summaries are
                         available electronically at www.hypertension.ca/bpc.

Hypertension is one of the major health issues facing our country. In 2007, 5.7 million
Canadians had been diagnosed with hypertension and just over 5 million were on
pharmacotherapy (1). For the last decade, hypertension has been the leading diagnosis for
adult visits to physicians and the proportion of total visits to a physician for hypertension is
increasing (2). The World Health Organization has indicated that increased blood pressure is
the leading risk for death, predicting an epidemic of hypertension and is advocating for
prevention and treatment programs as a priority (3;4). Worldwide over 7 million deaths in the
year 2000 were attributed to sub optimum blood pressure and increased blood pressure is
estimated to consume 10% of health care costs in developed countries like Canada(5;6).

2010 marks the 11th consecutive year that the Canadian Hypertension Education Program
(CHEP) has updated recommendations for the management of hypertension. CHEP was
developed to assist primary care providers in better managing and preventing hypertension.
As evidenced by the recent population-based surveys, Canada is one of the world’s leading
country in the prevention and control of hypertension (7). A decrease in cardiovascular
disease rates occurred concurrent with the increase in treatment of hypertension and the
CHEP program in 1999 (8;9). The success of the CHEP program is evidenced by the fact
that most developed countries have hypertension control rates well below those achieved in
Canada (10).

Nevertheless there is still much progress that can be made in Canada to further reduce
premature cardiovascular death and disability by improving hypertension management.
Recent (unpublished) surveys have found that many health care professionals are still not
aware of CHEP or its recommendations. Therefore special efforts are being made to increase
the accessibility to hypertension resources. In 2010 health care professionals can enroll at
www.htnupdate.ca to get automated email notices when new or updated hypertension
resources are available for them or their patients. They can also download current resources
at www.hypertension.ca/tools. A case-based interactive lecture series on clinically important
hypertension topics will also be launched on the internet so health care professionals can
learn and interact with top national hypertension experts. The lecture series will feature
important clinical topics provided by national experts, have a case presentation and an
opportunity to ask questions and make comments. The lectures can be watched wherever
there is internet coverage. Sign up at www.htnupdate.ca to be notified when they start.
CHEP will also continue and expand a program to train community leaders in hypertension.
Table 1 and 2 indicate current hypertension resources that are available for health care
professionals and people with hypertension.

Hypertension Canada will be developing a hypertension association for Canadians with high
blood pressure. Encourage your patients to sign up for 2010 membership at
www.myBPsite.ca. Members will receive notices of updated and new educational resources,
a regular newsletter, discount coupons to encourage a healthy lifestyle, lectures and possibly
in the future personalized health care professional advice. Members will be provided
opportunities to provide advice on the need for new hypertension resources and revise
current blood pressure resources.

Areas of Clinical Hypertension Management in Canada that are emphasized by CHEP in

Hypertension in People with Diabetes
Over 60% of people with diabetes die of cardiovascular disease and up to 75% of specific
diabetic complications are attributable to elevated blood pressure (11). Treating hypertension
in people with diabetes reduces premature death and disability by up to 50% (11). The current
target of less than 130/80 mmHg is important as more versus less intensive hypertension
treatment reduces premature death and cardiovascular events by 25% or more (12).
Combinations of lifestyle modification and 3 to 4 or more drugs may be required for blood
pressure control in persons with diabetes. The prescription of an angiotensin converting
enzyme inhibitor (ACE inhibitor) or angiotensin receptor blocker is recommended in all people
with diabetes who are hypertensive (Table 3). In the absence of micro or macro albuminuria, a
diuretic or a long acting calcium channel blocker is also a suitable first line drug therapy. If the
blood pressure is 150/90 mmHg or more, consider initiating therapy with a combination of two
drugs. Diuretic therapy is generally necessary for blood pressure control when multiple drugs
are used (13). Although many clinicians are uncomfortable prescribing diuretics to people with
diabetes, possibly because diuretics cause a small increase in blood glucose, diuretics have
been shown to be equally effective as ACE inhibitors in preventing cardiovascular
complications (14). Of note is that quality of life usually improves in the people treated to lower
blood pressure levels and treatment is cost saving because of the large reduction in
cardiovascular events (15-17).

