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ANANNUALUPDATE

THE2010CANADIAN HYPERTENSION

EDUCATION PROGRAM

RECOMMENDATIONS

Notice

The guidelines in this book are

presented as a convenient referencetool for health care professionals.Based on the 2010 CanadianHypertension Education Program(CHEP), which is now part of onenational hypertension organization Hypertension Canada. This presentationis designed as an abridged overviewbased on the more complete programrecommendat ions. For moreinformation, readers are invited tolog-on to www.hypertension.ca. Wehope this book proves a useful andpractical addition to your diagnosisand treatment of hypertension.Please be reminded, however, that alltherapeutic decisions are ultimatelythe responsibility of the attendingphysician.

Offered as a service to health careprofessionals by Bristol-Myers SquibbCanada Co. and Sanofi Canada

Partnership.This publication reflects the viewsand experience of the authors anddoes not necessarily represent theviews or opinions of Bristol-MyersSquibb and sanofi-aventis CanadaInc. Pharmaceutical productsmentioned within this publicationshould only be prescribed and usedin compliance with their respectiveproduct monographs.

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2010 Canadian HypertensionEducation ProgramRecommendations:

The Scientic Summary An Update of the 2010 Themeand the Science Behind New

CHEP Recommendations

Norman RC Campbell1 MD,Janusz Kaczorowski2 PhD,Richard Z. Lewanczuk3 MD PhD,Ross Feldman4,Luc Poirier5,Margaret Moy Lum Kwong6,Marcel Lebel7 MD,Finlay A. McAlister8 MD MSc,Sheldon W Tobe9 MD on behalfof the Canadian HypertensionEducation Program

From:1 Departments of Medicine, Community Health

Sciences, and Pharmacology and Therapeutics,University of Calgary, Calgary, AB

2 Department of Family Practice, University ofBritish Columbia, Vancouver, BC

3 Division of Endocrinology, University of Alberta,Edmonton, AB

4 Robarts Research Institute and Departments ofMedicine and of Physiology and Pharmacology,Schulich School of Medicine & Dentistry,University of Western Ontario, London, ON

5 Hypertension Unit and Pharmacy Department,Centre Hospitalier de lUniversit Laval, CHUQ,Qubec, QC

6 Heart and Stroke Foundation of Ontario7 CHUQ, Htel-Dieu de Qubec, Department of

Medicine, Universit Laval, Qubec, QC8 Division of General Internal Medicine, University

of Alberta, Edmonton, AB9 Division of Nephrology, University of Toronto,

Toronto, ON

TABlE OF CONTENTS

Scientific Summary ............................................................ 5

2010 Canadian Recommendations for the Management of

Hypertension:

Diagnosis & Assessment.......................................... 21

Therapy ...................................................................... 39

Therapy Tables .......................................................... 49

Evidence-Based Recommendations Task Force

2009 for the 2010 Recommendations.............................. 59

Corresponding Author:Dr NRC Campbe, Department of Medicine, Facuty of Medicinelibin Cardiovascuar Institute of Aberta, University of Cagary3330 Hospita Drive Northwest, Cagary, Aberta T2N 4N1FAX 403-2283-6151


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SCIENTIFICSUMMARY


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Summary

The 2010 Canadian Hypertension Education Program (CHEP)recommendations are the 11th annual update. The 2010 focusis to ensure Canadian health care professionals are updatedwith resources by signing up at www.htnupdate.ca. Innovativeinteractive internet based lectures are planned as well asprograms to train community leaders in hypertension. Peoplewith hypertension can sign up at www.myBPsite.ca to receiveregular hypertension updates. In 2010, there are newrecommendations regarding automated ofce blood pressuremeasurement, use of angiotensin receptor blockers as analternative to ACE inhibitors in people with ischemic heartdisease and new targets for dietary sodium.

AbstractThis is a summary of the theme, key recommendationsfor management of hypertension and the supportingclinical evidence of the 2010 Canadian HypertensionEducation Program (CHEP). In 2010, CHEP emphasizesthe need for health care professionals to stay informedabout hypertension through automated updates atwww.htnupdate.ca. A new interactive internet based lectureseries will be available in 2010 and a program to traincommunity hypertension leaders will be expanded. Patients

can also sign up to receive regular updates in a pilot programat www.myBPsite.ca. In 2010, the new recommendationsinclude: consideration of the use of automated ofce bloodpressure monitors; new targets for dietary sodium for theprevention and treatment of hypertension aligned with thenational adequate intake values; and recommendations forconsidering treatment of selected hypertensive patientsat high risk with calcium channel blockers/ACE inhibitorcombinations and the use of angiotensin receptor blockers.

Key Words

Hypertension, High Blood Pressure, Clinical PracticeGuidelines, Knowledge Translation.

2010 is the 11th year that the Canadian Hypertension EducationProgram (CHEP) has annually updated recommendationsfor the management of hypertension. CHEP recognizesthat health care professionals and patients have difcultyremaining up-to-date with hypertension prevention andmanagement recommendations and resources. A surveyby the Heart and Stroke Foundation (unpublished) found

that many health care professionals were unaware ofCHEP recommendations and were unable to name keyrecommendations required to optimally diagnose and

manage hypertension. Similarly, surveys have indicatedthat Canadians also have many misconceptions abouthypertension (1). Therefore, in 2010, CHEP will focus ondeveloping and enhancing mechanisms to assist health care

professionals and patients to stay up-to-date with the latestevidence and resources to prevent, diagnose and managehypertension.

Based on new evidence, there were important changesmade to the CHEP recommendations in 2010. Increasingevidence on the utility of automated ofce blood pressuremeasurement has led to a recommendation to consider itas an option for ofce blood pressure measurement (2-7).To prevent and control hypertension, dietary sodium targetshave been aligned with Health Canada adequate intake

recommendations for adults (8). Based on reconsiderationof data from ONTARGET and other recent clinical trials,there is a new CHEP recommendation to prescribe an ACEinhibitor or an angiotensin receptor blocker (ARB) in mostpeople with ischemic heart disease (9-11). However, thosewith ischemic heart disease assessed as being at low riskand having well controlled risk factors may not benet fromthis therapy. Further to the results of the ACCOMPLISHstudy (12), CHEP also recommends consideration of thepreferential use of a calcium channel blocker-ACE inhibitor

combination in selected high risk hypertensive patients whorequire combination therapy.

This is a short summary of the hypertension evidencethat supports the 2010 CHEP recommendations as wellas opinions from the CHEP executive on important issuesin hypertension management in Canada. The full CHEPrecommendations are available at www.hypertension.caand will be published in the May 2010 issue of the CanadianJournal of Cardiology.

