Part 2: Recommendations for Hypertension Treatment

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Part 2 Recommendations for Hypertension Treatment
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2008 Canadian Hypertension Education Program
(CHEP)

• A red flaghas been posted where recommendations
  were updated for 2008.
• A slide kit for medical education can be
  downloaded (English and French versions) from
• http//www.hypertension.ca

3
2008 Canadian Hypertension Education Program
(CHEP)

• Treatment Approaches
• Lifestyle
• Pharmacological

4
2008 Canadian Hypertension Education Program
(CHEP)

• What's New for 2008
• IMPORTANT ROLE FOR HOME MEASUREMENT OF BLOOD
  PRESSURE
• Encourage hypertensive patients to use an
  approved blood pressure measuring device and use
  proper technique to assess blood pressure at
  home.
• Measuring blood pressure at home has a stronger
  association with cardiovascular prognosis than
  office based readings.
• Home measurement can help to confirm the
  diagnosis of hypertension, improve blood pressure
  control, reduce the need for medications, help to
  identify white coat and masked hypertension and
  improve medication adherence in non adherent
  patients.

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2008 Canadian Hypertension Education Program
(CHEP)

• IMPORTANT ROLE FOR HOME MEASUREMETN OF BLOOD
  PRESSURE
• An internet based toolkit for home blood pressure
  measurement including recording and tracking of
  blood pressures can be found at
  www.heartandstroke.ca/BP.
• Patient information on selecting an approved
  device, and how to measure and track home blood
  pressure can be found at www.hypertension.ca.
• More information on home monitoring is in the
  CHEP diagnostic slide set and the BP measurement
  slide set

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Key CHEP messages for the management of
hypertension

• Assess blood pressure at all appropriate visits.
• Encourage hypertensive patients to use approved
  devices and proper technique to measure blood
  pressure at home.
• Assess and manage global cardiovascular risk in
  all hypertensive patients including smoking,
  dyslipidemia, diabetes, inactivity, unhealthy
  eating and abdominal obesity.
• Sustained lifestyle modification is the
  cornerstone for the prevention and management of
  hypertension and cardiovascular disease (CVD).
• Treat to target (lt140/90 mmHg lt130/80 mmHg in
  patients with diabetes or chronic kidney
  disease). Sustained lifestyle modification and
  more than one drug are usually required.

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2008 Canadian Hypertension Education Program
(CHEP)

• Important messages from 2007
• Approximately 95 of Canadians will develop
  hypertension if they live an average lifespan
• Most overweight patients with high normal blood
  pressure (130-139/85-89 mmHg) will develop
  hypertension within 4 years and almost 1/2 within
  2 years.
• Annual follow-up of patients with high normal
  blood pressure is recommended.

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2008 Canadian Hypertension Education Program
(CHEP)

• Important messages from 2007
• Up to 30 of hypertension in Canada can be
  attributed to high dietary sodium
• 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 2300
  mg/day to prevent and control hypertension

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TO REDUCE DIETARY SODIUM

• Advise patient to
• Increase the proportion of fresh foods,
  especially fruit and vegetables
• When buying processed foods look for those with
  low salt labels or brands with the lowest
  percentage of sodium on the food label
• Wash canned foods or other salty foods in water
  before eating or cooking
• Use unsalted spices to make foods taste better
• Eat less food at restaurants and ask for less
  salt to be added in food orders
• Use less sauces on food
• Advise patients not to
• Eat as much heavily salted foods (e.g. pickled
  foods, salted crackers or chips, processed meats,
  etc).
• Add salt in cooking and at the table

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Recommendations 2008Table of contents

• Indications for drug therapy
• Goal for therapy
• Adherence
• Lifestyle
• Uncomplicated
• CV IHD
• CHF
• Cerebrovascular / Stroke
• LVH
• X. Chronic kidney disease
• Renovascular
• Diabetes
• Smoking
• Global risk reduction

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Usual blood pressure threshold values for
initiation of pharmacological treatment of
hypertension
I. Indications for Pharmacotherapy
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I. Indications for Pharmacotherapy

• In low risk patients with stage 1 hypertension
  (140-159/90-99 mmHg) lifestyle modification can
  be the sole therapy.
• Over 90 of Canadians with hypertension have
  other risk factors and pharmacotherapy should be
  considered in these patients if blood pressure
  remains equal to or above 140/90 mmHg with
  lifestyle modification.
• Patients with target organ damage (e.g. left
  ventricular hypertrophy) are recommended to be
  treated with pharmacotherapy if blood pressure is
  equal to or above 140/90
• Patients with known atherosclerotic disease (e.g.
  past stroke) are recommended to be treated with
  pharmacotherapy even if the blood pressure is
  normal (see compelling indications)
• Patients with diabetes or chronic kidney disease
  should be considered for pharmacotherapy if the
  blood pressure is equal or over 130/80 mmHg

