Upload
bashaby
View
216
Download
0
Embed Size (px)
Citation preview
8/3/2019 TreatmentEN_2012
1/78
Part 2: Recommendations for
Hypertension Treatment
2012 Canadian Hypertension
Education ProgramRecommendations
8/3/2019 TreatmentEN_2012
2/78
The full slide set of the2012 CHEP Recommendations
is available at
www.hypertension.ca
8/3/2019 TreatmentEN_2012
3/78
2012 Canadian Hypertension EducationProgram (CHEP)
A red flag has been posted whererecommendations were updated for 2012.
Slide kits for health care professional and publiceducation can be downloaded (English and Frenchversions) from www.hypertension.ca
8/3/2019 TreatmentEN_2012
4/78
Key CHEP Messages for theManagement of Hypertension
1. Assess blood pressure at all appropriate visits.
2. Maintaining a healthy lifestyle and weight lowers blood pressureand prevents hypertension. Promote: smoking cessation, healthydiet reducing dietary sodium and increased physical activity.
3. Lower blood pressure to
8/3/2019 TreatmentEN_2012
5/78
CHEP 2012 Recommendations
Whats new?
Out-of-office blood pressure measurements areimportant in both the diagnosis and management of
hypertension For patients with nondiabetic chronic kidney disease,
target blood pressure should be < 140/90 mmHg
For patients with systolic dysfunction and hypertension
ACE inhibitors, beta-blockers and (for most)aldosterone antagonists are recommended
8/3/2019 TreatmentEN_2012
6/78
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.hypertension.ca forautomatic updates and
information on currenthypertension educationalresources
8/3/2019 TreatmentEN_2012
7/78
The Canadian Hypertension EducationProgram: 2012 Recommendations
Whats still important?
Lifestyle changes are a critical component ofhypertension management and prevention
The most important step in prescription ofantihypertensive therapy is achieving patient buy-in
Single pill combinations help achieve blood pressurecontrol
The management of hypertension is all about globalcardiovascular risk management and vascularprotection
8/3/2019 TreatmentEN_2012
8/78
2012 Canadian Hypertension EducationProgram (CHEP)
Treatment Approaches:
Lifestyle
Pharmacological
8/3/2019 TreatmentEN_2012
9/78
Recommendations 2012Table of contents
I. Lifestyle ManagementII. Indications for drug therapyIII. Choice of therapyIV. Global vascular protectionV. Goal of therapy
VI. CV IHDVII. CHF
VIII. Cerebrovascular / StrokeIX. LVHX. Chronic kidney disease
XI. RenovascularXII. DiabetesXIII. Adherence strategies for patientsXIV.Endocrine
8/3/2019 TreatmentEN_2012
10/78
I. Lifestyle management
2012 Canadian Hypertension
Education ProgramRecommendations
8/3/2019 TreatmentEN_2012
11/78
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 lessthan 14/week for men and less than 9/week for women)
Attaining and maintaining ideal body weight (BMI 18.5-24.9 kg/m2)
Waist Circumference: Men
8/3/2019 TreatmentEN_2012
12/78
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.