Hypertension CanadaIn 2010, the Canadian Hypertension Society, CHEP andBlood Pressure Canada will merge to create HypertensionCanada, a single national hypertension organization.The development and dissemination of hypertensionrecommendations and resources will be continued underthe label of CHEP, in addition to the rigorous program fordeveloping and implementing the recommendations.


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How can I stay up-to-date with hypertensionrecommendations and resources?

The hypertension knowledge base continues to rapidlyevolve and a large number of educational resources arebeing developed and regularly updated to assist health careprofessionals and hypertensive Canadians (Table 1). To assisthealth care professionals to stay current, three new programsare being launched. The rst is a website, www.htnupdate.ca,where health care professionals and organizations canregister to be informed about new or updated resources. Thesecond program is an interactive web-based lecture serieson clinically important hypertension topics to facilitatelearning and interaction with top Canadian hypertensionexperts. This will be launched in 2010. Because its web-

based, health care professionals will be able to learn fromthe comfort of their own home or ofce and take advantage ofgroups already developed for continuing education activities.Also in 2010, CHEP will host 4-6 hour training sessions forhealth care professionals to facilitate their development asleaders for hypertension education in their communities.

How can my patients stay up-to-date with hypertensionrecommendations and resources?

Hypertensive Canadians face challenges in nding reliable

and current sources of hypertension information. CHEP andHypertension Canada have a large number of resources forCanadians that are regularly updated (Table 2). Currently,people with hypertension must perform regular searchesto stay up-to-date and may find unreliable or outdatedinformation. To address this concern, a new hypertensionassociation with a website at www.myBPsite.ca is beingdeveloped. Those who register will be regularly informedwhen new resources are developed or existing ones updated.In addition, an internet-based public lecture series is

planned for 2010.New evidence has aowed CHEP to address additionacinica questions in the management of hypertension forthe 2010 recommendations.

1. Shoud I use an automated bood pressure monitor inmy ofce to monitor bood pressure?

In 2010, CHEP recommends consideration of the routineofce use of automated monitors designed to take multiplereadings and used under proper conditions. Increasing

evidence suggests automated ofce readings are moreaccurate than routine manual office blood pressuremeasurement in predicting target organ damage and

ambulatory blood pressure readings. However, thetherapeutic thresholds for interpreting automatedreadings remain undetermined, and at present there areno studies that directly correlate automated ofce readings

to cardiovascular events. An automated ofce reading of135/85 mm Hg is approximately equivalent to an ambulatoryblood pressure reading of 135/85 mm Hg. Only one smallstudy in a selected population (attending an ambulatorymonitoring clinic) has correlated repeated automatedofce readings with repeated manual ofce readings (onwhich the current therapeutic thresholds are based) (2).In a representative group of Ontario adults, the automatedreadings were 3/3 mm Hg lower than manual readingsat a single visit (3). However, in a small selected group of

reghters, the difference between automated and manualofce readings disappeared over 3-5 visits (2). It is notablethat other studies report much larger differences betweenautomated ofce readings and manual ofce readings (4).Current research on which this recommendation is basedoften examined populations that are likely to have a highprevalence of white coat hypertension (i.e., patients referredfor ambulatory blood pressure monitoring), patients whosereadings were taken in a specialist ofce, and patients forwhom the ofce readings were taken on one occasion, orwhere measurements were not performed by a trainedtechnician using standardized techniques (4) (5;7). Allof these limitations would be expected to increase thedifference between automated and manual blood pressurereadings and limit the ability to dene the exact threshold fortreating hypertension based on automated ofce readings inan unselected population of patients in a primary health caresetting. Ongoing studies are addressing these outstandingissues in order to develop a new algorithm for diagnosinghypertension. Despite these limitations, for 2010 CHEPrecommends greater use of automated blood pressure

readings.

2. What shoud be the target for imiting dietary sodium?

CHEP recommends decreasing the target for maximaldietary sodium intake to be consistent with Health Canadasrecommended adequate dietary intake recommendations(Table 3) (8). There is increasing evidence that high dietarysodium intake is a health risk. In 2009, high dietary sodiumwas estimated to be the 7th leading risk factor for deathin the United States (13). Worldwide, in low-to-middle

income countries, reducing dietary sodium was estimatedto be more cost effective than reducing smoking (althoughboth are highly recommended) (14). Further, the benets


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of dietary sodium restriction in lowering blood pressurecontinue to be appreciated. In 2009, a small short termrandomized study of sodium reduction in patients withresistant hypertension reported a blood pressure decrease

of 22/9 mm Hg with a reduction in average sodium intakefrom 5,796 mg/day to 1,060 mg/day (15). Brief advice forpatients to encourage reductions in dietary sodium can befound in Table 4 and resources for health care professionalsand patients can be found in Tables 1 and 2.

3. Are ARBs and ACE-inhibitors equivaent?

Previous iterations of the CHEP recommendations have notedthe evidence supporting the equivalence of angiotensin receptorantagonists and angiotensin-converting enzyme inhibitors

in patients with hypertension with diabetes and in patientswith hypertension without other signicant co-morbidities.In 2010, CHEP reconsidered data from the ONTARGET (9),TRANSCEND (10) and PROFESS (11) trials. ONTARGETwas a large, randomized double-blinded trial in over25,000 patients designed to determine if telmisartanwas non-inferior to ramipril at full doses and whetherthe combination of telmisartan and ramipril was superiorto ramipril alone (9). People over age 55 years who hadevidence of vascular disease or diabetes with target organ

damage were randomized to either telmisartan, ramipril,or a combination of telmisartan and ramipril. There was nosignicant difference in the primary outcome (cardiovasculardeath, myocardial infarction, stroke or hospitalization forcongestive heart failure) between the 3 treatment groups.The combination therapy group had more adverse events,leading CHEP to specically recommend against the useof the combination therapy in people with uncomplicatedhypertension, ischemic heart disease without heart failure,past stroke, non-proteinuric chronic kidney disease ordiabetes without albuminuria.

PROFESS was a large randomized factorial trial of ARBbased blood pressure reducing therapy and antiplatelettherapy to prevent recurrent strokes (11). Patients with a priorischemic stroke who were aged 50 or older were randomizedto telmisartan (ARB) or placebo. The ARB therapy neitherreduced the primary endpoint of recurrent stroke (HR: 0.95(0.86-1.04, p=0.23)) nor the secondary outcome of majorcardiovascular events (stroke, MI, vascular death, worseningCHF), HR: 0.94 (0.87-1.01, p=0.11) despite a 3.8/2.0 mm Hglower blood pressure. In secondary analyses, a smalldifference in favor of telmisartan began to emerge after

the rst 6 months of therapy. Adverse events were slightlymore common with telmisartan treatment.

