2011 Part 2 Recommendations for Hypertension Treatment

2011 Part 2: Recommendations for Hypertension Treatment

The full slide set of the 2011 CHEP Recommendations are available at www. hypertension. ca 2011 Canadian Hypertension Education Program Recommendations 2

2011 Canadian Hypertension Education Program (CHEP) • A red flag has been posted where recommendations were updated for 2011. • Slide kits for health care professional and public education can be downloaded (English and French versions) from http: //www. hypertension. ca 2011 Canadian Hypertension Education Program Recommendations 3

2011 Canadian Hypertension Education Program (CHEP) Treatment Approaches: • Lifestyle • Pharmacological 2011 Canadian Hypertension Education Program Recommendations 4

Key CHEP Messages for the Management of Hypertension 1. Assess blood pressure at all appropriate visits. 2. Promote a healthy lifestyle to lower blood pressure and reduce the risk of cardiovascular disease at each visit with interventions to reduce high dietary sodium, for smoking cessation, to reduce abdominal obesity, to promote a healthy weight, to increase physical activity and to manage dyslipidemia and dysglycemia. 3. Treat blood pressure to less than 140/90 mm. Hg in most people and to less than 130/80 mm. Hg in people with diabetes or chronic kidney disease using a combination of drugs and lifestyle modifications. 4. Advocate for healthy public policies to prevent hypertension and advance the health of patients and populations. 5. Keep up to date with resources for the prevention and control of hypertension by registering at www. htnupdate. ca and downloading and ordering tools at www. hypertension. ca/tools. 2011 Canadian Hypertension Education Program Recommendations 5

The Canadian Hypertension Education Program: 2011 Recommendations What’s new? • Increased emphasis on the use of single pill combinations (and more guidance on which combinations to use). • In stroke patients avoid excessive blood pressure reductions, except in the setting of the most severe elevations • The most important step in prescription of antihypertensive therapy is achieving patient “buy-in”: new tips for improving adherence 2011 Canadian Hypertension Education Program Recommendations 6

For your patients – ask them to sign up at www. my. BPsite. ca for free access to the latest Information & resources on high blood pressure For health care professionals – sign up at www. htnupdate. ca for automatic updates and on current hypertension educational resources. 2011 Canadian Hypertension Education Program Recommendations 7

The Canadian Hypertension Education Program: 2011 Recommendations What’s old but still important? • Out-of-office blood pressure measurements are important in both the diagnosis and management of hypertension • Lifestyle changes are still are critical component of hypertension management (and prevention!) • The management of hypertension is all about global risk management and vascular protection 2011 Canadian Hypertension Education Program Recommendations 8

Recommendations 2011 Table of contents I. III. IV. V. VIII. IX. X. XIII. XIV. Indications for drug therapy Goals of therapy Adherence Lifestyle Uncomplicated CV – IHD CHF Cerebrovascular / Stroke LVH Chronic kidney disease Renovascular Diabetes Smoking Overall risk reduction 2011 Canadian Hypertension Education Program Recommendations 9

2011 I. Indications for Pharmacotherapy

I. Indications for Pharmacotherapy Usual blood pressure threshold values for initiation of pharmacological treatment of hypertension Condition Initiation SBP or DBP mm. Hg • Systolic or Diastolic hypertension 140/90 • Diabetes • Chronic Kidney Disease 130/80 2011 Canadian Hypertension Education Program Recommendations 11

I. Indications for Pharmacotherapy after diagnosis of hypertension (1) • Patients at low risk with stage 1 hypertension (140 -159/90 -99 mm. Hg) • lifestyle modification can be the sole therapy. • Patients with target organ damage (e. g. left ventricular hypertrophy) (140 -159/90 -99 mm. Hg) • Treat with pharmacotherapy • Patients with diabetes or chronic kidney disease should be considered for pharmacotherapy if the blood pressure is equal or over 130/80 mm. Hg 2011 Canadian Hypertension Education Program Recommendations 12