Home measurement of blood pressure
Home measurement of blood pressure can increase patient self-efficacy and is recommended.
Home blood pressure readings more reliably predict the risk of cardiovascular outcomes than
readings taken in a health care professional’s office. Home blood pressure measurements can
be used to confirm the diagnosis of hypertension, to improve blood pressure control, to reduce
the need for medications in those with white coat effect, to identify those with white coat and
masked hypertension and to improve medication adherence (18). Patient instructions for
purchasing and using home blood pressure measurement can be found in Table 4 and at the
bottom of www.hypertension.ca/tools as well as at www.heartandstroke.ca/BP A
comprehensive instructional video on home measurement was developed in 2009 and can be
downloaded from www.hypertension.ca/video.

Automated office measurement of blood pressure
In 2010 CHEP is recommending consideration of the use of fully automated office blood
pressure devices. Automated office blood pressures are more closely correlated to
ambulatory blood pressure readings and to target organ damage than are manual readings.
A full review of office, home and ambulatory blood pressure recommendations is expected in

Combination of antihypertensive medications
Most people require lifestyle changes and multiple antihypertensive drugs. When using two
drugs to lower blood pressure combinations of a beta blocker, ACE inhibitor or angiotensin
receptor blocker produce less than additive hypotensive effect and should be avoided unless
there is a specific indication (e.g. heart failure) (19;20). If blood pressure is > 20/10 mmHg
above target initiating therapy with a combination of two ‘first line’ antihypertensive drugs is a
first line option (19). Use of a combination tablet that contains two medications can improve
adherence and lower drug costs relative to prescribing the two drugs separately and is
recommended to be considered.
CHEP recommends that the combination of an ACE inhibitor / calcium channel blocker based
therapy be considered when combination therapy is required in selected high risk patients. A
clinical trial was published in 2009 that showed an ACE inhibitor / calcium channel blocker
regime was superior to an ACE inhibitor /thiazide diuretic based regime in hypertensive
patients who had prior vascular disease or who had other vascular risk factors (21). The trial
results generated considerable discussion and more subgroup analyses are expected. It is
hoped new trials will be done to validate the finding that some specific combinations of
antihypertensive drugs are superior to others given the strong evidence that all current first
line drugs have similar reductions in cardiovascular events in people with hypertension who
do not have compelling indications. In resistant hypertension, the use of a diuretic (and
sometimes high doses of diuretics) is usually required to achieve blood pressure control (13).

Angiotensin Receptor Blockers or ACE inhibitors in most People with Ischemic Heart
In many settings, ACE inhibitors and ARBs are interchangeable. In people with heart failure,
prior stroke or in chronic kidney disease ACE inhibitors are preferred (19). In 2010, CHEP
recommends that most people with hypertension and ischemic heart disease should be
treated with EITHER an ACE inhibitor or an angiotensin receptor blocker (19). Although
effective when used useful individually, the combination of ACE inhibitor and ARB therapy
should only be considered in selected and closely monitored people with advanced heart
failure or proteinuric nephropathy. CHEP specifically recommends not to combine an ACE
inhibitor with an angiotensin receptor blocker in people with uncomplicated hypertension,
diabetes (without micro or macro albuminuria), chronic kidney disease (without nephropathy
(micro or macro albuminuria) or ischemic heart disease (without heart failure) (19).

Reducing Dietary sodium to prevent and treat hypertension.
Given the linear association between sodium intake and blood pressure and the proven
benefits of low sodium diets, CHEP now recommends adults adhere to the government
recommended adequate intake (AI) levels of sodium (Table 5) (19). In the United States high
dietary sodium is estimated to be the 7th leading risk for death (22). A new trial of sodium
restriction reported a reduction in blood pressure of 22/9 mmHg in patients with blood
pressure above 140/90 mmHg while on three antihypertensive drugs who reduced sodium
intake to 1060 mg/day from 5796 mg/day (23). Advice on how to reduce sodium intake is
available in Table 6 and patients can obtain more detailed information at
www.lowersodium.ca or www.sodium101.ca. Health Canada will produce additional
information for the public and patients in 2010.

