Treatment En 2011 Final

8/3/2019 Treatment En 2011 Final

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Part 2: Recommendations for

Hypertension Treatment

2011 Canadian Hypertension

Education ProgramRecommendations


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The full slide set of the2011 CHEP Recommendations

are available at

www.hypertension.ca


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2011 Canadian Hypertension EducationProgram (CHEP)

A red flag has been posted whererecommendations were updated for 2011.

Slide kits for health care professional and publiceducation can be downloaded (English and Frenchversions) from www.hypertension.ca


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Treatment Approaches:

Lifestyle

Pharmacological


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Key CHEP Messages for theManagement of Hypertension

1. Assess blood pressure at all appropriate visits.

2. Promote a healthy lifestyle to lower blood pressure and reducethe risk of cardiovascular disease at each visit with interventionsto reduce high dietary sodium, for smoking cessation, to reduceabdominal obesity, to promote a healthy weight, to increase

physical activity and to manage dyslipidemia and dysglycemia.3. Treat blood pressure to less than 140/90 mmHg in most people

and to less than 130/80 mmHg in people with diabetes orchronic kidney disease using a combination of drugs andlifestyle modifications.

4. Advocate for healthy public policies to prevent hypertension and

advance the health of patients and populations.5. Keep up to date with resources for the prevention and control of

hypertension by registering at www.htnupdate.ca anddownloading and ordering tools at www.hypertension.ca/tools.


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The Canadian Hypertension EducationProgram: 2011 Recommendations

Whats new?

Increased emphasis on the use of single pillcombinations (and more guidance on whichcombinations to use).

In stroke patients avoid excessive blood pressurereductions, except in the setting of the most severeelevations

The most important step in prescription of

antihypertensive therapy is achieving patient buy-in:new tips for improving adherence


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For your patients ask themto sign up atwww.myBPsite.ca for freeaccess to the latest

information & resources onhigh blood pressure

For health care professionals sign up atwww.htnupdate.ca forautomatic updates and on

current hypertensioneducational resources


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The Canadian Hypertension EducationProgram: 2011 Recommendations

Whats old but still important?

Out-of-office blood pressure measurements areimportant in both the diagnosis and management of

hypertension Lifestyle changes are still a critical component of

hypertension management (and prevention!)

The management of hypertension is all about global

risk management and vascular protection


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Recommendations 2011Table of contents

I. Indications for drug therapyII. Goals of therapyIII. AdherenceIV. LifestyleV. Uncomplicated

VI. CV IHDVII. CHFVIII. Cerebrovascular / StrokeIX. LVHX. Chronic kidney diseaseXI. RenovascularXII. DiabetesXIII. SmokingXIV.Overall risk reduction


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I. Indications for

Pharmacotherapy




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I. Indications for Pharmacotherapy

Usual blood pressure threshold values for initiation

of pharmacological treatment of hypertension

Condition Initiation

SBP or DBP mmHg

Systolic or Diastolic hypertension u140/90

Diabetes

Chronic Kidney Disease

u130/80


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I. Indications for Pharmacotherapyafter diagnosis of hypertension (1)

Patients at low risk with stage 1 hypertension(140-159/90-99 mmHg) lifestyle modification can be the sole therapy.

Patients with target organ damage (e.g. left

ventricular hypertrophy) (140-159/90-99 mmHg)

Treat with pharmacotherapy

Patients with diabetes or chronic kidney diseaseshould be considered for pharmacotherapy if the

blood pressure is equal or over 130/80 mmHg


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I. Indications for Pharmacotherapyafter diagnosis of hypertension (2)

Patients with other risk factors (over 90% ofCanadians with hypertension have other risk factors)(140-159/90-99 mmHg despite lifestyle modification)

Treat with pharmacotherapy

Treatment Gap Alert: Many younger hypertensiveCanadians with multiple cardiovascular risks arecurrently not treated with pharmacotherapy. Health

care professionals need to be aware of this importantcare gap and recommend pharmacotherapy.


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II. Goals of Therapy




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Blood pressure target values for treatment of

hypertension

Condition Target

SBP and DBP mmHgIsolated systolic hypertension


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To optimally reduce cardiovascular risk reduce theblood pressure to specified targets.