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Blood pressure target values for treatment of
hypertension
II. Goals of Therapy
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II. Goals of Therapy

• To optimally reduce cardiovascular risk reduce
  the blood pressure to specified targets.
• This usually requires two or more drugs and
  lifestyle changes
• The systolic target is more difficult to achieve
  however controlling systolic blood pressure is as
  important if not more important than controlling
  diastolic blood pressure

15
Follow-up of blood pressure above targets

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

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Part 2 Recommendations for Hypertension Treatment
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IV. Lifestyle management
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Lifestyle Recommendations for Prevention and
Treatment of Hypertension

• To reduce the possibility of becoming
  hypertensive,
• Reduce sodium intake to less than 2300 mg / day
• Healthy diet high in fresh fruits, vegetables,
  low fat dairy products, dietary and soluble
  fiber, whole grains and protein from plant
  sources, low in saturated fat, cholesterol and
  salt in accordance with Canada's Guide to Healthy
  Eating.
• Regular physical activity accumulation of 30-60
  minutes of moderate intensity cardiorespiratory
  activity (e.g. a brisk walk) 4-7/week in addition
  to routine activities of daily living
• Low risk alcohol consumption (2 standard
  drinks/day and less than 14/week for men and less
  than 9/week for women)
• Maintenance of ideal body weight (BMI 18.5-24.9
  kg/m2)
• Waist Circumference
  Men Women
• - Europid, Sub-Saharan African, Middle Eastern
  lt94 cm lt80 cm
• - South Asian, Chinese lt90 cm lt80 cm
• - Japanese lt85 cm lt90 cm
• Smoke free environment

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Lifestyle Recommendations for Hypertension
Dietary

• High in fresh fruits
• High in vegetables
• High in low fat dairy products
• High in dietary and soluble fibre
• High in plant protein
• Low in saturated fat and cholesterol
• Low in sodium

http//www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_g
uide_rainbow_e.html
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Recommendations for daily salt intake

• Less than
• 2,300 mg sodium (Na)
• 100 mmol sodium (Na)
• 5,8 g of salt (NaCl)
• 1 teaspoon of table salt

2,300 mg sodium 1 level teaspoon of table salt
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Salt 2008 Meta-analyses

• Hypertensives
• Reduction of BP
• 5.1 / 2.7 mmHg with a average reduction of 1800
  mg sodium/day
• 7.2/3.8 mmHg with a average reduction of 2300 mg
  sodium/day
• Normotensives
• Reduction of BP
• 2.0 / 1.0 mmHg with a average reduction of sodium
  1700 mg/day
• 3.6/1.7 mmHg with a average reduction of 2300
  mg/day sodium

The Cochrane Library 200631-41
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Salt 2008 Meta analysis on different reduction
in sodium on blood pressure
Hypertension 2003421093-1099
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Epidemiologic impact on mortality of blood
pressure reduction in the population
After Intervention
Before Intervention
Prevalence
Reduction in BP
Adapted from Whelton, P. K. et al. JAMA
20022881882-1888
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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 540 million per year
  related to fewer office visit, drugs and
  laboratory costs for hypertension
• Improvement of the hypertension treatment and
  control rate
• Reduction in CVD not yet estimated

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Lifestyle Recommendations for Hypertension
Physical Activity
Should be prescribed to reduce blood pressure
Frequency - Four to seven days per week
Type cardiorespiratory activity - Walking,
jogging - Cycling - Non-competitive swimming
Exercise should be prescribed as adjunctive to
pharmacological therapy
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Lifestyle Recommendations for Hypertension
Alcohol
Low risk alcohol consumption
0-2 standard drinks/day
Men maximum of 14 standard drinks/week
Women maximum of 9 standard drinks/week
A standard drink is about 142 ml or 5 oz of wine
(12 alcohol). 341 mL or 12 oz of beer (5
alcohol) 43 mL or 1.5 oz of spirits (40 alcohol).
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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.
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Lifestyle Recommendations for Hypertension
Weight LossHeight, weight, and waist
circumference (WC) should be measured and body
mass index (BMI) calculated for all adults.
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Waist Circumference Measurement
Last rib margin
Mid distance
Iliac crest
Courtesy J.P. Després 2006
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Impact of Lifestyle Therapies on Blood Pressure
in Hypertensive Adults
Applying the 2005 Canadian Hypertension Education
Program recommendations 3. Lifestyle
modifications to prevent and treat hypertension
Padwal R. et al. CMAJ ? SEPT. 27, 2005 173 (7)
749-751
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Lifestyle Therapies in Hypertensive Adults
Summary
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Pharmacotherapy
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2008 Canadian Hypertension Education Program
(CHEP)
Table of contents