Key issues in the Management of the patient with hypertension:
Assess blood pressure at all appropriate visits. Blood pressure increases with age. Half
of Canadians over age 60 have hypertension and it is estimated that 9 in 10 of those with
normal blood pressure at age 55-65 will develop hypertension within an average lifespan (24).
All adults require ongoing assessment of blood pressure and Canadians with high normal
blood pressure require annual blood pressure assessment as over ½ will develop
hypertension within 4 years (25).

Assess and manage overall cardiovascular risk in all people with hypertension
including: smoking, unhealthy eating, physical inactivity, abdominal obesity,
dyslipidemia, and dysglycemia (e.g. glucose intolerance, diabetes). Approximately 9 in
10 hypertensive Canadians have other cardiovascular risks (26). Comprehensive screening
and management of other risk factors in addition to hypertension can double the reduction in
cardiovascular risk, lower the blood pressure target (Table 7) and change the types of
antihypertensive medications recommended (Table 3). Many people with multiple
cardiovascular risks or cardiovascular disease have uncontrolled blood pressures and
surprisingly, those who smoke are less, rather than more, likely to be treated (27-29).
Pharmacotherapy has the potential for the greatest absolute benefit and cost effectiveness in
these higher risk patients.

A healthy lifestyle improves cardiovascular risk and reduces blood pressure in the
prevention and treatment of hypertension. Healthy eating, regular physical activity, low
risk alcohol consumption, reductions in dietary sodium and in some, stress reduction (Table
8) can prevent or treat hypertension as well as other cardiovascular risks. However few
Canadians improve their lifestyle after being diagnosed with hypertension. Importantly brief
health care professional advice assists patients to make lifestyle changes (30). The Heart
and Stroke Foundation’s eHealth tool, My Heart&Stroke Blood Pressure Action Plan
(www.heartandstroke.ca/BP) is designed to assess hypertensive patients’ lifestyles, provide
personalized e-mail support and facilitate self-management through its interactive portal that
allows people to track their BP and progress and achievements in their selected lifestyle area
of focus. Several patient handouts on hypertension can also be obtained from
www.hypertension.ca/tools. Patients can also sign up for regular updates and information on
hypertension at www.myBPsite.ca

Treat to target (<140/90 mmHg; <130/80 mmHg in people with diabetes or chronic
kidney disease). CHEP blood pressure targets reflect current best evidence to optimally
reduce cardiovascular disease (Table 7). Failure to achieve blood pressure targets result in
higher cardiovascular risk while lowering blood pressure substantially below a target is of
undetermined benefit/harm. People with known cardiovascular disease, diabetes or chronic
kidney disease are at high cardiovascular risk, more often have uncontrolled blood pressure
and have the greatest reduction in cardiovascular events by achieving blood pressure targets

Reassess patients at least every two months if their blood pressure is above target.
Follow-up at short intervals improves patient adherence and is required to increase the
intensity of treatment.

Help patients adhere to therapy. Adherence to prescribed lifestyle change and
pharmacotherapy should be assessed at each visit. Health care professional interventions
can prevent non-adherence and improve adherence in those who are having problems (Table

Comments from the CHEP executive
In 2010, CHEP will merge with the Canadian Hypertension Society and Blood Pressure
Canada to form a single national hypertension organization dedicated to advancing health by
the prevention and control of high blood pressure through research, advocacy, education and
knowledge development and translation. For Canadian health care professionals the
transition will likely be seamless and go unnoticed. Canadian educational material for health
care professionals and patients will carry the CHEP logo and name although the new
organization will be called Hypertension Canada.

CHEP recognizes the difficulties health care professionals and hypertensive Canadians have
in staying informed of the current best evidence in preventing and controlling high blood
pressure. In 2010 CHEP will help make staying up to date much easier. By enrolling at
www.htnupdate.ca you will be notified of all new hypertension resources produced by CHEP
for you or your patients. Further a new internet-based interactive lecture series will be
launched so you can be updated on important new hypertension topics by national leaders.
Also for those interested in being a community educator in hypertension, ‘train the trainer’
sessions have been developed and venues for training will be held across Canada. Sign up at
www.htnupdate.ca and stay informed.