This usually requires two or more drugs and lifestylechanges

The systolic target is more difficult to achieve howevercontrolling systolic blood pressure is as important if not moreimportant than controlling diastolic blood pressure


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Follow-up of blood pressureabove targets

Patients with blood pressure above target arerecommended to be followed at least every 2ndmonth

Follow-up visits are used to increase the intensity oflifestyle and drug therapy, monitor the response totherapy and assess adherence


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III. Adherence

2011 Canadian HypertensionEducation Program

Recommendations


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III. Adherence to anti-hypertensive managementcan 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 scheduleassociated 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 Replacing multiple pill antihypertensive combinations

with single pill combinations!


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III. Adherence to anti-hypertensive managementcan be improved by a multi-pronged approach

Encourage greater patient responsibility/autonomy inregular monitoring of their blood pressure

Educate patients and patients' families about their

disease/treatment regimens verbally and in writing Use an interdisciplinary care approach coordinating

with work-site health care givers and pharmacists ifavailable


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IV. Lifestyle management




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Lifestyle Recommendations forPrevention andTreatment of Hypertension

To reduce the possibility of becoming hypertensive,

Reduce sodium intake to less than 1500 mg/day

Healthy diet: high in fresh fruits, vegetables, low fat dairy products,dietary and soluble fibre, whole grains and protein from plant sources,low in saturated fat, cholesterol and salt in accordance with Canada'sGuide to Healthy Eating.

Regular physical activity: accumulation of 30-60 minutes of moderateintensity dynamic exercise 4-7 days per week in addition to dailyactivities

Low risk alcohol consumption (2 standard drinks/day and less than14/week for men and less than 9/week for women)

Attaining and maintaining ideal body weight (BMI 18.5-24.9 kg/m2)

W

aistC

ircumference MenW

omen Europid, Sub-Saharan African, Middle Eastern


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Dietary Sodium

Less than 2300mg / day

(Most of the salt in food is hidden and comesfrom processed food)

Dietary Potassium

Daily dietary intake >80 mmol

Calcium supplementation

No conclusive studies for hypertension

Magnesium supplementation

No conclusive studies for hypertension

Lifestyle Recommendations for Hypertension:Dietary

High in: Fresh fruits Fresh vegetables

Low fat dairy products Dietary and soluble fibre Plant protein

Low in:

Saturated fat and cholesterol Sodium

www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.


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Potential Benefits of a Wide Spread Reductionin Dietary Sodium in Canada

1 million fewer hypertensives

5 million fewer physicians visits a year for hypertension

Health care cost savings of $430 to 540 million per year relatedto fewer office visits, drugs and laboratory costs for hypertension

Improvement of the hypertension treatment and control rate

13% reduction in CVD

Total health care cost savings of over $1.3 billion/year

Penz ED, Cdn J Cardiol 2008.Joffres MR_CJC_ 23(6) 2007.

REDUCTION IN AVERAGE DIETARY SODIUM FROMABOUT 3500 MG TO 1700 MG


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Recommendations for daily salt intake

2,300 mg sodium (Na)

= 100 mmol sodium (Na)

= 5.8 g of salt (NaCl)

= 1 level teaspoon of

table salt

80% of average sodium intake is in processed foods

Only 10% is added at the table or in cooking

Age Recommended

Intake

19-50 1500

51-70 1300

71 and over 1200

Institute of Medicine, 2003


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Sodium: Meta-analyses

The Cochrane Library2006;3:1-41

Average Reduction of sodiumin mg/day

1800 mg/day

2300 mg/day

HypertensivesReduction of BP

5.1 / 2.7 mmHg

7.2/3.8 mmHg

Average Reduction of sodiumin mg/day

1700 mg/day

2300 mg/day

NormotensivesReduction of BP

2.0 / 1.0 mmHg

3.6/1.7 mmHg


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Important messages from past recommendations

High dietary sodium is estimated to increase blood pressure inthe Canadian population to the extent that 1,000,000 Canadiansmeet the diagnostic criteria for hypertension who wouldotherwise have normal blood pressure

Most of the sodium in Canadian diets comes from processedfoods and restaurants.

Pizza, breads, soups and sauces usually have high amounts ofsodium

Patient information on how to achieve a reduced sodium diet

can be found at www.hypertension.ca Aim to reduce sodium intake to less than 1500 mg/day to

prevent and control hypertension


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Reduce Your Sodium Intake

At home

Plan meals at least a day in advance.