• Indications for drug therapy
• Goal for therapy
• Adherence
• Lifestyle
• Uncomplicated
• CV IHD
• CHF
• Cerebrovascular / Stroke
• LVH
• X. Chronic kidney disease
• Renovascular
• Diabetes
• Smoking
• Global risk reduction

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V. Choice of Pharmacological Treatment
Uncomplicated
Associated risk factors? or Target organ
damage/complications? or Concomitant
diseases/conditions?
35
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

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V. Treatment of Adults with Systolic/Diastolic
Hypertension without Other Compelling Indications
TARGET lt140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy
A combination of 2 first line drugs may be
considered as initial therapy if the blood
pressure is gt20 mmHg systolic or gt10 mmHg
diastolic above target
Thiazide
Beta-blocker
Long-acting CCB
BBs are not indicated as first line therapy for
age 60 and above
ACEI and ARB are contraindicated in pregnancy and
caution is required in prescribing to women of
child bearing potential
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V. Considerations Regarding the Choice of
First-Line Therapy

• Use caution in initiating therapy with 2 drugs
  where substantive blood pressure lowering is more
  likely or more poorly tolerated (e.g. those with
  postural hypotension).
• ACE inhibitors and ARBs are contraindicated in
  pregnancy and caution is required in prescribing
  to women of child bearing potential.
• Beta adrenergic blockers are not recommended for
  patients age 60 without another compelling
  indication.
• Diuretic-induced hypokalemia should be avoided
  through the use of potassium sparing agent if
  required.
• ACE-I are not recommended (as monotherapy) for
  black patients without another compelling
  indication.

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V. Add-on Therapy for Systolic/Diastolic
Hypertension without Other Compelling Indications
If partial response to monotherapy
If blood pressure is still not controlled, or
there are adverse effects, other classes of
antihypertensive drugs may be combined (such as
alpha blockers or centrally acting agents).
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Drug Combinations

• When combining drugs, use first-line therapies.
• Two drug combinations of beta blockers, ACE
  inhibitors and angiotensin receptor blockers have
  not been proven to have additive hypotensive
  effects.
• Therefore these potential two drug combinations
  should not be used unless there is a compelling
  (non blood pressure lowering) indication such as
  ischemic heart disease, post myocardial
  infarction, congestive heart failure or chronic
  kidney disease with proteinuria.

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Drug Combinations contd

• Caution should be exercised in combining a non
  dihydropyridine CCB and a beta blocker to reduce
  the risk of bradycardia or heart block.
• Monitor creatinine and potassium when combining K
  sparing diuretics, ACE inhibitors and/or
  angiotensin receptor blockers.
• If a diuretic is not used as first or second line
  therapy, triple dose therapy should include a
  diuretic, when not contraindicated.

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Most HTN Pts need more than 1 drug (data from
ALLHAT)
42
Most HTN Pts need more than 1 drug
5
4
3
Number of drugs
2
1
0
HOT
IDNT
AASK
ABCD
MDRD
UKPDS
ALLHAT
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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
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V. Summary Treatment of Systolic-Diastolic
Hypertension without Other Compelling Indications
TARGET lt140/90 mmHg
Lifestyle modification
A combination of 2 first line drugs may be
considered as initial therapy if the blood
pressure is gt20 mmHg systolic or gt10 mmHg
diastolic above target
Initial therapy
Dual Combination

• CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?

Not indicated as first line therapy over 60 y
Triple or Quadruple Therapy
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Treatment Algorithm for Isolated Systolic
Hypertension without Other Compelling Indications
TARGET lt140 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy
Thiazide diuretic
ARB
Long-acting DHP CCB
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V. Add-on therapy for Isolated Systolic
Hypertension without Other Compelling Indications
If partial response to monotherapy
Dual combination Combine first line agents
Thiazide diuretic
ARB
Long-acting DHP CCB

• CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?