2010 will also be an important year for determining Canada’s performance in prevention and
control of hypertension. Three major national surveys will report. On February 17, 2010, a
Statistics Canada survey will report the national prevalence of hypertension and the
awareness, treatment and treatment and control rate. Based on surrogate data from other
surveys, the national survey is anticipated to confirm the 2006 Ontario survey (ONBP) that
suggested Canada is the world’s leader in prevention and control of hypertension (31).
Further a detailed Statistics Canada - Public Health Agency of Canada survey of Canadians
with hypertension has been completed and will provide an overview of their knowledge,
attitudes, beliefs and behaviors. This information will be used to develop new educational
resources based on the documented educational needs of hypertensive Canadians. Finally
in 2010, the first federal provincial hypertension survey using linked provincial administrative
data bases will be released. This ongoing surveillance mechanism will track the incidence
and prevalence of diagnosed hypertension in people with and without diabetes and tracks
their mortality rates. CHEP continues to work with the Public Health Agency of Canada and
the provincial governments to develop the methodology to add assessment of
antihypertensive treatment and specific complications and causes of death to this latter
survey. The results of these surveys are critical to assess the impact of programs to prevent
and control hypertension and redesign interventions to be more effective.

Reducing dietary sodium will be a priority for Hypertension Canada. Canadians with
hypertension have little change in lifestyles after a diagnosis of hypertension. Although
individual lifestyle advice can assist Canadians make healthy choices often our communities
are structured to make healthy choices very difficult. Hypertension Canada strongly supports
the Health Canada Dietary Sodium Work Group mandate to reduce dietary sodium and
CHEP has aligned its dietary sodium recommendations to those of the Canadian
Government. The Health Canada Work Group has a mandate to reduce sodium additives to
food, to educate Canadians regarding the risks of high dietary sodium and to ensure research
required to reduce dietary sodium is conducted.

The CHEP executive would like to thank the over 100 health care professional volunteers,
who are working in CHEP to prevent and control hypertension. The collaborative approach
between volunteers from clinic practice, academia and governments with the support of the
primary care professional associations, the pharmaceutical health care industry,
governments, charities and scientific organizations has been associated with marked
improvements in the management and outcomes of hypertensive Canadians.

Table 1 Health Care Professional Resources*

  1) CHEP primary care booklet. Brief outline of hypertension management
     recommendations in a pocket booklet form
  2) Key messages. The major 6 actions required by health care professionals to prevent
     and control cardiovascular disease in people with hypertension.
  3) One page summary. A one page summary of the CHEP theme, key messages and
     new recommendations.
  4) Short clinical summary. A brief narrative clinical summary of the current CHEP
     recommendations with an emphasis on what is new and what is important. Tables
     summarize key aspects of hypertension care.
  5) Short scientific summary. A brief narrative summary of what is new and what is
     important with an emphasis on the scientific basis for the recommendations. Tables
     summarize key aspects of hypertension care.
  6) CHEP specialist booklet. Contains the short scientific summary and the exact CHEP
     recommendations in a pocket booklet format
  7) Full scientific manuscripts. Detailed manuscripts that indicate the exact CHEP
     scientific recommendations for the management of hypertension with their scientific
     rationale. There are separate diagnostic and therapeutic manuscripts

Power Point Slide sets
  1) Public education slide set: A slide set that is intended to be used to develop a general
      talk on hypertension to a public and/or patient audience.
  2) Background slide set. A slide set that contains information on the health risks of
      hypertension and key therapeutic interventions.
  3) Methodology Slide set. A slide set that outlines the methods CHEP uses to develop it
      recommendations as well as the key messages and theme for 2010.
  4) Diagnostic Slide set. A slide set that outlines the diagnostic recommendations of
      CHEP as well as the key messages and theme for 2010.
  5) Treatment Slide Set. A slide set that outlines the treatment recommendations of CHEP
      as well as the key messages and theme for 2010.
  6) Blood Pressure Measurement. A slide set that outlines the measurement
      recommendations for blood pressure and includes advice on office, home and
      ambulatory blood pressure.
  7) Outcomes Slide set. A slide set that outlines the various surveillance methods used by
      CHEP as well as key outcomes associated with CHEP. Ongoing hypertension
      management gaps are featured.
  8) Hypertension resources. A new slide set that outlines what Canadian hypertension
      resources are available