Make more meals from unprocessed foods.

Gradually decrease the amount of salt used in cooking and atthe table (this includes sea salt).

Use condiments sparingly.

Flavour food with lemon juice, fresh garlic, spices, herbs andflavoured vinegars.

Try low-sodium seasoning mixes.

Cook and bake with vegetable oil rather than butter ormargarine.

Use tomato paste instead of tomato sauce or soup in recipes.


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At the grocery store

Buy pre-prepared, convenience foods that are low in sodiumsuch as frozen vegetables, frozen shrimp, skinless & bonelesschicken breasts and pre-cut salads and fruit.

Choose unsalted snack foods such as pretzels, nuts, seeds andcrackers.

Read food labels and compare sodium content between similarfoods

Look for foods labelled salt-free, no added salt, low in sodium,or reduced in sodium.

Always check the Nutrition Facts table


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When eating or taking out

Choose salads and meals made with foods low in sodium

Ask for no salt or MSG to be added during cooking

Ask for sauces, spreads or dressings on the side and usesparingly

Limit fast foods and take-out meals.


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Exercise should be prescribed as an adjunctive to pharmacological therapy

Lifestyle Recommendations for Hypertension:Physical Activity

Should be prescribed to reduce blood pressure

Frequency - Four to seven days per weekF

Intensity - ModerateI

Time - 30-60 minutesT

Type Cardiorespiratory Activity- Walking, jogging

- Cycling- Non-competitive swimming

T


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Lifestyle Recommendations for Hypertension:Weight Loss

Height, weight, and waist circumference (WC) should be measured

and body mass index (BMI) calculated for all adults.

Hypertensive and all patients

BMI over 25- Encourage weight reduction- Healthy BMI: 18.5-24.9 kg/m2

Waist Circumference Men Women- Europid, Sub-Saharan African, Middle Eastern


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Courtesy J.P. Desprs 2006

Measure here

Iliac crest

Waist Circumference Measurement


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Lifestyle Recommendations for Hypertension:Alcohol

Low risk alcohol consumption

Women: maximum of 9 standard drinks/week

Men: maximum of 14 standard drinks/week

0-2 standard drinks/day

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

Hypertensive patientsin whom stress appears to be an important issue

Individualized cognitive behavioural interventions aremore likely to be effective when relaxation techniques

are employed.

Stress management

Behaviour Modification


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Impact of Lifestyle Therapies on Blood Pressurein Hypertensive Adults

Intervention Intervention SBP/DBP

Reduce sodium intake-1800 mg/day sodium

Hypertensive

-5.1 / -2.7

Weight loss per kg lost -1.1 / -0.9

Alcohol intake -3.6 drinks/day -3.9 / -2.4

Aerobic exercise 120-150 min/week -4.9 / -3.7

Dietary patternsDASH diet

Hypertensive -11.4 / -5.5

Padwal R. et al. CMAJ SEPT. 27, 2005; 173 (7) 749-751


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Lifestyle Therapies in HypertensiveAdults: Summary

Intervention Target

Reduce foods withadded sodium

< 2300 mg /day

Weight loss BMI


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Epidemiologic impact on mortality of bloodpressure reduction in the population

Reduction in SBP(mmHg)

% Reduction in Mortality

Stroke CHD Total

2 -6 -4 -3

3 -8 -5 -4

5 -14 -9 -7

Adapted from Whelton, P. K. et al. JAMA 2002;288:1882-1888

AfterIntervention

BeforeIntervention

Reduction in BPPrevalence%


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V. Pharmacotherapy

2011 Canadian HypertensionE

ducationP

rogramRecommendations


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V. Choice of Pharmacological TreatmentUncomplicated

Associated risk factors?

or

Target organ damage/complications?

or

Concomitant diseases/conditions?

IndividualizedTreatment(and compelling

indications)

YES

Treatment in theabsence of compelling

indications for specific

therapies

NO


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V. Choice of Pharmacological Treatment

1. Treatment of Systolic/Diastolic hypertensionwithout other compelling indications

2. Treatment of Isolated Systolic hypertension without

other compelling indications


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V. Treatment of Adults with Systolic/DiastolicHypertension without Other Compelling Indications

TARGET 20

mmHg systolic or >10 mmHg diastolic above target


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V. Considerations Regarding the Choice ofFirst-Line Therapy

Use caution in initiating therapy with 2 drugs in whom adverseevents are more likely (e.g. frail elderly, those with posturalhypotension or who are dehydrated).

