|Grade A||Recommendations for interventions are on the basis of 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 on the basis of randomized trials, systematic reviews, or prespecified 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 are on the basis of trials that have lower levels of internal validity and/or precision, or trials for which unvalidated surrogate outcomes were reported, or results from nonrandomized observational studies|
|Grade D||Recommendations are on the basis of expert opinion alone|
1. Diagnosis and Treatment of Hypertension in Adults
- •Hypertension remains the most prevalent risk factor for cardiovascular disease in Canada.
- •Standardized BP measurement, using validated protocols and devices, continues to be recommended to screen for cases of hypertension.
- •Frequency and timing of screening can be tailored to each patient’s risk of hypertension. Risk factors for hypertension are: (1) diabetes mellitus; (2) chronic kidney disease; (3) low level of consumption of fresh fruits and vegetables; and (4) sedentary behaviour.
- •Use of out-of-office measurement (24-hour ambulatory BP monitoring [ABPM] or home BP monitoring [HBPM]) is recommended for all adults with: (1) high in-office BP to rule out white coat hypertension; and (2) suspected hypertension (including adults with diabetes) to rule out masked hypertension.
- •Adults with confirmed diagnosis of hypertension should have a baseline assessment of: (1) cardiovascular risk factors (including screening for diabetes, hyperlipidemia, and renal disease); (2) target organ damage; and (3) routine lab testing.
- •The possibility of pregnancy should be considered in all women of reproductive age with a new diagnosis of hypertension, and during follow-up visits.
Measurement and Diagnosis
I Accurate measurement of BP
- •The recommended measurement frequency for ABPM is at 20- to 30-minute intervals throughout the day and night (Supplemental Table S1).
- •HBPM should be considered in adults with inadequately controlled 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 and independently validated equipment for all methods (automated OBPM [AOBP], OBPM, ABPM, and HBPM) is recommended (Grade D; see Supplemental Table S1 for recommended techniques). Unless specified otherwise, measurement using electronic (oscillometric) upper arm devices is preferred over auscultation (Grade C). Devices that are appropriate for the individual and have met the ISO-81060 protocol (Association for the Advancement of Medical Instrumentation: Non-invasive sphygmomanometers - Part 2: Clinical investigation of automated measurement type. ANSI/AAMI/ISO 81060-2/ANSI-AAMI, 2nd ed. Arlington, VA: AAMI 2013; see https://www.iso.org/standard/57977.html) should be used. For HBPM, patients should be encouraged to use devices with data recording capabilities or automatic data transmission to increase the reliability of reported HBPM (Grade D).
- 3.In patients with large arm circumferences when standard upper arm cuffs cannot be used, validated wrist devices (used with arm and wrist supported at heart level) may be used for BP estimation (Grade D).
- 4.Four approaches can be used to assess BP:
- i.AOBP is the preferred method of performing OBPM (Grade D). The BP value calculated and displayed by the device should be used. When using AOBP (see the Recommended Technique for Automated Office Blood Pressure section in Supplemental Table S1), displayed mean SBP ≥ 135 mm Hg or DBP ≥ 85 mm Hg is high (Grade D).
- ii.When using OBPM, the first reading should be discarded and the latter readings averaged (see the Recommended Technique for Office Blood Pressure Measurement section in Supplemental Table S1). Mean SBP between 130 and 139 mm Hg or mean DBP between 85 and 89 mm Hg is high-normal, and mean SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg is high (Grade C).
- iii.Using ABPM, mean awake SBP ≥ 135 mm Hg or DBP ≥ 85 mm Hg or mean 24-hour SBP ≥ 130 mm Hg or DBP ≥ 80 mm Hg are high (Grade C).
- iv.Using HBPM, mean SBP ≥ 135 mm Hg or DBP ≥ 85 mm Hg are high and associated with an increased overall mortality risk (Grade C). HBPM values should be on the basis of a series comprised of the mean of duplicate measures, for morning and evening, for a 7-day period. First day home BP values should not be considered (Grade D).
- •Out-of-office BP measurements are essential to rule out white coat hypertension in subjects with and without diabetes and to diagnose masked hypertension, when suspected. A revised algorithm is presented (Figure 2).
II Diagnosis of hypertension and follow-up
- 1.At initial presentation, patients who exhibit features of a hypertensive urgency or emergency (Supplemental Table S2) should be diagnosed as hypertensive and require immediate management (Grade D). In all other patients, at least 2 more readings should be taken during the same visit.
- 2.If the visit 1 OBPM is high-normal (thresholds outlined in section I. Accurate measurement of BP, Recommendation 4. ii) the patient’s BP should be assessed at yearly intervals (Grade C).
- 3.If the visit 1 mean AOBP or OBPM is high (thresholds outlined in section I. Accurate measurement of BP, Recommendation 4. i and ii), a history and physical examination should be performed, and, if clinically indicated, diagnostic tests to search for target organ damage (Table 2) and associated cardiovascular risk factors (Table 3) should be arranged within 2 visits. Exogenous factors that can induce or aggravate hypertension should be assessed and removed if possible (Supplemental Table S3). Visit 2 should be scheduled within 1 month (Grade D).Table 2Examples of target organ damage
Ischemic stroke and transient ischemic attack
Aneurysmal subarachnoid hemorrhage
Mixed vascular dementia and dementia of the Alzheimer’s type
Left ventricular dysfunction
Left ventricular hypertrophy
Coronary artery disease
Acute coronary syndromes
Chronic kidney disease (GFR < 60 mL/min/1.73 m2)
Peripheral artery disease
Intermittent claudicationGFR, glomerular filtration rate.Reproduced with permission from Hypertension Canada.Table 3Examples of key cardiovascular risk factors for atherosclerosis
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)
Age ≥ 55 years
Family history of premature cardiovascular disease (age < 55 in men and < 65 in women)
Poor dietary habits
NonadherenceReproduced with permission from Hypertension Canada.
- 4.If the visit 1 mean AOBP or OBPM SBP is ≥ 180 mm Hg or DBP is ≥ 110 mm Hg then hypertension is diagnosed (Grade D).
