"2010 Canadian Hypertension Education Program Recommendations The"
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 leader. 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 email@example.com. Hypertension recommendations for patients with diabetes, developed in 2009, are also available. These summaries are available electronically at www.hypertension.ca/bpc. 1 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 2010 Hypertension in People with Diabetes 2 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 2011. 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 3 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 Disease 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 4 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 (27-29). 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 9). 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 5 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. 6 Table 1 Health Care Professional Resources* Documents 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 professionals 3) www.lowersodium.ca: for educational resources for health care professionals and patients on dietary sodium 7 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 advice 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. 8 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 recommendations 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. 9 Websites 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 sodium 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 10 Table 3: Considerations in the Individualization of Antihypertensive Therapy (With permission of CHEP.) Initial therapy Second-line therapy Notes and/or Cautions HYPERTENSION WITHOUT OTHER COMPELLING INDICATIONS TARGET BLOOD PRESSURE < 140/90 mmHg 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 CARDIOVASCULAR DISEASE TARGET BLOOD PRESSURE < 140/90 mmHg 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 recommendations Dyslipidemia Does not affect initial treatment Combinations of additional agents recommendations 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. 11 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 pain. • 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. 12 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. 13 Table 6: Advice for People to Assist them to Reduce Dietary Sodium DO • 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 DON’T • Buy or eat heavily salted foods (e.g. pickled foods, salted crackers or chips, processed meats, etc). • Add salt in cooking and at the table • Eat foods with more than 400 mg of sodium or more than 20% of the daily value per serving With permission of Hypertension Canada and the Canadian Hypertension Education Program 14 Table 7: Target Values for Blood Pressure Setting Target (SBP/DBP mmHg) Home: Home blood pressure and daytime ABPM* <135/85 Office: 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 15 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 16 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 combinations 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 regimens 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 17 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 support Patient Close association with Blood Pressure Canada to develop patient resources oriented for self efficacy and knowledge translation 18 Reference List (1) Campbell NR, Chen G. Canadian Efforts to Prevent and Control Hypertension. Canadian Journal of Cardiology. 2009;In Press. (2) Hemmelgarn BR, Chen G, Walker R, McAlister FA, Quan H, Tu K et al. Trends in antihypertensive drug prescriptions and physician visits in Canada between 1996 and 2006. Can J Cardiol. 2008;24:507-12. (3) Rodgers A, Vaughan P, Prentice T, Edejer TT-T, Evans D. The World Health Report 2002. Geneva, Switzerland: World Health Organization; 2002. (4) Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. The Lancet. 2005;365:217-23. (5) Lawes CMM, Vander Hoorn S, Law MR, Elliott P, MacMahon S, Rodgers A. Blood pressure and the global burden of disease 2000. Part II: Estimates of attributable burden. J Hypertens. 2006;24:423-30. (6) Gaziano TA, Bitton A, Anand S, Weinstein MC. The global cost of nonoptimal blood pressure. J Hypertens. 