ACE inhibitors, renin inhibitors and ARBs are contraindicated inpregnancy and caution is required in prescribing to women of childbearing potential.

Beta adrenergic blockers are not recommended for patients age 60and over without another compelling indication.

Diuretic-induced hypokalemia should be avoided through the use ofpotassium sparing agents if required.

The use of dual therapy with an ACE inhibitor and an ARB should

only be considered in selected and closely monitored people withadvanced heart failure or proteinuric nephropathy.

ACE-inhibitors are not recommended (as monotherapy)for black patients without another compelling indication.


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V. Add-on Therapy for Systolic/DiastolicHypertension without Other Compelling Indications

IF BLOOD PRESSURE IS NOT

CONTROLLED CONSIDER Nonadherence Secondary HTN Interfering drugs or lifestyle White coat effect

If blood pressure is still not controlled, or there are adverse effects,

other classes of antihypertensive drugs may be combined (such as

alpha blockers or centrally acting agents).

2. Triple or Quadruple Therapy

1. Add-on Therapy

If partial response to monotherapy


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Drug Combinations

When combining drugs, use first-line therapies.

Two drug combinations of beta blockers, ACEinhibitors and angiotensin receptor blockers have notbeen proven to have additive hypotensive effects.

Therefore these potential two drug combinationsshould not be used unless there is a compelling (nonblood pressure lowering) indication

Combinations of an ACEI with an ARB do not reducecardiovascular events more than the ACEI alone andhave more adverse effects therefore are notgenerally recommended


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Drug Combinations contd

Caution should be exercised in combining a nondihydropyridine CCB and a beta blocker to reducethe risk of bradycardia or heart block.

Monitor serum creatinine and potassium when

combining K sparing diuretics, ACE inhibitors and/orangiotensin 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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Medication Use and BP Controlin ALLHAT

0

20

40

60

80

100

Baseline 6 mo 1 y 3 y 5 y

%

3 Drugs

2 Drugs

1 drug

% controlled-

Canadian sites

Cushman et al. J Clin Hypertens2002;4:393-404


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Ratio of Incremental SBP lowering effect atstandard dose Combine or Double?

1.04 1

1.16

0.891.01

0.19 0.23 0.2

0.37

0.22

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Thiazide -blocker ACE-I CCB All

Combine Double

Inc

remenalSBPr

ed

uctionratio

Ob

served/Expected

(additive)

Wald et al, Combination Versus Monotherapy for Blood Pressure Reduction,The American Journal of Medicine, Vol 122, No 3, March 2009


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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 bloodpressure lowering effects

Law. BMJ 2003


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V. Summary: Treatment of Systolic-DiastolicHypertension without Other Compelling Indications

CONSIDER

Nonadherence Secondary HTN Interfering drugs or

lifestyle White coat effect

Dual Combination

Triple or Quadruple

Therapy

Lifestyle modification

Thiazidediuretic

ACEILong-acting

CCBBeta-

blocker*

TARGET 20 mmHg systolicor>10 mmHg diastolic above target


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V. Treatment Algorithm for Isolated SystolicHypertension without Other Compelling Indications

INITIAL TREATMENT AND MONOTHERAPY

Thiazide

diuretic

Long-acting

DHPCCB


therapy

ARB

TARGET


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V. Add-on therapy for Isolated SystolicHypertension without Other Compelling Indications

CONSIDER

Nonadherence Secondary HTN Interfering drugs or


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).

If partial response to monotherapy

Long-acting

DHPCCB

Triple therapy

Thiazide

diureticARB

Dual combinationCombine first line agents


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V. Summary: Treatment of Isolated SystolicHypertension without Other Compelling Indications

CONSIDER

Nonadherence

Secondary HTN Interfering drugs or


Thiazidediuretic

Long-actingDHPCCB

Dual therapy

Triple therapy


therapy

ARB

TARGET


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Choice of Pharmacological Treatmentfor Hypertension