   Website resources
   1) www.hypertension.ca/tools: to download current resources for health care professional
      and patients
   2) www.htnupdate.ca: to sign up to be regularly updated on new and updated resources
      for health care professional and patients and educational opportunities for health care
   3) www.lowersodium.ca: for educational resources for health care professionals and
      patients on dietary sodium

Dietary Sodium Resources
   1) A short scientific summary of the importance of reducing dietary sodium with advice on
       how to reduce dietary sodium
   2) A scientific summary of the evidence for lowering dietary sodium
   3) Key messages on the importance of lowering dietary sodium with brief intervention

Dietary Sodium Power Point Slide Sets
   1) Scientific and clinical slide set: A slide set intended to be used to develop a talk for a
       clinical or scientific audience
   2) Public Slide set: A slide set that is intended to be used to develop a talk on dietary
       sodium to a public and patient audience on hypertension
   3) Sodium Quiz

* Health care professional resources can be downloaded from www.hypertension.ca/tools and
www.lowersodium.ca and people who sign up at www.htnupdate.ca will be automatically
notified when resources are updated or newly developed.

Table 2: Resources for Canadians who have hypertension
Documents, power point slides and DVDs

  1) Brief public hypertension recommendations. A single page brochure that summaries
      hypertension and its management to people who have hypertension or are at risk, The
      summary is based on the 2010 CHEP health care professional management
  2) Public hypertension recommendations. A 4 page summary of hypertension and its
      management to people who have hypertension or are at risk, The summary is based
      on the 2010 CHEP health care professional management recommendations. The 2007
      recommendations are available in 4Indo Asian language and cultural translations.
  3) Hypertension in Diabetes. A 4 page summary of hypertension and its management for
      people who have hypertension and diabetes. The summary is based on the 2010
      CHEP health care professional management recommendations
  4) How to Measure your Blood Pressure at Home. A one page summary of how to
      purchase and use a home measurement device.
  5) Home Measurement of Blood Pressure. A more detailed 4 page summary of how to
      purchase and use a home measurement device.
  6) Measuring blood pressure the right way. A poster and small card that outlines
      pictorially the key steps to measuring blood pressure properly at home
  7) Home measurement DVD. A DVD that has a short and longer summary of how
      measure your blood pressure at home as well as how to purchase and use home
      measurement of blood pressure devices.
  8) Public Education DVD (‘Hypertension: the Silent Killer’). A short and longer summary
      of hypertension on DVD for the public or those with or at risk of having hypertension.
  9) Brief Action Tool. A set of 3 tools to be used by a health care professional educator to
      engage a patient more fully in his/her care. Action tool 1 takes about 4 minutes to
      complete. It defines BP, why a patient needs to be concerned if s/he has High BP, and
      the risks of hypertension. Action Tool 2 takes 10 minutes and basically motivates a
      patient to think about changing his/her lifestyle. Action Tool 3 takes 7 minutes to
      complete. It talks about home measurement & recording of BP, as well as information
      on BP medication.
  10) Public Education Hypertension Slide set. A slide set that is intended to be used by a
      knowledgeable health care professional in developing a presentation on hypertension
      to the public or people with hypertension.

  Dietary Sodium
  1) Public Education Dietary Sodium Slide set. A slide set that is intended to be used by a
     knowledgeable health care professional in developing a presentation on dietary
     sodium to the public or people with hypertension
  2) Get the facts: A one page summary of the importance of reducing dietary sodium and
     the key mechanisms to reduce dietary sodium
  3) Short summary. A very short summary of why reducing dietary sodium is important
     and how to reduce dietary summary
  4) Booklet: A more detailed summary of why it is important to reduce dietary sodium and
     how to reduce dietary sodium for the more interested consumer.
  5) Brochure: Beyond the salt shaker – Lower your sodium intake and improve your health
  6) Quiz: A short series of questions and answers for people to use to test their sodium
     knowledge. It is in power point format for use in talks.

