Abstract
Résumé
Executive Summary
Recommendations
Diagnosis and assessment
Prevention and treatment
Updates
Introduction
Methods
The 2014 CHEP Diagnosis and Assessment Recommendations
I. Accurate measurement of BP
- 1.Health 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).
- 2.Use of standardized measurement techniques (Supplemental Table S2) is recommended when assessing BP (Grade D).
- 3.Automated office BP measurement (OBPM) can be used in the assessment of office BP (Grade D).
- 4.When used in proper conditions, automated office SBP of ≥ 135 mm Hg or 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).
Recommendations
Background
II. Criteria for diagnosis of hypertension and recommendations for follow-up (Fig. 1)
- 1.At initial presentation, patients demonstrating features of a hypertensive urgency or emergency (Supplemental Table S3) should be diagnosed as hypertensive and require immediate management (Grade D).Figure 1The expedited assessment and diagnosis of patients with hypertension: Focus on validated technologies for BP assessment. ** Thresholds refer to BP values averaged across the corresponding number of visits and not just the most recent office visit. ABPM, ambulatory BP monitoring; BP, blood pressure (mm Hg); DBP, diastolic BP (mm Hg); HBPM, home BP measurement; HTN, hypertension; OBPM, office BP measurement; SBP, systolic BP (mm Hg).Reproduced with permission from the Canadian Hypertension Education Program.
- 2.If 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).
- 3.At the initial visit for the assessment of hypertension, if SBP is ≥ 140 and/or DBP is ≥ 90 mm Hg, at least 2 more readings should be taken during the same visit using a validated device and according to the recommended procedure for accurate BP determination (Supplemental Table S2). The first reading should be discarded and the latter 2 or more readings averaged. A history and physical examination should be performed and, if clinically indicated, diagnostic tests to search for target organ damage (Supplemental Table S4) and associated cardiovascular risk factors (Supplemental Table S5) should be arranged within 2 visits. Exogenous factors that can induce or aggravate hypertension should be identified and addressed if possible (Supplemental Table S6). Visit 2 should be scheduled within 1 month (Grade D).
- 4.At visit 2 for the assessment of hypertension, patients with macrovascular target organ damage, diabetes mellitus, or CKD (glomerular filtration rate < 60 mL/min/1.73 m2) can be diagnosed as hypertensive if SBP is ≥ 140 mm Hg and/or DBP is ≥ 90 mm Hg (Grade D).
- 5.At 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:
- i.OBPM: 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).
- ii.Ambulatory BP monitoring (ABPM): Using ABPM (see Recommendations 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).
- iii.Home BP monitoring (HBPM): Using HBPM (see Recommendations 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 home BP is < 135/85 mm Hg, it is advisable to either repeat home monitoring to confirm the home BP 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).
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- 6.Investigations for secondary causes of hypertension should be initiated in patients with suggestive clinical and/or laboratory features (outlined in sections V. Assessment for Renovascular Hypertension and VI. Endocrine Hypertension) (Grade D).
- 7.If, 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).
- 8.Hypertensive patients actively modifying their health behaviours should be followed up at 3- to 6-month intervals. Shorter intervals (every 1 or 2 months) are needed for patients with higher BP measurements (Grade D).
- 9.Patients using antihypertensive drugs 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).
Recommendations
Background
III. Assessment of overall cardiovascular risk in hypertensive patients
- 1.Global 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).
- 2.Consider 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).
Recommendations
Background
IV. Routine and optional laboratory tests for the investigation of patients with hypertension
- 1.Routine laboratory tests that should be performed for the investigation of all patients with hypertension include the following:
- i.Urinalysis (Grade D);
- ii.Blood chemistry (potassium, sodium, and creatinine) (Grade D);
- iii.Fasting blood glucose and/or glycated hemoglobin (A1C) (Grade D) (new recommendation);
- iv.Fasting serum total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides (Grade D); and
- v.Standard 12-lead electrocardiography (Grade C).
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- 2.Assess urinary albumin excretion in patients with diabetes (Grade D).
- 3.All treated hypertensive patients should be monitored according to the current Canadian Diabetes Association guidelines for the new appearance of diabetes (Grade B).
- 4.During the maintenance phase of hypertension management, tests (including those for electrolyte, creatinine, and fasting lipid levels) should be repeated with a frequency reflecting the clinical situation (Grade D).