The TRANSCEND study comprised 5,926 people withcoronary disease, prior stroke or diabetes mellitus withend-organ damage and intolerance of ACE inhibitors, whowere randomized to telmisartan or placebo (10). While themean blood pressure difference was 3.2/1.3 mm Hg lowerat study end in the ARB group, the ARB therapy did notreduce the primary outcome (composite of cardiovasculardeath, myocardial infarction, stroke or hospitalization forheart failure). A secondary endpoint of cardiovasculardeath, myocardial infarction or stroke approached statisticalsignicance: HR: 0.87 (0.76-1.00, p=0.068). Adverse eventrates were similar in the two groups. The low event

rates, modest reduction in blood pressure and relativelylow entry blood pressures were believed to reduce thestatistical power of the trial to detect a benet of ARB in thePROFESS and TRANSCEND trials. In view of the effectiveequivalence of ramipril to telmisartan in ONTARGET wheretelmisartan was non-inferior to ramipril, and the wealthof studies demonstrating the benefits of ACE inhibitortherapy in patients with known vascular disease, CHEPhas recommended that most people with ischemic heartdisease should be treated with an ACE inhibitor or an ARB.

Thus, in patients with ischemic heart disease (as in thosewith diabetes or hypertension without other signicant co-morbidities), angiotensin receptor antagonists can be usedinterchangeably with ACE inhibitors. However, in patientswith hypertension and congestive heart failure, or followinga stroke, ACE inhibitors continue to be preferentiallyrecommended.

4. Many patients with hypertension need combinationtherapy. Are there preferred combinations?

Previous iterations of the CHEP recommendations have givenonly limited advice regarding optimal drug combinations dueto limited clinical trial data. There has been little additionalguidance beyond recommending 1) that 2-drug combinationsshould include the rst-line therapies (diuretics, CCBs,ACE inhibitors, ARBs and in younger patients beta-blockers)and 2) that ACE inhibitors, ARBs and beta-blockers shouldgenerally not be combined. The 2010 recommendationshave highlighted preferred combination therapy for highrisk patients based on the ACCOMPLISH study. In 2009,the ACCOMPLISH trial evaluated if benazepril (an ACEinhibitor)/amlodipine (a dihydropyridine CCB) was betterthan benazepril and a thiazide diuretic in hypertensive


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individuals aged 55 or older who were at high cardiovascularrisk due to risk factors or prior cardiovascular events (12).Although blood pressures were very similar in both groupsduring the trial, there was a 20% relative (2.1% absolute)

reduction in cardiovascular events and deaths (9.6% vs.11.8%, HR: 0.80 [0.72-0.90]) in those randomized to the ACEinhibitor/CCB group.

Based on the main ACCOMPLISH results, CHEP hasrecommended that the results from the combination ACEinhibitor/CCB group be considered when combination therapyis required in selected high risk hypertensive patients.Notably, this recommendation does not invalidate the useof an ARB/diuretic or ACE inhibitor/diuretic combinations.These formulations have been demonstrated to be useful

for attaining blood pressure control in a high proportionof patients and have been linked to improved adherencewith therapy (16-20). Importantly, CHEP still discouragesthe use of two drug antihypertensive combinations withan ACE inhibitor, ARB and beta-blockers unless there is acompelling indication such as heart failure, angina or post-myocardial infarction (21). These two drug combinationsmay not result in an additive hypotensive effect, and ACEinhibitor/ARB combinations do not improve outcomes butincrease adverse effects, as demonstrated in the ONTARGET

study (9;22).

Comments from the CHEP executive

CHEP will merge with the Canadian Hypertension Societyand Blood Pressure Canada in 2010 to form a singlenational hypertension organization, Hypertension Canada.While this transition will likely be unnoticed by health careprofessionals, over time the merger is expected to increaseefciency and effectiveness in the prevention and control ofhypertension in Canada. Canadian educational material for

health care professionals and patients will carry the CHEPlogo and name. For scientists, Hypertension Canada willdevelop a strategic plan that will sustain Canadas strengthin basic and outcomes research while enhancing Canadasresearch capacity, especially in community and clinicalresearch. It will ensure communication and collaborationbetween all four Canadian Institute for Health Researchpillars. Reducing dietary sodium will continue to be a priorityfor Hypertension Canada to both prevent hypertension andto improve hypertension control.

CHEP will develop new programs in 2010 to help health careprofessionals and hypertensive Canadians stay up-to-datewith the best evidence and resources to prevent and control

hypertension. A new website, www.htnupdate.ca, will providean opportunity for health care professionals to sign up toreceive electronic notices of all new CHEP hypertensionresources and updates. Those who sign up can immediately

download all current resources, or the resources can bedownloaded at www.hypertension.ca/tools. In addition, anew internet-based lecture series will be launched in 2010to allow health care professionals to interact with Canadianhypertension leaders and discuss important hypertensiontopics. Also train the trainer sessions have been developedand sessions will be held in venues across Canada to trainhealth care professionals interested in becoming communityeducators in hypertension.

Canada will host the biennial scientic sessions of the

International Society of Hypertension in Vancouver, BC,September 26-30, 2010. Interested scientists and cliniciansshould plan to attend this premier clinical and scienticmeeting.

The state of hypertension diagnosis, treatment and controlin Canada will be much clearer in 2010. Three majornational surveys will report Canadas performance inprevention and control of hypertension in 2010. A StatisticsCanada Public Health Agency of Canada (PHAC) surveywill report the national prevalence of hypertension and

the awareness, treatment and control rates in February2010. The survey is much anticipated as the latest nationalsurveys were performed from 1985-1992 and many studiessince have suggested that there are marked improvementsin hypertension management (23-27). Furthermore, adetailed Statistics Canada PHAC survey of Canadianswith hypertension will report in 2010. The survey examinesthe knowledge, attitudes and behaviours of hypertensiveCanadians and will allow tailored and likely more effectivepatient educational resources to be developed. Also in

2010, the rst federal-provincial hypertension survey will bepublished, using linked provincial administrative databases.The methods for these surveys were developed in part byCHEP and allow ongoing examination of the incidenceand prevalence of diagnosed hypertension in people withand without diabetes as well as linkages to total mortalityrate. CHEP is developing methodology to add assessmentof antihypertensive treatment and specic complicationsand causes of death to this survey. These surveys assessthe national impact of programs to prevent and control

hypertension and allow CHEP to tailor educationalinterventions to the objective needs of Canadians.