  1) www.myBPsite.ca: To join a hypertension association and be regularly updated on
      hypertension resources and materials that are available.
  2) www.hypertension.ca/bpc: To download patient related resources
  3) www.hypertension.ca/chs: To examine the different home measurement devices that
      have passed international accuracy standards, are available in Canada and been
      approved by the Canadian Hypertension Society
  4) www.lowersodium.ca: Patient and health care professional information on dietary
  5) www.sodium101.ca: Public information on dietary sodium
  6) www.heartandstroke.ca/bp: For an individualized action plan for lifestyle change and
      monitoring of blood pressure
  7) www.nhlbi.nih.gov/hbp/prevent/h_eating/h_eating.htm: For detailed information on
      eating the DASH diet

         Table 3: Considerations in the Individualization of Antihypertensive Therapy
         (With permission of CHEP.)
                      Initial therapy                     Second-line therapy              Notes and/or Cautions
Diastolic+/- Systolic Thiazide diuretics, beta blockers,  Combinations of first-line drugs Beta-blockers are not recommended as initial therapy in
Hypertension          ACE-inhibitors, ARBs, or long-                                       those older than 60 years of age. Hypokalemia should be
                      acting calcium channel blockers                                      avoided by using potassium-sparing agents in those who
                      (consider ASA and statins in                                         are prescribed diuretics as monotherapy. ACE inhibitors
                      selected people). Consider                                           are not recommended in blacks as monotherapy.
                      initiating therapy with a                                            ACE inhibitors, ARBs and direct rennin inhibitors are
                      combination of two first line drugs                                  potential teratogens and caution is required if prescribing
                      if the blood pressure is >20 mmHg                                    to women of child-bearing potential. Combination of an
                      systolic or >10 mmHg diastolic                                       ACE-inhibitor with an ARB is not recommended.
                      above target.

Isolated systolic              Thiazide diuretics, ARBs or long-    Combinations of first-line drugs        Same as diastolic+/- systolic Hypertension
hypertension without other     acting dihydropyridine calcium
compelling indications         channel blockers.

DIABETES MELLITUS                                TARGET BLOOD PRESSURE < 130/80 mmHg
Diabetes mellitus with         ACE inhibitors or ARBs        Addition of thiazide diuretics,                If the serum creatinine level is >150 µmol/L, a loop
albuminuria*                                                 cardioselective beta-blockers, long-           diuretic should be used as a replacement for low-dose
                                                             acting CCBs                                    thiazide diuretics if volume control is required

Diabetes mellitus without      ACE inhibitors, ARBs,                Combination of first-line drugs or if   Normal albumin to creatinine ratio [ACR] < 2.0
albuminuria*                   dihydropyridine CCBs                 first line agents are not tolerated     mg/mmol in men and < 2.8 mg/mmol in women
                               or thiazide diuretics                addition of cardioselective beta-       Combination of an ACE-inhibitor with an ARB is
                                                                    blockers and/or long-acting non         specifically not recommended.
                                                                    dihydropyridine CCBs

Coronary artery disease ACE inhibitors or ARBs (except in Long-acting CCBs. When combination                Avoid short-acting nifedipine. Combination of an ACE-
                        low-risk patients); beta blockers for therapy is being used for high risk           inhibitor with an ARB is specifically not recommended.
                        patients with stable angina           patients, an ACE inhibitor/
                                                              dihydropyridine CCB is preferred

Prior myocardial infarction    Beta-blockers, ACE inhibitors        Long-acting CCBs                        Combination of an ACE-inhibitor with an ARB is
                               (ARBs if ACE inhibitor intolerant)                                           specifically not recommended.

Heart failure                  ACE inhibitors (ARBs if ACE          ARB in addition to ACE inhibitor.       Titrate doses of ACEI and ARB to those used in clinical
                               inhibitor- intolerant) and beta-     Hydralazine/isosorbide dinitrate        trials. Avoid nondihydropyridine CCBs (diltiazem,
                               blockers.                            combination                             verapamil). Monitor potassium and renal function if
                               Spironolactone in patients with      Thiazide or loop diuretics, are         combining an ACE inhibitor with ARB.
                               NYHA class III or IV symptoms.       recommended as additive therapy

