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					                2010

Hypertension
  as a Public
 Health Risk
   The full slide set of the
2010 CHEP Recommendations
      are available at
   www.hypertension.ca




     2010 Canadian Hypertension Education Program Recommendations
                                                                    2
         Key CHEP messages for the
        management of hypertension
   Know the current blood pressure of all your patients.
   Encourage the use of approved devices and proper
    technique to measure blood pressure at home.
   Assess and manage CV risk in hypertensives including:
    high dietary sodium intake, smoking, dyslipidemia,
    dysglycemia, abdominal obesity, unhealthy eating, and
    physical inactivity.
   Sustained lifestyle modification is the cornerstone for the
    prevention and control of hypertension and the
    management of CV disease. Encourage reducing sodium
    intake according to Health Canada's recommendations.
   Treat blood pressure to <140/90 mmHg. In people with
    diabetes or chronic kidney disease target to <130/80
    mmHg and more than one drug is usually required
    including diuretics to achieve BP targets.
   Keep up to date with evidence and resources for
    hypertension management, go to: www.htnupdate.ca.
    Download the latest tools at: www.hypertension.ca/tools.
    Have your patients sign up at www.myBPsite.ca to access
    the latest hypertension resources for patients.
              2010 Canadian Hypertension Education Program Recommendations
                                                                             3
              CHEP 2010 Recommendations


                          What’s new?
•Increased emphasis on measuring blood pressure using
 automated devices both in and out of the office: guidance on
 the use of AOBP machines
•Lifestyle changes are still a critical component of
 hypertension management (and prevention!): new guidelines
 for dietary sodium restriction
•Increased emphasis on the use of single pill combinations
 (and more guidance on which combinations to use).
•Keep up to date with new CHEP tools at www.htnupdate.ca

              2010 Canadian Hypertension Education Program Recommendations
                                                                             4
CHEP 2010 Recommendations: What’s New
               for 2010
• CHEP recognizes that automated office
  blood pressure (AOBP) monitors are
  more frequently being used and
  provides early guidance on their use
• Sodium intake recommendations now in
  line with Health Canada: lower targets
  recommended with advancing age
• ARBs = ACEi’s for most indications
• Combination therapy using first line agents:
   • Replace multiple pill antihypertensive
     combinations with single pill combinations
   • In high risk patients the combination of an
     ACEi and a DHP CCB is preferred
           2010 Canadian Hypertension Education Program Recommendations
                                                                          5
           What’s New for 2010

• Keep up to date on the prevention
  and control of hypertension
  Register for automatic email
  notification of new hypertension
  resources for you and your patients,
  at: www.htnupdate.ca.

• Have your patients sign up at
  www.myBPsite.ca to access latest
  hypertension resources.
       2010 Canadian Hypertension Education Program Recommendations
                                                                      6
  Information and Resources for Public




   Please encourage your patients to sign up for free access
to the latest information and resources on high blood pressure
                        www.mybpsite.ca



             2010 Canadian Hypertension Education Program Recommendations
                                                                            7
  The Canadian Hypertension Education
    Program: 2010 Recommendations

What’s still important?

• The management of hypertension is all about
  global risk management and vascular
  protection

• The management of hypertension is all about
  achieving “buy-in”




         2010 Canadian Hypertension Education Program Recommendations
                                                                        8
      2010 Canadian Hypertension Education
                Program (CHEP)
     Important messages from past recommendations

•   Patients with diabetes are at high cardiovascular risk
•   Most patients with diabetes have hypertension
•   Treatment of hypertension in patients with diabetes reduces
    total mortality, myocardial infarction, stroke, retinopathy and
    progressive renal failure rates.
•   Treating hypertension in patients with diabetes reduces
    death and disability and reduces health care system costs
•   In diabetes, TARGET <130 systolic and <80 mmHg diastolic
•   The use of the combination of ACE inhibitor with an ARB
    should only be considered in selected and closely
    monitored people with advanced heart failure or proteinuric
    nephropathy.
                2010 Canadian Hypertension Education Program Recommendations
                                                                               9
Proportion of deaths attributable to leading risk factors
worldwide (2000)