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The CHEP executive would like to thank the over 100 healthcare professional volunteers, who are working with CHEP toprevent and control hypertension. The collaborative approachbetween volunteers from clinical practice, academia

and government with the support of the primary careprofessional associations, the pharmaceutical health careindustry, governments, charities and scientic organizations has been associated with marked improvements in themanagement and outcomes of hypertensive Canadians.

Reference list

(1) Petrella RJ, Campbell NRC. Awareness and misconception of hypertensionin Canada: Results of a national sur vey. Can J Cardiol2005;21:589-93.

(2) Campbell NRC, Conradson HE, Kang J, Brant R, Anderson T. Automatedassessment of blood pressure using BpTRU compared to assessments by atrained technician and a clinic nurse. Blood Press Monit2005;10:257-62.

(3) Myers MG, McInnis NH, Fodor GJ, Leenen FH. Comparison between anautomated and manual sphygmomanometer in a population survey.Am J Hypertens2008;21:280-283.

(4) Myers MG. Automated blood pressure measurement in routine clinicalpractice. Blood Press Monit2006;11:59-62.

(5) Myers MG, Godwin M. Automated Measurement of Blood Pressure inRoutine Clinical Practice. J Clin Hypertens2007;9:267-70.

(6) Campbell NRC, McKay DW, Conradson HE, Lonn E, Title LM, Anderson T.Automated oscillometric blood pressure versus auscultatory bloodpressure as a predictor of carotid-intima medial thickness in malereghters. J Hum Hypertens2007;21:588-90.

(7) Beckett L, Godwin M. The BpTRU automatic blood pressure monitorcompared to 24 hour ambulatory blood pressur e monitoring in theassessment of blood pressure in patients with hyp ertension. BMC

Cardiovascular Disorders2005;5:18-23.(8) Panel on Dietary Reference Intakes for Electrolytes and Water andStanding Committee on the Scientic Evaluation of Dietary ReferenceIntakes. Dietary Reference Intakes for Water, Potassium, Sodium, Chlorideand Sulfate. 1-640. 2004 . Washington, D.C., National Academies Press.Ref Type: Report.

(9) Yusuf S, Teo KK, Pogue J, Dyal L, Copland I, Schumacher H et al.Telmisartan, ramipril, or both in patients at high risk for vascular events.N Engl J Med2008;358:1547-59.

(10) Yusuf S, Teo KK, Anderson C, Pogue J, Dy al L, Copland I et al. Effects ofthe angiotensin-receptor blocker telmisartan on cardiovasc ular events inhigh-risk patients intolerant to angiotensin-converting enzyme inhibitors:a randomised controlled trial. Lancet2008;372:1174-83.

(11) Yusuf S, Diener HC, Sacco RL, Cotton D, Ounpuu S, Lawton WA et al.Telmisartan to Prevent Recurrent Stroke and Cardiovascular Events.

N Engl J Med2008;359:1225-37.(12) Jamerson K, Weber MA, B akris GL, Dahlof B, Pitt B, Shi V et al. Benazepril

plus Amlodipine or Hydrochlorothiazide for Hypertension in High-RiskPatients. N Engl J Med2008;359:2417-28.

(13) Danaei G, Ding EL, Mozaffarian D, Taylor B, Rehm J, Murray CJ et al.The preventable causes of death in the United States: comparative riskassessment of dietary, lifestyle, and metabolic risk factors.PLoS Med2009;6:e1000058.

(14) Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic diseaseprevention: health effects and nancial costs of strategies to reduce saltintake and control tobacco use. Lancet2007;370:2044-53.

(15) Appel LJ. A nother major role for dietary sodium reduction: improving bloodpressure control in patients with resistant hypertension. Hypertension2009;54:444-46.

(16) Lachaine J, Petrella RJ, Merikle E, Ali F. Choices, persistence andadherence to antihypertensive agents: evidence from RAMQ data.Can J Cardiol2008;24:269-73.

(17) C aro JJ, Salas M, Speckman JL, Raggio G, Jackson JD.Persistence with treatment for hypertension in actual practice.CMAJ1999;160:31-37.

(18) Bourgault C, Senecal M, Brisson M, Marentette MA, Gregoire J -P.Persistence and discontinuation patterns of antihypertensive therapyamong newly treated patients: a population-based study. J Hum Hypertens

2005;19:607-13.(19) Costanzo P, Perrone-Filardi P, Petretta M, Marciano C, Vass allo E,

Gargiulo P et al. Calcium channel blockers and cardiovascular outcomes:a meta-analysis of 175,634 patients. J Hypertens2009;27:1136-51.

(20) Gupta AK, Ar shad S, Poulter NR. Compliance, Safety, and Effectiveness ofFixed-Dose Combinations of Antihypertensive Agents. A Meta-Analysis.Hypertension2010;55:399-407.

(21) Khan NA, H emmelgarn B, Herman RJ, Bell CM, Mahon JL, Leiter LA et al.The 2009 Canadian Hyper tension Education Program recommendationsfor the management of hypertension: Part 2 therapy. Can J Cardiol2009;25:287-98.

(22) Mann JF, Schmieder RE, McQueen M, Dyal L, Schumacher H, Pogue J etal. Renal outcomes with telmisartan, ramipril, or both, in people at highvascular risk (the ONTARGE T study): a multicentre, randomised, double-

blind, controlled trial. Lancet2008;372:547-53.(23) Godwin M, Pike A, Kirby A, Jewer C, Murphy L. Prehyper tension andhypertension in a primary care practice. Can Fam Physician2008;54:1418-23.

(24) Leenen FH, Dumais J, McInnis NH, Turton P, Stratychuk L, Nemeth K et al.Results of the Ontario survey on the prevalence and control of hypertension.CMAJ2008;178:1441-49.

(25) Campbell NR, Brant R, Johansen H, Walker RL, Wielgosz A, Ony sko J et al.Increases in antihypertensive prescriptions and reductions incardiovascular events in Canada. Hypertension2009;53:128-34.

(26) Hemmelgarn BR, Chen G, Walker R, McAlister FA, Quan H, Tu K et al.Trends in antihypertensive drug prescriptions and physician visits inCanada between 1996 and 2006. Can J Cardiol2008;24:507-12.

(27) Onysko J, Maxwell C, Eliasziw M, Zhang J, Johansen H, Campbell N.Large Increases in Hypertension Diagnosis and Treatment in CanadaFollowing a Health Care Professional Education Program. Hypertension

2006;48:853-60.

TABlE 1: Heath Care Professiona Resources*

Documents

1) CHEP primary care booklet. Brief outline ofhypertension management recommendations in apocket booklet form.