Left ventricular hypertrophy   Does not affect initial treatment    Combination of additional agents        Hydralazine and minoxidil can increase left ventricular
                               recommendations                                                              hypertrophy.
Past stroke or TIA             ACE inhibitor/diuretic                  Combination of additional agents     This does not apply to acute stroke. Blood pressure
                               combinations                                                                 reduction reduces recurrent strokes in stable patients.
                                                                                                            Combination of an ACE-inhibitor with an ARB is
                                                                                                            specifically not recommended.
NON-DIABETIC CHRONIC KIDNEY DISEASE                                  TARGET BLOOD PRESSURE < 130/80 mmHg
Non-diabetic chronic kidney ACE inhibitors (ARBs if ACE                Combinations of additional agents    Avoid ACE inhibitors or ARB if bilateral renal artery
disease with proteinuria†      inhibitor-intolerant) if there is                                            stenosis or unilateral disease with solitary kidney.
                               proteinuria. Diuretics as additive                                           Patients placed on an ACE inhibitor or an ARB should
                               therapy                                                                      have their serum creatinine and potassium carefully
                                                                                                            monitored. Combinations of an ACE-inhibitor and ARB
                                                                                                            are specifically not recommended in patients with
                                                                                                            chronic kidney disease without proteinuria
Renovascular disease           Does not affect initial treatment       Combinations of additional agents    Avoid ACE inhibitors or ARB if bilateral renal artery
                               recommendations                                                              stenosis or unilateral disease with solitary kidney.
OTHER CONDITIONS                                          TARGET BLOOD PRESSURE < 140/90 mmHg
Peripheral arterial disease    Does not affect initial treatment       Combinations of additional agents    Avoid beta-blockers with severe disease
Dyslipidemia                   Does not affect initial treatment       Combinations of additional agents
Overall vascular protection    Statin therapy for patients with 3 or                                        Caution should be exercised with the ASA
                               more cardiovascular risk factors or                                          recommendation if blood pressure is not controlled.
                               with atherosclerotic disease
                               Low dose ASA in patients with
                               controlled blood pressure
*Albuminuria is defined as persistent albumin to creatinine ratio [ACR] >2.0 mg/mmol in men and >2.8 mg/mmol in women. †Proteinuria is defined as urinary protein
>500 mg/24hr or albumin to creatinine ratio [ACR] >30 mg/mmol. ACE Angiotensin-converting enzyme; ARB Angiotensin receptor blocker; ASA Acetylsalicylic acid;
CCB Calcium channel blocker; NYHA New York Heart Association; TIA Transient ischemic attack.** the accumulated weight of placebo-controlled trial evidence
supports the provision of ACE inhibitor therapy for this indication.
Table 4: Patient instructions to prepare for home blood pressure measurement
Purchasing Equipment

•   Buy an approved machine marked by the                     logo

•   Make sure the device has a cuff size that is correct for you. Ask for help if you are unsure.

To measure blood pressure -
• Follow the directions that come with the device.
• Only measure and record blood pressure if you have time to do it correctly.
• Do not measure blood pressure when you are uncomfortable, cold, anxious, stressed or in
• Wait for at least two hours after heavy physical activity (e.g. long run) and at least half an
   hour after light physical activity (e.g. short walk), drinking coffee or smoking.
• Empty your bladder or bowels if uncomfortable before taking a reading.
• It is very important to rest and relax for 5 minutes in a quiet comfortable place with no
   distractions (e.g. TV or talking) before measuring your blood pressure.
• Put the cuff on a bare arm or one that has a thin sleeve
• Sit in a chair that supports your back and beside a table that can support your arm. If
   required put a pillow or towel under your arm so that it rests at heart level (see Figure).
   Do not cross your legs.
• Measure blood pressure in the morning before medications and eating and in the evening
   before going to bed, bathing or taking medications.
• Take at least two readings and record them with the date and time.

 Table 5: Targets for dietary sodium
Age                                    Adequate Intake        Upper limit

19-31                                  1500                   2300

31-50                                  1500                   2300

51-70                                  1300                   2300

71 and over                            1200                   2300

 To prevent and control hypertension adults should be advised to eat the level recommended
 as adequate intake and avoid eating over the upper limit.