- 5.If the visit 1 mean AOBP SBP is 135-179 mm Hg or DBP is 85-109 mm Hg or the mean OBPM SBP is 140-179 mm Hg or DBP is 90-109 mm Hg, out-of-office BP measurements should be performed before visit 2 (Grade C).
- i.ABPM is the recommended out-of-office measurement method (Grade D). Patients can be diagnosed with hypertension according to the following thresholds:
- a.if the mean awake SBP is ≥ 135 mm Hg or DBP is ≥ 85 mm Hg, or
- b.if the mean 24-hour SBP is ≥ 130 mm Hg or DBP is ≥ 80 mm Hg (Grade C).
- ii.HBPM (as outlined in section I. Accurate measurement of BP, Recommendation 4. iv) is recommended if ABPM is not tolerated, not readily available, or patient preference (Grade D). Patients can be diagnosed with hypertension if the mean SBP is ≥ 135 mm Hg or DBP is ≥ 85 mm Hg (Grade C).
- iii.If the out-of-office ABPM or HBPM average is not elevated, white coat hypertension should be diagnosed and pharmacologic treatment should not be instituted (Grade C). If the mean HBPM is < 135/85 mm Hg, before diagnosing white coat hypertension, it is advisable to either: (1) perform ABPM to confirm that the mean awake BP is < 135/85 mm Hg and the mean 24-hour BP is < 130/80 mm Hg (preferred); or (2) repeat a HBPM series to confirm the home BP is < 135/85 mm Hg (Grade D).
- 6.If the out-of-office measurement, although preferred, is not performed after visit 1, then patients can be diagnosed as hypertensive using serial OBPM visits if any of the following conditions are met:
- i.At visit 2, the mean OBPM (averaged across all visits) is ≥ 140 mm Hg SBP and/or ≥ 90 mm Hg DBP in patients with macrovascular target organ damage, diabetes mellitus, or chronic kidney disease (glomerular filtration rate [GFR] < 60 mL/min/1.73 m2; Grade D);
- ii.At visit 3, the mean OBPM (averaged across all visits) is ≥ 160 mm Hg SBP or ≥ 100 mm Hg DBP; and
- iii.At visit 4 or 5, the mean OBPM (averaged across all visits) is ≥ 140 mm Hg SBP or ≥ 90 mm Hg DBP.
- 7.Investigations for secondary causes of hypertension should be initiated in patients with clinical and/or laboratory features indicative of hypertension (outlined in sections III. Routine and optional laboratory tests for the investigation of patients with hypertension, XVI. Assessment for renovascular hypertension, XVII. Treatment of hypertension in association with renovascular disease, XVIII. Assessment for endocrine hypertension, and XIX. Treatment of secondary hypertension due to endocrine causes; Grade D).
- 1.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).
- 2.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 (Grade D).
- 3.Patients receiving 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).
- 4.Standard OBPM should be used for follow-up. Measurement using electronic (oscillometric) upper arm devices is preferred over auscultation (Grade C).
- 5.ABPM or HBPM is recommended for follow-up of patients with demonstrated white coat effect (Grade D).
- 1.In addition to a general recommendation for hypertensive patients (in section II. Diagnosis of hypertension and follow-up, 5), 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).
- 2.The magnitude of changes in nocturnal BP should be taken into account in any decision to prescribe or withhold drug therapy on the basis of ABPM (Grade C) because a decrease in nocturnal BP of < 10% is associated with increased risk of cardiovascular events.
- 1.The use of HBPM on a regular basis should be considered for patients with hypertension, particularly those with:
- i.Inadequately controlled hypertension (Grade B; revised recommendation);
- ii.Diabetes mellitus (Grade D);
- iii.Chronic kidney disease (Grade C);
- iv.Suspected nonadherence (Grade D);
- v.Demonstrated white coat effect (Grade C); or
- vi.BP controlled in the office but not at home (masked hypertension; Grade C).
- 2.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).
III Routine and optional laboratory tests for the investigation of patients with hypertension
- •Consider the potential for pregnancy in women with hypertension.
- 1.Routine 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 (Grade D);
- iv.Serum total cholesterol, low-density lipoprotein, high-density lipoprotein (HDL), and non-HDL cholesterol, and triglycerides (Grade D); lipids may be drawn fasting or nonfasting (Grade C); and
- v.Standard 12-lead electrocardiography (Grade C).
- 2.Assess urinary albumin excretion in patients with diabetes (Grade D).
- 3.All treated hypertensive patients should be monitored according to the current Diabetes Canada guidelines for the new appearance of diabetes (Grade B).
- 4.During the maintenance phase of hypertension management, tests (including those for electrolytes, creatinine, fasting lipids, and pregnancy) should be repeated with a frequency reflecting the clinical situation (Grade D; revised recommendation).
- 5.A pregnancy test should be considered before initiation of health behaviour management changes or drug therapy (Grade D; new recommendation).
- 6.Routine echocardiographic evaluation of all hypertensive patients is not recommended (Grade D).
- 7.An echocardiogram for assessment of left ventricular hypertrophy is useful in selected cases to help define the future risk of cardiovascular events (Grade C).
- 8.Echocardiographic 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 (CAD; Grade D).
- 9.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).
Cardiovascular Risk Assessment
IV Assessment of overall cardiovascular risk in hypertensive patients
- 1.Global cardiovascular risk should be assessed. Multifactorial risk assessment models can be used to:
- i.Predict more accurately an individual’s global cardiovascular risk (Grade A);
- ii.Help engage individuals in conversations about health behaviour change to lower BP (Grade D); and,
- iii.Use antihypertensive therapy more efficiently (Grade D).
- 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).
Cardiovascular Health Promotion
- •Health behaviour change plays an important role in hypertension prevention and BP-lowering in people diagnosed with hypertension
- •Health behaviour change is strongly recommended as a first-line intervention to lower BP in people with hypertension
- •Optimization of lipid levels with the use of statins in higher-risk patients is recommended
- •The use of acetylsalicylic acid (ASA) for primary prevention of cardiovascular disease is no longer recommended in people with hypertension
V Global vascular protection therapy for adults with hypertension without compelling indications for specific agents
- •The recommendation for the use of low-dose ASA in the primary prevention of cardiovascular disease has been removed.