2) Key messages. The major 6 actions required byhealth care professionals to prevent and controlcardiovascular disease in people with hypertension.

3) One page summary. A one page summaryof the CHEP theme, key messages and newrecommendations.

4) Short clinical summary. A brief narrative clinicalsummary of the current CHEP recommendationswith an emphasis on what is new and what isimportant. Tables summarize key aspects ofhypertension care.

* With permission of the Canadian Hypertension Education Program

Health care professional resources can be downloaded from www.hypertension.ca/toolsand www.lowersodium.ca and people who sign up at w ww.htnupdate.ca will beautomatically notied when resources are updated or newly developed.


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5) Short scientic summary. A brief narrativesummary of what is new and what is importantwith an emphasis on the scientic basis for therecommendations. Tables summarize key aspects of

hypertension care.6) CHEP specialist booklet. Contains the short

scientic summary and the exact CHEPrecommendations in a pocket booklet format.

7) Full scientic manuscripts. Detailed manuscriptsthat indicate the exact CHEP scienticrecommendations for the management ofhypertension with their scientic rationale.There are separate diagnostic and therapeuticmanuscripts.

Powerpoint Side Sets

1) Public Education slide set. A slide set that isintended to be used to develop a general talk onhypertension to a public and/or patient audience.

2) Background slide set. A slide set that containsinformation on the health risks of hypertension andkey therapeutic interventions.

3) Methodology slide set. A slide set that outlines themethods CHEP uses to develop its recommendations

as well as the key messages and theme for 2010.4) Diagnostic slide set. A slide set that outlines the

diagnostic recommendations of CHEP as well as thekey messages and theme for 2010.

5) Treatment slide set. A slide set that outlines thetreatment recommendations of CHEP as well as thekey messages and theme for 2010.

6) Blood Pressure Measurement slide set. A slide setthat outlines the measurement recommendationsfor blood pressure and includes advice on ofce,home and ambulatory blood pressure.

7) Outcomes slide set. A slide set that outlines thevarious surveillance methods used by CHEP as wellas key outcomes associated with CHEP. Ongoinghypertension management gaps are featured.

8) Hypertension Resources slide set. A new slide setthat outlines what Canadian hypertension resourcesare available.

Website Resources

1) ww w.hypertension.ca/tools: to download currentresources for health care professionals and patients.

2) ww w.htnupdate.ca: to sign up to be regularlyupdated on new and updated resources for healthcare professionals and patients and educationalopportunities for health care professionals.

3) ww w.lowersodium.ca: for educational resources forhealth care professionals and patients on dietarysodium.

Dietary Sodium Resources

1) A short scientic summary of the importance ofreducing dietary sodium with advice on how toreduce dietary sodium.

2) A scientic summary of the evidence for loweringdietary sodium.

3) Key messages on the importance of lowering dietarysodium with brief intervention advice.

Dietary Sodium Powerpoint Side Sets

1) Scientic and Clinical slide set. A slide set intendedto be used to develop a talk for a clinical or scienticaudience.

2) Public slide set. A slide set that is intended to beused to develop a talk on dietary sodium to a publicand patient audience on hypertension.

3) Sodium Quiz.

TABlE 2: Resources for Canadians Who HaveHypertension

Documents, powerpoint sides and DVDs

1) Brief public hypertension recommendations.

A single page brochure that summarizeshypertension and its management to people whohave hypertension or are at risk. The summary isbased on the 2010 CHEP health care professionalmanagement recommendations.

2) Public hypertension recommendations. A 4-pagesummary of hypertension and its management topeople who have hypertension or are at risk. Thesummary is based on the 2010 CHEP health careprofessional management recommendations. The

2007 recommendations are available in 4 Indo-Asianlanguages and cultural translations.


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3) Hypertension in diabetes. A 4-page summary ofhypertension and its management for people whohave hypertension and diabetes. The summary isbased on the 2010 CHEP health care professional

management recommendations.4) How to measure your blood pressure at home. A

one-page summary of how to purchase and use ahome measurement device.

5) Home measurement of blood pressure. A moredetailed 4-page summary of how to purchase anduse a home measurement device.

6) Measuring blood pressure the right way. A posterand small card that outlines pictorially the key stepsto measuring blood pressure properly at home.

7) Home measurement DVD. A DVD that has a shortand longer summary of how to measure your bloodpressure at home as well as how to purchase anduse home measurement of blood pressure devices.

8) Public education DVD (Hypertension: The SilentKiller). A short and longer summary of hypertensionon DVD for the public or those with or at risk ofhaving hypertension.

9) Brief action tool. A set of 3 tools to be used by ahealth care professional educator to engage apatient more fully in his/her care. Action tool 1takes about 4 minutes to complete. It denes BP,why a patient needs to be concerned if he/she hashigh BP, and the risks of hypertension. Action tool 2takes 10 minutes and basically motivates a patientto think about changing his/her lifestyle. Actiontool 3 takes 7 minutes to complete. It talks abouthome measurement and recording of BP, as well asinformation on BP medication.

10) Public education hypertension slide set. A slideset that is intended to be used by a knowledgeablehealth care professional in developing apresentation on hypertension to the public or peoplewith hypertension.

Dietary Sodium

1) Public education dietary sodium slide set. A slideset that is intended to be used by a knowledgeablehealth care professional in developing apresentation on dietary sodium to the public or

people with hypertension.

2) Get the facts. A one page summary of theimportance of reducing dietary sodium and the keymechanisms to reduce dietary sodium.

3) Short summary. A very short summary of why

reducing dietary sodium is important and how toreduce dietary sodium.

4) Booklet. A more detailed summary of why it isimportant to reduce dietary sodium and how toreduce dietary sodium for the more interestedconsumer.

5) Brochure. Beyond the salt shaker Lower yoursodium intake and improve your health.

6) Quiz. A short series of questions and answers forpeople to use to test their sodium knowledge. It is ina powerpoint format for use in talks.

Websites

1) www.myBPsite.ca: To join a hypertensionassociation and be regularly updated onhypertension resources and materials that areavailable.

2) www.hypertension.ca/bpc: To download patientrelated resources.

3) www.hypertension.ca/chs: To examine the differenthome measurement devices that have passedinternational accuracy standards, are availablein Canada and been approved by the CanadianHypertension Society.

4) www.lowersodium.ca: Patient and health careprofessional information on dietary sodium.

5) www.sodium101.ca: Public information on dietarysodium.

6) www.heartandstroke.ca/bp: For an individualized

action plan for lifestyle change and monitoring ofblood pressure.