Table 6: Advice for People to Assist them to Reduce Dietary Sodium

• Buy and eat more fresh foods especially fruit and vegetables
• Choose processed foods 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 your
   food orders
• Use less sauces on your food
• Eat foods with less than 200 mg of sodium or less than 10% of the daily value per serving

• 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

With permission of Hypertension Canada and the Canadian Hypertension Education Program

Table 7: Target Values for Blood Pressure

Setting                               Target (SBP/DBP mmHg)

Home blood pressure and daytime ABPM*       <135/85

Diastolic ± systolic hypertension     <140/90
Isolated systolic hypertension        <140
Diabetes                              <130/80
Chronic kidney disease                <130/80

* The target value readings taken by home measurement and ABPM in those with diabetes or
chronic kidney disease have not been established.

With permission of Hypertension Canada and the Canadian Hypertension Education Program

Table 8: Lifestyle therapy to reduce the possibility of becoming hypertensive, to
reduce blood pressure and to reduce the risk of blood pressure-related cardiovascular
complications in people with hypertension.

1.    Healthy diet: high in fresh fruits and 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

2.    Regular physical activity: accumulation of 30-60 minutes of moderate intensity dynamic
      exercise 4-7 days per week in addition to daily activities

3.    Low risk alcohol consumption (≤2 standard drinks/day and less than 14/week for men
      and less than 9/week for women)

4.    Attaining and maintaining ideal body weight (BMI 18.5-24.9 kg/m2)

5.    A healthy waist circumference
             Europid                     < 94 cm for men
                                         < 80 cm for women
             South Asian, Japanese,      < 90 cm for men
             Chinese                     < 80 cm for women

6.    Reduction in sodium intake to 1500 mg /day is recommended for adults if under age
      50; 1300 mg if aged 51-70; 1200 mg if age >70*

7.    A smoke free environment

With permission of Hypertension Canada and the Canadian Hypertension Education Program
   *lower levels of intake are recommended by the Canadian government for children

Table 9: Strategies to Improve Patient Adherence*

1) Assist your patient to adhere
   i)      Tailoring pill-taking to fit patients’ daily habits
   ii)     Simplifying medication regimens to once-daily dosing

   iii)    replacing multiple pill antihypertensive combinations with single pill
   iv)     Utilizing unit-of-use packaging (of several medications to be taken together)

   v)      Adherence to an antihypertensive prescription can be improved by a
           multidisciplinary team approach

2) Assist your patient in getting more involved in their treatment
   vi)     Encouraging greater patient responsibility/autonomy in monitoring their blood
           pressure and adjusting their prescriptions
   vii)    Educating patients and patients' families about their disease/treatment

3) Improve your management in the office and beyond

   viii)   Assessing adherence to pharmacological and non-pharmacological therapy
           at every visit

   ix)     encouraging adherence with therapy by out-of-office contact (either by phone
           or mail), particularly during the first three months of therapy

   x)      Coordinating with work-site healthcare givers to improve monitoring of
           adherence with pharmacological and lifestyle modification prescriptions
   xi)     Utilizing electronic medication compliance aids

With permission of Hypertension Canada and the Canadian Hypertension Education Program

Table 10: The Canadian Hypertension Education Program

Steering       Blood Pressure Canada
committee      Canadian Council of Cardiovascular Nurses
               Canadian Hypertension Society
               Canadian Pharmacists Association
               College of Family Physicians of Canada
               Heart and Stroke Foundation of Canada
               Public Health Agency of Canada
Volunteers     Over 100 volunteers from clinical practice, academia and government
Evidence       Recommendations Task Force with over 50 clinical and academic volunteers
based          Centered around a core group of evidence based medicine experts who do
               not have potential commercial conflicts of interest
Knowledge      Implementation Task Force with over 25 volunteers from nursing, pharmacy,
translation    family medicine and health education to translate the recommendations to
               meet discipline specific needs and to facilitate inter disciplinary care
Outcomes       Outcomes Research Task Force with over 40 volunteers from academia and
evaluation     government to assess the impact of the program on an ongoing basis.
Administrative Susan Carter at Debut Medical Education
Patient        Close association with Blood Pressure Canada to develop patient resources
oriented       for self efficacy and knowledge translation

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