- 1.Statin therapy is recommended in hypertensive patients with ≥ 3 cardiovascular risk factors as defined in Supplemental Table S4 (Grade A in patients older than 40 years) or with established atherosclerotic disease (Grade A regardless of age).
- 2.Tobacco use status of all patients should be updated on a regular basis and health care providers should clearly advise patients to quit smoking (Grade C).
- 3.Advice in combination with pharmacotherapy (eg, varenicline, bupropion, nicotine replacement therapy) should be offered to all smokers with a goal of smoking cessation (Grade C).
VI Health behaviour management
- •Reduce alcohol consumption (or abstain) to reduce BP and prevent hypertension.
- •To prevent hypertension, there is no safe limit for alcohol consumption.59
- A.Physical exercise
- 1.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). For nonhypertensive or hypertensive individuals with SBP/DBP of 140-159/90-99 mm Hg , 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).
- 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 18.5-24.9, 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).
- C.Alcohol consumption
- 1.In healthy adults, abstaining from alcohol or reducing alcohol intake to 2 drinks per day or less is recommended to prevent hypertension (Grade B; revised recommendation).
- 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, whole grain foods rich in dietary fibre, and protein from plant sources that is reduced in saturated fat and cholesterol (Dietary Approaches to Stop Hypertension [DASH] diet63,64,65,66; Supplemental Table S5; Grade B).
- E.Sodium intake
- 1.To prevent hypertension and reduce BP in hypertensive adults, consider reducing sodium intake toward 2000 mg (5 g of salt or 87 mmol of sodium) per day (Grade A).
- F.Calcium and magnesium intake
- 1.Supplementation of calcium and magnesium is not recommended for the prevention or treatment of hypertension (Grade B).
- G.Potassium intake
- 1.In patients not at risk of hyperkalemia (see Table 4), increase dietary potassium intake to reduce BP (Grade A).Table 4Risk factors for hyperkalemia
Before advising an increase in potassium intake, the following types of patients, who are at high risk of developing hyperkalemia, should be assessed for suitability, and monitored closely:
- •Patients taking renin-angiotensin-aldosterone inhibitors
- •Patients taking other drugs that can cause hyperkalemia (eg, trimethoprim and sulfamethoxazole, amiloride, triamterene)
- •Chronic kidney disease (glomerular filtration rate < 45 mL/min/1.73 m2)
- •Baseline serum potassium > 4.5 mmol/L
- H.Stress management
- 1.In hypertensive patients in whom stress might be contributing to high BP, stress management should be considered as an intervention (Grade D).
- 2.Individualized cognitive-behavioural interventions are more likely to be effective when relaxation techniques are used (Grade B).
Management: Uncomplicated Pharmacotherapy
- •Hypertension Canada continues to promote a risk-based approach to treatment thresholds and targets (Table 5, Table 6).Table 5Blood pressure thresholds for initiation of antihypertensive therapy and treatment targets in adults
Patient population BP threshold (mm Hg) for initiation of antihypertensive therapy BP target (mm Hg) for treatment Low risk (no target organ damage or cardiovascular risk factors) SBP ≥ 160 (Grade A)
DBP ≥ 100 (Grade A)
SBP < 140 (Grade A)
DBP < 90 (Grade A)
High risk of cardiovascular disease∗ SBP ≥ 130 (Grade B) SBP < 120 (Grade B) Diabetes mellitus SBP ≥ 130 (Grade C)
DBP ≥ 80 (Grade A)
SBP < 130 (Grade C)
DBP < 80 (Grade A)
All others SBP ≥ 140 (Grade C)
DBP ≥ 90 (Grade A)
SBP < 140 (Grade A)
DBP < 90 (Grade A)BP, blood pressure; DBP, diastolic blood pressure; SBP, systolic blood pressure.∗ See Table 6; on the bass of automated office blood pressure measurement.Table 6Clinical indications defining high-risk adult patients as candidates for intensive management
Clinical or subclinical cardiovascular disease; or Chronic kidney disease (nondiabetic nephropathy, proteinuria < 1 g/d,∗estimated glomerular filtration rate 20-59 mL/min/1.73 m2); or Estimated 10-year global cardiovascular risk ≥ 15%†; or Age ≥ 75 years Patients with 1 or more clinical indications should consent to intensive management.∗ Four-variable Modification of Diet in Renal Disease equation.† Framingham Risk Score.109
- •Hypertension Canada continues to encourage the use of clinical judgement and shared decision-making when identifying BP targets to ensure feasibility in the patient’s broader clinical, social, and economic context.
- •Patients with existing cardiovascular disease or with elevated cardiovascular risk should be considered for intensive SBP targets (ie, SBP ≤ 120 mm Hg).
- •Angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), and longer-acting thiazide-like diuretics continue to be recommended as effective first-line treatment in all adults with uncomplicated hypertension.
- •β-Blockers can be used safely as first-line therapy in younger patients only with uncomplicated hypertension.
- •When possible, the use of a single-pill combination (SPC) should be considered to improve treatment efficacy, efficiency, and tolerability.54
|Initial therapy||Second-line therapy||Notes and/or cautions|
|Hypertension without other compelling indications|
|Diastolic hypertension with or without systolic hypertension||Monotherapy or SPC. Recommended monotherapy choices include thiazide/thiazide-like diuretics (with longer-acting diuretics preferred), β-blockers, ACE inhibitors, ARBs, or long-acting CCBs. Recommended SPC choices include combinations of an ACE inhibitor with CCB, ARB with CCB, or ACE inhibitor/ARB with a diuretic (consider statins in selected patients)||Combination of first-line drugs||Not recommended for monotherapy: α-blockers, β-blockers in those 60 years of age or older, ACE inhibitors in black people. Hypokalemia should be avoided in those prescribed diuretics. Combination of an ACE inhibitor with an ARB is not recommended|
|Isolated systolic hypertension without other compelling indications||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 with microalbuminuria,|
∗renal disease, cardiovascular disease, or additional cardiovascular risk factors
|ACE inhibitors or ARBs||Additional use of a dihydropyridine CCB is preferred over a thiazide/thiazide-like diuretic||A loop diuretic could be considered in hypertensive chronic kidney disease 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|
|Coronary artery disease||ACE inhibitors or ARBs; β-blockers or CCBs for patients with stable angina||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 not recommended. Exercise caution when lowering SBP to target if DBP is ≤ 60 mm Hg, especially in patients with LVH|
|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 CCB can also be used.
