Diagnosis and assessment
Prevention and treatment
|Grade A||Recommendations are based on randomized trials (or systematic reviews of trials) with high levels of internal validity and statistical precision, and for which the study results can be directly applied to patients because of similar clinical characteristics and the clinical relevance of the study outcomes.|
|Grade B||Recommendations are based on randomized trials, systematic reviews or pre-specified subgroup analyses of randomized trials that have lower precision, or there is a need to extrapolate from studies because of differing populations or reporting of validated intermediate/surrogate outcomes rather than clinically important outcomes.|
|Grade C||Recommendations from trials that have lower levels of internal validity and/or precision, or report unvalidated surrogate outcomes, or results from nonrandomized observational studies.|
|Grade D||Recommendations are based on expert opinion alone.|
The 2012 CHEP Diagnosis and Assessment Recommendations
I. Accurate measurement of BP
- 1Health care professionals who have been specifically trained to measure BP accurately should assess BP in all adult patients at all appropriate visits to determine cardiovascular risk and monitor antihypertensive treatment (Grade D).
- 2Use of standardized measurement techniques (see Supplemental Table S1) is recommended when assessing BP (Grade D).
- 3Automated office BP measurements (OBPM) can be used in the assessment of office BP (Grade D).
- 4When used in proper conditions, automated office systolic BP (SBP) of ≥ 135 mm Hg or diastolic BP (DBP) of ≥ 85 mm Hg should be considered analogous to mean awake ambulatory SBP of ≥ 135 mm Hg and DBP of ≥ 85 mm Hg, respectively (Grade D).
II. Criteria for diagnosis of hypertension and recommendations for follow-up (Fig. 1)
- 1At initial presentation, patients demonstrating features of a hypertensive urgency or emergency (Table 2) should be diagnosed as hypertensive and require immediate management (Grade D).Table 2Examples of hypertensive urgencies and emergenciesReprinted with permission of the Canadian Hypertension Education Program.
Asymptomatic diastolic BP ≥ 130 mm Hg Severe elevation of BP in the setting of any of: Hypertensive encephalopathy Acute aortic dissection Acute left ventricular failure Acute coronary syndrome Acute kidney injury Intracranial hemorrhage Acute ischemic stroke Eclampsia of pregnancyBP, blood pressure.
- 2If SBP is ≥ 140 mm Hg and/or DBP is ≥ 90 mm Hg, a specific visit should be scheduled for the assessment of hypertension (Grade D). If BP is high-normal (SBP 130-139 mm Hg and/or DBP 85-89 mm Hg), annual follow-up is recommended (Grade C).
- 3At the initial visit for the assessment of hypertension, if SBP is ≥ 140 and/or DBP is ≥ 90 mm Hg, more than 2 additional readings should be taken during the same visit using a validated device and according to the recommended procedure for accurate BP determination (see Supplemental Table S1). The first reading should be discarded and the latter 2 readings averaged. A history and physical examination should be performed and, if clinically indicated, diagnostic tests to search for target organ damage (Table 3) and associated cardiovascular risk factors (Table 4) should be arranged within 2 visits. Exogenous factors that can induce or aggravate hypertension should be assessed and removed if possible (Table 5). Visit 2 should be scheduled within 1 month (Grade D).Table 3Examples of target organ damageReprinted with permission of the Canadian Hypertension Education Program.
Cerebrovascular disease Stroke Ischemic stroke and transient ischemic attack Intracerebral hemorrhage Aneurysmal subarachnoid hemorrhage Dementia Vascular dementia Mixed vascular dementia and dementia of the Alzheimer's type Hypertensive retinopathy Left ventricular dysfunction Left ventricular hypertrophy Coronary artery disease Myocardial infarction Angina pectoris Congestive heart failure Renal disease Chronic kidney disease (GFR < 60 mL per minute per 1.73 m2) Albuminuria Peripheral artery disease Intermittent claudicationGFR, glomerular filtration rate.Table 4Examples of key cardiovascular risk factors for atherosclerosisReprinted with permission of the Canadian Hypertension Education Program. Nonmodifiable Age ≥ 55 years Male Family history of premature cardiovascular disease (age < 55 in men and < 65 in women) Modifiable Sedentary lifestyle Poor dietary habits Abdominal obesity Dysglycemia Smoking Dyslipidemia Stress NonadherencePrior history of clinically overt atherosclerotic disease indicates a very high risk for a recurrent atherosclerotic event (eg, peripheral arterial disease, previous stroke, or transient ischemic attack).Table 5Examples of exogenous factors that can induce/aggravate hypertensionReprinted with permission of the Canadian Hypertension Education Program. Prescription drugs NSAIDs, including coxibs Corticosteroids and anabolic steroids Oral contraceptive and sex hormones Vasoconstricting/sympathomimetic decongestants Calcineurin inhibitors (cyclosporin, tacrolimus) Erythropoietin and analogues Antidepressants: MAOIs, SNRIs, SSRIs Midodrine Other substances Licorice root Stimulants including cocaine Salt Excessive alcohol useMAOIs, monoamine oxidase inhibitors; NSAIDs, nonsteroidal anti-inflammatory drugs; SNRIs, serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors.
