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2001 Canadian Hypertension Education Program Recommendations 1
Focus on the 2001 Canadian Recommendations for the
Management of Hypertension
Version: April 25, 2002
2001 Canadian Hypertension Education Program Recommendations 2
Recommendations for the Management and Treatment of
Hypertension
The Canadian Hypertension Education Program
April 25, 2002
2001 Canadian Hypertension Education Program Recommendations 3
2001 Canadian Recommendations for the Management of Hypertension
• Systematic review of the literature supplemented by personal files to Nov 2001
• Application of an evidence-based grading scheme• Use of a Central Review Committee comprised of methodologists to
improve consistency of grading• 1 day conference to discuss recommendations and evidence• National presentation• Voting with removal of recommendations that >30% disagree with
2001 Canadian Hypertension Education Program Recommendations 4
Office Measurement of BP: C Abbott (Chair), K Mann; Follow-up of BP: P Bolli; Risk Assessment: S GroverSelf-measurement of BP: D McKay (Chair), B Ens; Ambulatory BP Monitoring: M Myers, S Rabkin; Routine Laboratory Testing: T Wilson; Echocardiography: G Honos; Lifestyle Modification: E Burgess (Chair), R Petrella, R Touyz; Pharmacotherapy of Uncomplicated Hypertension: R Lewanczuk (Chair);
B Culleton, J Wright; sub group Hypertension in the Elderly: G. Fodor, P Hamet, R Herman
Pharmacotherapy for Hypertension in patients with Cardiovascular Disease:
F Leenen (Chair); S Rabkin, J Stone; Diabetes: J Mahon, P Larochelle, R Ogilvie, C Jones, S Tobe; Renal and Renovascular HTN: M Lebel (Chair), E Burgess, S Tobe; Endocrine forms of hypertension: E SchiffrinConcordance Strategies for Patients: RD Feldman (Chair), J Irvine
The Canadian Hypertension Recommendations Working Group:
Subgroups for the 2001 recommendations:
2001 Canadian Recommendations for the Management of Hypertension
2001 Canadian Hypertension Education Program Recommendations 5
2001 Canadian Recommendations for the Management of Hypertension
Working Group for slides development:
Dr. Norm Campbell, Dr. Denis Drouin,Dr. Ross Feldman,Dr. Alain Milot,Dr. Guy Tremblay.
2001 Canadian Hypertension Education Program Recommendations 6
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
2001 Canadian Hypertension Education Program Recommendations 7
11.7%
6.0% 5.8% 5.3%
3.9%
0%
2%
4%
6%
8%
10%
12%
14%
Malnutrition Tobacco Use Hypertension Poor WaterSupply
PhysicalInactivity
% of Global
Disability
Murray et al. 1996
Proportion of Deaths Attributable to Leading Risk Factors
World Health Organization Global Burden of Disease Study
2001 Canadian Hypertension Education Program Recommendations 8
BrainStroke, TIA,
hypertensive encephalopathy,
etc.
EyesRetinal hemorrhage, exudate, optical disc
edema, arteriolar constriction, etc.
Blood vesselsAneurysm, arterial occlusive disease,
etc.
HeartAngina, MI, CHF,
LVH, etc.
KidneyESRF, etc.