A combined ARB/neprilysin-inhibitor is recommended (in place of an ACE inhibitor or ARB) in symptomatic patients with hypertension and HFrEF according to standard guideline-based therapies
|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|
|LVH||ACE inhibitor, ARB, long-acting CCB, or thiazide/thiazide-like diuretic||Combination of first-line agents||Hydralazine and minoxidil should not be used|
|Past stroke or TIA||ACE inhibitor and a thiazide/thiazide-like diuretic combination||Combination of first-line agents||Treatment of hypertension should not be routinely undertaken in patients with acute stroke unless extreme BP elevation. Combination of an ACE inhibitor with an ARB is not recommended|
|Nondiabetic chronic kidney disease|
| Nondiabetic chronic kidney disease with proteinuria|
|ACE inhibitors (ARBs if ACE inhibitor-intolerant) if there is proteinuria|
Diuretics as additive therapy
|Combinations of first-line agents||Carefully monitor renal function and potassium for those receiving an ACE inhibitor or ARB. Combinations of an ACE inhibitor and ARB are not recommended|
VII 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; target established using OBPM) or average SBP measurements of ≥ 160 mm Hg (Grade A; target established using OBPM) in patients without macrovascular target organ damage or other cardiovascular risk factors.
- 2.Antihypertensive therapy should be strongly considered for average DBP readings ≥ 90 mm Hg (Grade A) or for average SBP readings ≥ 140 mm Hg (Grade B for 140-160 mm Hg; Grade A for > 160 mm Hg; targets established using OBPM) in the presence of macrovascular target organ damage or other independent cardiovascular risk factors.
- 3.For high-risk patients (Table 5), aged 50 years or older, with SBP levels ≥ 130 mm Hg, intensive management to target a SBP < 120 mm Hg should be considered. Intensive management should be guided by AOBP measurements (see section I. Accurate measurement of BP, and the Recommended Technique for Automated Office Blood Pressure section of Supplemental Table S1). Patient selection for intensive management is recommended and caution should be taken in certain high-risk groups (Table 8; Grade B).Table 8Generalizability of intensive blood pressure-lowering in adults: Cautions and contraindications
Limited or no evidence
Heart failure (left ventricular ejection fraction < 35%) or recent myocardial infarction (within past 3 months)
Indication for, but not currently receiving, a β-blocker
Institutionalized elderly individuals
eGFR < 20 mL/min/1.73 m2
Patient unwilling or unable to adhere to multiple medications
Standing SBP < 110 mm Hg
Inability to measure SBP accurately
Known secondary cause(s) of hypertensioneGFR, estimated glomerular filtration rate; SBP, systolic blood pressure.
VIII Choice of therapy for adults with hypertension without compelling indications for specific agents
- A.Indications for drug therapy for adults with diastolic hypertension with or without systolic hypertension
- 1.Initial therapy should be with either monotherapy or SPC.
- i.Recommended monotherapy choices are:
- a.a thiazide/thiazide-like diuretic (Grade A), with longer-acting diuretics preferred (Grade B);
- b.a β-blocker (in patients younger than 60 years; Grade B);
- c.an ACE inhibitor (in nonblack patients; Grade B);
- d.an ARB (Grade B); or
- e.a long-acting CCB (Grade B).
- ii.Recommended SPC choices are those in which an ACE inhibitor is used with a CCB (Grade A), an ARB is used with a CCB (Grade B), or an ACE inhibitor or ARB is used with a diuretic (Grade B).
- iii.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 A 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.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).
- 4.Possible reasons for poor response to therapy (Supplemental Table S6) should be considered (Grade D).
- 5.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.
- B.Indications for drug therapy for adults 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 combined or substituted (Grade D).
- 4.Possible reasons for poor response to therapy (Supplemental Table S6) 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 or older (Grade A). However, both agents may be used in patients with certain comorbid conditions or in combination therapy.
- C.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). These targets were established using OBPM.
Management: Complex Comorbidity
- •Hypertension frequently coexists with other conditions that influence therapeutic decision-making. Polypharmacy and competing risks need to be considered carefully.
- •Adults with diabetes and certain forms of chronic kidney disease (Table 9) might benefit from more intensive BP targets (ie, SPB ≤ 130 mm Hg or ≤ 120 mm Hg).Table 9Systolic blood pressure targets in patients with nondiabetic CKD
Nondiabetic CKD Systolic BP target Patients meeting SPRINT criteria∗ < 120 mm Hg† Patients with APCKD < 110 mm Hg‡ All other patients with nondiabetic CKD < 140 mm Hg§Measurement is on the basis of office BP. Further reduction in systolic BP target may be individualized at the discretion of the treating physician considering the patient’s specific kidney disease, comorbidities, and age. Moreover, we recommend that potential benefits and adverse events related to lower systolic BP targets be discussed with each patient and therapeutic decisions should be shared.APCKD, adult polycystic kidney disease; BP, blood pressure; CKD, chronic kidney disease; SPRINT, Systolic Blood Pressure Intervention Trial.∗ Patients > 50 years of age, at elevated cardiovascular risk with systolic BP 130-180 mm Hg.† Measurement is on the basis of automated office BP.‡ Measurement is on the basis of HBPM.§ Measurement is on the basis of office BP. Further reduction in systolic BP target may be individualized at the discretion of the treating physician considering the patient’s specific kidney disease, comorbidities, and age. Moreover, we recommend that potential benefits and adverse events related to lower systolic BP targets be discussed with each patient and therapeutic decisions should be shared.
Diabetes and Hypertension
IX 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).
- 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).
Hypertension in Chronic Kidney Disease
- •Individualize BP targets in patients with chronic kidney disease. Consider intensive targets (SBP < 120 mm Hg) in appropriate patients.
X Treatment of hypertension in association with nondiabetic chronic kidney disease
- 1.For patients with hypertension and proteinuric chronic kidney disease (urinary protein level > 150 mg in 24 hours or albumin to creatinine ratio > 30 mg/mmol), initial therapy should be with an ACE inhibitor (Grade A) or an ARB (Grade B; revised recommendation).