- 4At visit 2 for the assessment of hypertension, patients with macrovascular target organ damage, diabetes mellitus, or CKD (glomerular filtration rate [GFR] < 60 mL per minute per 1.73m2) can be diagnosed as hypertensive if SBP is ≥ 140 mm Hg and/or DBP is ≥ 90 mm Hg (Grade D).
- 5At visit 2 for the assessment of hypertension, patients without macrovascular target organ damage, diabetes mellitus, or CKD can be diagnosed as hypertensive if the SBP is ≥ 180 mm Hg and/or the DBP is ≥ 110 mm Hg (Grade D). Patients without macrovascular target organ damage, diabetes mellitus, or CKD but with lower BP levels should undergo further evaluation using any of the 3 approaches outlined next:
- iOBPM: Using manual OBPM, patients can be diagnosed as hypertensive if the SBP is ≥ 160 mm Hg or the DBP is ≥ 100 mm Hg averaged across the first 3 visits, or if the SBP averages ≥ 140 mm Hg or the DBP averages ≥ 90 mm Hg averaged across 5 visits (Grade D).
- iiABPM: Using ABPM (see Recommendation in section VIII. ABPM), patients can be diagnosed as hypertensive if the mean awake SBP is ≥ 135 mm Hg or the DBP is ≥ 85 mm Hg or if the mean 24-hour SBP is ≥ 130 mm Hg or the DBP is ≥ 80 mm Hg (Grade C).
- iiiHome BP monitoring (HBPM): Using HBPM (see Recommendation in section VII. HBPM), patients can be diagnosed as hypertensive if the average SBP is ≥ 135 mm Hg or the DBP is ≥ 85 mm Hg (Grade C). If the average HBPM is < 135/85 mm Hg, it is advisable to either repeat home monitoring to confirm the HBPM is < 135/85 mm Hg or perform 24-hour ABPM to confirm that the mean 24-hour ABPM is < 130/80 mm Hg and the mean awake ABPM is < 135/85 mm Hg before diagnosing white coat hypertension (Grade D).
- 6Investigations for secondary causes of hypertension should be initiated in patients with suggestive clinical and/or laboratory features (outlined later) (Grade D).
- 7If at the last diagnostic visit the patient is not diagnosed as hypertensive and has no evidence of macrovascular target organ damage, the patient's BP should be assessed at yearly intervals (Grade D).
- 8Hypertensive patients receiving lifestyle modification advice alone (nonpharmacological treatment) should be followed up at 3- to 6-month intervals. Shorter intervals (every 1 or 2 months) are needed for patients with higher BP (Grade D).
- 9Patients given antihypertensive drug treatment should be seen monthly or every 2 months, depending on the level of BP, until readings on 2 consecutive visits are below their target (Grade D). Shorter intervals between visits will be needed for symptomatic patients and those with severe hypertension, intolerance to antihypertensive drugs, or target organ damage (grade D). When the target BP has been reached, patients should be seen at 3- to 6-month intervals (grade D).
III. Assessment of overall cardiovascular risk in hypertensive patients
- 1Global cardiovascular risk should be assessed. Multifactorial risk assessment models can be used to predict more accurately an individual's global cardiovascular risk (Grade A) and to use antihypertensive therapy more efficiently (Grade D). In the absence of Canadian data to determine the accuracy of risk calculations, avoid using absolute levels of risk to support treatment decisions (Grade C).
- 2Consider informing patients of their global risk to improve the effectiveness of risk factor modification (Grade B). Consider also using analogies that describe comparative risk such as “cardiovascular age,” “vascular age,” or “heart age” to inform patients of their risk status (Grade B).
IV. Routine and optional laboratory tests for the investigation of patients with hypertension
- 1Routine laboratory tests that should be performed for the investigation of all patients with hypertension include the following:
- iUrinalysis (Grade D);
- iiBlood chemistry (potassium, sodium, and creatinine) (Grade D);
- iiiFasting blood glucose (Grade D);
- ivFasting serum total cholesterol and high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides (Grade D);
- vStandard 12-lead electrocardiography (Grade C).
- 2Assess urinary albumin excretion in patients with diabetes (Grade D).
- 3All treated hypertensive patients should be monitored according to the current Canadian Diabetes Association guidelines for the new appearance of diabetes (Grade B).
- 4During the maintenance phase of hypertension management, tests (including those for electrolytes, creatinine, and fasting lipids) should be repeated with a frequency reflecting the clinical situation (Grade D).
V. Assessment for renovascular hypertension
- 1Patients presenting with ≥ 2 of the clinical clues listed next, suggesting renovascular hypertension, should be investigated (Grade D):
- iSudden onset or worsening of hypertension and age > 55 or < 30 years;
- iiPresence of an abdominal bruit;
- iiiHypertension resistant to ≥ 3 drugs;
- ivRise in serum creatinine level ≥30% associated with use of an angiotensin-converting enzyme (ACE) inhibitor or ARB;
- vOther atherosclerotic vascular disease, particularly in patients who smoke or have dyslipidemia;
- viRecurrent pulmonary edema associated with hypertensive surges. When available, the following tests are recommended to aid in the usual screening for renal vascular disease: captopril-enhanced radioisotope renal scan, Doppler sonography, magnetic resonance angiography, and computed tomography angiography (for those with normal renal function) (Grade B). Captopril-enhanced radioisotope renal scan is not recommended for those with CKD (GFR < 60 mL per minute per 1.73m2) (Grade D).
