Transcript Part 2: Recommendations for Hypertension Treatment

2007
Part 2:
Recommendations
for Hypertension
Treatment
January 2007
Key CHEP messages for the
management of hypertension
Assess blood pressure at all appropriate
visits.
Almost one half of those with blood pressure
130-139/85-89 will develop hypertension
within 2 years. They require annual
reassessment.
Assess global cardiovascular risk in all
hypertensive patients.
Lifestyle modification is the cornerstone for
the prevention and management of
hypertension and CVD.
2007 Canadian Hypertension Education Program Recommendations
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Key CHEP messages for the
management of hypertension
Treat to target (<140/90 mmHg; <130/80
mmHg in patients with diabetes or chronic
kidney disease).
To achieve targets sustained lifestyle
modification and more than one drug is
usually required.
Follow patients with uncontrolled blood
pressure at least monthly until blood pressure
targets are achieved.
Strategies to improve patient adherence to
lifestyle modifications and antihypertensive
therapy need to be incorporated in every
patients management
2007 Canadian Hypertension Education Program Recommendations
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2007 Canadian Hypertension
Education Program
• A red flag
has been posted where recommendations
were updated for 2007.
• A slide kit for medical education can be
downloaded (English and French versions) from
http://www.hypertension.ca
2007 Canadian Hypertension Education Program Recommendations
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2007 Canadian Hypertension
Education Program
Treatment Approaches:
• Lifestyle
• Pharmacological
2007 Canadian Hypertension Education Program Recommendations
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2007 Canadian Hypertension
Education Program
What's New for 2007
• Approximately 95% of Canadians will develop
hypertension if they live an average lifespan
• Most overweight patients with high normal
blood pressure (130-139/85-89 mmHg) will
develop hypertension within 4 years and
almost 1/2 within 2 years.
• Annual follow-up of patients with high normal
blood pressure is recommended.
2007 Canadian Hypertension Education Program Recommendations
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2007 Canadian Hypertension
Education Program
What's New for 2007
• Up to 17% of hypertension can be
attributed to high sodium diets
• Reduce sodium intake to less than
100 mmol in normotensive patients
to prevent hypertension
2007 Canadian Hypertension Education Program Recommendations
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Recommendations 2007
Table of contents
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.
XIII.
XIV.
Indications for drug therapy
Goal for therapy
Adherence
Lifestyle
Uncomplicated
CV – IHD
CHF
Cerebrovascular / Stroke
LVH
Chronic kidney disease
Renovascular
Diabetes
Smoking
Global risk reduction
2007 Canadian Hypertension Education Program Recommendations
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I. Indications for Pharmacotherapy
Usual blood pressure threshold values for
initiation of pharmacological treatment of
hypertension
Condition
Initiation
SBP or DBP mmHg
• Systolic or Diastolic hypertension
140/90
• Diabetes
• Chronic Kidney Disease
130/80
2007 Canadian Hypertension Education Program Recommendations
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I. Indications for Pharmacotherapy
• In low risk patients with stage 1 hypertension (140-159/90-99
mmHg) lifestyle modification can be the sole therapy.
• Over 90% of Canadians with hypertension have other risk
factors and pharmacotherapy should be considered in these
patients if blood pressure remains equal to or above 140/90
mmHg with lifestyle modification.
• Patients with target organ damage (e.g. left ventricular
hypertrophy) are recommended to be treated with
pharmacotherapy if blood pressure is equal to or above
140/90
• Patients with known atherosclerotic disease (e.g. past stroke)
are recommended to be treated with pharmacotherapy even if
the blood pressure is normal (see compelling indications)
• Patients with diabetes or chronic kidney disease should be
considered for pharmacotherapy if the blood pressure is equal
or over 130/80 mmHg
2007 Canadian Hypertension Education Program Recommendations
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II. Goals of Therapy
Blood pressure target values for treatment
of hypertension
Target
Condition
SBP and DBP mmHg
Isolated systolic hypertension
Systolic/Diastolic Hypertension
• Systolic BP
• Diastolic BP
Diabetes
• Systolic
• Diastolic
<140
<140
<90
<130
<80
Chronic Kidney disease
• Systolic
• Diastolic
<130
<80
2007 Canadian Hypertension Education Program Recommendations
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II. Goals of Therapy
• To optimally reduce cardiovascular risk
reduce the blood pressure to specified
targets.