Hypertension and Target Organ Damage
2001 Canadian Hypertension Education Program Recommendations 9
BP and Risk of CAD Mortality
0
5
10
15
20
25
30
35
40
75-79 80-89 90-99 100+ <120 120-139 140-159 160+
Blood pressure (mm Hg)
Ris
k o
f C
AD
mo
rta
lity
pe
r 1
0,0
00
p
ers
on
-ye
ars
Diastolic Systolic
Multiple Risk Factor Intervention Trial (MRFIT); n=347,978 men. Neaton et al. Arch Intern Med 1992;152:56-64
2001 Canadian Hypertension Education Program Recommendations 10
BP and Risk of Stroke Mortality
0
2
4
6
8
10
<85 85-89 90-99 100+ <130 130-139 140-159 160+
Blood pressure (mm Hg)
Ris
k o
f s
tro
ke
mo
rta
lity
pe
r 1
0,0
00
pe
rso
n-y
ea
rs
Diastolic Systolic
Multiple Risk Factor Intervention Trial (MRFIT); n=347,978 men. Neaton et al. In: Laragh et al (eds). Hypertension: Pathophysiology, Diagnosis, and Management.2 ed. NY: Raven, 1995:127
2001 Canadian Hypertension Education Program Recommendations 11
PP=Pulse Pressure. Adapted from : Third National Health and Nutrition. Examination Survey, Hypertension 1995;25:305-13
30-39 40-49 50-59 60-69 70-79 80
70
80
110
130
150
Age
30-39 40-49 50-59 60-69 70-79 80
70
80
110
130
150
Age
Men Women
PPPP
Blood Pressure Distribution in the Population According to Age
2001 Canadian Hypertension Education Program Recommendations 12
Benefits of Treating Hypertension
• Younger than 60– reduces the risk of stroke by 42%– reduces the risk of coronary event by 14%
• Older than 60– reduces overall mortality by 20% – reduces cardiovascular mortality by 33%– reduces incidence of stroke by 40%– reduces coronary artery disease by 15%
2001 Canadian Hypertension Education Program Recommendations 13
Benefits of Treating to Target
• Older than 60 with isolated systolic hypertension(SBP 160 mm Hg and DBP <90 mm Hg)
– 36% reduction in the risk of stroke– 25% reduction in the risk of coronary events
2001 Canadian Hypertension Education Program Recommendations 14
Joffres et al. Am J Hyper 2001;14:1099 –1105
21%13%
43%22%
Hypertensive patients who are treated
but BP uncontrolled
Hypertensive patientswho are treated
and BP controlled
Hypertensive patients who are unaware
Patients who are awarebut remain untreatedand BP uncontrolled
22% of Canadians 18-70 years of age have hypertension50% of Canadians >65 years of age have hypertension
9%
Diabetic patientsWho are treated and
BP controlled
The Challenge In Canada
2001 Canadian Hypertension Education Program Recommendations 15
Results of a survey on awareness on hypertension (Canada)
67% of aware hypertensive patients believe that their BP was their own primary responsibility
HOWEVER two thirds of these patients stated that high BP was not a serious concern.
Thus the mandate to improve public awareness of the consequences of hypertension is clear.
R. Petrella MD, Perspective in Cardiology, March 2002.
2001 Canadian Hypertension Education Program Recommendations 16
A slide kit and clinical practice algorithms supporting the full recommendations can be downloaded from the CHS website at:
www.chs.md
2001 Canadian Recommendations for the Management of Hypertension
2001 Canadian Hypertension Education Program Recommendations 17
DIAGNOSIS
AND FOLLOW-UP
OF HYPERTENSION
2001 Canadian Recommendations for the Management of Hypertension
2001 Canadian Hypertension Education Program Recommendations 18
Classification of Hypertension According to WHO/ISH*
Category Systolic DiastolicOptimal <120 <80
Normal <130 <85
High-Normal 130-139 85-89
Grade 1 (mild hypertension ) 140-159 90-99
- Subgroup: borderline 140-149 90-94
Grade 2 (moderate hypertension) 160-179 100-109
Grade 3 (severe hypertension) 180 110
Isolated Systolic Hypertension (ISH) 140 <90
- Subgroup: borderline 140-149 <90
*ISH=International Society of Hypertension. Chalmers J et al. J Hypertens 1999;17:151-85.
2001 Canadian Hypertension Education Program Recommendations 19
Blood Pressure Assessment
• Patients should be assessed at all appropriate visits
– To determine cardiovascular risk– To monitor antihypertensive treatment
2001 Canadian Hypertension Education Program Recommendations 20
Recommended Technique for Measuring Blood Pressure
• Standardized technique:
– Have the patient rest for 5 minutes
– Use an appropriate cuff size
– Use a mercury manometer or a recently calibrated aneroid or electronic device
2001 Canadian Hypertension Education Program Recommendations 21
Recommended Technique for Measuring Blood Pressure (cont.)
– Position cuff appropriately
– Support arm with antecubital fossa at heart level
– Place stethoscope over the brachial artery
2001 Canadian Hypertension Education Program Recommendations 22
Recommended Technique for Measuring Blood Pressure (cont.)