Triple therapy
If blood pressure is still not controlled, or
there are adverse effects, other classes of
antihypertensive drugs may be combined (such as
ACE inhibitors, alpha adrenergic blockers,
centrally acting agents, or nondihydropyridine
calcium channel blocker).
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V. Summary Treatment of Isolated Systolic
Hypertension without Other Compelling Indications
TARGET lt140 mmHg
Lifestyle modification therapy
Thiazide diuretic
ARB
Long-acting DHP CCB
Dual therapy

• CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?

If blood pressure is still not controlled, or
there are adverse effects, other classes of
antihypertensive drugs may be combined (such as
ACE inhibitors, alpha blockers, centrally acting
agents, or nondihydropyridine calcium channel
blocker).
Triple therapy
48
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

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Choice of Pharmacological Treatment for
Hypertension

• Individualized treatment
• Compelling indications
• Ischemic Heart Disease
• Recent ST Segment Elevation-MI or non-ST Segment
  Elevation-MI
• Left Ventricular Systolic Dysfunction
• Cerebrovascular Disease
• Left Ventricular Hypertrophy
• Non Diabetic Chronic Kidney Disease
• Renovascular Disease
• Smoking
• Diabetes Mellitus
• With Diabetic Nephropathy
• Without Diabetic Nephropathy
• Global Vascular Protection for Hypertensive
  Patients
• Statins if 3 or more additional cardiovascular
  risks
• Aspirin once blood pressure is controlled

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VI. Treatment of Hypertension in Patients with
Ischemic Heart Disease
Caution should be exercised when combining a
non DHP-CCB and a beta-blocker If abnormal
systolic left ventricular function avoid non
DHP-CCB (Verapamil or Diltiazem)
Those at low risk with well controlled risk
factors may not benefit from ACEI therapy
51
VI. Treatment of Hypertension in Patients with
Recent ST Segment Elevation-MI or non-ST Segment
Elevation-MI
An ARB can be used if the patient is intolerant
to ACE-I
Beta-blocker and ACE-I
Recent myocardial infarction
If beta-blocker contraindicated or not effective
Long-acting Dihydropyridine CCB (Amlodipine,
Felodipine)
YES
Heart Failure ?
NO
Long-acting CCB
Avoid non dihydropyridine CCBs (diltiazem,
verapamil)
52
VII. Treatment of Hypertension with Left
Ventricular Systolic Dysfunction
ACE-I and Beta blocker if ACE-I intolerant
ARB Titrate doses of ACEI and ARB to those used
in clinical trials
Systolic cardiac dysfunction

• If additional therapy is needed
• Diuretic (Thiazide for hypertension Loop for
  volume control)
• for CHF class III-IV or post MI Aldosterone
  Antagonist

If ACE-I and ARB are contraindicated Hydralazine
and Isosorbide dinitrate in combination
If additional antihypertensive therapy is
needed ACE-I / ARB Combination
Long-acting DHP-CCB (Amlodipine or Felodipine)
Beta-blockers used in clinical trials were
bisoprolol, carvedilol and metoprolol.
53
VIII. Treatment of Hypertensionfor Patients
with Cerebrovascular Disease
54
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.

• ACE-I
• ARB,
• CCB
• Thiazide Diuretic
• - BB (if age below 60)