• This usually requires two or more drugs and
lifestyle changes
• The systolic target is more difficult to
achieve however controlling systolic blood
pressure is as important if not more
important than controlling diastolic blood
pressure
2007 Canadian Hypertension Education Program Recommendations
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Follow-up of blood pressure
above targets
• Patients with blood pressure at target
are recommended to be followed at
least every 2nd month
• Follow-up visits are used to increase the
intensity of lifestyle and drug therapy,
monitor the response to therapy and
assess adherence
2007 Canadian Hypertension Education Program Recommendations
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2007
Part 2:
Recommendations
for Hypertension
Treatment
January, 2007
2007
IV. Lifestyle
management
Lifestyle Recommendations for Prevention of
Hypertension for NON-Hypertensive Individuals.
To reduce the possibility of becoming hypertensive,
Restriction of sodium intake to less than 100 mmol (2300 mg) / day
Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary
and soluble fiber, whole grains and protein from plant sources,
low in saturated fat, cholesterol and salt in accordance with Canada's
Guide to Healthy Eating.
Regular physical activity: accumulation of 30-60 minutes of moderate
intensity cardiorespiratory activity 4-7/week
Low risk alcohol consumption (≤2 standard drinks/day and less than
14/week for men and less than 9/week for women)
Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2)
Waist Circumference
< 102 cm for men
< 88 cm for women
Smoke free environment
2007 Canadian Hypertension Education Program Recommendations
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Lifestyle Recommendations for the
Treatment of Hypertension
Restriction of sodium intake to less than 100 mmol (2300 mg) / day
Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary
and soluble fiber, whole grains and protein from plant sources,
low in saturated fat, cholesterol and salt in accordance with Canada's
Guide to Healthy Eating.
Regular physical activity: accumulation of 30-60 minutes of moderate
intensity cardiorespiratory activity 4-7/week
Low risk alcohol consumption (≤2 standard drinks/day and less than
14/week for men and less than 9/week for women)
Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2)
Weight loss (> 5 Kg) in those who are over weight (BMI>25)
Waist Circumference
< 102 cm for men
< 88 cm for women
Smoke free environment
2007 Canadian Hypertension Education Program Recommendations
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Lifestyle Recommendations for
Hypertension: Dietary
• High in fresh fruits
• High in vegetables
• High in low fat
dairy products
• High in dietary and
soluble fibre
• High in plant
protein
• Low in saturated
fat and cholesterol
Dietary Sodium
Restrict to target range of 65-100 mmol/day
(Most of the salt in food is hidden and comes
from processed food)
Dietary Potassium
If required, daily dietary intake
>80 mmol
Calcium supplementation
No conclusive studies for hypertension
Magnesium supplementation
No conclusive studies for hypertension
http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_guide_rainbow_e.html
2007 Canadian Hypertension Education Program Recommendations
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Recommendations for daily salt intake
Less than:
•
•
•
•
100 mmol sodium (Na)
or 2,3 g sodium (Na)
or 5,8 g of salt (NaCl)
or 1 teaspoon of table salt
2,300 mg sodium = 1 teaspoon of table salt
2007 Canadian Hypertension Education Program Recommendations
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Salt 2007: Meta-analyses
Hypertensives
Reduction of BP
5.1 / 2.7 mmHg with a average reduction of 78
mmol sodium/day (162 to 87mmol/day)
7.2/3.8 mmHg with a average reduction of 100
mmol sodium/day
Normotensives
Reduction of BP
2.0 / 1.0 mmHg with a average reduction of sodium
74 mmol/day
3.6/1.7 mmHg with a average reduction of 100
mol/day sodium
The Cochrane Library 2006;3:1-41;
2007 Canadian Hypertension Education Program Recommendations
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Salt 2007: Meta analysis on different
reduction in sodium on blood pressure
12
SBP hyper
10
DBP hyper
BP reduction
SBP normo
8
DBP normo
6
4
2
0
52
104
156
m m ol reduction in sodium
Hypertension 2003;42:1093-1099
2007 Canadian Hypertension Education Program Recommendations
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Prevalence %
Epidemiologic impact on mortality of blood
pressure reduction in the population
After
Intervention
Before
Intervention
Reduction in BP
Reduction in
SBP
% Reduction in Mortality
(mmHg)
Stroke
CHD
Total
2
-6
-4
-3
3
-8
-5
-4
5
-14
-9
-7
Adapted from Whelton, P. K. et al. JAMA 2002;288:1882-1888
2007 Canadian Hypertension Education Program Recommendations
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Lifestyle Recommendations for
Hypertension. Physical Activity
Should be prescribed to reduce blood pressure
F
Frequency
- Four to seven days per week
I
Intensity
- Moderate
T
Time
- 30-60 minutes
Type
cardiorespiratory activity
- Walking, jogging
- Cycling
- Non-competitive swimming
T
Exercise should be prescribed as adjunctive to pharmacological
therapy
2007 Canadian Hypertension Education Program Recommendations
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Lifestyle Recommendations for
Hypertension: Alcohol
Low risk alcohol consumption
• 0-2 standard drinks/day
• Men: maximum of 14 standard drinks/week
• Women: maximum of 9 standard drinks/week
A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or 12 oz of
beer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).