7) www.nhlbi.nih.gov/hbp/prevent/h_eating/h_eating.htm: For detailed information on eating the DASHdiet.


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TABlE 3: Targets for Dietary Sodium*

Age Adequate Intake(mg)

Upper limit(mg)

19-31 1,500 2,300

31-50 1,500 2,300

51-70 1,300 2,300

71 and over 1,200 2,300

To prevent and control hypertens ion, adults should be advised to eat the levelrecommended as adequate intake and avoid eating over the upper limit.

TABlE 4: Advice for Peope to Assist Them to ReduceDietary Sodium

DO

Buy and eat more fresh foods especially fruits andvegetables.

Choose processed foods with low salt labels or brandswith the lowest percentage of sodium on the food label.

Wash canned foods or other salty foods in water beforeeating or cooking.

If desired, use unsalted spices to make foods tastebetter.

Eat less food at restaurants and fast food outlets and

ask for less salt to be added in your food orders.

Use less sauces on your food.

Eat foods with less than 200 mg of sodium or less than10% of the daily value per serving.

DONT

Buy or eat heavily salted foods (e.g., pickled foods,salted crackers or chips, processed meats, etc.).

Add salt in cooking and at the table.

Eat foods with more than 400 mg of sodium or morethan 20% of the daily value per serving.

DIAGNOSIS&ASSESSMENT

PART1

* With permission of the Canadian Hypertension Education Program With permission of Hypertension Canada and the Canadian Hypertension Education Program


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I ACCURATEMEASUREMENTOFBLOODPRESSURE

1) Health care professionals who have been specicallytrained to measure blood pressure (BP) accuratelyshould assess BP in all adult patients at all

appropriate visits to determine cardiovascular riskand monitor antihypertensive treatment (Grade D).

2) Use of standardized measurement techniques (Table 1)is recommended when assessing blood pressure(Grade D).

3) Automated ofce blood pressure measurements canbe used in the assessment of ofce blood pressure(Grade D).

4) When used under proper conditions, automated

ofce SBP of 135 mm Hg or higher or DBP values of85 mm Hg or higher should be considered analogousto mean awake ambulatory SBP of 135 mm Hg orhigher and DBP of 85 mm Hg or higher, respectively(Grade D).

II CRITERIAFORDIAGNOSISOFHYPERTENSIONAND

RECOMMENDATIONSFORFOLLOW-UP

1) At initial presentation, patients demonstratingfeatures of a hypertensive urgency or emergency

(Table 2) should be diagnosed as hypertensive andrequire immediate management (Grade D).

2) If systolic BP (SBP) is 140 mm Hg and/or diastolicBP (DBP) is 90 mm Hg, a specific visit shouldbe scheduled for the assessment of hypertension(Grade D). If BP is high-normal (SBP 130-139 mm Hgand/or DBP 85-89 mm Hg), annual follow-up isrecommended (Grade C).

3) At the initial visit for the assessment of hypertension,

if SBP is 140 mm Hg and/or DBP is 90 mm Hg, atleast two more readings should be taken during thesame visit using a validated device and accordingto the recommended procedure for accurate BPdetermination (Table 1). The first reading shouldbe discarded and the latter two averaged. A historyand physical examination should be performed and,if clinically indicated, diagnostic tests to searchfor target organ damage (Table 3) and associatedcardiovascular risk factors (Table 4) should bearranged within two visits. Exogenous factors thatcan induce or aggravate hypertension should beassessed and removed if possible (Table 5). Schedulevisit two within one month (Grade D).

4) At visit two for the assessment of hypertension,patients with macrovascular target organ damage,diabetes mellitus, or chronic kidney disease (CKD;GFR


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8) Hypertensive patients receiving lifestyle modicationadvice alone (nonpharmacological treatment) shouldbe followed up at three-to six-month intervals.Shorter intervals (every one or two months) are

needed for patients with higher BPs (Grade D).9) Patients on an tihypertensi ve drug treatmen t

should be seen monthly or every two months,depending on the level of BP, until readings on twoconsecutive visits are below their target (Grade D).Shorter intervals between visits will be neededfor symptomatic patients and those with severehypertension, intolerance to antihypertensive drugsor target organ damage (Grade D). Once the targetBP has been reached, patients should be seen at

three-to six-month intervals (Grade D).

III ASSESSMENTOFOVERALLCARDIOVASCULARRISK

INHYPERTENSIVEPATIENTS

1) Global cardiovascular risk should be assessed.Multifactorial risk assessment models can beused to predict more accurately an individualsglobal cardiovascular risk (Grade A) and to useantihypertensive therapy more efciently (Grade D).In the absence of Canadian data to determine the

accuracy of risk calculations, avoid using absolutelevels of risk to support treatment decisions (Grade C).

2) Consider informing patients of their global risk toimprove the effectiveness of risk factor modication(Grade C).

IV ROUTINEANDOPTIONALLABORATORYTESTS

FORTHEINVESTIGATIONOFPATIENTSWITH

HYPERTENSION

1) Routine laboratory tests that should be performedfor the investigation of all patients with hypertensioninclude:

i) urinalysis (Grade D)

ii) blood chemistry (potassium , sodium andcreatinine) (Grade D)

iii) fasting blood glucose (Grade D)

iv) fasting serum total cholesterol and high densitylipoprotein cholesterol, low density lipoprotein

cholesterol and triglycerides (Grade D)v) standard 12-lead electrocardiography (Grade C)

2) Assess urinary albumin excretion in patients withdiabetes (Grade D).

3) i) All treated hypertensive patients should bemonitored according to the current Canadian

Diabetes Association (CDA) guidelines for thenew appearance of diabetes (Grade B).

ii) During the maintenance phase of hypertensionmanagement, tests (including those forelectrolytes, creatinine, glucose and fasting lipids)should be repeated with a frequency reectingthe clinical situation (Grade D).

V ASSESSMENTFORRENOVASCULARHYPERTENSION

1) Patients presenting with two or more of the clinicalclues listed below, suggesting renovascularhypertension, should be investigated (Grade D):

i) sudden onset or worsening of hypertension andage greater than 55 or less than 30 years

ii) the presence of an abdominal bruit

iii) hypertension resistant to three or more drugs

iv) a rise in serum creatinine level of30% associatedwith use of an angiotensin-converting enzyme

inhibitor or angiotensin II receptor antagonistv) other atherosclerotic vascular disease, particularly

in patients who smoke or have dyslipidemia

vi) recurrent pulmonary edema associated withhypertensive surges

2) When available, the following tests are recommendedto aid in the usual screening for renal vasculardisease: captopril-enhanced radioisotope renalscan, Doppler sonography, magnetic resonance

angiography, and CT-angiography (for those withnormal renal function) (Grade B). Captopril-enhancedradioisotope renal scan is not recommended forthose with CKD (GFR


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ii) hypertensive patients with marked diuretic-induced hypokalemia (K+ less than 3.0 mmol/L)

iii) patients with hypertension refractory to treatmentwith three or more drugs

iv) hypertensive patients found to have an incidentaladrenal adenoma

2) Screening for hyperaldosteronism should includeassessment of plasma aldosterone and plasma reninactivity (Table 6).