Recommendations
Background
V. Assessment for renovascular hypertension
- 1.Patients presenting with ≥ 2 of the clinical clues listed below, suggesting renovascular hypertension, should be investigated (Grade D):
- i.Sudden onset or worsening of hypertension and age > 55 or < 30 years;
- ii.Presence of an abdominal bruit;
- iii.Hypertension resistant to ≥ 3 drugs;
- iv.Increase in serum creatinine level ≥ 30% associated with use of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB);
- v.Other atherosclerotic vascular disease, particularly in patients who smoke or have dyslipidemia;
- vi.Recurrent pulmonary edema associated with hypertensive surges.
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- 2.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 (glomerular filtration rate < 60 mL/min/1.73m2) (Grade D).
Recommendations
Background
VI Endocrine hypertension
- A.Hyperaldosteronism: screening and diagnosis
- 1.Screening for hyperaldosteronism should be considered for the following patients (Grade D):
- i.Hypertensive patients with spontaneous hypokalemia (K+ < 3.5 mmol/L);
- ii.Hypertensive patients with marked diuretic-induced hypokalemia (K+ < 3.0 mmol/L);
- iii.Patients with hypertension refractory to treatment with ≥ 3 drugs;
- iv.Hypertensive patients found to have an incidental adrenal adenoma.
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- 2.Screening for hyperaldosteronism should include assessment of plasma aldosterone and plasma renin activity or plasma renin (Supplemental Table S7).
- 3.For patients with suspected hyperaldosteronism (on the basis of the screening test; Supplemental Table S7, item iii. Definition of a Positive Screening Test), a diagnosis of primary aldosteronism should be established by demonstrating inappropriate autonomous hypersecretion of aldosterone using at least 1 of the manoeuvres listed in Supplemental Table S7, item iv. Manoeuvres to demonstrate Autonomous Hypersecretion of Aldosterone. When the diagnosis is established, the abnormality should be localized using any of the tests described in Supplemental Table S7, item v. Differentiating Potential Causes of Primary Aldosteronism.
- 1.
- B.Pheochromocytoma: screening and diagnosis
- 1.If pheochromocytoma is strongly suspected, the patient should be referred to a specialized hypertension centre, particularly if biochemical screening tests (Supplemental Table S8) have already been found to be positive (Grade D).
- 2.The following patients should be considered for screening for pheochromocytoma (Grade D):
- i.Patients with paroxysmal and/or severe (BP ≥ 180/110 mm Hg) sustained hypertension refractory to usual antihypertensive therapy;
- ii.Patients with hypertension and multiple symptoms suggestive of catecholamine excess (eg, headaches, palpitations, sweating, panic attacks, and pallor);
- iii.Patients with hypertension triggered by β-blockers, monoamine oxidase inhibitors, micturition, or changes in abdominal pressure;
- iv.Patients with incidentally discovered adrenal mass and patients with hypertension and multiple endocrine neoplasia 2A or 2B, von Recklinghausen neurofibromatosis, or von Hippel-Lindau disease;
- v.For patients with positive biochemical screening tests, localization of pheochromocytomas should involve the use of magnetic resonance imaging (preferable), computed tomography (if magnetic resonance imaging is unavailable), and/or iodine I-131 meta-iodobenzylguanidine scintigraphy (Grade C for each modality).
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- 1.
Recommendations
Background
VII. HBPM
- 1.HBPM can be used in the diagnosis of hypertension (Grade C).
- 2.The use of HBPM on a regular basis should be considered for patients with hypertension, particularly those with:
- i.Diabetes mellitus (Grade D);
- ii.CKD (Grade C);
- iii.Suspected nonadherence (Grade D);
- iv.Demonstrated white coat effect (Grade C); or
- v.BP controlled in the office but not at home (masked hypertension) (Grade C).
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- 3.When white coat hypertension is suggested by HBPM, its presence should be confirmed by repeat HBPM (see Recommendation 8 in this section) or ABPM before treatment decisions are made (Grade D).
- 4.Patients 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).
- 5.Home SBP values ≥ 135 mm Hg or DBP values ≥ 85 mm Hg should be considered increased and associated with an increased overall mortality risk analogous to office SBP readings of ≥ 140 mm Hg or DBP ≥ 90 mm Hg (Grade C).
- 6.Health 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).
- 7.The accuracy of all individual patients' validated devices (including electronic devices) must be regularly checked against a device of known calibration (Grade D).
- 8.HBPM 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).
Recommendations
Background
VIII. ABPM
- 1.ABPM 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:
- i.BP that is not below target despite receiving appropriate chronic antihypertensive therapy (Grade C);
- ii.Symptoms suggestive of hypotension (Grade C); or
- iii.Fluctuating office BP readings (Grade D).
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- 2.Physicians should use only ABPM devices that have been validated independently using established protocols (Grade D).