I. Indications for Pharmacotherapy after diagnosis of hypertension (2) • Patients with other risk factors (over 90% of Canadians with hypertension have other risk factors) (140 -159/90 -99 mm. Hg despite lifestyle modification) • Treat with pharmacotherapy • Treatment Gap Alert: Many younger hypertensive Canadians with multiple cardiovascular risks are currently not treated with pharmacotherapy. Health care professionals need to be aware of this important care gap and recommend pharmacotherapy. 2011 Canadian Hypertension Education Program Recommendations 13

2011 II. Goals of Therapy

II. Goals of Therapy Blood pressure target values for treatment of hypertension Condition Target SBP and DBP mm. Hg Isolated systolic hypertension <140 Systolic/Diastolic Hypertension • Systolic BP • Diastolic BP <140 <90 Diabetes or Chronic Kidney Disease • Systolic • Diastolic <130 <80 2011 Canadian Hypertension Education Program Recommendations 15

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 2011 Canadian Hypertension Education Program Recommendations 16

Follow-up of blood pressure above targets • Patients with blood pressure above target are recommended to be followed at least every 2 nd month • Follow-up visits are used to increase the intensity of lifestyle and drug therapy, monitor the response to therapy and assess adherence 2011 Canadian Hypertension Education Program Recommendations 17

2011 III. Adherence

III. Adherence to anti-hypertensive management can be improved by a multipronged 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 Replacing multiple pill antihypertensive combinations with single pill combinations! 2011 Canadian Hypertension Education Program Recommendations 19

III. Adherence to anti-hypertensive management can be improved by a multipronged approach • Encourage greater patient responsibility/autonomy in regular monitoring of their blood pressure • Educate patients and patients' families about their disease/treatment regimens verbally and in writing • Use an interdisciplinary care approach coordinating with work-site health care givers and pharmacists if available 2011 Canadian Hypertension Education Program Recommendations 20

2011 IV. Lifestyle management

Lifestyle Recommendations for Prevention and Treatment of Hypertension To reduce the possibility of becoming hypertensive, Reduce sodium intake to less than 1500 mg/day Healthy diet: high in fresh fruits, 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. Regular physical activity: accumulation of 30 -60 minutes of moderate intensity dynamic exercise 4 -7 days per week in addition to daily activities Low risk alcohol consumption (≤ 2 standard drinks/day and less than 14/week for men and less than 9/week for women) Attaining and maintaining ideal body weight (BMI 18. 5 -24. 9 kg/m 2) Waist Circumference - Europid, Sub-Saharan African, Middle Eastern - South Asian, Chinese - Tobacco free environment Men Women <102 cm <90 cm 2011 Canadian Hypertension Education Program Recommendations <88 cm <80 cm 22

Lifestyle Recommendations for Hypertension: Dietary High in: • Fresh fruits • Fresh vegetables • Low fat dairy products • Dietary and soluble fibre • Plant protein Low in: • Saturated fat and cholesterol • Sodium Dietary Sodium Less than 2300 mg / day (Most of the salt in food is ‘hidden’ and comes from processed food) Dietary Potassium Daily dietary intake >80 mmol Calcium supplementation No conclusive studies for hypertension Magnesium supplementation No conclusive studies for hypertension www. hc-sc. gc. ca/fn-an/food-guide-aliment/index-eng. php 2011 Canadian Hypertension Education Program Recommendations 23

Potential Benefits of a Wide Spread Reduction in Dietary Sodium in Canada • • • REDUCTION IN AVERAGE DIETARY SODIUM FROM ABOUT 3500 MG TO 1700 MG 1 million fewer hypertensives 5 million fewer physicians visits a year for hypertension Health care cost savings of $430 to 540 million per year related to fewer office visits, drugs and laboratory costs for hypertension Improvement of the hypertension treatment and control rate 13% reduction in CVD Total health care cost savings of over $1. 3 billion/year Penz ED, Cdn J Cardiol 2008 Joffres MR_CJC_ 23(6) 2007. 2011 Canadian Hypertension Education Program Recommendations 24

Recommendations for daily salt intake Age Recommended Intake 19 -50 1500 51 -70 1300 71 and over 1200 2, 300 mg sodium (Na) = 100 mmol sodium (Na) = 5. 8 g of salt (Na. Cl) = 1 level teaspoon of table salt • 80% of average sodium intake is in processed foods • Only 10% is added at the table or in cooking Institute of Medicine, 2003 2011 Canadian Hypertension Education Program Recommendations 25