3) For patients with suspected hyperaldosteronism (onthe basis of the screening test, Table 6 [Section iii]),a diagnosis of primary aldosteronism should beestablished by demonstrating inappropriate

autonomous hypersecretion of aldosterone usingat least one of the maneuvers listed in Table 6(Section iv). When the diagnosis is established, theabnormality should be localized using any of the testsdescribed in Table 6 (Section v).

B)PheochromocytomaScreeningandDiagnosis

1) If pheoc hromocytoma is strongly su spected,the patient should be referred to a specializedhypertension center, particularly if biochemistryscreening tests (Table 7) have already been found tobe positive (Grade D).

2) The following patients should be considered forscreening for pheochromocytoma (Grade D):

i) patients with paroxysmal and/or severe(BP 180/110 mm Hg) sustained hypertensionrefractory to usual antihypertensive therapy

ii) patients with hypertension and multiplesymptoms suggestive of catecholamine excess(e.g., headaches, palpitations, sweating, panicattacks and pallor)

iii) patients with hypertension triggered by beta-blockers, monoamine oxidase inhibitors,micturition, or changes in abdominal pressure

iv) patients with incidentally discovered adrenalmass, patients with hypertension and multipleendocrine neoplasia (MEN) 2A or 2B, vonRecklinghausens neurofibromatosis, or vonHippel-Lindau disease

3) For patients with positive biochemical screeningtests, localization of pheochromocytomas shouldemploy magnetic resonance imaging (preferable),computed tomography (if MRI unavailable), and/

or iodine I-131 metaiodobenzylguanidine (MIBG)scintigraphy (Grade C for each modality).

VII HOMEMEASUREMENTOFBLOODPRESSURE

1) Home BP readings can be used in the diagnosis ofhypertension (Grade C).

2) The use of home BP monitoring on a regular basisshould be considered for patients with hypertension,particularly those with:

i) diabetes mellitus (Grade D)ii) chronic kidney disease (Grade C)

iii) suspected non-adherence (Grade D)

iv) demonstrated white coat effect (Grade C)

v) BP controlled in the office but not at home(masked hypertension) (Grade C)

3) When white coat hypertension is suggested by homemonitoring, its presence should be conrmed withABPM before making treatment decisions (Grade D).

4) Patients should be advised to purchase and use onlyhome BP monitoring devices that are appropriatefor the individual and that have met standards ofthe Association for the Advancement of MedicalInstrumentation, the most recent requirements ofthe British Hypertension Society protocol or theInternational Protocol for validation of automated BPmeasuring devices. Patients should be encouragedto use devices with data recording capabilities orautomatic data transmission to increase the reliabilityof reported home BP values (Grade D).

5) Home SBP values 135 mm Hg or DBP values85 mm Hg should be considered elevated andassociated with an increased overall mortality riskanalogous to ofce SBP readings of 140 mm Hg orDBP 90 mm Hg (Grade C).

6) Health care professionals should ensure thatpatients who measure their BP at home haveadequate training, and if necessary, repeat training

in measuring their BP. Patients should be observed todetermine that they measure BP correctly and should


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be given adequate information about interpretingthese readings (Grade D).

7) The accuracy of all individual patients validateddevices (including electronic devices) must be

regularly checked against a device of knowncalibration (Grade D).

8) Home BP values for assessing white coat hypertensionor sustained hypertension should be based onduplicate measures, morning and evening, for aninitial seven-day period. First day home BP valuesshould not be considered (Grade D).

VIIIAMBULATORYBLOODPRESSUREMEASUREMENT

1) Ambulatory BP readings can be used in the diagnosisof hypertension (Grade C).

2) ABPM should be considered when an ofce-inducedincrease in BP is suspected in treated patients with:

i) BP that is not below target despite receivingappropriate chronic antihypertensive therapy(Grade C)

ii) symptoms suggestive of hypotension (Grade C)

iii) uctuating ofce BP readings (Grade D)

3) Physicians should use only ABPM devices that havebeen validated independently using establishedprotocols (Grade D).

4) Therapy adjustment should be considered in patientswith a 24h ambulatory SBP of 130 mm Hg or DBPof 80 mm Hg or an awake SBP of 135 mm Hg orDBP of 85 mm Hg (Grade D).

5) The magnitude of changes in nocturnal BP shouldbe taken into account in any decision to prescribe or

withhold drug therapy based upon ambulatory BP(Grade C) because a decrease in nocturnal BP ofless than 10% is associated with increased risk ofCV events.

IX ROLEOFECHOCARDIOGRAPHY

1) Routine echocardiographic evaluation of allhypertensive patients is not recommended (Grade D).

2) An echocardiogram for assessment of left ventricularhypertrophy is useful in selected cases to help denethe future risk of cardiovascular events (Grade C).

3) Echocardiographic assessment of left ventricularmass, as well as of systolic and diastolic left ventricularfunction, is recommended for hypertensive patientssuspected to have left ventricular dysfunction or

coronary artery disease (Grade D).4) Patients with hypertension and evidence of heart

failure should have an objective assessment of leftventricular ejection fraction, either by echocardiogramor nuclear imaging (Grade D).

DIAGNOSIS&ASSESSMENTTABLES

TABLE1:

RecommendedTechniqueforMeasuringBloodPressure *

1) Measurements should be taken with a sphygmomanometerknown to be accurate. A recently calibrated aneroid ora validated and recently calibrated electronic device canbe used. Aneroid devices or mercury columns need tobe clearly visible at eye level.

2) Choose a cuff with an appropriate bladder size matchedto the size of the arm. For measurements taken byauscultation, bladder width should be close to 40%of arm circumference and bladder length should

cover 80100% of arm circumference. When using anautomated device, select the cuff size as recommendedby its manufacturer.