- 3.Therapy 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).
- 4.The magnitude of changes in nocturnal BP should be taken into account in any decision to prescribe or withhold drug therapy based on ABPM (Grade C) because a decrease in nocturnal BP of < 10% is associated with increased risk of cardiovascular events.
Recommendations
Background
IX. Role of echocardiography
- 1.Routine echocardiographic evaluation of all hypertensive patients is not recommended (Grade D).
- 2.An echocardiogram for assessment of left ventricular hypertrophy is useful in selected cases to help define the future risk of cardiovascular events (Grade C).
- 3.Echocardiographic assessment of left ventricular mass, and of systolic and diastolic left ventricular function is recommended for hypertensive patients suspected to have left ventricular dysfunction or CAD (Grade D).
- 4.Patients with hypertension and evidence of heart failure should have an objective assessment of left ventricular ejection fraction, either using echocardiogram or nuclear imaging (Grade D).
Recommendations
Background
The CHEP 2014 Prevention and Treatment Recommendations
I. Health behaviour management
- A.Physical exercise
- 1.For nonhypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise (such as free weight lifting, fixed weight lifting, or handgrip exercise) does not adversely influence BP (Grade D). For 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).
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- B.Weight reduction
- 1.Height, weight, and waist circumference should be measured and body mass index calculated for all adults (Grade D).
- 2.Maintenance of a healthy body weight (body mass index of 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).
- 3.Weight loss strategies should use a multidisciplinary approach that includes dietary education, increased physical activity, and behavioural intervention (Grade B).
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- C.Alcohol consumption
- 1.To reduce BP, alcohol consumption should be in accordance with Canadian low-risk drinking guidelines in 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 to 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.)
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- D.Dietary recommendations
- 1.It 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] diet34,35,36,37; Supplemental Table S9) (Grade B).
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- E.Sodium intake
- 1.To decrease BP, consider reducing sodium intake toward 2000 mg (5 g of salt or 87 mmol of sodium) per day (Grade A) (revised recommendation).
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- F.Potassium, calcium, and magnesium intake
- 1.Supplementation of potassium, calcium, and magnesium is not recommended for the prevention or treatment of hypertension (Grade B).
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- G.Stress management
- 1.In hypertensive patients in whom stress might be a contributor to high BP, 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).
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Recommendations
Background
Institute of Medicine of the National Academies. Sodium intake in populations: assessment of evidence. Available at: www.iom.edu/sodiumconsequences. Accessed March 19, 2014.
II. Indications for drug therapy for adults with hypertension without compelling indications for specific agents
- 1.Antihypertensive 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.
- 2.Antihypertensive 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).
- 3.Antihypertensive 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).
- 4.Antihypertensive therapy should be considered in all patients meeting indications 1-3 in this section, regardless of age (Grade B). Caution should be exercised in elderly patients who are frail.
- 5.In the very elderly (age ≥ 80 years) patients who do not have diabetes or target organ damage, the SBP threshold for initiating drug therapy is ≥ 160 mm Hg (Grade C) (revised recommendation).
Recommendations
Background
III. Choice of therapy for adults with hypertension without compelling indications for specific agents
- A.Recommendations for individuals with diastolic and/or systolic hypertension
- 1.Initial therapy should be a single-agent thiazide/thiazide-like diuretic (Grade A), a β-blocker (in patients younger than 60 years; Grade B), an ACE inhibitor (in non-black 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/thiazide-like diuretic monotherapy (Grade C).
- 2.Additional 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/thiazide-like diuretic or CCB with either: ACE inhibitor, ARB or β-blocker (Grade B for the combination of thiazide/thiazide-like 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).
- 3.Combination therapy using 2 first-line agents might also be considered as initial treatment of hypertension (Grade C) if SBP is 20 mm Hg greater than target or if DBP is 10 mm Hg greater than target. However, caution should be exercised in patients in whom a substantial decrease in BP from initial combination therapy is more likely to occur or in whom it would be poorly tolerated (eg, elderly patients).
- 4.If 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).
- 5.Possible reasons for poor response to therapy (Supplemental Table S10) should be considered (Grade D).
- 6.α-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.
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Recommendations
Background
- B.Recommendations for individuals with isolated systolic hypertension
- 1.Initial therapy should be single-agent therapy with a thiazide/thiazide-like 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/thiazide-like diuretic monotherapy (Grade C).
- 2.Additional 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).
- 3.If 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).
- 4.Possible reasons for poor response to therapy (Supplemental Table S10) should be considered (Grade D).
- 5.α-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.