Sodium: Meta-analyses Average Reduction of sodium in mg/day 1800 mg/day 2300 mg/day Average Reduction of sodium in mg/day 1700 mg/day 2300 mg/day Hypertensives Reduction of BP 5. 1 / 2. 7 mm. Hg 7. 2/3. 8 mm. Hg Normotensives Reduction of BP 2. 0 / 1. 0 mm. Hg 3. 6/1. 7 mm. Hg The Cochrane Library 2006; 3: 1 -41 2011 Canadian Hypertension Education Program Recommendations 26

2011 Canadian Hypertension Education Program (CHEP) Important messages from past recommendations • High dietary sodium is estimated to increase blood pressure in the Canadian population to the extent that 1, 000 Canadians meet the diagnostic criteria for hypertension who would otherwise have ‘normal’ blood pressure • Most of the sodium in Canadian diets comes from processed foods and restaurants. • Pizza, breads, soups and sauces usually have high amounts of sodium • Patient information on how to achieve a reduced sodium diet can be found at www. hypertension. ca • Aim to reduce sodium intake to less than 1500 mg/day to prevent and control hypertension 2011 Canadian Hypertension Education Program Recommendations 27

Reduce Your Sodium Intake At home • Plan meals at least a day in advance. • Make more meals from unprocessed foods. • Gradually decrease the amount of salt used in cooking and at the table (this includes sea salt). • Use condiments sparingly. • Flavour food with lemon juice, fresh garlic, spices, herbs and flavoured vinegars. • Try low-sodium seasoning mixes. • Cook and bake with vegetable oil rather than butter or margarine. • Use tomato paste instead of tomato sauce or soup in recipes. 2011 Canadian Hypertension Education Program Recommendations 28

Reduce Your Sodium Intake At the grocery store • Buy pre-prepared, convenience foods that are low in sodium such as frozen vegetables, frozen shrimp, skinless & boneless chicken breasts and pre-cut salads and fruit. • Choose unsalted snack foods such as pretzels, nuts, seeds and crackers. • Read food labels and compare sodium content between similar foods • Look for foods labelled salt-free, no added salt, low in sodium, or reduced in sodium. • Always check the Nutrition Facts table 2011 Canadian Hypertension Education Program Recommendations 29

Reduce Your Sodium Intake When eating or “taking” out • Choose salads and meals made with foods low in sodium • Ask for no salt or MSG to be added during cooking • Ask for sauces, spreads or dressings on the side and use sparingly • Limit fast foods and take-out meals. 2011 Canadian Hypertension Education Program Recommendations 30

Lifestyle Recommendations for Hypertension: Physical Activity Should be prescribed to reduce blood pressure F Frequency I Intensity - Moderate T Time - 30 -60 minutes Type Cardiorespiratory Activity T - Four to seven days per week - Walking, jogging - Cycling - Non-competitive swimming Exercise should be prescribed as an adjunctive to pharmacological therapy 2011 Canadian Hypertension Education Program Recommendations 31

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/m 2 Waist Circumference - Europid, Sub-Saharan African, Middle Eastern - South Asian, Chinese, Japanese Men Women <94 cm <80 cm <90 cm <80 cm 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 behaviour modification CMAJ 2007; 176: 1103 -6 2011 Canadian Hypertension Education Program Recommendations 32

Waist Circumference Measurement Measure here Iliac crest Courtesy J. P. Després 2006 2011 Canadian Hypertension Education Program Recommendations 33

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 m. L or 12 oz of beer (5% alcohol) 43 m. L or 1. 5 oz of spirits (40% alcohol). 2011 Canadian Hypertension Education Program Recommendations 34

Lifestyle Recommendations for Hypertension: Stress Management Stress management Hypertensive patients in whom stress appears to be an important issue Behaviour Modification Individualized cognitive behavioural interventions are more likely to be effective when relaxation techniques are employed. 2011 Canadian Hypertension Education Program Recommendations 35

Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults Intervention SBP/DBP Reduce sodium intake -1800 mg/day sodium Hypertensive -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 -11. 4 / -5. 5 Weight loss Alcohol intake Padwal R. et al. CMAJ ･ SEPT. 27, 2005; 173 (7) 749 -751 2011 Canadian Hypertension Education Program Recommendations 36

Lifestyle Therapies in Hypertensive Adults: Summary Intervention Target Reduce foods with added sodium < 2300 mg /day Weight loss BMI <25 kg/m 2 Alcohol restriction < 2 drinks/day Physical activity Dietary patterns 30 -60 minutes 4 -7 days/week DASH diet Smoking cessation Smoke free environment Waist Circumference - Europid - South Asian, Chinese Men Women <94 cm <90 cm <80 cm 2011 Canadian Hypertension Education Program Recommendations 37

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 (mm. Hg) 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 2011 Canadian Hypertension Education Program Recommendations 38

2011 V. Pharmacotherapy

V. Choice of Pharmacological Treatment Uncomplicated Associated risk factors? or Target organ damage/complications? or Concomitant diseases/conditions? NO Treatment in the absence of compelling indications for specific therapies YES Individualized Treatment (and compelling indications) 2011 Canadian Hypertension Education Program Recommendations 40

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 2011 Canadian Hypertension Education Program Recommendations 41

V. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling Indications TARGET <140/90 mm. Hg INITIAL TREATMENT AND MONOTHERAPY Lifestyle modification therapy Thiazide ACEI ARB Longacting CCB Betablocker* A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mm. Hg systolic or >10 mm. Hg diastolic above target • BBs are not indicated as first line therapy for age 60 and above ACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential 2011 Canadian Hypertension Education Program Recommendations 42

V. Considerations Regarding the Choice of First-Line Therapy • Use caution in initiating therapy with 2 drugs in whom adverse events are more likely (e. g. frail elderly, those with postural hypotension or who are dehydrated). • ACE inhibitors, renin 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 and over without another compelling indication. • Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agents if required. • The use of dual therapy with an ACE inhibitor and an ARB should only be considered in selected and closely monitored people with advanced heart failure or proteinuric nephropathy. • ACE-inhibitors are not recommended (as monotherapy) for black patients without another compelling indication. 2011 Canadian Hypertension Education Program Recommendations 43

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 IF BLOOD PRESSURE IS NOT CONTROLLED CONSIDER • Nonadherence • Secondary HTN • Interfering drugs or lifestyle • White coat effect If blood pressure is still not controlled, or there adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers or centrally acting agents). 2011 Canadian Hypertension Education Program Recommendations 44

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 • Combinations of an ACEI with an ARB do not reduce cardiovascular events more than the ACEI alone and have more adverse effects therefore are not generally recommended 2011 Canadian Hypertension Education Program Recommendations 45

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 serum 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. 2011 Canadian Hypertension Education Program Recommendations 46

Medication Use and BP Control in ALLHAT <140/90 mm Hg Cushman et al. J Clin Hypertens 2002; 4: 393 -404. 2011 Canadian Hypertension Education Program Recommendations 47

Incremenal SBP reduction ratio Observed/Expected (additive) Ratio of Incremental SBP lowering effect at “standard dose”– Combine or Double? Wald et al, Combination Versus Monotherapy for Blood Pressure Reduction, The American Journal of Medicine, Vol 122, No 3, March 2009 2011 Canadian Hypertension Education Program Recommendations 48

BP lowering effects from antihypertensive drugs • Dose response curves for efficacy are relatively flat • 80% of the BP lowering efficacy is achieved at half-standard dose • Combinations of standard doses have additive blood pressure lowering effects Law. BMJ 2003 2011 Canadian Hypertension Education Program Recommendations 49

V. Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications TARGET <140/90 mm. Hg Lifestyle modification Initial therapy Thiazide diuretic CONSIDER • Nonadherence • Secondary HTN • Interfering drugs or lifestyle • White coat effect ACEI ARB Long-acting CCB A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mm. Hg systolic or >10 mm. Hg diastolic above target Betablocker* Dual Combination Triple or Quadruple Therapy 2011 Canadian Hypertension Education Program Recommendations *Not indicated as first line therapy over 60 y 50

V. Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications TARGET <140 mm. Hg INITIAL TREATMENT AND MONOTHERAPY Lifestyle modification therapy Thiazide diuretic ARB Long-acting DHP CCB 2011 Canadian Hypertension Education Program Recommendations 51

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 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). 2011 Canadian Hypertension Education Program Recommendations 52

V. Summary: Treatment of Isolated Systolic Hypertension without Other Compelling Indications TARGET <140 mm. Hg Lifestyle modification therapy Thiazide diuretic CONSIDER • Nonadherence • Secondary HTN • Interfering drugs or lifestyle • White coat effect ARB Dual therapy Triple therapy Long-acting DHP CCB *If blood pressure is still not controlled, or there adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker). 2011 Canadian Hypertension Education Program Recommendations 53

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 Nephropathy • Without Nephropathy • Global Vascular Protection for Hypertensive Patients • Statins if 3 or more additional cardiovascular risks • Aspirin once blood pressure is controlled 2011 Canadian Hypertension Education Program Recommendations 54

VI. Treatment of Hypertension in Patients with Ischemic Heart Disease Stable angina 1. Beta-blocker 2. Long-acting CCB ACEI are recommended for most patients with established CAD* ARBs are not inferior to ACEI in IHD • 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) • Dual therapy with an ACEI and an ARB are not recommended in the absence of refractory heart failure • The combination of an ACEi and CCB is preferred *Those at low risk with well controlled risk factors may not benefit from ACEI therapy 2011 Canadian Hypertension Education Program Recommendations Short-acting nifedipine 55

VI. Treatment of Hypertension in Patients with Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI Recent myocardial infarction Beta-blocker and ACEI or ARB If beta-blocker contraindicated or not effective Heart Failure ? YES Long-acting Dihydropyridine CCB* NO Long-acting CCB *Avoid non dihydropyridine CCBs (diltiazem, verapamil) 2011 Canadian Hypertension Education Program Recommendations 56

VII. Treatment of Hypertension with Left Ventricular Systolic Dysfunction Systolic cardiac dysfunction • ACEI and Beta blocker • if ACEI intolerant: ARB Titrate doses of ACEI or ARB to those used in clinical trials If additional therapy is needed: • Diuretic (Thiazide for hypertension; Loop for volume control) • for CHF class III-IV or post MI: Aldosterone Antagonist If ACEI and ARB are contraindicated: Hydralazine and Isosorbide dinitrate in combination If additional antihypertensive therapy is needed: Non dihydropyridine CCB • ACEI / ARB Combination • Long-acting DHP-CCB (Amlodipine) Beta-blockers used in clinical trials were bisoprolol, carvedilol and metoprolol. 2011 Canadian Hypertension Education Program Recommendations 57

VIII. TREATMENT OF HYPERTENSION IN ASSOCIATION WITH STROKE Acute Stroke: Onset to 72 hours Acute ischemic Stroke Treat extreme BP elevation (systolic > 220 mm. Hg, diastolic > 120 mm. Hg) by 15 -25% over the first 24 hour with gradual reduction after. • If eligible for thrombolytic therapy treat very high BP (>185/110 mm. Hg) Avoid excessive lowering of BP which can exacerbate ischemia 2011 Canadian Hypertension Education Program Recommendations 58

VIII. TREATMENT OF HYPERTENSION IN ASSOCIATION WITH STROKE After the acute Phase of Stroke or TIA Strongly consider blood pressure reduction in all patients after the acute phase of stroke or TIA. Stroke TIA Target BP < 140/90 mm. Hg An ACEI / diuretic combination is preferred Combinations of an ACEI with an ARB are not recommended 2011 Canadian Hypertension Education Program Recommendations 59

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 - ACEI - ARB, - CCB - Thiazide Diuretic - BB (if age below 60)* Vasodilators: Hydralazine, Minoxidil can increase LVH 2011 Canadian Hypertension Education Program Recommendations 60