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X. Treatment of Hypertension in Patients with Non
Diabetic Chronic Kidney Disease
albumincreatinine ratio ACR gt 30 mg/mmol or
urinary protein gt 500 mg/24hr
Monitor potassium and creatinine carefully in
patients with CKD prescribed an ACEI or ARB
56
XI. Treatment of Hypertension in Patients with
Renovascular Disease
57
XII. Treatment of Hypertension in association
with Diabetes Mellitus
58
XII. Treatment of Hypertension in association
with Diabetes Mellitus
Threshold equal or over 130/80 mmHg and Target
below 130/80 mmHg
Urinary albumin to creatinine ratio gt 2.0
mg/mmol in men or gt 2.8mg/mmol in women or
chronic kidney disease
Urinary albumin to creatinine ratio lt2.0
mg/mmol in men or lt2.8mg/mmol in women
based on at least 2 of 3 measurements
59
XII. Treatment of Hypertension in association
with Diabetic Nephropathy
Monitor potassium and creatinine carefully in
patients with CKD prescribed an ACEI or ARB
60
XII. Treatment of Systolic-Diastolic Hypertension
without Diabetic Nephropathy
Threshold equal or over 130/80 mmHg and TARGET
below 130/80 mmHg
1. ACE-Inhibitor or ARB or 2. Thiazide diuretic
or Dihydropyridine CCB
Combination of first line agents
Diabetes without Nephropathy
IF ACE-I and ARB and DHP-CCB or Thiazide are
contraindicated or not tolerated, SUBSTITUTE
Cardioselective BB or Long-acting NON DHP-CCB
Addition of one or more of Cardioselective BB
or Long-acting CCB
DHP dihydropyridine
Cardioselective BB Acebutolol, Atenolol,
Bisoprolol , Metoprolol
More than 3 drugs may be needed to reach target
values for diabetic patients
61
XII. Treatment of Hypertension in association
with Diabetes Mellitus Summary
Threshold equal or over 130/80 mmHg and TARGET
below 130/80 mmHg
ACE Inhibitor or ARB
1. ACE-Inhibitor or ARB or 2. Thiazide diuretic
or DHP-CCB
Combination (Effective 2-drug combination)
without Nephropathy
Monitor potassium and creatinine carefully in
patients with CKD prescribed an ACEI or ARB
More than 3 drugs may be needed to reach target
values for diabetic patients If Creatinine over
150 µmol/L or creatinine clearance below 30
ml/min ( 0.5 ml/sec), a loop diuretic should be
substituted for a thiazide diuretic if control of
volume is desired
62
XIII. Treatment of Hypertension for Patients Who
Use Tobacco
63
XIV. Global Vascular Protection for Patients
with Hypertension
64
Most hypertensive Canadians have other
cardiovascular risks

• Assess and manage hypertensive patients for
  smoking, unhealthy eating, physical inactivity,
  abdominal obesity, dyslipidemia and diabetes

65
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

ASCOT-LLA Lancet 20033611149-58
66
XIV. Vascular Protection for Hypertensive
Patients ASA
Consider low dose ASA
Caution should be exercised if BP is not
controlled.
67
Adherence to anti-hypertensive management can be
improved by a multi-pronged approach

• Assess adherence to pharmacological and
  non-pharmacological therapy at every visit
• Teach patients to take their pills on a regular
  schedule associated with a routine daily activity
  e.g. brushing teeth.
• Simplify medication regimens using long-acting
  once-daily dosing
• Utilize fixed-dose combination pills
• Utilize unit-of-use packaging e.g. blister
  packaging

68
Adherence to anti-hypertensive management can be
improved by a multi-pronged 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

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NEW PATIENT RESOURCES FOR HYPERTENSION ON LINE

• www.heartandstroke.ca/BP
• To monitor home blood pressure and encourage self
  management of lifestyle
• www.hypertension.ca
• To access up to date downloadable patient
  information on hypertension

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Public translation of CHEP recommendations
Download at www.hypertension.ca
71
Educate patients and patients' families about
their disease/treatment regimens verbally and in
writing
Useful patient information can be obtained in
recent publications from the Canadian
Hypertension Society.
Available by order from CHS Secretariat-Canadian
Hypertension Society. Tel [phone], Fax
613-533-6927 E mail HYPERTENSION_at_QUEENSU.CA .
Coming soon to bookstores near you.
72
Encourage greater patient responsibility/autonomy
73
Summary I

• Regarding the treatment of hypertension, the
  recommendations endorse
• ASSESSMENT OF BLOOD PRESSURE AT ALL APPROPRIATE
  VISITS
• Most Canadians will develop hypertension during
  their lives. Routine assessment of blood pressure
  is required for early detection and risk
  management
• Encourage appropriate patients to properly
  measure blood pressure at home
• Most can assess blood pressure at home. Home
  measurement can confirm a diagnosis of
  hypertension, improve adherence to drug
  treatment, improve control rates and screen for
  those with white coat hypertension and masked
  hypertension.

74
Summary II

• Regarding the treatment of hypertension, the
  recommendations endorse
• INDIVIDUALIZING THERAPY
• consider concomitant risk factors and/or
  concurrent diseases, other patient
  characteristics and preferences (e.g. age,
  diabetes, CVD) and other considerations e.g.
  costs
• LIFESTYLE MODIFICATION
• To prevent hypertension
• In those with hypertension alone if effective to
  reach the goal value or in combination with
  pharmacological treatment

75
Summary III

• Regarding the treatment of hypertension, the
  recommendations endorse
• TREATING TO TARGET BP
• treat aggressively using combinations of drugs
  and lifestyle modification to achieve
  individualized target
• PROMOTING ADHERENCE
• a multi-faceted approach should be used to
  improve adherence with both non pharmacological
  and pharmacological strategies