Individualized treatment

Compelling indications: Ischemic Heart Disease

Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI

Left Ventricular Systolic Dysfunction

Cerebrovascular Disease

Left Ventricular Hypertrophy Non Diabetic Chronic Kidney Disease

Renovascular Disease

Smoking

Diabetes Mellitus With Nephropathy

Without Nephropathy

Global Vascular Protection for Hypertensive Patients Statins if 3 or more additional cardiovascular risks

Aspirin once blood pressure is controlled


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VI. Treatment of Hypertension in Patients withIschemic 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) Dual therapy with an ACEI and an ARB are not recommended in the absence of

refractory heart failure The combination of an ACEi and CCB is preferred

1. Beta-blocker2. Long-acting CCB

Stable angina

ACEI are recommended for most

patients with establishedC

AD*ARBs are not inferior to ACEI in IHD

Short-actingnifedipine

*Those at low risk with well controlled risk factors may not benefit from ACEI therapy


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VI. Treatment of Hypertension in Patients with Recent STSegment Elevation-MI or non-ST Segment Elevation-MI

Long-acting

DihydropyridineCCB*

Beta-blocker

and ACEI or

ARB

Recent

myocardialinfarction

HeartFailure

?

NO

YES

Long-acting CCB

If beta-blockercontraindicated

or not effective

*Avoid non dihydropyridine CCBs (diltiazem, verapamil)


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VII. Treatment of Hypertension with LeftVentricular Systolic Dysfunction

Beta-blockers used in clinical trials were bisoprolol, carvedilol and metoprolol.

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

Systoliccardiac

dysfunction

ACEI and Beta blocker if ACEI intolerant: ARBTitrate doses of ACEI or ARB to those used in clinical trials

If ACEI and ARB are contraindicated: Hydralazine and Isosorbidedinitrate in combination

If additional antihypertensive therapy is needed:

ACEI / ARB Combination Long-acting DHP-CCB (Amlodipine)

NondihydropyridineCCB


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Viii. Treatment of Hypertension in Association With StrokeAcute Stroke: Onset to 72 Hours

Treat extreme BP elevation (systolic

> 220 mmHg, diastolic > 120 mmHg)

by 15-25% over the first 24 hour

with gradual reduction after.

If eligible for thrombolytic therapytreat very high BP (>185/110 mmHg)

Acute

ischemic

Stroke

Avoid excessive lowering of BP which can exacerbate ischemia


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VIII. Treatment of Hypertension in Association With StrokeAfter the acute Phase of Stroke or TIA

Strongly consider blood pressure reduction in all patients

after the acute phase of stroke or TIA .

Target BP < 140/90 mmHg

An ACEI / diuretic

combination is preferred

StrokeTIA

Combinations of an ACEI with an ARB are not recommended


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IX. Treatment of Hypertension in Patients withLeft Ventricular Hypertrophy

Hypertensive patients with left ventricular hypertrophy should

be treated with antihypertensive therapy to lower the rate of

subsequent cardiovascular events

Vasodilators:

Hydralazine, Minoxidil can increase LVH

Left ventricular

hypertrophy

- ACEI

- ARB,- CCB- Thiazide Diuretic- BB (if age below 60)*

X T f H i i P i i h


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X. Treatment of Hypertension in Patients withNon Diabetic Chronic Kidney Disease

Chronic kidney

disease and

proteinuria *

ACEI/ARB:Bilateral renalartery stenosis

ACEI or ARB (if ACEI tolerated)

Combination with other agents

Additive therapy: Thiazide diuretic.

Alternate: If volume overload: loop diuretic

Target BP: < 130/80 mmHg

* albumin:creatinine ratio [ACR] > 30 mg/mmol

orurinary protein > 500 mg/24hr

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB

Combinations of a ACEI and a ARB are specifically not recommended in the absence of proteinuria

XI T t t f H t i i P ti t ith


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XI. Treatment of Hypertension in Patients withRenovascular Disease

Close follow-up and intervention (angioplasty and stenting or surgery) should

be considered for patients with: uncontrolled hypertension despite therapywith three or more drugs, or deteriorating renal function, or bilateral

atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in asingle kidney), or recurrent episodes of flash pulmonary edema.