X. Treatment of Hypertension in Patients with Non Diabetic Chronic Kidney Disease Target BP: < 130/80 mm. Hg Chronic kidney disease and proteinuria * ACEI or ARB (if ACEI tolerated) 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/24 hr ACEI/ARB: Bilateral renal artery stenosis Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB Combinations of a ACEI and a ARB are specifically not recommended in the absence of proteinuria 2011 Canadian Hypertension Education Program Recommendations 61

XI. Treatment of Hypertension in Patients with Renovascular Disease Renovascular disease Does not imply specific treatment choice Caution in the use of ACEI or ARB in bilateral renal artery stenosis or unilateral disease with solitary kidney Close follow-up and 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. 2011 Canadian Hypertension Education Program Recommendations 62

XII. Treatment of Hypertension in association with Diabetes Mellitus 2011

XII. Treatment of Hypertension in association with Diabetes Mellitus Threshold equal or over 130/80 mm. Hg and Target below 130/80 mm. Hg with Nephropathy* *Urinary albumin to creatinine ratio > 2. 0 mg/mmol in men or > 2. 8 mg/mmol in women* Diabetes without Nephropathy** Systolicdiastolic Hypertension Isolated Systolic Hypertension A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mm. Hg systolic or >10 mm. Hg diastolic above target Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria * based on at least 2 of 3 measurements 2011 Canadian Hypertension Education Program Recommendations 64

XII. Treatment of Hypertension in association with Diabetic Nephropathy THRESHOLD equal or over 130/80 mm. Hg and TARGET below 130/80 mm. Hg DIABETES ACE Inhibitor or ARB Addition of one or more of Long-acting CCB or Thiazide diuretic IF ACEI and ARB are contraindicated or not tolerated, SUBSTITUTE • Long-acting CCB or • Thiazide diuretic with Nephropathy 3 - 4 drugs combination may be needed 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 Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB 2011 Canadian Hypertension Education Program Recommendations 65

2011 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 mm. Hg 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. 2011 Canadian Hypertension Education Program Recommendations 66

XII. Treatment of Systolic-Diastolic Hypertension without Diabetic Nephropathy Threshold equal or over 130/80 mm. Hg and TARGET below 130/80 mm. Hg Diabetes without Nephropathy DHP: dihydropyridine 1. ACE Inhibitor or ARB or 2. Dihydropyridine CCB or Thiazide diuretic IF ACE Inhibitor and ARB and DHP-CCB and 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 Combinations of an ACE Inhibitor with an ARB are specifically not recommended in the absence of proteinuria * Cardioselective BB: Acebutolol, Atenolol, Bisoprolol , Metoprolol More than 3 drugs may be needed to reach target values for diabetic patients 2011 Canadian Hypertension Education Program Recommendations 67

ACCORD Study: Results and rational for lack of impact on BP recommendations • • • Overall BP study was neutral with no benefit of systolic target < 120 mm. Hg vs < 140 mm. Hg for primary outcome, yet: Power issue: Annual rate of primary outcome 1. 87% in the intensive arm versus 2. 09% in the standard arm vs 4%/year event rate projected during sample size calculations Significant interaction between BP and glycaemia control studies such that those in usual care glycaemia group (A 1 c 7%+) had a significant improvement in primary outcome with lower BP target Secondary outcome for stroke reduction showed a benefit for lower BP target Therefore no clear evidence supporting a change in BP targets for people with diabetes at this point ACCORD study NEJM 2010 2011 Canadian Hypertension Education Program Recommendations 68

XII. Treatment of Hypertension in association with Diabetes Mellitus: Summary Threshold equal or over 130/80 mm. Hg and TARGET below 130/80 mm. Hg with Nephropathy ACE Inhibitor or ARB Diabetes without Nephropathy 1. ACE Inhibitor or ARB A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mm. Hg systolic or >10 mm. Hg diastolic above target. Combining an ACEi and a DHP-CCB is recommended. or 2. DHP-CCB or Thiazide diuretic > 2 -drug combinations Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria 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 2011 Canadian Hypertension Education Program Recommendations 69

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 indication like angina or post-MI MRC Working Party. MRC trial of treatment of mild hypertension: 1985 Jul 13; 291(6488): 97 -104. 2011 Canadian Hypertension Education Program Recommendations 70