VI. Endocrine hypertension
- 1Screening for hyperaldosteronism should be considered for the following patients (Grade D):
- iHypertensive patients with spontaneous hypokalemia (K+ < 3.5 mmol/L);
- iiHypertensive patients with marked diuretic-induced hypokalemia (K+ < 3.0 mmol/L);
- iiiPatients with hypertension refractory to treatment with ≥ 3 drugs;
- ivHypertensive patients found to have an incidental adrenal adenoma.
- 2Screening for hyperaldosteronism should include assessment of plasma aldosterone and plasma renin activity (Supplemental Table S2).
- 3For patients with suspected hyperaldosteronism (on the basis of the screening test, Supplemental Table S2, Item 3), a diagnosis of primary aldosteronism should be established by demonstrating inappropriate autonomous hypersecretion of aldosterone using at least one of the manoeuvres listed in Supplemental Table S2, Item 4. When the diagnosis is established, the abnormality should be localized using any of the tests described in Supplemental Table S2, Item 5.
B. Pheochromocytoma: screening and diagnosis
- 1If pheochromocytoma is strongly suspected, the patient should be referred to a specialized hypertension centre, particularly if biochemical screening tests (Supplemental Table S3) have already been found to be positive (Grade D).
- 2The following patients should be considered for screening for pheochromocytoma (Grade D):
- iPatients with paroxysmal and/or severe (BP ≥ 180/110 mm Hg) sustained hypertension refractory to usual antihypertensive therapy;
- iiPatients with hypertension and multiple symptoms suggestive of catecholamine excess (eg, headaches, palpitations, sweating, panic attacks, and pallor);
- iiiPatients with hypertension triggered by β-blockers, monoamine oxidase inhibitors, micturition, or changes in abdominal pressure;
- ivPatients with incidentally discovered adrenal mass and patients with hypertension and multiple endocrine neoplasia 2A or 2B, von Recklinghausen's neurofibromatosis, or von Hippel-Lindau disease;
- vFor patients with positive biochemical screening tests, localization of pheochromocytomas should involve the use of magnetic resonance imaging (preferable), computed tomography (if magnetic resonance imaging unavailable), and/or iodine I-131 meta-iodobenzylguanidine scintigraphy (Grade C for each modality).
- 1HBPM can be used in the diagnosis of hypertension (Grade C).
- 2The use of HBPM on a regular basis should be considered for patients with hypertension, particularly those with:
- iDiabetes mellitus (Grade D);
- iiCKD (Grade C);
- iiiSuspected nonadherence (Grade D);
- ivDemonstrated white coat effect (Grade C);
- vBP controlled in the office but not at home (masked hypertension) (Grade C).
- 3When white coat hypertension is suggested by HBPM, its presence should be confirmed by repeat HBPM (see Recommendation 8) or ABPM before treatment decisions are made (Grade D).
- 4Patients should be advised to purchase and use only HBPM devices that are appropriate for the individual and have met standards of the Association for the Advancement of Medical Instrumentation, the most recent requirements of the British Hypertension Society protocol, or the International Protocol for validation of automated BP measuring devices. Patients should be encouraged to use devices with data recording capabilities or automatic data transmission to increase the reliability of reported HBPM (Grade D).
- 5Home SBP values ≥ 135 mm Hg or DBP values ≥ 85 mm Hg should be considered elevated and associated with an increased overall mortality risk analogous to office SBP readings of ≥ 140 mm Hg or DBP ≥ 90 mm Hg (Grade C).
- 6Health care professionals should ensure that patients who measure their BP at home have adequate training and, if necessary, repeat training in measuring their BP. Patients should be observed to determine that they measure BP correctly and should be given adequate information about interpreting these readings (Grade D).
- 7The accuracy of all individual patients' validated devices (including electronic devices) must be regularly checked against a device of known calibration (Grade D).
- 8HBPM for assessing white coat hypertension or sustained hypertension should be based on duplicate measures, morning and evening, for an initial 7-day period. First-day home BP values should not be considered (Grade D).
- 1BP monitoring can be used in the diagnosis of hypertension (Grade C). ABPM should be considered when an office-induced increase in BP is suspected in treated patients with:
- iBP that is not below target despite receiving appropriate chronic antihypertensive therapy (Grade C);
- iiSymptoms suggestive of hypotension (Grade C);
- iiiFluctuating office BP readings (Grade D).
- 2Physicians should use only ABPM devices that have been validated independently using established protocols (Grade D).
- 3Therapy adjustment should be considered in patients with a mean 24-hour ambulatory SBP of ≥ 130 mm Hg or DBP of ≥ 80 mm Hg or a mean awake SBP of ≥ 135 mm Hg or DBP of ≥ 85 mm Hg (Grade D).