– To exclude possibility of auscultatory gap, increase cuff pressure rapidly to 30 mmHg above level of disappearance of radial pulse
– Drop pressure by 2 mmHg / beat:• appearance of sound (phase I Korotkoff) = systolic
pressure• disappearance of sound (phase V Korotkoff) = diastolic
pressure
– Take 2 blood pressure measurements, 1 minute apart
2001 Canadian Hypertension Education Program Recommendations 23
Diagnosis of Hypertension: Summary
Visit 1
Visit 2
Visit 3
Visit 5
Blood pressuremeasurement
every year
- Hypertensive urgency?
- Target organ damage or BP >180/105? (Visit 3) Hypertension
diagnosisconfirmed
BP >threshold for initiation of
treatment
Yes
No Validated technique andBP measurement device
Visit 4
History-taking,physical examination
BP
140
/90
180
/10
5
2001 Canadian Hypertension Education Program Recommendations 24
Blood Pressure Threshold Values for Initiation of Pharmacological Treatment of Hypertension
Condition Initiation
SBP / DBP mmHg
Diastolic ± systolic hypertension 140/90
Isolated systolic hypertension 160
Diabetes 130/80
Renal disease 130/80
Proteinuria >1 g/day 125/75
2001 Canadian Hypertension Education Program Recommendations 25
Target Values for Blood Pressure
Condition Target
SBP / DBP mmHg
Diastolic ± systolic hypertension
Isolated systolic hypertension
<140/90
<140
Home BP measurement
(No diabetes, renal disease or proteinuria) <135/85
Diabetes <130/80
Renal disease <130/80
Proteinuria >1 g/day <125/75
2001 Canadian Hypertension Education Program Recommendations 26
Threshold for Initiation of Treatment and Target Values
Condition Initiation Target
SBP / DBP mmHg SBP / DBP mmHg
Diastolic ± systolic hypertension >140/90 <140/90
Isolated systolic hypertension SBP >160 <140
Home BP measurement (no diabetes, renal disease or proteinuria)
>135/85 <135/85
Diabetes >130/80 <130/80
Renal disease >130/80 <130/80
Proteinuria >1 g/day >125/75 <125/75
2001 Canadian Hypertension Education Program Recommendations 27
Routine and Optional Laboratory Tests
1. Urinalysis
2. Complete blood count
3. Blood chemistry (Potassium, Sodium and creatinine)
4. Fasting glucose
5. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides
6. Standard 12 leads ECG
Investigation of all patients with hypertension
New recommendations for investigation of endocrine and renal hypertension syndromes
2001 Canadian Hypertension Education Program Recommendations 28
Screening for Renovascular Hypertension
• Should be considered for patients with the following characteristics: – Patients who are candidates for angioplasty or
revascularization and who have• Uncontrolled hypertension despite therapy with 3 drugs• Or deteriorating renal function• Or recurrent episodes of flash pulmonary edema
Screening should include a post captopril renogram
2001 Canadian Hypertension Education Program Recommendations 29
Screening for Hyperaldosteronism
• Spontaneous hypokalemia
• Profound diuretic-induced hypokalemia (<3.0 mmol/L)
• Hypertension refractory to treatment with 3 or more drugs
• Incidental adrenal adenomas.
should be considered for patients with the following characteristics:
2001 Canadian Hypertension Education Program Recommendations 30
Screening for Hyperaldosteronism
• Screening for hyperaldosteronism should include a plasma aldosterone and plasma renin activity
measured in morning samples taken from patients in a sitting position after resting at least 15 minutes. Antihypertensive drugs with the exception of aldosterone antagonists may be continued prior to testing.