2007 Canadian Hypertension Education Program Recommendations
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Lifestyle Recommendations for
Hypertension Stress Management
Stress management
Hypertensive patients
in whom stress appears to be an important issue
Behavior Modification
Individualized cognitive behavioral
interventions are more likely to be
effective when relaxation techniques
are employed.
2007 Canadian Hypertension Education Program Recommendations
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Lifestyle Recommendations for
Hypertension Weight Loss
Height, weight, and waist circumference (WC) should be
measured and body mass index (BMI) calculated for all adults.
Hypertensive and all patients
BMI over 25
- Encourage weight reduction
- Healthy BMI: 18.5-24.9 kg/m2
Waist Circumference
< 102 cm for men
< 88 cm for women
For patients prescribed pharmacological therapy: weight
loss has additional antihypertensive effects. Weight loss
strategies should employ a multidisciplinary approach and
include dietary education, increased physical activity and
behavioural modification
2007 Canadian Hypertension Education Program Recommendations
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Waist circumference measurement
Last rib margin
Mid distance
Iliac crest
Courtesy J.P. Després 2006
2007 Canadian Hypertension Education Program Recommendations
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Impact of Lifestyle Therapies on Blood
Pressure in Hypertensive Adults
Intervention
Amount
SBP/DBP
1.8g or 78 mmol/d
-5.1 / -2.7
per kg lost
-1.1 / -0.9
- 3.6 drinks/day
-3.9 / -2.4
Aerobic exercise
120-150 min/week
-4.9 / -3.7
Dietary patterns
DASH diet
Hypertensive
Normotensive
-11.4 / -5.5
-3.6 / -1.8
Reduce foods with
added sodium
Weight loss
Alcohol intake
Applying the 2005 Canadian Hypertension Education Program recommendations: 3. Lifestyle modifications to prevent and treat
hypertension Padwal R. et al. CMAJ ･ SEPT. 27, 2005; 173 (7) 749-751
2007 Canadian Hypertension Education Program Recommendations
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Lifestyle Therapies in Hypertensive
Adults: Summary
Target
Intervention
Reduce foods with
added sodium
< 100 mmol/day
Weight loss
BMI <25 kg/m2
Alcohol restriction
Less or equal to 2 drinks/day
Exercise
at least 4 times/week
Dietary patterns
DASH diet
Smoking cessation
Smoke free environment
Waist Circumference
< 102 cm for men
< 88 cm for women
2007 Canadian Hypertension Education Program Recommendations
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2007
Pharmacotherapy
2007 Canadian Hypertension
Education Program
Table of contents
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.
XIII.
XIV.
Indications for drug therapy
Goal for therapy
Adherence
Lifestyle
Uncomplicated
CV – IHD
CHF
Cerebrovascular / Stroke
LVH
Chronic kidney disease
Renovascular
Diabetes
Smoking
Global risk reduction
2007 Canadian Hypertension Education Program Recommendations
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V. Choice of Pharmacological
Treatment Uncomplicated
Associated risk factors?
or
Target organ damage/complications?
or
Concomitant diseases/conditions?