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Background
IV. Global vascular protection therapy for adults with hypertension without compelling indications for specific agents
- 1.Statin therapy is recommended in hypertensive patients with 3 or more cardiovascular risk factors as defined in Supplemental Table S11 (Grade A in patients > 40 years) or with established atherosclerotic disease (Grade A regardless of age).
- 2.Consideration should be given to the addition of low-dose ASA therapy in hypertensive patients ≥ 50 years (Grade B) (revised recommendation). Caution should be exercised if BP is not controlled (Grade C).
Recommendations
Background
- Vandvik P.O.
- Lincoff A.M.
- Gore J.M.
- et al.
V. Goals of therapy for adults with hypertension without compelling indications for specific agents
- 1.The 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).
- 2.In the very elderly (age 80 years or greater), the BP target is < 150 mm Hg (Grade C).
Recommendations
Background
VI. Treatment of hypertension in association with ischemic heart disease
- A.Recommendations for hypertensive patients with CAD
- 1.An ACE inhibitor or ARB is recommended for most patients with hypertension and CAD (Grade A).
- 2.For patients with stable angina, β-blockers are preferred as initial therapy (Grade B). CCBs may also be used (Grade B).
- 3.Short-acting nifedipine should not be used (Grade D).
- 4.For patients with CAD, but without coexisting systolic heart failure, the combination of an ACE inhibitor and ARB is not recommended (Grade B).
- 5.In 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 thiazide/thiazide-like diuretic in selected patients (Grade A).
- 6.When decreasing SBP to target levels in patients with established CAD (especially if isolated systolic hypertension is present), be cautious when the DBP is ≤ 60 mm Hg because of concerns that myocardial ischemia might be exacerbated (Grade D) (new recommendation).
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Recommendations
Background
- Bangalore S.
- Qin J.
- Sloan S.
- Murphy S.A.
- Cannon C.P.
- B.Recommendations for patients with hypertension who have had a recent myocardial infarction
- 1.Initial therapy should include a β-blocker and an ACE inhibitor (Grade A).
- 2.An ARB can be used if the patient is intolerant of an ACE inhibitor (Grade A in patients with left ventricular systolic dysfunction).
- 3.CCBs may be used in patients after myocardial infarction when β-blockers are contraindicated or not effective. Nondihydropyridine CCBs should not be used when there is heart failure, evidenced by pulmonary congestion at time of examination or radiography (Grade D).
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VII. Treatment of hypertension in association with heart failure
- 1.In patients with systolic dysfunction (ejection fraction < 40%), ACE inhibitors (Grade A) and β-blockers (Grade A) are recommended for initial therapy. Aldosterone antagonists (mineralocorticoid receptor antagonists) might 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 class II-IV symptoms (Grade A). Careful monitoring for hyperkalemia is recommended when adding an aldosterone antagonist to an ACE inhibitor or ARB. Other diuretics are recommended as additional therapy if needed (Grade B for thiazide/thiazide-like 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).
- 2.An ARB is recommended if ACE inhibitors are not tolerated (Grade A).
- 3.A combination of hydralazine and isosorbide dinitrate is recommended if ACE inhibitors and ARBs are contraindicated or not tolerated (Grade B).
- 4.For 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 because of potential adverse effects such as hypotension, hyperkalemia, and worsening renal function (Grade C). Additional therapies might also include dihydropyridine CCBs (Grade C).
Recommendations
Background
VIII. Treatment of hypertension in association with stroke
- A.BP management in acute stroke (onset to 72 hours)
- 1.For 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 increases (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 because this might exacerbate existing ischemia or might 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 decreases in BP (Grade D).
- 2.For 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).
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- B.BP management after acute stroke
- 1.Strong consideration should be given to the initiation of antihypertensive therapy after the acute phase of a stroke or transient ischemic attack (Grade A).
- 2.After the acute phase of a stroke, BP-lowering treatment is recommended to a target of consistently < 140/90 mm Hg (Grade C).
- 3.Treatment with an ACE inhibitor and thiazide/thiazide-like diuretic combination is preferred (Grade B).
- 4.For patients with stroke, the combination of an ACE inhibitor and ARB is not recommended (Grade B).
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Recommendations
Background
IX. Treatment of hypertension in association with left ventricular hypertrophy
- 1.Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events (Grade C).
- 2.The 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/thiazide-like diuretics. Direct arterial vasodilators such as hydralazine or minoxidil should not be used.
Recommendations
Background
X. Treatment of hypertension in association with nondiabetic CKD
- 1.For patients with nondiabetic CKD, target BP is < 140/90 mm Hg (Grade B).