- 4The magnitude of changes in nocturnal BP should be taken into account in any decision to prescribe or withhold drug therapy based upon ABPM (Grade C) because a decrease in nocturnal BP of < 10% is associated with increased risk of cardiovascular events.
IX. Role of echocardiography
- 1Routine echocardiographic evaluation of all hypertensive patients is not recommended (Grade D).
- 2An echocardiogram for assessment of left ventricular hypertrophy is useful in selected cases to help define the future risk of cardiovascular events (Grade C).
- 3Echocardiographic assessment of left ventricular mass, as well as of systolic and diastolic left ventricular function is recommended for hypertensive patients suspected to have left ventricular dysfunction or coronary artery disease (Grade D).
- 4Patients with hypertension and evidence of heart failure should have an objective assessment of left ventricular EF, either by echocardiogram or nuclear imaging (Grade D).
The CHEP 2012 Prevention and Treatment Recommendations
I. Lifestyle management
- 1For nonhypertensive individuals (to reduce the possibility of becoming hypertensive) or for hypertensive patients (to reduce their BP), prescribe the accumulation of 30-60 minutes of moderate intensity dynamic exercise (eg, walking, jogging, cycling or swimming) 4-7 days per week in addition to the routine activities of daily living (Grade D). Higher intensities of exercise are not more effective (Grade D).
- 1Height, weight, and waist circumference should be measured, and body mass index calculated for all adults (Grade D).
- 2Maintenance of a healthy body weight (body mass index 18.5 to 24.9, and waist circumference < 102 cm for men and < 88 cm for women) is recommended for nonhypertensive individuals to prevent hypertension (Grade C) and for hypertensive patients to reduce BP (Grade B). All overweight hypertensive individuals should be advised to lose weight (Grade B).
- 3Weight loss strategies should employ a multidisciplinary approach that includes dietary education, increased physical activity, and behavioural intervention (Grade B).
- 1To reduce BP, alcohol consumption should be in accordance with Canadian low-risk drinking guidelines in both normotensive and hypertensive individuals. Healthy adults should limit alcohol consumption to ≤ 2 drinks per day, and consumption should not exceed 14 standard drinks per week for men and 9 standard drinks per week for women (Grade B). (Note: One standard drink is considered to be equivalent of 13.6 g or 17.2 mL of ethanol or approximately 44 mL [1.5 oz] of 80 proof [40%] spirits, 355 mL [12 oz] of 5% beer, or 148 mL [5 oz] of 12% wine).
- 1It is recommended that hypertensive patients and normotensive individuals at increased risk of developing hypertension consume a diet that emphasizes fruits, vegetables, low-fat dairy products, dietary and soluble fibre, whole grains, and protein from plant sources that is reduced in saturated fat and cholesterol (Dietary Approaches to Stop Hypertension [DASH] diet41,42,43,44) (Supplemental Table S4) (Grade B).
- 1For prevention and treatment of hypertension, a dietary sodium intake of 1500 mg (65 mmol) per day is recommended for adults aged ≤50 years; 1300 mg (57 mmol) per day for age 51-70 years; and 1200 mg (52 mmol) per day for age > 70 years (Grade B).
- 1Supplementation of potassium, calcium, and magnesium is not recommended for the prevention or treatment of hypertension (Grade B).
- 1In hypertensive patients in whom stress may be contributing to BP elevation, stress management should be considered as an intervention (Grade D). Individualized cognitive-behavioural interventions are more likely to be effective when relaxation techniques are used (Grade B).
II. Indications for drug therapy for adults with hypertension without compelling indications for specific agents
- 1Antihypertensive therapy should be prescribed for average DBP measurements of ≥ 100 mm Hg (Grade A) or average SBP measurements of ≥ 160 mm Hg (Grade A) in patients without macrovascular target organ damage or other cardiovascular risk factors.
- 2Antihypertensive therapy should be strongly considered if DBP readings average ≥ 90 mm Hg in the presence of macrovascular target organ damage or other independent cardiovascular risk factors (Grade A).
- 3Antihypertensive therapy should be strongly considered if SBP readings average ≥ 140 mm Hg in the presence of macrovascular target organ damage (Grade C for 140-160 mm Hg; Grade A for > 160 mm Hg).
- 4Antihypertensive therapy should be considered in all patients meeting the above indications regardless of age (Grade B). Caution should be exercised in elderly patients who are frail.
III. Choice of therapy for adults with hypertension without compelling indications for specific agents
- 1Initial therapy should be monotherapy with a thiazide diuretic (Grade A), a β-blocker (in patients younger than 60 years, Grade B), an ACE inhibitor (in nonblack patients, Grade B), a long-acting calcium channel blocker (CCB) (Grade B); or an ARB (Grade B). If there are adverse effects, another drug from this group should be substituted. Hypokalemia should be avoided in patients treated with thiazide diuretic monotherapy (Grade C).