8/3/2019 TreatmentEN_2012
13/78
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 related
to fewer office visits, drugs and laboratory costs for hypertension
Improvement of the hypertension treatment and control rate
13% reduction in CVD
Total health care cost savings of over $1.3 billion/year
1. Penz ED, Cdn J Cardiol 2008.2. Joffres MR_CJC_ 23(6) 2007.
Reduction in average dietary sodium from about3500 mg to 1700 mg1,2
8/3/2019 TreatmentEN_2012
14/78
Recommendations for adequate daily sodium 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 Adequate
Intake
(mg)
Upper
Limit
(mg)
19-50 1500 2300
51-70 1300 2300
71 and
over
1200 2300
Institute of Medicine, 2003
8/3/2019 TreatmentEN_2012
15/78
Sodium: Meta-analyses
The Cochrane Library2006;3:1-41
Average Reduction of sodiumin mg/day
1800 mg/day
2300 mg/day
Hypertensives
Reduction of BP
5.1 / 2.7 mmHg
7.2/3.8 mmHg
Average Reduction of sodiumin mg/day
1700 mg/day
2300 mg/day
Normotensives
Reduction of BP
2.0 / 1.0 mmHg
3.6/1.7 mmHg
8/3/2019 TreatmentEN_2012
16/78
2012 Canadian Hypertension EducationProgram (CHEP)
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 dietary sodium intake to prevent and controlhypertension
8/3/2019 TreatmentEN_2012
17/78
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
8/3/2019 TreatmentEN_2012
18/78
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
BMIover 25- Encourage weight reduction
- Healthy BMI: 18.5-24.9 kg/m2
Waist CircumferenceMen
8/3/2019 TreatmentEN_2012
19/78
Courtesy J.P. Desprs 2006
Measure here
Iliac crest
Waist Circumference Measurement
8/3/2019 TreatmentEN_2012
20/78
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).
8/3/2019 TreatmentEN_2012
21/78
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
8/3/2019 TreatmentEN_2012
22/78
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
8/3/2019 TreatmentEN_2012
23/78
Lifestyle Therapies in Adults with Hypertension:Summary
Intervention Target
Reduce foods withadded sodium
< 2300 mg /day
Weight loss BMI
8/3/2019 TreatmentEN_2012
24/78
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%
8/3/2019 TreatmentEN_2012
25/78
II. Indications for
Pharmacotherapy
2012 Canadian Hypertension
Education ProgramRecommendations
8/3/2019 TreatmentEN_2012
26/78
II. 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
ChronicK
idney Disease
u130/80
u
140/90
8/3/2019 TreatmentEN_2012
27/78
II. 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 140/90 mmHg
8/3/2019 TreatmentEN_2012
28/78
II. 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. Healthcare professionals need to be aware of this importantcare gap and recommend pharmacotherapy.
8/3/2019 TreatmentEN_2012
29/78
III. Choice of pharmacological
therapy
2012 Canadian Hypertension
Education ProgramRecommendations
8/3/2019 TreatmentEN_2012
30/78
III. 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
8/3/2019 TreatmentEN_2012
31/78
III. Choice of Pharmacological Treatment
1. Treatment of Systolic/Diastolic hypertensionwithout other compelling indications
2. Treatment of Isolated Systolic hypertension without
other compelling indications
8/3/2019 TreatmentEN_2012
32/78
III. Treatment of Adults with Systolic/DiastolicHypertension without Other Compelling Indications
TARGET 20
mmHg systolic or >10 mmHg diastolic above target
8/3/2019 TreatmentEN_2012
33/78
III. 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 blockers are not recommended as first line therapy for patientsage 60 and 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.
8/3/2019 TreatmentEN_2012
34/78
III. Add-on Therapy for Systolic/DiastolicHypertension without Other Compelling Indications
IF BLOOD PRESSUREIS 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
8/3/2019 TreatmentEN_2012
35/78
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
8/3/2019 TreatmentEN_2012
36/78
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 whencombining K sparing diuretics (such as aldosteroneantagonists), ACE inhibitors and/or angiotensinreceptor blockers.
If a diuretic is not used as first or second line therapy,
triple dose therapy should include a diuretic, whennot contraindicated.