2001 Canadian Hypertension Education Program Recommendations 31
Screening for Pheochromocytoma
• Paroxysmal and/or severe sustained hypertension refractory to usual antihypertensive therapy;
• Hypertension and symptoms suggestive of catacholamine excess (two or more of headaches, palpitations, sweating, etc);
• Hypertension triggered by beta-blockers, monoamine oxidase inhibitors, micturition, or changes in abdominal pressure;
• Incidentally discovered adrenal adenoma;
• Multiple endocrine neoplasia (MEN) 2A or 2B; von Recklinghausen’s neurofibromatosis, or von Hippel-Lindau disease.
should be considered for patients with the following characteristics:
2001 Canadian Hypertension Education Program Recommendations 32
Screening for Pheochromocytoma
Screening for pheochromocytoma should include a 24 hour urine for metanephrines and creatinine
Assessment of urinary VMA is inadequate
2001 Canadian Hypertension Education Program Recommendations 33
WHO/ISH Recommendations forRisk Assessment
Stratification of risk to quantify prognosis
Grade 1 Grade 2 Grade 3
–Other Risk Factors & Disease History
–SBP 140-159 orDBP 90-99
(mild hypertension)
–SBP 160-179 or DBP 100-109
(moderate hypertension)
–SBP ≥ 180 or DBP ≥ 110
(severe hypertension)
I. No other risk factors
–Low risk Medium risk High risk
II. 1-2 risk factors Medium risk Medium risk V high risk
III. 3 risk factors or TOD or diabetes High risk High risk V high risk
IV. ACC V high risk V high risk V high risk
Risk strata (typical 10 year risk of stroke, myocardial infarction and cardiovascular mortality)
Chalmers J et al. J Hyper 1999;17:151-85.
2001 Canadian Hypertension Education Program Recommendations 34
Hypertension anddiabetes
Non adherence
Which patients?
Further assessusing
ambulatoryblood pressure
monitoring
Normal
Home BP?Office-induced blood
pressure elevation
BP >135/85 mm Hg should be considered elevated
Home (Self) Measurement of BP:Specific Role in Selected Patients
2001 Canadian Hypertension Education Program Recommendations 35
Home (Self) Measurement of BP:Patient Education
Values over135 / 85 mm Hg
should beconsidered elevated
How to?
Adequate patient training in:- measuring their BP- interpreting these readings
Regular verifications- accuracy of the device- measuring techniques
Use devices:- appropriate for the individual (cuff size)- have met the standards of the AAMI and/or the BHS
AAMI=Association for the Advancement of Medical Instrumentation; BHS=British Hypertension Society
Self measurement can help to improve patient adherence
2001 Canadian Hypertension Education Program Recommendations 36
Ambulatory BP Monitoring: Specific Role in Selected Patients*
Untreated- Mild (Grade 1) to moderate (Grade 2) clinic BP elevation and
without target organ damage
Treated patients- Apparent resistance to drug therapy
- Symptoms suggestive of hypotension
- Fluctuating office blood pressure readings
Which patients?Those with suspected office-induced BP elevation
* When available
2001 Canadian Hypertension Education Program Recommendations 37
Ambulatory BP Monitoring Specific Role in Selected Patients
How to interpret?
Mean daytime ambulatory blood pressure
>135/85 mm Hg
is considered elevated
Use validated devices
* A drop in nocturnal BP of <10% is associated with increased risk of CV events
How to ?
2001 Canadian Hypertension Education Program Recommendations 38
The Role of Echocardiography: Specific Role in Selected Patients
Presence of
Coronary artery disease
Routine Evaluation
Tracking of thetherapeutic regression
Assessment ofLeft ventricular
dysfunction
Most antihypertensives regress LVH over 6 months treatment period except arterial vasodilators (eg. Hydralazine)
2001 Canadian Hypertension Education Program Recommendations 39
Recommendations for Follow-up
Are BP readings below target during 2 consecutive visits*?