- 2Additional antihypertensive drugs should be used if target BP levels are not achieved with standard-dose monotherapy (Grade B). Add-on drugs should be chosen from first-line choices. Useful choices include a thiazide diuretic or CCB with either: ACE inhibitor, ARB, or β-blocker (Grade B for the combination of thiazide diuretic and a dihydropyridine CCB; Grade C for the combination of dihydropyridine CCB and ACE inhibitor; and Grade D for all other combinations). Caution should be exercised in combining a nondihydropyridine CCB and a β-blocker (Grade D). The combination of an ACE inhibitor and an ARB is not recommended (Grade A).
- 3Combination therapy using 2 first-line agents may also be considered as initial treatment of hypertension (Grade C) if SBP is 20 mm Hg above target or if DBP is 10 mm Hg above target. However, caution should be exercised in patients in whom a substantial fall in BP from initial combination therapy is more likely to occur or in whom it would be poorly tolerated (eg, elderly patients).
- 4If BP is still not controlled with a combination of 2 or more first-line agents, or there are adverse effects, other antihypertensive drugs may be added (Grade D).
- 5Possible reasons for poor response to therapy (Table 6) should be considered (Grade D).Table 6Possible reasons for poor response to antihypertensive therapyAdapted from McAlister et al.45
Noncompliance Dietary Medication Associated conditions Obesity Cigarette smoking Excessive alcohol consumption Sleep apnea Chronic pain Drug interactions Nonsteroidal anti-inflammatory drugs (including cyclo-oxygenase-2 inhibitors) Oral contraceptives Corticosteroids and anabolic steroids Sympathomimetics and decongestants Cocaine Amphetamines Erythropoietin Cyclosporine, tacrolimus Licorice Over-the-counter dietary supplements (eg, ephedra, ma huang, bitter orange) Monoamine oxidase inhibitors, certain selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors Suboptimal treatment regimens Dosage too low Inappropriate combinations of antihypertensive agents Volume overload Excessive salt intake Renal sodium retention (pseudotolerance) Secondary hypertension Renal insufficiency Renovascular disease Primary hyperaldosteronism Thyroid disease Pheochromocytoma and other rare endocrine causes Obstructive sleep apneaNote that causes of ‘pseudo-resistance' (such as white coat hypertension or pseudo-hypertension in the elderly) should be ruled out first.
- 6α-Blockers are not recommended as first-line agents for uncomplicated hypertension (Grade A); β-blockers are not recommended as first-line therapy for uncomplicated hypertension in patients 60 years of age or older (Grade A); and ACE inhibitors are not recommended as first-line therapy for uncomplicated hypertension in black patients (Grade A). However, these agents may be used in patients with certain comorbid conditions or in combination therapy.
- 1Initial therapy should be monotherapy with a thiazide diuretic (Grade A), a long-acting dihydropyridine CCB (Grade A), or an ARB (Grade B). If there are adverse effects, another drug from this group should be substituted. Hypokalemia should be avoided in patients treated with thiazide diuretic monotherapy (Grade C).
- 2Additional antihypertensive drugs should be used if target BP levels are not achieved with standard-dose monotherapy (Grade B). Add-on drugs should be chosen from first-line options (Grade D).
- 3If BP is still not controlled with a combination of 2 or more first-line agents, or there are adverse effects, other classes of drugs (such as α-blockers, ACE inhibitors, centrally acting agents or nondihydropyridine CCBs) may be added or substituted (Grade D).
- 4Possible reasons for poor response to therapy (Table 6) should be considered (Grade D).
- 5α-Blockers are not recommended as first-line agents for uncomplicated isolated systolic hypertension (Grade A); and β-blockers are not recommended as first-line therapy for isolated systolic hypertension in patients aged ≥ 60 years (Grade A). However, both agents may be used in patients with certain comorbid conditions or in combination therapy.
FDA Drug Safety Communication: No increase in risk of cancer with certain blood pressure drugs – Angiotensine Receptor Blockers (ARBs) Drug Safety and Availability 2011 March 6.
IV. Global vascular protection therapy for adults with hypertension without compelling indications for specific agents
- 1Statin therapy is recommended in hypertensive patients with 3 or more cardiovascular risk factors as defined in Table 7 (Grade A in patients > 40 years), or with established atherosclerotic disease (Grade A regardless of age).Table 7Cardiovascular risk factors for consideration of statin therapy in nondyslipidemic patients with hypertensionData from Sever et al.47
Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial - Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial.Lancet. 2003; 361: 1149-1158
- Sever P.S.
- Dahlof B.
- Poulter N.R.
- et al.
Male sex Age ≥ 55 years Left ventricular hypertrophy Other electrocardiogram abnormalities: left bundle branch block, left ventricular strain pattern, abnormal Q-waves or ST-T changes compatible with ischemic heart disease Peripheral arterial disease Previous stroke or transient ischemic attack Microalbuminuria or proteinuria Diabetes mellitus Smoking Family history of premature cardiovascular disease Total cholesterol to high-density lipoprotein ratio 6If hypertensive patients have ≥ 3 of these risk factors, statins should be considered.
- 2Strong consideration should be given to the addition of low-dose acetylsalicylic acid therapy in hypertensive patients (Grade A in patients > 50 years). Caution should be exercised if BP is not controlled (Grade C).