NO
Treatment in the
absence of specific
indication
YES
Individualized
Treatment
(and compelling indications)
2007 Canadian Hypertension Education Program Recommendations
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V. Choice of Pharmacological Treatment
1. Treatment of Systolic/Diastolic
hypertension without other
compelling indications
2. Treatment of Isolated Systolic
hypertension without other
compelling indications
2007 Canadian Hypertension Education Program Recommendations
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V. Treatment of Adults with
Systolic/Diastolic Hypertension without
Other Compelling Indications
TARGET <140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy
Thiazide
ACE-I
ARB
Longacting
CCB
Betablocker*
* BBs are not indicated as first line therapy for age 60 and above
ACEI and ARB are contraindicated in pregnancy and caution is required
in prescribing to women of child bearing potential
2007 Canadian Hypertension Education Program Recommendations
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V. Considerations Regarding the Choice
of First-Line Therapy
• ACE inhibitors and ARBs are contraindicated in
pregnancy and caution is required in prescribing to
women of child bearing potential
• Beta adrenergic blockers are not recommended for
patients age 60+ without another compelling indication
• Diuretic-induced hypokalemia should be avoided
through the use of potassium sparing agent
• ACE-I are not recommended (as monotherapy)
for black patients without another compelling indication
2007 Canadian Hypertension Education Program Recommendations
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Major Congenital Malformations after
First Trimester Exposure to ACE inhibitors
• Cardiovascular and neurological defects
• ACEI risk ratio 2.71 (1.72-4.27) vs.
other drugs 0.66 (0.25-1.75) vs. no
drug
NEJM 2006;354:2443-51
2007 Canadian Hypertension Education Program Recommendations
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V. Add-on Therapy for Systolic/Diastolic
Hypertension without Other Compelling
Indications
If partial response to monotherapy
1. Add-on Therapy
2. Triple or Quadruple Therapy
CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?
• Resistant Hypertension?
If blood pressure is still not controlled, or there are
adverse effects, other classes of antihypertensive drugs
may be combined (such as alpha blockers or centrally
acting agents).
2007 Canadian Hypertension Education Program Recommendations
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Drug Combinations
• When combining drugs, use first-line therapies
• Two drug combinations of beta blockers, ACE inhibitors
and angiotensin receptor blockers have not been proven
to have additive hypotensive effects.
• Therefore these potential two drug combinations should
not be used unless there is a compelling (non blood
pressure lowering) indication such as ischemic heart
disease, post myocardial infarction, congestive heart
failure or chronic kidney disease with proteinuria.
2007 Canadian Hypertension Education Program Recommendations
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Drug Combinations cont’d
• Caution should be exercised in combining a non
dihydropyridine CCB and a beta blocker to reduce the
risk of bradycardia or heart block.
• Monitor creatinine and potassium when combining K
sparing diuretics, ACE inhibitors and/or angiotensin
receptor blockers.
• If a diuretic is not used as first or second line therapy,
triple dose therapy should include a diuretic, when not
contraindicated.
2007 Canadian Hypertension Education Program Recommendations
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Most HTN Pts need more than 1 drug
(data from ALLHAT)
2007 Canadian Hypertension Education Program Recommendations
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Most HTN Pts need more than 1 drug
Number of drugs
5
4
3
2
1
0
2007 Canadian Hypertension Education Program Recommendations
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BP Effects from antihypertensive therapy
Law. BMJ 2003 (SR of 354 RCTs)
• Dose response curves for efficacy
are relatively flat
• 80% of the BP lowering efficacy is
achieved at half-standard dose
• Combinations of high standard dose
have additive blood pressure
lowering effects
2007 Canadian Hypertension Education Program Recommendations
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V. Summary: Treatment of Systolic-Diastolic
Hypertension without Other Compelling Indications
TARGET <140/90 mmHg
Lifestyle modification
therapy
Thiazide
diuretic
CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or
lifestyle?
• White coat effect?
ACE-I
ARB
Long-acting
CCB
Dual Combination
Triple or Quadruple
Therapy
2007 Canadian Hypertension Education Program Recommendations
Betablocker*
* Not indicated as first
line therapy over 60
ACEI and ARB are
contraindicated in
pregnancy and caution is
required in prescribing to
women of child bearing
potential
43
V.
Treatment Algorithm for Isolated Systolic
Hypertension without Other Compelling
Indications
TARGET <140 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy
Thiazide
diuretic
ARB
Long-acting
DHP CCB
2007 Canadian Hypertension Education Program Recommendations
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V. Add-on therapy for Isolated Systolic Hypertension
without Other Compelling Indications
If partial response to monotherapy
Dual combination
Combine first line agents
Thiazide
diuretic
ARB
Long-acting
DHP CCB
CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or
lifestyle?