- 2.In most cases, combination therapy with other antihypertensive agents might be needed to reach target BP levels (Grade D).
- 3.The combination of an ACE inhibitor and ARB is not recommended for patients with chronic kidney disease (Grade B; revised recommendation).
Hypertension and Stroke
XI Treatment of hypertension in association with stroke
- A.BP management in acute ischemic stroke (onset to 72 hours)
- 1.For guidelines on BP management in acute ischemic stroke, refer to the current Canadian Stroke Best Practices recommendations (www.strokebestpractices.ca/recommendations).
- B.BP management after acute ischemic 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 A).
- 4.For patients with stroke, the use of an ACE inhibitor with an ARB is not recommended (Grade B).
- C.BP management in hemorrhagic stroke (onset to 72 hours)
- 1.For guidelines on BP management in acute hemorrhagic stroke, refer to the current Canadian Stroke Best Practices recommendations (www.strokebestpractices.ca/recommendations).
Hypertensive Patients With Cardiovascular Disease
XII Treatment of hypertension in association with ischemic heart disease
- A.Recommendations for hypertensive patients with CAD
- 1.For most hypertensive patients with CAD, an ACE inhibitor or ARB is recommended (Grade A).
- 2.For hypertensive patients with CAD, but without coexisting systolic heart failure, the combination of an ACE inhibitor and ARB is not recommended (Grade B).
- 3.For high-risk hypertensive 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).
- 4.For patients with stable angina pectoris but without previous heart failure, myocardial infarction, or coronary artery bypass surgery, either a β-blocker or CCB can be used as initial therapy (Grade B).
- 5.Short-acting nifedipine should not be used (Grade D).
- 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, especially in patients with left ventricular hypertrophy (Grade D).
- B.Recommendations for patients with hypertension who have had a recent myocardial infarction
- 1.Initial therapy should include a β-blocker as well as 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 on examination or radiography (Grade D).
XIII 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) may be combined 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 an aldosterone antagonist is used with 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 used with an ACE inhibitor and other antihypertensive drug treatment (Grade A). Careful monitoring should be used if an ACE inhibitor and an ARB are used together because of potential adverse effects such as hypotension, hyperkalemia, and worsening renal function (Grade C). Additional therapies may also include dihydropyridine CCBs (Grade C).
- 5.An angiotensin receptor-neprilysin inhibitor combination should be used in place of an ACE inhibitor or ARB for patients with heart failure with reduced ejection fraction (HFrEF) (ejection fraction < 40%) who remain symptomatic despite treatment with an appropriate dose of guideline-directed heart failure therapy (usually a β-blocker, an ACE inhibitor or ARB, and where appropriate, a mineralocorticoid receptor antagonist; Grade A). Eligible patients must have a serum potassium level < 5.2 mmol/L, an estimated GFR (eGFR) ≥ 30 mL/min/1.73 m2, and close surveillance of serum potassium and creatinine (Grade A).
XIV Treatment of hypertension in association with left ventricular hypertrophy
- 1.Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to decrease 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.
- •Resistant hypertension is defined as BP above target despite 3 or more BP-lowering drugs at optimal doses preferably including a diuretic (and usually a renin-angiotensin-aldosterone system blocker and a CCB).
- •Accurate office and out-of-office BP measurement is essential.
- •Other reasons for apparent resistant hypertension should be eliminated before diagnosing true resistant hypertension, including nonadherence, white coat effect, and secondary hypertension.
- •Pharmacotherapy with the additional use of spironolactone, bisoprolol, doxazosin, amiloride, eplerenone, or clonidine with the baseline regimen decreases BP significantly, with the greatest BP-lowering shown with spironolactone.
XV Resistant hypertension
- •Patients with resistant hypertension should be referred to providers with expertise in diagnosis and management of hypertension.
- 1.We recommend that patients with resistant hypertension, defined as BP above target despite ≥ 3 BP-lowering drugs at optimal doses, preferably including a diuretic, be referred to a provider with expertise in hypertension management for diagnosis (Table 10) and therapeutic (Table 11) purposes (Grade D; new recommendation).
- •When investigating renovascular hypertension, carefully consider renal function.
XVI Assessment for renovascular hypertension
- 1.Patients who present with 2 or more of the following clinical clues, which suggest renovascular hypertension, should be investigated (Grade D):
- i.Sudden onset or worsening of hypertension and age older than 55 or younger than 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 ACE inhibitor or ARB;
- v.Other atherosclerotic vascular disease, particularly in patients who smoke or have dyslipidemia;
- vi.Recurrent pulmonary edema associated with hypertensive surges.
- 2.The following tests are recommended for screening for atherosclerotic renal vascular disease: captopril-enhanced radioisotope renal scan (for patients with eGFR > 60 mL/min/1.73 m2), Doppler sonography, computed tomography angiography, and magnetic resonance angiography (for patients with eGFR > 30 mL/min/1.73 m2; Grade D; revised recommendation).
- 3.Patients with hypertension who present with at least 1 of the following clinical clues should be investigated for fibromuscular dysplasia (FMD)-related renal artery stenosis (Grade D):
- i.Significant (> 1.5 cm), unexplained asymmetry in kidney sizes;
- ii.Abdominal bruit without apparent atherosclerosis;
- iii.FMD in another vascular territory;
- iv.Family history of FMD.
- 4.In patients with confirmed renal FMD (Grade D):
- i.Screening for cervicocephalic lesions and intracranial aneurysm is recommended;
- ii.Screening for FMD in other vascular beds in the presence of suggestive symptoms is recommended.
- 5.The following tests are recommended to screen for renal FMD (both with similar sensitivity and specificity; Grade D): magnetic resonance angiography and computed tomography angiography.
XVII Treatment of hypertension in association with renovascular disease
- 1.Patients with hypertension attributable to atherosclerotic renal artery stenosis should be primarily medically managed because renal angioplasty and stenting offers no benefit over optimal medical therapy alone (Grade B).