XIV. Overall Vascular Protection for Patients with Hypertension 2011

Most hypertensive Canadians have other cardiovascular risks • Assess and manage hypertensive patients for smoking, dyslipidemia and dysglycemia (impaired fasting glucose or diabetes) abdominal obesity, unhealthy eating and physical inactivity. • Discuss global risk using analogies that describe comparative risk such as “Cardiovascular Age”, “Vascular Age” or “Heart Age” to inform patients of their risk status and to improve the effectiveness of risk factor modification. 2011 Canadian Hypertension Education Program Recommendations 72

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 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 2011 Canadian Hypertension Education Program Recommendations 73

XIV. Vascular Protection for Hypertensive Patients: ASA Consider low dose ASA Caution should be exercised if BP is not controlled. 2011 Canadian Hypertension Education Program Recommendations 74

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. my. BPsite. ca • Have your patients sign up to access the latest hypertension resources www. sodium 101. 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 2011 Canadian Hypertension Education Program Recommendations 75

Public translation of CHEP recommendations • Hypertension recommendations for the public • Translated into 4 Indo-Asian languages (2007) • Based on CHEP guidelines (annually updated) Download at www. hypertension. ca/bpc 2011 Canadian Hypertension Education Program Recommendations 76

Sodium Slide Kit • Tool used to educate the public and patients on dietary sodium. • Annually updated. Download at www. hypertension. ca/bpc 2011 Canadian Hypertension Education Program Recommendations 77

Brief Hypertension Action Tool Can by used by a healthcare provider to better inform and engage a hypertensive patient to ultimately become more active in their care. Involves 3 Action Tools: Action Tool # 1 – Explains High BP Action Tool # 2 – Self-management of lifestyle Action Tool # 3 – Proper home measurement & information about medication 2011 Canadian Hypertension Education Program Recommendations Download at www. hypertension. ca/bpc 78

Measuring Blood Pressure the Right Way – Poster • Posters (24’’ by 36’’) can be ordered from our website. • Brief highlights: 1. Preparing to taking your blood pressure 2. Using endorsed BP devices. 2011 Canadian Hypertension Education Program Recommendations Download at www. hypertension. ca/bpc 79

Summary I Regarding the treatment of hypertension, the recommendations endorse: • Know the current blood pressure of all your patients • Most Canadians will develop hypertension during their lives. Routine assessment of blood pressure is required for early detection and risk management • Encourage the use of approved devices and proper technique to measure blood pressure at home. • Most can assess blood pressure at home. Home measurement can confirm a diagnosis of hypertension, improve adherence to therapy and control rates and detect patients with white coat or masked hypertension. 2011 Canadian Hypertension Education Program Recommendations 80

Summary II Regarding the treatment of hypertension, the recommendations endorse: • Assess and manage CV risk in hypertensives • high dietary sodium intake, smoking, dyslipidemia, dysglycemia, abdominal obesity, unhealthy eating, and physical inactivity. • LIFESTYLE MODIFICATION • Sustained lifestyle modification is the cornerstone for the prevention and control of hypertension and the management of cardiovascular disease. Encourage patients to reduce their sodium intake according to Health Canada’s recommendations. 2011 Canadian Hypertension Education Program Recommendations 81

Summary III Regarding the treatment of hypertension, the recommendations endorse: • • TREATING TO TARGET BP • Treat blood pressure to less than <140/90 mm. Hg. In people with diabetes or chronic kidney disease target to <130/80 mm. Hg and more than one drug is usually required including diuretics to achieve BP targets KEEP UP TO DATE • To keep up to date with the latest evidence and resources for the prevention and control of hypertension, go to: www. htnupdate. ca. Download current resources at: www. hypertension. ca/tools. Have your patients sign up at www. my. BPsite. ca to access the latest hypertension resources for patients. 2011 Canadian Hypertension Education Program Recommendations 82

For your patients – ask them to sign up at www. my. BPsite. ca for free access to the latest Information & resources on high blood pressure For health care professionals – sign up at www. htnupdate. ca for automatic updates and on current hypertension educational resources. 2011 Canadian Hypertension Education Program Recommendations 83