Non Pharmacological treatment
With or without Pharmacological treatment
Diagnosis of hypertension
Follow-up at 3-6 month intervals
Symptoms, Severe hypertension, Intolerance to anti-hypertensive treatment or Target Organ Damage
NoYes
NoYes
More frequentvisits
Monthly visits
2001 Canadian Hypertension Education Program Recommendations 40
LIFESTYLE MANAGEMENT
2001 Canadian Recommendations for the Management of Hypertension
2001 Canadian Hypertension Education Program Recommendations 41
Healthy diet; High in fresh fruits, vegetables and low fat dairy products, low in saturated fat, and salt in accordance with Canada's Guide to Healthy Eating
Regular physical activity: optimum 45-60 minutes of moderate cardiorespiratory activity 4-5/week
Reduction in alcohol consumption in those who drink excessively (<2 drinks/ day
Weight loss (> 5 Kg) in those who are over weight (BMI>25)
Smoke free environment
Lifestyle Recommendations for Hypertension
2001 Canadian Hypertension Education Program Recommendations 42
Dietary Potassium
Dietary Sodium
Magnesium supplementation
Calcium supplementation
Restrict to target range of 90-130 mmol/day (Limitation of salt additives and foods with
excessive added salt)
Daily dietary intake >60 mmol
Fresh fruits,
Vegetables,
Low fat dairy products,
Low fat diet,
in accordance with
Canada's Guide
to Healthy EatingNo conclusive studies for hypertension
No conclusive studies for hypertension
Lifestyle Recommendations for Hypertension: Dietary
2001 Canadian Hypertension Education Program Recommendations 43
Should be prescribed to reduce blood pressure
For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapy
Lifestyle Recommendations for Hypertension: Physical Activity
Type Dynamic exercise- Walking- Cycling- Non-competitive swimming
Time - 45-60 minutes
Intensity - Moderate
Frequency - Four or five times per weekF
I
T
T
2001 Canadian Hypertension Education Program Recommendations 44
Low risk alcohol consumption
• Women: <9 drinks/week
• Men: <14 drinks/week
• 0-2 drinks/day
Lifestyle Recommendations for Hypertension: Alcohol
2001 Canadian Hypertension Education Program Recommendations 45
Lifestyle Recommendations for Hypertension: Stress Management
Hypertensive patientsin whom stress appears to be an important issue
- Individualized - Cognitive
Stress management
Behaviour Modification
2001 Canadian Hypertension Education Program Recommendations 46
Hypertensive and all patients
BMI over 25
- Encourage weight reduction- Lose a minimum of 4.5 kg
For patients prescribed pharmacological therapy: weight loss has additional antihypertensive effects
Lifestyle Recommendations for Hypertension: Weight Loss
2001 Canadian Hypertension Education Program Recommendations 47
Impact of Lifestyle Therapies on BP in Hypertensive Adults
Intervention Targeted change SBP/DBP
Sodium reduction 100 mmol/day -5.8 / -2.5
Weight loss -4.5 kg -7.2 / -5.9
Alcohol reduction -2.7 drinks/day -4.6 / -2.3
Exercise 3 times/week -10.3 / -7.5
Dietary patterns DASH diet -11.4 / -5.5
Potassium increase 75 mmol/day -4.4 / -2.5
Result of aggregate and metaanalyses of short term trials. Miller ER et al. J Clin Hyper 1999:Nov/Dec:191-8.
2001 Canadian Hypertension Education Program Recommendations 48
PHARMACOLOGICAL
TREATMENT
2001 Canadian Recommendations for the Management of Hypertension
2001 Canadian Hypertension Education Program Recommendations 49
Indications for Pharmacotherapy
• Strongly consider prescription if:– Sustained DBP >90 mm Hg and:
• Target-organ damage or CVD• OR concomitant diseases such as diabetes mellitus• OR other cardiovascular risk factors
• if no other risk factors, prescribe if:DBP >100 mm Hg and/or SBP >160 mm Hg
2001 Canadian Hypertension Education Program Recommendations 50
Associated risk factors?or
Target organ damage/complications?or
Concomitant diseases/conditions?