                                                     Systolic blood pressure
                                                     greater than 115 mmHg




                           0      1     2     3     4     5      6     7     8
                                        Attributable Mortality
                                     Education Program Lancet. 2002;360:1347-1360.
           2010 Canadian HypertensionWHO 2000 Report. Recommendations
                                                                                     10
       Hypertension as a Risk Factor


Hypertension is a significant risk factor for:
  •   cerebrovascular disease
  •   coronary artery disease
  •   congestive heart failure
  •   renal failure
  •   peripheral vascular disease
  •   dementia
  •   atrial fibrillation




           2010 Canadian Hypertension Education Program Recommendations
                                                                          11
            Blood Pressure Distribution in the
               Population According to Age


                    Men                                                 Women
150                                                 150
130                                                 130
                                              PP                                                    PP
110                                                 110

 80                                                   80

 70                                                   70


      30-39 40-49 50-59 60-69 70-79  80                     30-39 40-49 50-59 60-69 70-79  80

                    Age                      PP=Pulse Pressure.                Age

      Adapted from : Third National Health and Nutrition. Examination Survey, Hypertension 1995;25:305-13
                      2010 Canadian Hypertension Education Program Recommendations
                                                                                                            12
          European Society of Hypertension
           Classification of Blood Pressure


  Category                                 Systolic                              Diastolic
  Optimal                                        <120           and / or               <80

  Normal                                         <130           and / or               <85

  High-Normal                                  130-139          and / or               85-89

  Grade 1 (mild hypertension )                 140-159          and / or               90-99

  Grade 2 (moderate hypertension)              160-179          and / or              100-109

  Grade 3 (severe hypertension)                   180          and / or                110

  Isolated Systolic Hypertension                 140              and                 <90
  (ISH)



The category pertains to the highest risk blood pressure

*ISH=Isolated Systolic Hypertension. J Hypertens 2007;25:1105-87,

                       2010 Canadian Hypertension Education Program Recommendations
                                                                                                13
               JNC (American) Classification
                    of Blood Pressure

   Category                                 Systolic                             Diastolic
   Optimal                                       <120           and / or                <80

   Normal                                        <130           and / or                <85

   High-Normal                                 130-139          and / or               85-89

   Stage 1 (mild hypertension )                140-159          and / or               90-99

   Stage 2 (moderate to severe                    160          and / or              100-109
   hypertension)
   Isolated Systolic Hypertension                 140             and                  <90
   (ISH)




The category pertains to the highest risk blood pressure

*ISH=Isolated Systolic Hypertension. JAMA 2003;289:2560-72

                       2010 Canadian Hypertension Education Program Recommendations
                                                                                                 14
Blood Pressure and Risk of Stroke Mortality




       2010 Canadian Hypertension Education Program Recommendations   Lancet 2002;360:1903-13
                                                                                                15
Blood Pressure and Risk of Ischemic
   Heart Disease (IHD) Mortality




                                                               Lancet 2002;360: 1903-13
2010 Canadian Hypertension Education Program Recommendations
                                                                                     16
                    Effect of SBP and DBP on
                Age-Adjusted CAD Mortality: MRFIT


                                   CAD Death Rate per 10,000 Person-years
                                                                                                                 80.6



                       48.3                                                  43.8
                                        37.4             34.7                                    38.1


                31.0
                                 25.8             24.6                25.3                25.2                24.9

         23.8
                                                                                                                               160+
                          16.9             13.9                12.8                12.6                11.8
  20.6                                                                                                                  140-159
                   10.3             11.8                 8.8                 8.5                 9.2
                                                                                                                     120-139
                                                                                                              <120             Systolic BP
100+             90-99           80-89             75-79              70-74                <70                                  (mmHg)
                                 Diastolic BP (mmHg)

                                                                             Neaton et al. Arch Intern Med 1992; 152:56-64.