Does not imply specific

treatment choice

Renovascular

disease

Caution in the use of ACEI or ARB inbilateral renal artery stenosis orunilateral disease with solitary kidney


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XII. Treatment ofHypertension in association

with Diabetes Mellitus2011 Canadian Hypertension


XII T t t f H t i i i ti


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XII. Treatment of Hypertension in associationwith Diabetes Mellitus

Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg

with

Nephropathy*

*Urinary albumin to creatinine

ratio > 2.0 mg/mmol in men or

> 2.8mg/mmol in women*

Diabetes

without

Nephropathy**

Isolated

Systolic

Hypertension

Systolic-

diastolic

Hypertension

* based on at least 2 of 3 measurements

A combination of 2 first line drugs maybe considered as initial therapy if theblood pressure is >20 mmHg systolicor>10 mmHg diastolic above target

Combinations of an ACEI with an ARB are specifically

not recommended in the absence of proteinuria

XII T t t f H t i i i ti


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XII. Treatment of Hypertension in associationwith Diabetic Nephropathy

IfCreatinine over 150 mol/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

THRESHOLD equal or over 130/80 mmHg and TARGET below 130/80 mmHg

DIABETES

with

Nephropathy

ACE Inhibitor

or ARB

IF ACEI and ARB arecontraindicated or not

tolerated,SUBSTITUTE

Long-acting CCB or

Thiazide diuretic

Addition of one or more ofLong-acting CCB or Thiazidediuretic

3 - 4 drugs combination maybe needed

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB

2011 C di H t i Ed ti


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Important messages from past recommendations

Patients with diabetes are at high cardiovascular risk

Most patients with diabetes have hypertension

Treatment of hypertension in patients with diabetes reduces

total mortality, myocardial infarction, stroke, retinopathy andprogressive renal failure rates.

Treating hypertension in patients with diabetes reduces deathand disability and reduces health care system costs

In diabetes, TARGET


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XII. Treatment of Systolic-DiastolicHypertension without Diabetic Nephropathy

1. ACE Inhibitor or ARB or

2. Dihydropyridine CCB or

Thiazide diuretic

IF ACE Inhibitor and ARB andDHP-CCB and Thiazide arecontraindicated or nottolerated,

SUBSTITUTE

Cardioselective BB* or

Long-acting NON DHP-CCB

More than 3 drugs may be needed to reach target values for diabetic patients

* Cardioselective BB: Acebutolol, Atenolol, Bisoprolol , Metoprolol

Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg

Combination of first line

agents

Addition of one or more of:Cardioselective BB orLong-acting CCB

Diabetes

without

Nephropathy

DHP: dihydropyridine

Combinations of an ACE Inhibitor with an ARB are specifically not recommended in theabsence of proteinuria

ACCORD St d R lt d ti l f l k f


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ACCORD Study: Results and rational for lack ofimpact on BP recommendations

Overall BP study was neutral with no benefit of systolic target< 120 mmHg vs < 140 mmHg for primary outcome, yet:

Power issue: Annual rate of primary outcome 1.87% in theintensive arm versus 2.09% in the standard arm vs 4%/yearevent rate projected during sample size calculations

Significant interaction between BP and glycaemia controlstudies such that those in usual care glycaemia group (A1c7%+) had a significant improvement in primary outcome withlower BP target

Secondary outcome for stroke reduction showed a benefit forlower BP target

Therefore no clear evidence supporting a change in BP targetsfor people with diabetes at this point

ACCORD study NEJM 2010

XII Treatment of Hypertension in association


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XII. Treatment of Hypertension in associationwith Diabetes Mellitus: Summary

More than 3 drugs may be needed to reach target values for diabetic patients

If Creatinine over 150 mol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for athiazide diuretic if control of volume is desired

Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg

Diabetes

with

Nephropathy

> 2-drugcombinations

ACE Inhibitor

or ARB

without

Nephropathy

1. ACE Inhibitoror ARB

or

2. DHP-CCB orThiazidediuretic

Monitor serum potassium and creatinine carefully in patients withCKD prescribed an ACEI or ARB

Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria

A combination of 2 first linedrugs may be considered asinitial therapy if the bloodpressure is >20 mmHg systolicor >10 mmHg diastolic abovetarget. Combining an ACEi and

a DHP-CCB is recommended.

XIII Treatment of Hypertension for Patients


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The benefits of treating smokers with beta-

blockers remain uncertain in the absence of a

specific indication like angina or post-MI

Smoking Beta-blocker

XIII. Treatment of Hypertension for PatientsWho Use Tobacco

MRCWorking Party. MRC trial of treatment of mild hypertension: 1985 Jul 13;291(6488):97-104.