- 2.Renal artery angioplasty and stenting for atherosclerotic hemodynamically significant renal artery stenosis could be considered for patients with any of the following (Grade D; revised recommendation):
- i.Uncontrolled hypertension resistant to maximally tolerated pharmacotherapy,
- ii.Progressive renal function loss,
- iii.Acute pulmonary edema.
- 3.Patients with confirmed renal FMD should be referred to a hypertension specialist (Grade D).
- 4.Renal artery angioplasty without stenting is recommended for treatment of FMD-related renal artery stenosis. Stenting is not recommended unless needed because of a periprocedural dissection. Surgical revascularization should be considered in case of complex lesions less amendable to angioplasty, stenosis associated with complex aneurysm, and restenosis despite 2 unsuccessful attempts of angioplasty (Grade D).
XVIII Assessment for endocrine hypertension
- A.Primary aldosteronism: screening and diagnosis
- 1.Screening for primary aldosteronism should be considered in hypertensive patients with the following (Grade D):
- i.Unexplained spontaneous hypokalemia (K+ < 3.5 mmol/L) or marked diuretic-induced hypokalemia (K+ < 3.0 mmol/L);
- ii.Resistance to treatment with ≥ 3 drugs;
- iii.An incidental adrenal adenoma.
- 2.Screening for primary aldosteronism should include assessment of plasma aldosterone and plasma renin activity or plasma renin (Table 13).Table 13Primary aldosteronism
- I.Plasma aldosterone and plasma renin activity or renin mass/concentration (see section II, below, for suggested conversion factors) should be collected as follows:
- A.In the morning after the patient has been ambulatory (sitting, standing, or walking) for at least 2 hours
- B.Patients should be seated for 5-15 minutes before the blood draw
- C.Hypokalemia should be corrected and sodium intake should be liberalized
- D.At least 4-6 weeks before testing, agents that markedly affect the results (aldosterone antagonists, potassium-sparing and -wasting diuretics) should be withdrawn
- E.If the results are not diagnostic, and if hypertension can be controlled with medications less likely to affect testing (slow-release verapamil, diltiazem, hydralazine, prazosin, doxazosin, and terazosin), repeat testing 2 weeks after withdrawing the following medications that can interfere with test accuracy: β-blockers, centrally acting α2 agonists, angiotensin receptor blockers, angiotensin converting enzyme inhibitors, directly acting renin inhibitors, and dihydropyridine calcium channel blockers
- FFalse positive results might occur with direct renin mass/concentration if the patient is a woman using an oral contraceptive pill. If possible, oral contraception should be discontinued for 1 month before testing, or alternately, plasma renin activity should be measured instead
- II.The aldosterone to renin ratio is the preferred screening test for primary aldosteronism. Traditionally this was on the basis of measuring aldosterone according to radioimmunoassay and renin activity. Currently most laboratories use automated chemiluminescent assays for aldosterone and renin mass. Interpretation of a positive screening test is dependent on the local laboratory method for renin measurement but assumes standard reporting of aldosterone in pmol/L. Optimal screening cut-offs remain undefined. Suggested cut-offs are:
Renin method used Aldosterone to renin ratio Higher sensitivity, lower specificity Lower sensitivity, higher specificity Plasma renin activity (ng/mL/h)1 555 750 Direct renin concentration (mIU/L) 60 91 Direct renin concentration (ng/L) 100 144 Confirmatory testing
- III.If 1 of the following criteria is met, autonomous hypersecretion of aldosterone is confirmed (interfering drugs should continue to be held, as outlined above):
- ASaline loading tests (perform either):
- iAdminister 2 L of normal saline intravenously over 4 hours with the patient in a recumbent position. This test is contraindicated in the presence of severe, uncontrolled hypertension or congestive heart failure. Primary aldosteronism is defined as a postinfusion plasma aldosterone > 280 pmol/L. If < 140 pmol/L, primary aldosteronism is unlikely. Values in between are considered indeterminate
- ii.Administer > 200 mmol/d of oral sodium (ie, equivalent to > 5 g/d of sodium; > 12 g/d of sodium chloride; or > 2 tsp/d of salt) for 3 days, with primary aldosteronism defined as a 24-hour urinary aldosterone > 33 nmol/d (measured from the morning of day 3 to the morning of day 4). If < 28 nmol/d, primary aldosteronism is unlikely
- B.A plasma aldosterone to plasma renin activity ratio > 1400 pmol/L/ng/mL/h (or > 270 pmol/L/ng/L), with a plasma aldosterone > 440 pmol/L
- C.Captopril suppression test: Administer 25-50 mg captopril orally after the patient has been sitting or standing for 1 hour. While seated, renin and plasma aldosterone levels should be measured at time 0 and 1 to 2 hours after ingestion. Primary aldosteronism is unlikely if plasma aldosterone is suppressed by > 30% after captopril ingestion. In primary aldosteronism, plasma aldosterone level remains elevated, while renin level remains suppressed
- IV.Differentiating potential causes of confirmed primary aldosteronism (unilateral vs bilateral secretion):
- A.Computed tomography scanning (or magnetic resonance imaging) can help localize the presence of adrenal lesion(s). If imaging shows an adrenal lesion/adenoma, it might be nonfunctional. Therefore, if surgery to remove a suspected unilateral source of primary aldosteronism is planned, selective adrenal venous sampling should be considered first (to verify that an abnormally appearing adrenal gland is the source of hypersecretion)
- B.For patients with established primary aldosteronism and in whom surgery is an option, selective adrenal venous sampling should be considered to differentiate unilateral from bilateral overproduction of aldosterone
- C.Adrenal venous sampling should be conducted in centres with experience in performing this diagnostic technique
- DWe suggest selective genetic testing for glucocorticoid-remediable aldosteronism in patients with confirmed primary aldosteronism and either:
- iA family history of primary aldosteronism or stroke at a young age (≤ 40 years); or
- iiOnset of hypertension at 20 years of age or younger and negative imaging
Modified and reprinted with permission from Hypertension Canada.