8/3/2019 TreatmentEN_2012
37/78
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
8/3/2019 TreatmentEN_2012
38/78
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
eductionratio
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
8/3/2019 TreatmentEN_2012
39/78
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
8/3/2019 TreatmentEN_2012
40/78
III. 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
8/3/2019 TreatmentEN_2012
41/78
III. Treatment Algorithm for Isolated SystolicHypertension without Other Compelling Indications
INITIAL TREATMENT AND MONOTHERAPY
Thiazide
diuretic
Long-acting
DHPCCB
Lifestyle modification
therapy
ARB
TARGET
8/3/2019 TreatmentEN_2012
42/78
III. Add-on therapy for Isolated SystolicHypertension without Other Compelling Indications
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 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
8/3/2019 TreatmentEN_2012
43/78
III. Summary: Treatment of Isolated SystolicHypertension without Other Compelling Indications
CONSIDER
Nonadherence
Secondary HTN Interfering drugs or
lifestyle White coat effect
Thiazidediuretic
Long-actingDHPCCB
Dual therapy
Triple therapy
Lifestyle modification
therapy
ARB
TARGET
8/3/2019 TreatmentEN_2012
44/78
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
8/3/2019 TreatmentEN_2012
45/78
IV. Global Vascular Protection
for Patients with Hypertension
2012 Canadian Hypertension
Education ProgramRecommendations
8/3/2019 TreatmentEN_2012
46/78
IV. 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 6
mmol/L or higher
Family History of PrematureCV disease
LVH
ECG abnormalities
Microalbuminuria or Proteinuria
ASCOT-LLA Lancet 2003;361:1149-58
8/3/2019 TreatmentEN_2012
47/78
IV. Vascular Protection for HypertensivePatients: ASA
Consider low dose ASA
Caution should be exercised if BP is not controlled.
8/3/2019 TreatmentEN_2012
48/78
V. Goals of Therapy
2012 Canadian Hypertension
Education ProgramRecommendations
8/3/2019 TreatmentEN_2012
49/78
49
Blood pressure target values for treatment of hypertensionCondition Target
SBP and DBP mmHg
Isolated systolic hypertension
8/3/2019 TreatmentEN_2012
50/78
V. Goals of Therapy
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
8/3/2019 TreatmentEN_2012
51/78
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
8/3/2019 TreatmentEN_2012
52/78
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 established CAD*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
8/3/2019 TreatmentEN_2012
53/78
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-actingCCB
If beta-blockercontraindicated
or not effective
*Avoid non dihydropyridine CCBs (diltiazem, verapamil)
8/3/2019 TreatmentEN_2012
54/78
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)
forCHF classII-IV
or post MIand selected patients with L
V
dysfunction (see notes): 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
8/3/2019 TreatmentEN_2012
55/78
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
8/3/2019 TreatmentEN_2012
56/78
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 orTIA .
Target BP < 140/90 mmHg
An ACEI / diuretic
combination is preferred
StrokeTIA
Combinations of an ACEI with an ARB are not recommended
8/3/2019 TreatmentEN_2012
57/78
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)*
8/3/2019 TreatmentEN_2012
58/78
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: < 140/90 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
8/3/2019 TreatmentEN_2012
59/78
XI. Treatment of Hypertension in Patients withRenovascular Disease
Close follow-up and intervention (angioplasty and stenting or surgery) shouldbe considered for patients with: uncontrolled hypertension despite therapy
with three or more drugs, or deteriorating renal function, or bilateralatherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a
single 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
8/3/2019 TreatmentEN_2012
60/78
XII. Treatment ofHypertension in association
with Diabetes Mellitus2012 Canadian Hypertension
Education ProgramRecommendations
XII T f H i i i i
8/3/2019 TreatmentEN_2012
61/78
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
8/3/2019 TreatmentEN_2012
62/78
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
ACEInhibitor
or ARB
IF ACEI and ARB arecontraindicated or not
tolerated,SUBSTITUTE
Long-actingCCB 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
2012 C di H t i Ed ti
8/3/2019 TreatmentEN_2012
63/78
2012 Canadian Hypertension EducationProgram (CHEP)
Important messages from past recommendations
Patients with diabetes are at high cardiovascular risk
Most patients with diabetes have hypertension
Treatment of hypertension in patients with diabetes reducestotal 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
8/3/2019 TreatmentEN_2012
64/78
XII. Treatment of Systolic-DiastolicHypertension without Diabetic Nephropathy
1. ACEInhibitor or ARB or
2. Dihydropyridine CCB or
Thiazide diuretic
IFACEInhibitor and ARB andDHP-CCB and Thiazide arecontraindicated or nottolerated,
SUBSTITUTE
Cardioselective BB* or
Long-actingNON 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 ACEInhibitor with an ARB are specifically not recommended in theabsence of proteinuria
ACCORD St d R lt d ti l f l k
8/3/2019 TreatmentEN_2012
65/78
ACCORD Study: Results and rationale for lackof impact 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 (41% RRR)
Therefore no clear evidence supporting a change in BP targetsfor people with diabetes at this point
ACCORD study NEJM 2010
XII T t t f H t i i i ti
8/3/2019 TreatmentEN_2012
66/78
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
ACEInhibitor
or ARB
without
Nephropathy
1. ACEInhibitoror ARB
or
2. DHP-CCB orThiazidediuretic
Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria
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.