2009;27:1472-77. (7) Leenen FH, Dumais J, McInnis NH, Turton P, Stratychuk L, Nemeth K et al. Results of the Ontario survey on the prevalence and control of hypertension. CMAJ. 2008;178:1441-49. (8) Campbell NR, Brant R, Johansen H, Walker RL, Wielgosz A, Onysko J et al. Increases in antihypertensive prescriptions and reductions in cardiovascular events in Canada. Hypertension. 2009;53:128-34. (9) McAlister FA, Feldman RD, Wyard K, Brant R, Campbell NR. The impact of the CHEP in its first decade. Eur Heart J. 2009;30:1434-39. (10) Kearney PM, Whelton M, Reynolds K, Whelton PK, He J. Worldwide prevalence of hypertension: a systematic review. J Hypertens. 2004;22:11-19. (11) Campbell NR, Leiter LA, Larochelle P, Tobe S, Chockalingam A, Ward R et al. Hypertension in diabetes: a call to action. Can J Cardiol. 2009;25:299-302. (12) Blood Pressure Lowering Treatment Trialists' Collaboration. Effects of Different Blood Pressure-Lowering Regimens on Major Cardiovascular Events in Individuals With and Without Diabetes Mellitus. Arch Intern Med. 2005;165:1410-1419. (13) Sarafidis PA, Bakris GL. Resistant hypertension: an overview of evaluation and treatment. J Am Coll Cardiol. 2008;52:1749-57. (14) Whelton PK, Barzilay J, Cushman WC, Davis BR, Ilamathi E, Kostis JB et al. Clinical Outcomes in antihypertensive treatment of type 2 diabetes, impaired fasting glucose concentration, and normoglycemia: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med. 2005;165:1401-9. 19 (15) Wiklund I, Halling K, Ryden-Bergsten T, Fletcher A. Does lowering the blood pressure improve the mood? Quality-of-life results from the Hypertension Optimal Treatment (HOT) Study. Blood Pressure. 1997;6:357-64. (16) Applegate WB. Quality of Life During Antihypertensive Treatment. Lessons from the Systolic Hypertension in the Elderly Program. AJH. 1998;11:57S-61S. (17) CDC Diabetes Cost-effectiveness Group. Cost-effectiveness of Intensive Glycemic Control, Intensified Hypertension Control, and Serum Cholesterol Level Reduction for Type 2 Diabetes. JAMA. 2002;287:2542-51. (18) Padwal RS, Hemmelgarn BR, Khan NA, Grover S, McKay DW, Wilson T et al. The 2009 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 1--blood pressure measurement, diagnosis and assessment of risk. Can J Cardiol. 2009;25:279-86. (19) Khan NA, Hemmelgarn B, Herman RJ, Bell CM, Mahon JL, Leiter LA et al. The 2009 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 2--therapy. Can J Cardiol. 2009;25:287-98. (20) Yusuf S, Teo KK, Pogue J, Dyal L, Copland I, Schumacher H et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008;358:1547-59. (21) Jamerson K, Weber MA, Bakris GL, Dahlof B, Pitt B, Shi V et al. Benazepril plus Amlodipine or Hydrochlorothiazide for Hypertension in High-Risk Patients. The New England Journal of Medicine. 2008;359:2417-28. (22) Danaei G, Ding EL, Mozaffarian D, Taylor B, Rehm J, Murray CJ et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med. 2009;6:e1000058. (23) Pimenta E, Gaddam KK, Oparil S, Aban I, Husain S, Dell'Italia LJ et al. Effects of dietary sodium reduction on blood pressure in subjects with resistant hypertension: results from a randomized trial. Hypertension. 2009;54:475-81. (24) Vasan RS, Beiser A, Seshadri S, Larson MG, Kannel WB, D'Agostino RB et al. Residual Lifetime Risk for Developing Hypertension in Middle-aged Women and Men. JAMA. 2002;287:1003-10. (25) Padwal RS, Hemmelgarn BR, McAlister FA, McKay DW, Grover S, Wilson T et al. The 2007 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 1 - blood pressure measurement, diagnosis, and assessment of risk. Can J Cardiol. 2007;23:529-38. (26) Khan N, Chockalingam A, Campbell NRC. Lack of control of high blood pressure and treatment recommendations in Canada. Can J Cardiol. 2002;18:657-61. (27) Campbell NR, So L, Amankwah E, Quan H, Maxwell C. Characteristics of hypertensive Canadians not receiving drug therapy. Can J Cardiol. 2008;24:485-90. 20 (28) Hackam DG, Leiter LA, Yan AT, Yan RT, Mendelsohn A, Tan M et al. Missed opportunities for the secondary prevention of cardiovascular disease in Canada. Can J Cardiol. 2007;23:1124-30. (29) McInnis NH, Fodor G, Lum-Kwong MM, Leenen FH. Antihypertensive medication use and blood pressure control: a community-based cross-sectional survey (ON-BP). Am J Hypertens. 2008;21:1210-1215. (30) Ashenden R, Silagy C, Weller D. A systematic review of the effectiveness of promoting lifestyle change in general practice. Family Practice. 1997;14:160-176. (31) Mohan S, Campbell NR. Hypertension management in Canada: good news, but important challenges remain. CMAJ. 2008;178:1458-60. 21