Individualizedtreatment
Standardizedtreatment
YESNO
Choice of Treatment
2001 Canadian Hypertension Education Program Recommendations 51
Recommendations for Improving Adherence to Antihypertensive Prescription
• Adherence can be improved by a multi-pronged approach– Simplify medication regimens to once daily dosing– Tailor pill-taking to fit patients’ daily habits– Encourage greater patient responsibility/autonomy in
monitoring their BP and adjusting their prescriptions– Coordinate with worksite health care givers to improve
monitoring of adherence with pharmacological and lifestyle modification prescriptions
– Educate patients and patients’ families about their disease/treatment regimens
2001 Canadian Hypertension Education Program Recommendations 52
Suggestions: Improving Adherence to Antihypertensive Prescription
• Provide quality information on the consequences of hypertension and the benefits of lifestyle and drug therapy
• Ask about side effects and record any that occur • Tailor pill taking into a usual daily routine (same
time/place/situation)• Simplify drug and lifestyle regime• Ensure regime is affordable• Involve family and friends in lifestyle and medication adherence• Maintain regular BP follow-up• Consider Dosett® or other adherence aids• Consider self measurement of blood pressure• Record prescription refill dates on calendar and consider self
monitoring pill countsCampbell 2002
2001 Canadian Hypertension Education Program Recommendations 53
ACE-I Beta-blockers
Low-dosethiazides
CombinationCombine adjacent classes
Lifestyle modificationtherapy
Long-actingDHP-CCB
Alpha-blockeras initial
monotherapy
Triple or quadruple therapy
Treatment Algorithmfor Systolic-Diastolic Hypertension
TARGET <140/90 mmHg
CONSIDER
• Nonadherence?• Secondary HTN?• Interfering drugs or
lifestyle?• White coat effect?
2001 Canadian Hypertension Education Program Recommendations 54
Low-doseThiazide
Long-actingDHP CCB
CONSIDER
• Nonadherence?• Secondary HTN?• Interfering drugs or
lifestyle?• White coat effect?
CombinationEffective 2-drug combination(Add ACE-I or beta blocker)
Alpha-blockers and beta-blockers as
initial monotherapy
Combination
Triple or quadruple therapy
Treatment algorithmfor Isolated Systolic Hypertension
TARGET <140 mmHg
Lifestyle modificationtherapy
2001 Canadian Hypertension Education Program Recommendations 55
ACE-I * Beta-blockers **
Low-dosethiazides
CombinationCombine adjacent classes
Lifestyle modificationtherapy
Long-actingDHP-CCB
Alpha-blockeras initial
monotherapy
*Not recommended for ISH; **Not recommended for patients >60 years or ISH
Triple or quadruple therapy
Global Treatment Algorithmfor HypertensionTARGET <140/90 mm Hg
CONSIDER
• Nonadherence?• Secondary HTN?• Interfering drugs or
lifestyle?• White coat effect?
2001 Canadian Hypertension Education Program Recommendations 56
Rationale for Drug Combination Therapy
• Even higher proportion of hypertensive patients with diabetes require multi-drug therapy
• Low doses of multiple drugs may be more effective and better tolerated than higher doses of fewer drugs
Many patients require multiple drugs to achieve BP targets
33%
3 Drugs
50%
2 Drugs1 Drug
50%
2001 Canadian Hypertension Education Program Recommendations 57
Useful Combinations
Column 1 Column 2
• Low dose thiazide diuretics
• Long-acting dihydropyridine calcium channel blocker
• Beta-blocker
• ACE Inhibitor
For additive hypotensive effect in dual therapy combine an agent from
Column 1 with any in Column 2
2001 Canadian Hypertension Education Program Recommendations 58
Dyslipidemia
Treatment of uncomplicated hypertension,
hypertension associated with other conditions or
concomitant risk factors.
Treatment of Hypertension With Associated Risk Factors
2001 Canadian Hypertension Education Program Recommendations 59
Smoking Beta-blocker
The benefits of treatingsmokers with beta-blockers
remain uncertainin the absence
of a specific indicationlike angina or post-MI
Treatment of Hypertension With Associated Risk Factors
2001 Canadian Hypertension Education Program Recommendations 60
Diabetes
withNephropathy
withoutNephropathy
1. ACE Inhibitor2. ARB
ACE-Inhibitor
ACE-Inhibitor
Long-acting dihydropyridine
CCB
Low-dose thiazide
More than 3 drugs may be needed to reach target values for diabetic patients
Alpha-blockers
COMBINATION
Cardioselective BBLong-acting CCBLow-dose thiazide diuretic
Treatment of Hypertension with DiabetesTARGET <130/80 mmHg
Combination
Effective 2-drug combination
IsolatedSystolic
Hypertension
2001 Canadian Hypertension Education Program Recommendations 61
Ischemiccardiopathy
Stableangina
Priormyocardialinfarction
Normal systolicleft ventricular
function
1. Beta-blocker2. Long-acting CCB
CombinationBeta-blocker
and long-actingDihydropyridine CCB
ACE-I,Beta-blocker
or both
Verapamilor
Diltiazem
Alternate
Short-actingnifedipine
Treatment of Hypertension with Ischemic Heart Disease
ACE-I should be strongly considered in all patients with CAD
2001 Canadian Hypertension Education Program Recommendations 62
ACE-I/ARB(use with caution)
Peripheralvasculardisease
AtheroscleroticPVD
Renal artery stenosis
Raynaud’ssyndrome
Treatment of uncomplicated hypertension,hypertension associated with other
conditions or concomitant risk factors.