• White coat effect?
Triple therapy
If blood pressure is still not controlled, or there are adverse effects,
other classes of antihypertensive drugs may be combined (such as
ACE inhibitors, alpha adrenergic blockers, centrally acting agents,
or nondihydropyridine calcium channel blocker).
2007 Canadian Hypertension Education Program Recommendations
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V. Summary: Treatment of Isolated Systolic
Hypertension without Other Compelling Indications
TARGET <140 mmHg
Lifestyle modification
therapy
Thiazide
diuretic
ARB
CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or
lifestyle?
• White coat effect?
Dual therapy
Triple therapy
Long-acting
DHP CCB
*If blood pressure is still not
controlled, or there are
adverse effects, other
classes of antihypertensive
drugs may be combined
(such as ACE inhibitors,
alpha blockers, centrally
acting agents, or
nondihydropyridine calcium
channel blocker).
2007 Canadian Hypertension Education Program Recommendations
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V. Choice of Pharmacological Treatment
1. Treatment of systolic-diastolic hypertension
without other compelling indications
2. Treatment of isolated systolic hypertension without
other compelling indications
2007 Canadian Hypertension Education Program Recommendations
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Choice of Pharmacological Treatment
for Hypertension
Individualized treatment
• Compelling indications:
•
•
•
•
•
•
•
•
Ischemic Heart Disease
Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI
Left Ventricular Systolic Dysfunction
Cerebrovascular Disease
Left Ventricular Hypertrophy
Non Diabetic Chronic Kidney Disease
Renovascular Disease
Smoking
• Diabetes Mellitus
• With Diabetic Nephropathy
• Without Diabetic Nephropathy
• Global Vascular Protection for Hypertensive Patients
• Statins if 3 or more additional cardiovascular risks
• Aspirin once blood pressure is controlled
2007 Canadian Hypertension Education Program Recommendations
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VI. Treatment of Hypertension in Patients
with Ischemic Heart Disease
Stable angina
1. Beta-blocker
2. Long-acting CCB
ACE-I are recommended for most
patients with established CAD*
• Caution should be exercised when combining a non DHP-CCB and a beta-blocker
• If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or
Diltiazem)
Those at low risk with well controlled risk factors may not benefit from ACEI therapy
Short-acting
nifedipine
2007 Canadian Hypertension Education Program Recommendations
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VI. Treatment of Hypertension in Patients with
Recent ST Segment Elevation-MI or non-ST Segment
Elevation-MI
Recent
myocardial
infarction
An ARB can be
used if the patient
is intolerant to
ACE-I
Beta-blocker
and ACE-I
If beta-blocker
contraindicated or
not effective
Heart
Failure
?
YES
Long-acting
DHP CCB
(Amlodipine,
Felodipine)
NO
Long-acting CCB
2007 Canadian Hypertension Education Program Recommendations
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VII. Treatment of Hypertension with
Left Ventricular Systolic Dysfunction
Systolic
cardiac
dysfunction
• ACE-I
• if ACE-I intolerant: ARB
and Beta-Blocker
If additional therapy is needed:
• Diuretic*
• for CHF class III-IV: Aldosterone Antagonist
If ACE-I and ARB are contraindicated: Hydralazine and
Isosorbide dinitrate in combination
If additional antihypertensive therapy is needed:
Non
dihydropyridine
CCB
• ACE-I / ARB Combination
• Long-acting DHP-CCB (Amlodipine or Felodipine)
Beta-blockers used in clinical trials were bisoprolol, carvedilol and metoprolol. Physicians who are not yet
experienced in the use of beta-blockers should consider initiation of treatment in conjunction with a physician
experienced in heart failure management particularly for NYHA Class III-IV patients
2007 Canadian Hypertension Education Program Recommendations
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VIII. Treatment of Hypertension
for Patients with Cerebrovascular Disease
Strongly consider blood pressure
reduction in all patients after the acute
phase of non disabling stroke or TIA .
Stroke
TIA
An ACE-I / diuretic
combination is preferred
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IX. Treatment of Hypertension in Patients with Left
Ventricular Hypertrophy
Hypertensive patients with left ventricular hypertrophy should be
treated with antihypertensive therapy to lower the rate of subsequent
cardiovascular events.