V. Goal of therapy for adults with hypertension without compelling indications for specific agents
- 1The SBP treatment goal is a pressure level of < 140 mm Hg (Grade C). The DBP treatment goal is a pressure level of < 90 mm Hg (Grade A).
VI. Treatment of hypertension in association with ischemic heart disease
- 1An ACE inhibitor or ARB is recommended for most patients with hypertension and coronary artery disease (Grade A).
- 2For patients with stable angina, β-blockers are preferred as initial therapy (Grade B). CCBs may also be used (Grade B).
- 3Short-acting nifedipine should not be used (Grade D).
- 4For patients with coronary artery disease, but without coexisting systolic heart failure, the combination of an ACE inhibitor and ARB is not recommended (Grade B).
- 5In high-risk patients, when combination therapy is being used, choices should be individualized. The combination of an ACE inhibitor and a dihydropyridine CCB is preferable to an ACE inhibitor and a diuretic in selected patients (Grade A).
- 1Initial therapy should include both a β-blocker and an ACE inhibitor (Grade A).
- 2An ARB can be used if the patient is intolerant of an ACE inhibitor (Grade A in patients with left ventricular systolic dysfunction).
- 3CCBs may be used in postmyocardial infarction patients when β-blockers are contraindicated or not effective. Nondihydropyridine CCBs should not be used when there is heart failure, as evidenced by pulmonary congestion on examination or radiography (Grade D).
VII. Treatment of hypertension in association with heart failure
- 1In patients with systolic dysfunction (ejection fraction [EF] < 40%), ACE inhibitors (Grade A) and β-blockers (Grade A) are recommended for initial therapy. Aldosterone antagonists (mineralocorticoid receptor antagonists) may be added for patients with a recent cardiovascular hospitalization, acute myocardial infarction, elevated B-type natriuretic peptide or N-terminal pro–B-type natriuretic peptide level, or New York Heart Association (NYHA) class II to IV symptoms (Grade A). Careful monitoring for hyperkalemia is recommended when adding an aldosterone antagonist to ACE inhibitor or ARB. Other diuretics are recommended as additional therapy if needed (Grade B for thiazide diuretics for BP control, Grade D for loop diuretics for volume control). Beyond considerations of BP control, doses of ACE inhibitors or ARBs should be titrated to those found to be effective in trials unless adverse effects become manifest (Grade B).
- 2An ARB is recommended if ACE inhibitors are not tolerated (Grade A).
- 3A combination of hydralazine and isosorbide dinitrate is recommended if ACE inhibitors and ARBs are contraindicated or not tolerated (Grade B).
- 4For hypertensive patients whose BP is not controlled, an ARB may be added to an ACE inhibitor and other antihypertensive drug treatment (Grade A). Careful monitoring should be used if combining an ACE inhibitor and an ARB due to potential adverse effects such as hypotension, hyperkalemia, and worsening renal function (Grade C). Additional therapies may also include dihydropyridine CCBs (Grade C).
VIII. Treatment of hypertension in association with stroke
- 1For patients with ischemic stroke not eligible for thrombolytic therapy, treatment of hypertension in the setting of acute ischemic stroke or transient ischemic attack should not be routinely undertaken (Grade D). Extreme BP elevation (eg, SBP > 220 mm Hg or DBP > 120 mm Hg) may be treated to reduce the BP by approximately 15% (Grade D), and not more than 25%, over the first 24 hours with gradual reduction thereafter (Grade D). Avoid excessive lowering of BP as this may exacerbate existing ischemia or may induce ischemia, particularly in the setting of intracranial arterial occlusion or extracranial carotid or vertebral artery occlusion (Grade D). Pharmacological agents and routes of administration should be chosen to avoid precipitous falls in BP (Grade D).
- 2For patients with ischemic stroke eligible for thrombolytic therapy, very high BP (> 185/110 mm Hg) should be treated concurrently in patients receiving thrombolytic therapy for acute ischemic stroke to reduce the risk of secondary intracranial hemorrhage (Grade B).
- 1Strong consideration should be given to the initiation of antihypertensive therapy after the acute phase of a stroke or transient ischemic attack (Grade A).
- 2After the acute phase of a stroke, BP-lowering treatment is recommended to a target of consistently < 140/90 mm Hg (Grade C).
- 3Treatment with an ACE inhibitor/diuretic combination is preferred (Grade B).
- 4For patients with stroke, the combination of an ACE inhibitor and ARB is not recommended (Grade B).
IX. Treatment of hypertension in association with left ventricular hypertrophy
- 1Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events (Grade C).
- 2The choice of initial therapy can be influenced by the presence of left ventricular hypertrophy (Grade D). Initial therapy can be drug treatment using ACE inhibitors, ARBs, long-acting CCBs, or thiazide diuretics. Direct arterial vasodilators such as hydralazine or minoxidil should not be used.
X. Treatment of hypertension in association with nondiabetic CKD
- 1For patients with nondiabetic CKD, target BP is < 140/90 mm Hg (Grade B).