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XIV. Overall VascularProtection for Patients with

Hypertension2011 Canadian Hypertension


Most hypertensive Canadians have other


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Most hypertensive Canadians have othercardiovascular risks

Assess and manage hypertensive patients forsmoking, dyslipidemia and dysglycemia (impairedfasting glucose or diabetes) abdominal obesity,unhealthy eating and physical inactivity.

Discuss global risk using analogies that describecomparative risk such as Cardiovascular Age,Vascular Age or Heart Age to inform patients oftheir risk status and to improve the effectiveness of

risk factor modification.

XIV Vascular Protection for Hypertensive


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XIV. Vascular Protection for HypertensivePatients: Statins

In addition to currentCanadian recommendations on management

of dyslipidemia, statins are recommended in high-risk

hypertensive patients with established atherosclerotic disease

or with at least 3 of the following criteria:

Male

Age 55 or older

Smoking

Total-C/HDL-C ratio of 6mmol/L or higher

Family History of PrematureCV disease

LVH

ECG abnormalities

Microalbuminuria or Proteinuria

ASCOT-LLA Lancet 2003;361:1149-58

XIV Vascular Protection for Hypertensive


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XIV. Vascular Protection for HypertensivePatients: ASA

Consider low dose ASA

Caution should be exercised if BP is not controlled.

New Patient Resources For


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New Patient Resources ForHypertension On Line

www.hypertension.ca/tools - Download current resources for theprevention and control of hypertension

www.htnupdate.ca -To keep up to date with the latest evidence andresources

www.myBPsite.ca - Have your patients sign up to access the latest

hypertension resources www.lowersodium.ca - Tools and resources for healthcareprofessionals to use in educating other healthcare professionals, thepublic or patients about the risks of high dietary sodium in Canada.

www.sodium101.ca -To access a simple to use demonstration of foodsodium content for your patients

www.heartandstroke.ca/BP -To monitor home blood pressure andencourage self management of lifestyle

http://www.hypertension.qc.ca/ - Socit Qubcoise dhypertensionartrielle


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Public translation of CHEP recommendations

Hypertension recommendations for the public

Translated into 4 Indo-Asian languages (2007)

Based on CHEP guidelines (annually updated)

Download at www.hypertension.ca


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Sodium Slide Kit

Tool used to educate the public and patients ondietary sodium.

Annually updated.



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Brief Hypertension Action Tool

Can by used by a healthcare provider to better inform and engage a

hypertensive patient to ultimately become more active in their

care.

Involves 3 Action Tools:

Action Tool # 1 Explains High BP

Action Tool # 2 Self-management of

lifestyle

Action Tool # 3 Proper home measurement& information about medication


Measuring Blood Pressure the Right Way


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Measuring Blood Pressure the Right Way Poster

Posters (24 by 36)can be ordered fromour website.

Brief highlights:1. Preparing to taking your

blood pressure

2. Using endorsed BPdevices.



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Summary I

Regarding the treatment of hypertension, therecommendations endorse:

Know the current blood pressure of all your patients

Most Canadians will develop hypertension during their lives.

Routine assessment of blood pressure is required for earlydetection and risk management

Encourage the use of approved devices and propertechnique to measure blood pressure at home.

Most can assess blood pressure at home. Home measurement

can confirm a diagnosis of hypertension, improve adherence totherapy and control rates and detect patients with white coat ormasked hypertension.


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Summary II


Assess and manage CV risk in hypertensives

high dietary sodium intake, smoking, dyslipidemia,dysglycemia, abdominal obesity, unhealthy eating, and physical

inactivity.

LIFESTYLEMODIFICATION

Sustained lifestyle modification is the cornerstone for theprevention and control of hypertension and the management ofcardiovascular disease. Encourage patients to reduce theirsodium intake according to Health Canadas recommendations.


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Summary III


TREATING TO TARGET BP Treat blood pressure to less than


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For your patients ask themto sign up atwww.myBPsite.ca for freeaccess to the latestinformation & resources on

high blood pressure

For health care professionals sign up atwww.htnupdate.ca forautomatic updates and oncurrent hypertension

educational resources

Treatment En 2011 Final

Documents

Transcript of Treatment En 2011 Final