                          2010 Canadian Hypertension Education Program Recommendations
                                                                                                                                             17
    Impact of High-Normal Blood Pressure on the Risk
                of Cardiovascular Disease


CUMULATIVE INCIDENCE OF CV EVENTS IN MEN WITHOUT HYPERTENSION ACCORDING TO BASELINE BLOOD PRESSURE




                                                                                            mmHg

                                                                                           (130-139)


                                                                                           (121-129)



                                                                                           (< 120)




                                                                       N Engl J Med 2001;345:1291-7

                       2010 Canadian Hypertension Education Program Recommendations
                                                                                                       18
              The Concept of Masked Hypertension


                      200


                      180
Home/Ambulatory SBP




                                                            True
                               Masked HTN                   hypertensive
                      160


                      140
                                                                                                 135
                      120     True
                              Normotensive                   White Coat HTN
mmHg




                      100
                        100         120           140         160          180             200

                                                 Office SBP mmHg
                                                          Derived from Pickering et al. Hypertension 2002: 40: 795-796.
                            2010 Canadian Hypertension Education Program Recommendations
                                                                                                                      19
The Prognosis of White Coat and Masked
             Hypertension
 Prevalence is approximately 10% of the adult population




                        2.5
 Cardiovascular Event




                         2
    Odds Ratio of a




                        1.5

                         1

                        0.5

                         0        Normal BP         White coat         Masked          Hypertension
                                                   Hypertension      Hypertension




                                                                         J Hypertension 2007;25:2193-2198

                              2010 Canadian Hypertension Education Program Recommendations
                                                                                                            20
Long term follow-up of Normotensive, White Coat
  Hypertension, and Ambulatory Hypertension



                                   8                                                           Ambulatory
 Cumulative hazard of stroke (%)                     White Coat Hypertension
                                                                                               Hypertension
                                   7

                                   6
                                                                                                      Normotensive
                                                                                                      group
                                   5

                                   4

                                   3

                                   2
                                                                                         p = 0.0013
                                   1

                                   0
                                        0   1    2   3   4   5   6   7   8   9   10 11 12 13 14 15 16

                                                             Time to stroke (years)


                                                                                        Hypertension. 2005;45(2):203-208
                                       2010 Canadian Hypertension Education Program Recommendations
                                                                                                                           21
       Benefits of Treating Hypertension

• Younger than 60 (reducing BP 10/5-6
  mmHg)
  • reduces the risk of stroke by 42%
  • reduces the risk of coronary event by 14%

• Older than 60 (reducing BP 15/6
  mmHg)
  •   reduces   overall mortality by 15%
  •   reduces   cardiovascular mortality by 36%
  •   reduces   incidence of stroke by 35%
  •   reduces   coronary artery disease by 18%
                   Lancet 1990;335:827-38                 Arch Fam Med 1995;4:943-50
           2010 Canadian Hypertension Education Program Recommendations
                                                                                       22
       Benefits of Treating to Target



• Older than 60 with isolated systolic
  hypertension
 (SBP 160 mm Hg and DBP <90 mm Hg)

  • 42% reduction in the risk of stroke
  • 26% reduction in the risk of coronary
    events




                                                                         Lancet 1997;350:757-64

          2010 Canadian Hypertension Education Program Recommendations
                                                                                                  23
Correlation Between Reduction in SBP and
               Stroke or MI

            Stroke                                   Myocardial Infarction




                                                      Staessen et al. Lancet 2001;358:1305-15.
      2010 Canadian Hypertension Education Program Recommendations
                                                                                                 24
Correlation Between Reduction in SBP and
    Cardiovascular Mortality or Events