Left ventricular
hypertrophy
- ACE-I
- ARB,
- CCB
- Thiazide Diuretic
- BB (if age below 60)*
Vasodilators:
Hydralazine, Minoxidil can increase LVH
2007 Canadian Hypertension Education Program Recommendations
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X. Treatment of Hypertension in Patients with Non
Diabetic Chronic Kidney Disease
Target BP: Nondiabetic: < 130/80 mmHg
Chronic kidney
disease and
proteinuria *
1. ACE-I
2. Alternate if ACE-I not tolerated: ARB
Additive therapy: Thiazide diuretic.
Alternate: If volume overload: loop diuretic
Combination with other agents
* albumin:creatinine ratio [ACR] > 30 mg/mmol
or urinary protein > 500 mg/24hr
ACE-I/ARB:
Bilateral renal
artery stenosis
Monitor potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
2007 Canadian Hypertension Education Program Recommendations
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XI. Treatment of Hypertension in Patients with
Renovascular Disease
Renovascular
disease
Does not imply specific
treatment choice
Caution in the use of ACE-I/ARB in bilateral
renal artery stenosis or unilateral disease
with solitary kidney
Close follow-up and early intervention (angioplasty and stenting or surgery)
should be considered for patients with: uncontrolled hypertension despite
therapy with three or more drugs, or deteriorating renal function, or bilateral
atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a single
kidney), or recurrent episodes of flash pulmonary edema.
2007 Canadian Hypertension Education Program Recommendations
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XII.
Treatment of
Hypertension
in association
with Diabetes
Mellitus
2007
XII. Treatment of Hypertension in association
with Diabetes Mellitus
Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg
with
Nephropathy*
*Urinary albumin to creatinine
ration > 2.0 mg/mmol in men
or > 2.8mg/mmol in women or
chronic kidney disease*
Diabetes
without
Nephropathy**
Systolicdiastolic
Hypertension
**Urinary albumin to
creatinine ratio <2.0 mg/mmol
in men or <2.8mg/mmol in
women
Isolated
Systolic
Hypertension
2007 Canadian Hypertension Education Program Recommendations
* based on at least 2 of 3 measurements
57
XII. Treatment of Hypertension in
association with Diabetic Nephropathy
THRESHOLD equal or over 130/80 mmHg and TARGET below 130/80 mmHg
DIABETES
with
Nephropathy
ACE Inhibitor
or ARB
Addition of one or more of
Thiazide diuretic or
Long-acting CCB
IF ACE-I and ARB are
contraindicated or not
tolerated,
SUBSTITUTE
• Long-acting CCB or
• Thiazide diuretic
3 - 4 drugs combination may
be needed
Monitor potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted
for a thiazide diuretic if control of volume is desired
2007 Canadian Hypertension Education Program Recommendations
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XII. Treatment of Systolic-Diastolic
Hypertension without Diabetic Nephropathy
Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg
1. ACE-Inhibitor or ARB or
Diabetes
without
Nephropathy
2. Thiazide diuretic or
Dihydropyridine CCB
IF ACE-I and ARB and DHPCCB or Thiazide are
contraindicated or not
tolerated,
SUBSTITUTE
• Cardioselective BB* or
• Long-acting NON DHP-CCB
Combination of first line
agents
Addition of one or more of:
Cardioselective BB or
Long-acting CCB
DHP: dihydropyridine
* Cardioselective BB: Acebutolol, Atenolol, Bisoprolol , Metoprolol
More than 3 drugs may be needed to reach target values for diabetic patients
2007 Canadian Hypertension Education Program Recommendations
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XII. Treatment of Hypertension in association with
Diabetes Mellitus: Summary
Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg
with
Nephropathy
ACE Inhibitor
or ARB
Diabetes
1. ACE-Inhibitor or
ARB
without
Nephropathy
or
2. Thiazide diuretic
or DHP-CCB
Combination
(Effective
2-drug combination)
Monitor potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
More than 3 drugs may be needed to reach target values for diabetic patients
If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic
should be substituted for a thiazide diuretic if control of volume is desired
2007 Canadian Hypertension Education Program Recommendations
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XIII. Treatment of Hypertension for Patients
Who Use Tobacco
Smoking
Beta-blocker
The benefits of treating smokers with beta-blockers
remain uncertain in the absence of a specific
indications like angina or post-MI
2007 Canadian Hypertension Education Program Recommendations
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XIV. Global
Vascular
Protection for
Patients with
Hypertension
2007
XIV. Vascular Protection for Hypertensive
Patients: Statins
In addition to current Canadian recommendations on
management of dyslipidemia, statins are recommended
in high-risk hypertensive patients with established
atherosclerotic disease or with at least 3 of the
following criteria:
•
•
•
•
•
Male
Age 55 or older
Smoking
Type 2 Diabetes
Total-C/HDL-C ratio of 6
mmol/L or higher
• Family History of Premature
CV disease
• LVH
• ECG abnormalities
• Microalbuminuria or
Proteinuria
ASCOT-LLA Lancet 2003;361:1149-58
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XIV. Vascular Protection for Hypertensive
Patients: ASA
Consider low dose ASA
Caution should be exercised if BP is not controlled.