- V.Treatment is informed by subtype classification (unilateral vs bilateral secretion):
- A.Surgery with ipsilateral adrenalectomy should be considered for unilateral forms of hypersecretion (eg, aldosterone-producing adenomas). Patients should be followed closely after surgery because a significant proportion might remain hypertensive
- B.Mineralocorticoid receptor antagonists (particularly spironolactone in low to moderate doses) are quite effective for those with bilateral disease (eg, idiopathic/bilateral adrenal hyperplasia). Monitoring of potassium and creatinine are required, especially if used with angiotensin receptor blockers or angiotensin converting enzyme inhibitors.
- C.Mineralocorticoid receptor antagonists should be considered for individuals who are not surgical candidates or for those who refuse surgery (even with confirmed unilateral hypersecretion). Blood pressure-lowering responses to other antihypertensive medications (eg, angiotensin receptor blockers, angiotensin converting enzyme inhibitors, and calcium channel blockers) are often only modest to moderate
- D.Primary aldosteronism is associated with a relative hyperfiltration injury to the kidney in excess of that seen in essential hypertension. Treatment of primary aldosteronism (with either surgery or medical therapy) might unmask significant underlying renal disease with an increase in creatinine and decrease in eGFR. Patients should have their renal function monitored closely after treatment
- 3.For patients with suspected primary aldosteronism (on the basis of the screening test; Table 13, section II), a diagnosis of primary aldosteronism should be established by demonstrating inappropriate autonomous hypersecretion of aldosterone using at least 1 of the manoeuvres listed in Table 13, section III. When the diagnosis is established, the abnormality should be localized using any of the tests described in Table 13, section IV.
- 4.In patients with primary aldosteronism and a definite adrenal mass who are eligible for surgery, adrenal venous sampling is recommended to assess for lateralization of aldosterone hypersecretion. Adrenal vein sampling should be performed exclusively by experienced teams working in specialized centres (Grade C).
- B.Pheochromocytoma and paraganglioma: screening and diagnosis
- 1.If pheochromocytoma or paraganglioma is strongly suspected, the patient should be referred to a specialized hypertension centre, particularly if biochemical screening tests (Table 14) have already been shown to be positive (Grade D).Table 14Pheochromocytoma
Screening and diagnosis
- ITo screen for pheochromocytoma:
- ATwenty-four-hour urinary total metanephrines and catecholamines (sensitivity 90%-95%) or 24-hour urine fractionated metanephrines (sensitivity of approximately 95%) should be measured. Concomitant measurement of 24-hour urine creatinine should also be performed to confirm accurate collection
- BPlasma free metanephrines and free normetanephrines, where available, might also be considered (sensitivity up to 99%)
- CUrinary vanillylmandelic acid measurements should not be used for screening
- IIKeep in mind that potential false positive results should be considered in the setting of:
- AInterfering drugs
- BIncorrect patient preparation and positioning (for plasma metanephrine measures)
- CMild elevation of screening values (ie, less than twofold the upper limit of normal)
- DNormal values on repeat testing
- EOnly 1 abnormal biochemical test in the panel of assays
- FAtypical imaging results for pheochromocytoma
- GA low pretest probability of pheochromocytoma
- HAcute illness/hospitalization
- IIIIn the presence of borderline biochemical test results or potentially false positive results, repeat testing may be performed and/or the clonidine suppression test may be used. This should be done before imaging is requested to avoid identifying potential incidentalomas
- IVImaging (eg, computed tomography, magnetic resonance, with or without iodine I-131 meta-iodobenzylguanidine scintigraphy) should generally be performed only after biochemical confirmation of disease
Modified and reproduced with permission from Hypertension Canada.
- IDefinitive treatment is surgical resection. Preoperative planning is recommended for blood pressure control and volume expansion
- Aα-Blockade should be started 10-14 days preoperatively. Typical options include phenoxybenzamine (a long-acting, nonselective irreversible α-blocker), prazosin, or doxazosin
- BOther antihypertensive medications may be added as necessary but diuretics should be avoided if possible. Oral β-blockers may be considered after achieving adequate α-blockade to control tachycardia and prevent arrhythmias during surgery
- CVolume replacement and liberal sodium intake should be encouraged because volume contraction is common in this condition. Intravenous volume expansion in the perioperative period is recommended to prevent postoperative shock
- IIPostoperatively, long-term follow-up is recommended with urinary or plasma metanephrine levels to screen for recurrence, especially in those with a genetic predisposition
- IIIGenetic testing should be considered for individuals younger than 50 years of age and for all patients with multiple lesions, malignant lesions, bilateral pheochromocytomas, or paragangliomas, or a family history of pheochromocytoma or paraganglioma
- 2.The following patients should be considered for screening for pheochromocytoma or paraganglioma (Grade D):
- i.Patients with paroxysmal, unexplained, labile, 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, changes in abdominal pressure, surgery, or anaesthesia;
- iv.Patients with an incidentally discovered adrenal mass;
- v.Patients with a predisposition to hereditary causes (eg, multiple endocrine neoplasia 2A or 2B, von Recklinghausen neurofibromatosis type 1, or Von Hippel-Lindau disease);
- vi.For patients with positive biochemical screening tests, localization of pheochromocytomas or paragangliomas magnetic resonance imaging (preferable), computed tomography (if magnetic resonance imaging unavailable), and/or iodine I-131 meta-iodobenzylguanidine scintigraphy should be used (Grade C for each modality).
- •Adherence should be routinely evaluated in adults being treated for hypertension.
XX Adherence strategies for patients
- 1.Adherence to an antihypertensive prescription can be improved by using a multipronged approach (Table 12).Table 12Strategies to improve patient adherence
Assist your patient by:
- •Tailoring pill-taking to fit patient’s daily habits (Grade D)
- •Simplifying medication regimens to once-daily dosing (Grade D)
- •Replacing multiple pill antihypertensive combinations with single-pill combinations (Grade C)
- •Using 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 their families about their disease and treatment regimens (Grade C)
Improve your management in the office and beyond by:
Modified and reproduced with permission from Hypertension Canada.