Beta-blocker
Vasodilators:Alpha-blockers, CCB,
ACE-I, ARB
May aggravatesymptoms
May induce renalinsufficiency
May havebeneficial effects
severe
mild
Beta-blocker
± ACE-I ?
Treatment of Hypertension with Peripheral Vascular Diseases
2001 Canadian Hypertension Education Program Recommendations 63
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
* Diuretics:
- Thiazides- Loop diuretics
Systoliccardiac
dysfunction
ACE-I+
Additional therapy, if abnormal water
retention: Diuretic*
If ACE-I are contraindicated or not tolerated:
Hydralazine and Isosorbide dinitrate in combination
Or ARB
AddBisoprolol, Carvedilol,
Metoprolol
Additionaltherapy
Amlodipine or
Felodipine
NYHA class II - IV
Non dihydropyridine
CCB or nifedipineAdd Spironolactone
Treatment of Hypertension with Systolic Dysfunction
NYHA class III - IV
2001 Canadian Hypertension Education Program Recommendations 64
Arrhythmiaand
conductionproblems
Atrial fibrillation andsupraventricular
tachycardia
Sinoatrial node dysfunction and atrioventricular
conduction problems
Beta-blockerVerapamilDiltiazem
Beta-blockerVerapamilDiltiazemClonidine
Methyldopa
May inhibitventricular response
* Caution is recommended when diuretics are used with class 1A, 1C or III antiarrythmic drugs
Caution if systolic dysfunction is
present
Treatment of Hypertension with Arrhythmia*
2001 Canadian Hypertension Education Program Recommendations 65
Left ventricularhypertrophy
Vasodilators:Hydralazine, Minoxidil
Mostantihypertensives
Can IncreaseLVH
Most antihypertensives regress LVH over 6 months treatment period except arterial vasodilators (eg. hydralazine)
Can reduce LVH over a 6 months treatment period
Treatment of Hypertension with Left Ventricular Hypertrophy
2001 Canadian Hypertension Education Program Recommendations 66
ACE-I
Additive therapy:Diuretic
Renaldisease
Combination with other agents
Nondiabetic: < 130/80
Proteinuria > 1 g/day: < 125/ 85Target BP
ACE-I: Bilateral renal artery
stenosis
Treatment of Hypertension with Nondiabetic Renal Disease
2001 Canadian Hypertension Education Program Recommendations 67
Treatment of Hypertension After the Acute Phase of Nondisabling Stroke or TIA
Stroke,TIA
Strongly consider blood pressure reduction after
the acute phase
An ACE-I should be strongly considered in all patients with stroke and TIA
2001 Canadian Hypertension Education Program Recommendations 68
Summary I
• Regarding the treatment of hypertension, the recommendations endorse: – Individualizing therapy
• consider concomitant risk factors and/or concurrent diseases (i.e., diabetes, CVD, renal disease)
– Treating to target BP • treat aggressively to achieve individualized targets
– Using nonpharmacological strategies• lifestyle modifications
2001 Canadian Hypertension Education Program Recommendations 69
Summary II
• Regarding the treatment of hypertension, the recommendations endorse: – Using combination therapy
• addition of medications in combination to achieve BP targets is preferred to maximal dose titration or serially switching drugs
– Promoting adherence• a multi-pronged approach should be used to improve
adherence with both non pharmacological and pharmacological strategies
2001 Canadian Hypertension Education Program Recommendations 70
Summary III
Regarding the treatment of hypertension, the recommendations endorse:
Hypertension is a major factor responsible for progression of atherosclerotic disease.
Therefore, a comprehensive treatment of hypertension should include all associated risk factors.