- 2For patients with hypertension and proteinuric CKD (urinary protein > 500 mg/24 hours or albumin-to-creatinine ratio > 30 mg/mmol), initial therapy should be an ACE inhibitor (Grade A) or an ARB if there is intolerance to ACE inhibitors (Grade B).
- 3Thiazide diuretics are recommended as additive antihypertensive therapy (Grade D). For patients with CKD and volume overload, loop diuretics are an alternative (Grade D).
- 4In most cases, combination therapy with other antihypertensive agents may be needed to reach target BP levels (Grade D).
- 5The combination of an ACE inhibitor and ARB is not recommended for patients with nonproteinuric CKD (Grade B).
XI. Treatment of hypertension in association with renovascular disease
- 1Renovascular hypertension should be treated in the same manner as hypertension without compelling indications, except for caution in the use of ACE inhibitors or ARBs due to the risk of acute renal failure in bilateral disease or unilateral disease with a solitary kidney (Grade D).
- 2Close follow-up and early intervention (angioplasty and stenting or surgery) should be considered for patients with uncontrolled hypertension despite therapy with ≥ 3 drugs, deteriorating kidney function, bilateral atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a single kidney), or recurrent episodes of flash pulmonary edema (Grade D).
XII. Treatment of hypertension in association with diabetes mellitus
- 1Persons with diabetes mellitus should be treated to attain SBPs of < 130 mm Hg (Grade C) and DBPs of < 80 mm Hg (Grade A). (These target BP levels are the same as the BP treatment thresholds.) Combination therapy using 2 first-line agents may also be considered as initial treatment of hypertension (Grade B) if SBP is 20 mm Hg above target or if DBP is 10 mm Hg above target. However, caution should be exercised in patients in whom a substantial fall in BP is more likely or poorly tolerated (eg, elderly patients and patients with autonomic neuropathy).
- 2For persons with cardiovascular or kidney disease, including microalbuminuria or with cardiovascular risk factors in addition to diabetes and hypertension, an ACE inhibitor or an ARB is recommended as initial therapy (Grade A).
- 3For persons with diabetes and hypertension not included in the above recommendation, appropriate choices include (in alphabetical order): ACE inhibitors (Grade A), ARBs (Grade B), dihydropyridine CCBs (Grade A), and thiazide/thiazide-like diuretics (Grade A).
- 4If target BP levels are not achieved with standard-dose monotherapy, additional antihypertensive therapy should be used. For persons in whom combination therapy with an ACE inhibitor is being considered, a dihydropyridine CCB is preferable to hydrochlorothiazide (Grade A).
XIII. Adherence strategies for patients
- 1Adherence to an antihypertensive prescription can be improved by a multipronged approach (Table 8).Table 8Strategies to improve patient adherenceReprinted with permission of the Canadian Hypertension Education Program.
Assist your patient to adhere by: • Tailoring pill-taking to fit patients' daily habits (Grade D) • Simplifying medication regimens to once-daily dosing (Grade D) • Replacing multiple pill antihypertensive combinations with single pill combinations (Grade C) • Utilizing unit-of-use packaging (of several medications to be taken together) (Grade D) • Using a multidisciplinary team approach to improve adherence to an antihypertensive prescription (Grade B) Assist your patient in getting more involved in their treatment by: • Encouraging greater patient responsibility/autonomy in monitoring their blood pressure and adjusting their prescriptions (Grade C) • Educating patients and patients' families about their disease and treatment regimens (Grade C) Improve your management in the office and beyond by: • Assessing adherence to pharmacological and nonpharmacological therapy at every visit (Grade D) • Encouraging adherence with therapy by out-of-office contact (either by phone or mail), particularly during the first three months of therapy (Grade D) • Coordinating with pharmacists and work-site health care givers to improve monitoring of adherence with pharmacological and lifestyle modification prescriptions (Grade D) • Utilizing electronic medication compliance aids (Grade D)
XIV. Treatment of secondary hypertension due to endocrine causes
|Initial therapy||Second-line therapy||Notes and/or cautions|
|Hypertension without other compelling indications (target BP < 140/90 mm Hg)|
|Diastolic with or without systolic hypertension||Thiazide diuretics, β-blockers, ACE inhibitors, ARBs, or long-acting CCBs (consider ASA and statins in selected patients). Consider initiating therapy with a combination of first-line drugs if the BP is ≥ 20 mm Hg systolic or ≥ 10 mm Hg diastolic above target||Combinations of first-line drugs||Not recommended for monotherapy: α-blockers, β-blockers in those ≥60 years of age, ACE inhibitors in blacks. Hypokalemia should be avoided in those prescribed diuretic monotherapy. ACE inhibitors, ARBs, and direct renin inhibitors are potential teratogens, and caution is required if prescribing to women of child-bearing potential. Combination of an ACE-inhibitor with an ARB is not recommended.|
|Isolated systolic hypertension without other compelling indications||Thiazide diuretics, ARBs, or long-acting dihydropyridine CCBs||Combinations of first-line drugs||Same as diastolic with or without systolic hypertension|