2007 Canadian Hypertension Education Program Recommendations
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Adherence to anti-hypertensive management
can be improved by a multi-pronged approach
• Assess adherence to pharmacological and
non-pharmacological therapy at every
visit
• Teach patients to take their pills on a
regular schedule associated with a routine
daily activity e.g. brushing teeth.
• Simplify medication regimens using longacting once-daily dosing
• Utilize fixed-dose combination pills
• Utilize unit-of-use packaging e.g. blister
packaging
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Adherence to anti-hypertensive management
can be improved by a multi-pronged approach
• Encourage greater patient
responsibility/autonomy in regular
monitoring their blood pressure
• Educate patients and patients' families
about their disease/treatment regimens
verbally and in writing
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Public translation of CHEP recommendations
Download at www.hypertension.ca
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Educate patients and patients' families about their
disease/treatment regimens verbally and in writing
Useful patient information can be obtained in recent
publications from the Canadian Hypertension Society.
Available by order from CHS Secretariat Canadian Hypertension Society
Tel: 613-533-3299, Fax: 613-533-6927
E mail: [email protected] .
Coming soon to bookstores near you.
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Encourage greater patient responsibility/autonomy
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Summary I
Regarding the treatment of hypertension, the
recommendations endorse:
• ASSESSMENT OF BLOOD PRESSURE AT ALL
APPROPRIATE VISITS
• Most Canadians will develop hypertension during
their lives. Routine assessment of blood pressure
is required for early detection and risk
management
• ANNUAL FOLLOW-UP OF PATIENTS WITH HIGH
NORMAL BLOOD PRESSURE
• Most overweight patients with high normal blood
pressure (130-139/85-89 mmHg) will develop within
4 years and almost 1/2 within 2 years.
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Summary II
Regarding the treatment of hypertension, the
recommendations endorse:
• INDIVIDUALIZING THERAPY
• consider concomitant risk factors and/or concurrent
diseases, other patient characteristics and preferences
(e.g. age, diabetes, CVD) and other considerations e.g.
costs
• LIFESTYLE MODIFICATION
• To prevent hypertension
• In those with hypertension alone if effective to reach
the goal value or in combination with pharmacological
treatment
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Summary III
Regarding the treatment of hypertension, the
recommendations endorse:
• TREATING TO TARGET BP
• treat aggressively using combinations of drugs
and lifestyle modification to achieve individualized
target
• PROMOTING ADHERENCE
• a multi-faceted approach should be used to
improve adherence with both non
pharmacological and pharmacological strategies
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Key CHEP messages for the
management of hypertension
Assess blood pressure at all appropriate visits.
Almost one half of those with blood pressure 130139/85-89 will develop hypertension within 2
years. They require annual reassessment.
Assess global cardiovascular risk in all hypertensive
patients.
Lifestyle modification is the cornerstone for the
prevention and management of hypertension and
CVD.
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Key CHEP messages for the
management of hypertension
Treat to target (<140/90 mmHg; <130/80 mmHg in
patients with diabetes or chronic kidney disease).
To achieve targets sustained lifestyle modification
and more than one drug is usually required.
Follow patients with uncontrolled blood pressure at
least monthly until blood pressure targets are
achieved.
Strategies to improve patient adherence to lifestyle
modifications and antihypertensive therapy need to
be incorporated in every patients management
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