- 2.For patients with hypertension and proteinuric CKD (urinary protein > 500 mg per 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).
- 3.Thiazide/thiazide-like diuretics are recommended as additive antihypertensive therapy (Grade D). For patients with CKD and volume overload, loop diuretics are an alternative (Grade D).
- 4.In most cases, combination therapy with other antihypertensive agents might be needed to reach target BP levels (Grade D).
- 5.The combination of an ACE inhibitor and ARB is not recommended for patients with nonproteinuric CKD (Grade B).
Recommendations
Background
XI Treatment of hypertension in association with renovascular disease
- 1.Renovascular hypertension should be treated in the same manner as hypertension without compelling indications, except for caution in the use of ACE inhibitors or ARBs because of the risk of acute renal failure in bilateral disease or unilateral disease with a solitary kidney (Grade D).
- 2.Close 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).
Recommendations
Background
XII. Treatment of hypertension in association with diabetes mellitus
- 1.Persons with diabetes mellitus should be treated to attain SBP of < 130 mm Hg (Grade C) and DBP 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 might also be considered as initial treatment of hypertension (Grade B) if SBP is 20 mm Hg greater than target or if DBP is 10 mm Hg greater than target. However, caution should be exercised in patients in whom a substantial decrease in BP is more likely or poorly tolerated (eg, elderly patients and patients with autonomic neuropathy).
- 2.For 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).
- 3.For persons with diabetes and hypertension not included in other recommendations in this section, appropriate choices include (in alphabetical order): ACE inhibitors (Grade A), ARBs (Grade B), dihydropyridine CCBs (Grade A), and thiazide/thiazide-like diuretics (Grade A).
- 4.If 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 a thiazide/thiazide-like diuretic (Grade A).
Recommendations
Background
XIII. Adherence strategies for patients
- 1.Adherence to an antihypertensive prescription can be improved by a multipronged approach (Supplemental Table S12).
Recommendations
Background
XIV. Treatment of secondary hypertension because of endocrine causes
- 1.Treatment of hyperaldosteronism and pheochromocytoma are outlined in Supplemental Tables S7 and S8, respectively.
Recommendations
Background
Implementation
Future Directions
Initial therapy | Second-line therapy | Notes and/or cautions | |
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Hypertension without other compelling indications | |||
Diastolic hypertension with or without systolic hypertension (target BP < 140/90 mm Hg) | Thiazide/thiazide-like 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 greater than target | Combinations of first-line drugs | Not recommended for monotherapy: α-blockers, β-blockers in those ≥ 60 years of age, and ACE inhibitors in black people. Hypokalemia should be avoided in those prescribed diuretics. ACE inhibitors, ARBs, and direct renin inhibitors are potential teratogens, and caution is required if prescribing to women with child-bearing potential. Combination of an ACE-inhibitor with an ARB is not recommended |
Isolated systolic hypertension without other compelling indications (target BP for age < 80 is < 140/90 mm Hg; for age ≥ 80: target SBP is < 150 mm Hg | Thiazide/thiazide-like diuretics, ARBs or long-acting dihydropyridine CCBs | Combinations of first-line drugs | Same as diastolic hypertension 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 a dihydropyridine CCB is preferred over a thiazide/thiazide-like diuretic | 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/thiazide-like diuretics | Combination of first-line drugs. If combination with ACE inhibitor is being considered, a dihydropyridine CCB is preferable to a thiazide/thiazide-like diuretic | Normal urine microalbumin to creatinine ratio < 2.0 mg/mmol |
Cardiovascular disease (target BP < 140/90 mm Hg) | |||
Coronary artery disease | ACE inhibitors or ARBs; 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. Exercise caution when decreasing SBP to target if DBP is ≤ 60 mm Hg |
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 BNP or NT-proBNP level, or NYHA class II-IV symptoms | ACE inhibitor and ARB combined. Hydralazine/isosorbide dinitrate combination if ACE inhibitor and ARB contraindicated or not tolerated. Thiazide/thiazide-like or loop diuretics are recommended as additive therapy. Dihydropyridine CCBs can also be used | 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/thiazide-like diuretics. | Combination of additional agents | Hydralazine and minoxidil should not be used |
Past stroke or TIA | ACE inhibitor and a thiazide/thiazide-like diuretic combination | Combination of additional agents | Treatment of hypertension should not be routinely undertaken in acute stroke unless extreme BP increase. 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 ARBs 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 ≥ 3 cardiovascular risk factors or atherosclerotic disease; low-dose ASA in patients ≥ 50 years | — | Caution should be exercised with the ASA recommendation if BP is not controlled |
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See page 500 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).
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