|Diabetes mellitus (target BP < 130/80 mm Hg)|
|Diabetes mellitus with microalbuminuria,|
⁎renal disease, cardiovascular disease, or additional cardiovascular risk factors
|ACE inhibitors or ARBs||Addition of dihydropyridine CCB is preferred over thiazide||A loop diuretic could be considered in hypertensive CKD patients with extracellular fluid volume overload|
|Diabetes mellitus not included in the above category||ACE inhibitors, ARBs, dihydropyridine CCBs, or thiazide diuretics||Combination of first-line drugs. If combination with an ACE inhibitor is being considered, a dihydropyridine CCB is preferable to thiazide diuretic||Normal ACR < 2.0 mg/mmol in men and < 2.8 mg/mmol in women|
|Cardiovascular disease (target BP < 140/90 mm Hg)|
|Coronary artery disease||ACE inhibitors or ARBs (except in low-risk patients); β-blockers for patients with stable angina||Long-acting CCBs. When combination therapy is being used for high risk patients, an ACE inhibitor/dihydropyridine CCB is preferred||Avoid short-acting nifedipine. Combination of an ACE inhibitor with an ARB is specifically not recommended|
|Recent myocardial infarction||β-Blockers and ACE inhibitors (ARBs if ACE inhibitor-intolerant)||Long-acting CCBs if β-blocker contraindicated or not effective||Nondihydropyridine CCBs should not be used with concomitant heart failure|
|Heart failure||ACE inhibitors (ARBs if ACE inhibitor-intolerant) and β-blockers. Aldosterone antagonists (mineralocorticoid receptor antagonists) may be added for patients with a recent cardiovascular hospitalization, acute myocardial infarction, elevated B-type natriuretic peptide or N-terminal-proBNP level, or NYHA class II to IV symptoms||ACE inhibitor and ARB combined. Hydralazine/isosorbide dinitrate combination if ACE inhibitor and ARB contraindicated or not tolerated. Thiazide or loop diuretics are recommended as additive therapy. Dihydropyridine CCB||Titrate doses of ACE inhibitors and ARBs to those used in clinical trials. Carefully monitor potassium and renal function if combining any of ACE inhibitor, ARB, and/or aldosterone antagonist|
|Left ventricular hypertrophy||ACE inhibitor, ARB, long-acting CCB, or thiazide diuretics.||Combination of additional agents||Hydralazine and minoxidil should not be used|
|Past stroke or TIA||ACE inhibitor/diuretic combinations||Combination of additional agents||Treatment of hypertension should not be routinely undertaken in acute stroke unless extreme BP elevation. Combination of an ACE inhibitor with an ARB is not recommended|
|Nondiabetic CKD (target BP < 140/90 mm Hg)|
|Nondiabetic CKD with proteinuria|
|ACE inhibitors (ARBs if ACE inhibitor-intolerant) if there is proteinuria. Diuretics as additive therapy||Combinations of additional agents||Carefully monitor renal function and potassium for those taking an ACE inhibitor or ARB. Combinations of an ACE inhibitor and ARB are not recommended in patients without proteinuria|
|Renovascular disease||Does not affect initial treatment recommendations||Combinations of additional agents||Avoid ACE inhibitors or ARB if bilateral renal artery stenosis or unilateral disease with solitary kidney|
|Other conditions (target BP < 140/90 mm Hg)|
|Peripheral arterial disease||Does not affect initial treatment recommendations||Combinations of additional agents||Avoid β-blockers with severe disease|
|Dyslipidemia||Does not affect initial treatment recommendations||Combinations of additional agents||—|
|Overall vascular protection||Statin therapy for patients with 3 or more cardiovascular risk factors or atherosclerotic disease. Low dose ASA in patients with controlled BP||—||Caution should be exercised with the ASA recommendation if BP is not controlled|
- Supplemental Table S1 to S4 and Supplemental Appendix S1 and S2
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- Evaluation of the overall efficacy of the Omron office digital blood pressure HEM-907 monitor in adults.Blood Press Monit. 2001; 6: 107-110
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- Variability of office, 24-hour ambulatory, and self-monitored blood pressure measurements.Br J Gen Pract. 2010; 60: 675-680
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- Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial - Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial.Lancet. 2003; 361: 1149-1158
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- Blood pressure control, proteinuria, and the progression of renal disease.Ann Intern Med. 1995; 123: 754-762
- Blood pressure targets in subjects with type 2 diabetes mellitus/impaired fasting glucose: observations from traditional and bayesian random-effects meta-analyses of randomized trials.Circulation. 2011; 123 (9 p following 810): 2799-2810
- Effects of intensive blood pressure reduction on myocardial infarction and stroke in diabetes: a meta-analysis in 73,913 patients.J Hypertens. 2011; 29: 1253-1269
- Effects of intensive blood-pressure control in type 2 diabetes mellitus.N Engl J Med. 2010; 362: 1575-1585
- Diagnosed hypertension in Canada: incidence, prevalence and associated mortality.CMAJ. 2012; 184: E49-E56
See page 285 for disclosure information.
A version of the hypertension recommendations designed for patient and public education has been developed to assist health care practitioners managing hypertension. The summary is available electronically (go to http://www.hypertension.ca or http://www.heartandstroke.ca).