 Cardiovascular mortality                         Cardiovascular events




                                                   Staessen et al. Lancet 2001;358:1305-15.
      2010 Canadian Hypertension Education Program Recommendations
                                                                                              25
   90% of Hypertensive Canadians
have other Cardiovascular Risk factors




                                  10%                                   45%
   10%
Reduction
  in BP
                  +            Reduction
                               in Total-C
                                                         =           Reduction
                                                                      in CVD



            Emberson et al. Eur Heart J. 2004;25:484-491.
            2010 Canadian Hypertension Education Program Recommendations
                                                                                 26
                               Treating Hypertension and Other Risk Factors


                                 Treatment                      Treatment               Treatment Based on
                               Based on lipids                 Based on BP              Overall Absolute Risk
                                  (statin)                                                (ASA, lipids, BP)
                          0
Predicted Reduction in




                          -5

                         -10
                                -6                              -6
    Major CVD (%)




                                       -9                              -8
                                                                             -10
                         -15                 -12
                         -20                                                                    -17
                         -25    Treatment thresholds
                                  Top 10%
                         -30                                                                          -28
                                  Top 20%
                         -35
                                  Top 30%
                         -40                                                                                -37

                                     Adapted from Emberson et al. Eur Heart J. 2004;25:484-491.

                                     2010 Canadian Hypertension Education Program Recommendations
                                                                                                                  27
      Challenges to Hypertension
    Management: Public Perceptions

44% of people could not identify a normal or a
high blood pressure reading

80% of people were unaware of the association
between hypertension and heart disease

63% believed that hypertension was not a
serious condition

38% of people thought they could control high
blood pressure without the help of a health
professional
                                                                        Can J Cardiol 2005;21:589-93



         2010 Canadian Hypertension Education Program Recommendations
                                                                                                   28
     The Canadian Hypertension
     Education Program (CHEP)
                      Goal
To reduce the burden of cardiovascular disease in
Canada through optimized hypertension
management
                    Activities
 • Regularly updated evidence-based
   recommendations for the management of
   hypertension
 • Knowledge translation and exchange of the
   recommendations to support implementation
 • Regular evaluation and revision of the program
 • Assessment of patient outcomes
         2010 Canadian Hypertension Education Program Recommendations
                                                                        29
Leading diagnoses resulting in visits
   to physician offices in Canada

                        25




                                                                                              Acute respiratory
                                                                            Routine medical
  Million visits/year




                                                    Depression
                        20




                                                                                              tract infection
                                                                 Diabetes
                                     Hypertension
                        15




                                                                            exams
                        10


                        5


                        0


                                                                                              Source: IMS HEALTH Canada 2002



                         2010 Canadian Hypertension Education Program Recommendations
                                                                                                                               30
         NEW PATIENT RESOURCES FOR
           HYPERTENSION ON LINE
•   www.hypertension.ca/tools
     • Download current resources for the prevention and control of
       hypertension
•   www.htnupdate.ca
     • To keep up to date with the latest evidence and resources
•   www.myBPsite.ca
     •  Have your patients sign up to access the latest hypertension
        resources
•   www.lowersodium.ca
     • Tools and resourcesfor healthcare professionals to use in
        educating other healthcare professionals, the public or patients
        about the risks of high dietary sodium in Canada.
•   www.sodium101.ca
     • To access a simple to use demonstration of food sodium content
        for your patients
•   www.heartandstroke.ca/BP
     • To monitor home blood pressure and encourage self management
        of lifestyle
•   http://www.hypertension.qc.ca/
     • Société Québécoise d’hypertension artérielle

                2010 Canadian Hypertension Education Program Recommendations
                                                                               31
           For your patients – ask them to sign
           up at www.myBPSite.ca for free
           access to the latest Information &
           resources on HBP

                 For health care professionals –
                 sign up at www.htnupdate.ca
                 for automatic updates and on
                 current hypertension
                 educational resources.

2010 Canadian Hypertension Education Program Recommendations
                                                               32

				
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