3) Place the cuff so that the lower edge is 3 cm abovethe elbow crease and the bladder is centered overthe brachial artery. The patient should be restingcomfortably for 5 minutes in the seated position withback support. The arm should be bare and supportedwith the BP cuff at heart level, as a lower position willresult in an erroneously higher SBP and DBP. There

should be no talking, and the patients legs should notbe crossed. At least three measurements should betaken in the same arm with the patient in the sameposition. The rst reading should be discarded and thelatter two averaged. Blood pressure also should beassessed after 2 minutes standing (with arm supported)and at times when patients report symptoms suggestiveof postural hypotension. Supine BP measurements mayalso be helpful in the assessment of elderly and diabeticpatients. For auscultation, at least three measurementsshould be taken in the same arm with the patient in the Unless specifically mentioned, steps apply to measurement by auscultation and

oscillometry using an upper arm cuff.



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same position. The rst reading should be discardedand the latter two averaged.

When using automated office oscillometric devicessuch as the BpTRU, the patient should be seated in a

quiet room (no specied period of rest). With the deviceset to take measures at 1 or 2 minute intervals, the rstmeasurement is taken by a health care professional toverify cuff position and validity of the measurement. Thepatient is left alone after the rst measurement whilethe device automatically takes subsequent readings.The BpTRU automatically discards the rst measureand averages the next ve measures.

Steps 4 to 7 are specic to auscultation.

4) Increase the pressure rapidly to 30 mm Hg above thelevel at which the radial pulse is extinguished (to excludethe possibility of a systolic auscultatory gap).

5) Place the bell or diaphragm of the stethoscope gentlyand steadily over the brachial artery.

6) Open the control valve so that the rate of deflationof the cuff is approximately 2 mm Hg per heart beat.A cuff deation rate of 2 mm Hg per beat is necessaryfor accurate systolic and diastolic estimation.

7) Read the systolic level the rst appearance of a cleartapping sound (phase I Korotkoff) and the diastoliclevel (the point at which the sounds disappear (phase VKorotkoff)). If Korotkoff sounds persist as the levelapproaches 0 mm Hg, then the point of mufing ofthe sound is used (phase IV) to indicate the diastolicpressure. Leaving the cuff partially inflated for toolong will ll the venous system and make the soundsdifficult to hear. To avoid venous congestion, it isrecommended that at least one minute should elapsebetween readings.

8) Record the blood pressure to the closest 2 mm Hg onthe manometer (or 1 mm Hg on electronic devices)as well as the arm used and whether the patient wassupine, sitting or standing. Avoid digit preference bynot rounding up or down. Record the heart rate. Theseated blood pressure is used to determine and monitortreatment decisions. The standing blood pressure isused to examine for postural hypotension, if present,which may modify the treatment.

9) In the case of arrhythmia, additional readings withauscultation may be required to estimate the averagesystolic and diastolic pressure. Isolated extra beats


should be ignored. Note the rhythm and pulse rate.

10) Leaving the cuff partially inated for too long will ll thevenous system and make the sounds difcult to hear.To avoid venous congestion, it is recommended that at

least one minute should elapse between readings.

11) Blood pressure should be taken in both arms on atleast one visit and if one arm has a consistently higherpressure, that arm should be subsequently used forblood pressure measurement and interpretation.

TABLE2:

ExamplesofHypertensiveUrgenciesandEmergencies*

Asymptomatic diastolic BP 130 mm Hg

Hypertensive encephalopathy

Acute aortic dissection

Acute left ventricular failure

Acute myocardial ischemia

TABLE3:

ExamplesofTargetOrganDamage*

Cerebrovascular Disease

StrokeIschemic stroke and transient ischemic attackIntracerebral hemorrhageAneurysmal sub-arachnoid hemorrhage

DementiaVascular dementiaMixed vascular dementia and dementia of theAlzheimers type

Hypertensive Retinopathy

Left Ventricular DysfunctionLeft ventricular hypertrophy

Coronary Artery Disease

Myocardial infarctionAngina pectorisCongestive heart failure

Renal Disease

Chronic kidney disease (GFR


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TABLE4:

ExamplesofKeyCardiovascularRiskFactorsfor

Atherosclerosis*

Prior history of clinically overt atherosclerotic disease

indicates a very high risk for a recurrent atheroscleroticevent (e.g., peripheral arterial disease, previous stroke or TIA).

Non-Modiable

Age 55 yearsMale sexFamily history of premature cardiovascular disease(age


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less than 240 pmol/L two hours after 25 mg of oralcaptopril)

5) Differentiating potential causes of primary aldosteronism:

a) for patients with established primary aldosteronism,attempts to differentiate potential causes should bemade and may include localization with adrenal CT-scan (standard: 3 mm contiguous cuts) or magneticresonance imaging (where available), or assessmentof plasma aldosterone before (supine) and after 2hto 4h of upright posture

b) for patients with established primary aldosteronismand negative imaging studies, selective adrenalvenous sampling should be considered because it

may be the only way to reliably differentiate unilateralfrom bilateral overproduction of aldosterone. Adrenalvenous sampling should be conducted in centres withexperience in performing this diagnostic technique.

TABLE7:

Pheochromocytoma:ScreeningandDiagnosis*

Biochemicalscreeningtestsforpheochromocytomas:

a) to screen for pheochromocytomas, 24h urinarytotal metanephrines (sensitivity 95%) and urinary

metanephrine-to-creatinine ratio (sensitivity 100%)should be assessed. Plasma catecholaminesand, where available, plasma metanephrines mayalso be considered if clinical suspicion is high,particularly during a hypertensive episode or forthose with familial forms. Urinary or plasma VMAmeasurements should not be used as screeningtests. In a low risk setting, plasma fractionated freemetanephrine measurements can be used to ruleout pheochromocytoma.

b) in the presence of borderline biochemical test results(e.g., plasma noradrenaline and adrenaline levels ofapproximately 500 ng/L to 2,000 ng/L) or potentiallyfalse positive results, repeated testing and/or theclonidine suppression test may be used.



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Elevated

Out-of-the-OfceBP

Measurement

ElevatedRandomOfceBPMeasureme

nt

Hypertensive

Urgency/Emergency

Diagnosis

ofHTN

Yes

Hyp

ertensionVisit1

B

PMeasurement,

HistoryandPhysical

Diagnostictestsordering

atvisit1or2

BP

180/110mmH

gOR

BP140-179/90-109mmH

g

withTargetOrganDamage,

Diabetes

orChronicKidneyDisease

No

Yes

Figure1:The

ExpeditedAssessmenta

ndDiagnosisofPatientswithHypertension:

FocusonValidatedTechnologiesforBloodPressureAs

sessment*

Hyp

ertensionVisit2

with

in1month

ClinicBPM

Diagnosis

of

HTN

AB

PMor

Hom

eBPM

ifav

ailable

Diagnosis

of

HTN

Continueto

foll

ow-up

160mmH

gSBPor

100mmH

gDBP