8/3/2019 TreatmentEN_2012
67/78
XIII. Adherence
2012 Canadian HypertensionEducation Program
Recommendations
XIII Adh t ti h t i t
8/3/2019 TreatmentEN_2012
68/78
XIII. 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. brushingteeth.
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!
XIII Adherence to anti hypertensive management
8/3/2019 TreatmentEN_2012
69/78
XIII. 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 theirdisease/treatment regimens verbally and in writing
Use an interdisciplinary care approach coordinatingwith work-site health care givers and pharmacists ifavailable
New Patient Resources for
8/3/2019 TreatmentEN_2012
70/78
New Patient Resources forHypertension Online
www.hypertension.ca/tools - Download current resources for the prevention andcontrol of hypertension
www.myBPsite.ca - Have your patients sign up to access the latest hypertensionresources
www.lowersodium.ca - Tools and resources for healthcare professionals to use ineducating other healthcare professionals, the public or patients about the risks of high
dietary sodium in Canada. www.sodium101.ca -To access a simple to use demonstration of food sodium content
for your patients
www.c-changeprogram.ca -To learn more about the harmonized recommendationsfor CVD prevention and treatment
www.heartandstroke.ca/BP -To monitor home blood pressure and encourage selfmanagement of lifestyle
www.canadianstrokenetwork.ca Download current resources to support bestpractice recommendations for stroke care
http://www.hypertension.qc.ca/ - Socit Qubcoise dhypertension artrielle
8/3/2019 TreatmentEN_2012
71/78
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
8/3/2019 TreatmentEN_2012
72/78
Sodium Slide Kit
Tool used to educate the public and patients ondietary sodium.
Annually updated.
Download at www.hypertension.ca
8/3/2019 TreatmentEN_2012
73/78
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
Download at www.hypertension.ca
Measuring Blood Pressure the Right Way
8/3/2019 TreatmentEN_2012
74/78
Measuring Blood Pressure the Right Way Poster
Pocket cards can beordered from ourwebsite.
Brief highlights:1. Preparing to taking your
blood pressure
2. Using endorsed BPdevices.
Download at www.hypertension.ca
8/3/2019 TreatmentEN_2012
75/78
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.
8/3/2019 TreatmentEN_2012
76/78
Summary II
Regarding the treatment of hypertension, therecommendations endorse:
Assess and manage CV risk in hypertensives
high dietary sodium intake, smoking, dyslipidemia,dysglycemia, abdominal obesity, unhealthy eating, and physical
inactivity.
LIFESTYLE MODIFICATION
Sustained lifestyle modification is the cornerstone for theprevention and control of hypertension and the management ofcardiovascular disease. Encourage patients to reduce theirsodium intake according to Health Canadas recommendations.
8/3/2019 TreatmentEN_2012
77/78
Summary III
Regarding the treatment of hypertension, therecommendations endorse:
TREATING TO TARGET BP Treat blood pressure to less than
8/3/2019 TreatmentEN_2012
78/78
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.hypertension.ca forautomatic updates and oncurrent hypertension
educational resources