- •In patients with hypertension who are not at target, adherence to all health behaviour recommendations (including use of prescription medications) should be reviewed before adjustment in therapy is considered (Grade D; revised recommendation)
- •Encouraging adherence with therapy using out-of-office contact (either phone or mail), particularly during the first 3 months of therapy (Grade D)
- •Coordinating with pharmacists and work-site health caregivers to improve monitoring of adherence with pharmacological and health behaviour modification prescriptions (Grade D)
- •Using electronic medication compliance aids (Grade D)
Digital and e-health strategies
Special Populations 2. Hypertension and Pediatrics
- •BP should be measured regularly in children 3 years of age or older; the auscultatory method is the gold-standard at present.
- •Simplified diagnostic thresholds can be used (in addition to or as an alternative to normative tables) to diagnose hypertension in children and adolescents.
- •If office BP readings are elevated, ABPM is recommended using devices independently validated in children and interpreted with appropriate pediatric normative data.
- •In children with confirmed hypertension, routine echocardiographic evaluation should be performed, and cardiovascular risk factors should be assessed with routine laboratory tests.
- •Health behaviour management should aim for a healthy body weight through a comprehensive approach that includes dietary education and increased physical activity.
- •Secondary hypertension should be ruled out before pharmacological therapy is introduced in children with symptomatic hypertension, target organ damage, comorbidities, persistent, or stage 2 hypertension.
- •Initial therapy should be monotherapy, with an ACE inhibitor or ARB (not first-line in black children), or a long-acting dihydropyridine CCB.
- •The treatment goal is systolic and diastolic office BP and/or ABPM < 95th percentile or < 90th percentile in children with risk factors or target organ damage.
- •Complex cases should be referred to an expert in pediatric hypertension.
I Accurate measurement of BP in children
- 1.BP should be measured regularly in children 3 years of age and older by a health care professional using standardized pediatric techniques (Table 15) (Grade D).Table 15Standard approach for BP measurement in children (Grade D)
1. Children who will undergo BP measurement should avoid stimulant medications before evaluation. At the time of evaluation, the child should be seated in a quiet room for 5 minutes with back supported before the measurement of blood pressure 2. The right arm is the preferred location for BP measurement for comparison with normative data because of the possibility of coarctation of the aorta, which might result in an erroneously low BP measurement being obtained in the left arm 3. A cuff size with a bladder width that is at least 40% of the arm circumference and the cuff bladder length should cover 80%-100% of the circumference of the arm. The arm should be bare and supported with the BP cuff at heart level. To obtain accurate measurements in children a range of pediatric and adult cuff sizes should be available 4. The pressure should be increased rapidly to 30 mm Hg above the level at which the radial pulse is extinguished 5. The stethoscope should be placed below the bottom edge of the cuff and above the antecubital fossa. The bell or diaphragm of the stethoscope should be held gently and steadily over the brachial artery 6. The control valve should be opened so that the rate of deflation of the cuff is approximately 2 mm Hg per heartbeat 7. The systolic level—the first appearance of a clear tapping sound (phase I Korotkoff)—and the diastolic level (the point at which the sounds disappear; phase V Korotkoff) should be recorded. In some children, Korotkoff sounds can be heard to 0 mm Hg. If Korotkoff sounds persist as the level approaches 0 mm Hg, then the point of muffling of the sound is used (phase IV Korotkoff) to indicate the diastolic pressure 8. The BP should be recorded to the closest 2 mm Hg on the manometer (or 1 mm Hg on electronic devices)BP, blood pressure.
- 2.BP may be measured with a mercury sphygmomanometer, aneroid sphygmomanometer, or oscillometric device (Grade D). Abnormal oscillometric values should be confirmed with auscultation (Grade C).
- 3.BP varies with age, sex, and height in children and, therefore, BP values should be compared with norms for age, sex, and height (Table 16; Grade D).Table 16Determining normative data for BP values in children (Grade D)
1. The BP tables use growth parameters as defined in the CDC growth charts 2. The normative BP data obtained with the auscultatory method includes the US National Health and Nutrition Examination Survey, 1999-2000. Normative BP data for oscillometric measurements are now available 3. To determine BP percentile, use the standard CDC height charts to determine the height percentile 4. Measure the child’s blood pressure. Use the appropriate gender table. Locate the child’s age on the left side of the table and follow the age row horizontally across the table to the intersection of the line for the height percentile as shown in the vertical column 5. The 50th, 90th, 95th, and 99th percentiles are defined for systolic and diastolic blood pressure on the basis of gender, age, and heightBP, blood pressure; CDC, Centers for Disease Control and Prevention.
II Criteria for diagnosis of hypertension in children
- •Simplified diagnostic thresholds can also (in addition to or as an alternative to normative tables) be used to diagnose hypertension in children and adolescents.
- •Consider assessing non-HDL cholesterol when evaluating cardiovascular risk in children and adolescents with hypertension.
- 1.Using OBPMs, children can be diagnosed as hypertensive if SBP or DBP is at the 95th percentile or greater for age, sex, and height, measured on at least 3 separate occasions (Grade C), or if SBP or DBP is > 120/80 mm Hg in children 6-11 years of age, or greater than 130/85 mm Hg in children 12-17 years of age (Grade C; revised recommendation).
- 2.If the SBP and/or DBP is at the 95th percentile or greater, BP should be staged. Stage 1 is defined by BP between the 95th percentile and 95th percentile plus 12 mm Hg. Stage 2 is defined by BP > 95th percentile plus 12 mm Hg (Grade D; revised recommendation).
- i.If BP is stage 1, BP measurements should be repeated on 2 more occasions within 1 month; if hypertension is confirmed, evaluation (as described in section IV. Routine laboratory tests for the investigation of children with hypertension)95and/or appropriate referral should be initiated within 1 month, or both (Grade D).
- ii.If BP is stage 2, prompt referral should be made for evaluation and therapy (Grade C).
- 3.All children with suspected or confirmed hypertension should undergo a hypertension-focused history and physical evaluation (Table 17; Grade C).Table 17History and physical examination of children (Grade C)
1. Medical history
- •Of hypertension
- •Of an underlying disorder
- •For underlying cause of hypertension
- Identify other cardiovascular risk factors including inactivity, smoking, and dietary factors
- Family history
∗ Systems to review include renal, cardiovascular, endocrine, and neurologic, as well as medications/drugs and sleep disorders.
- Height, weight, and body mass index
- Vital signs including upper and lower limb blood pressures
- Evaluation for signs of end organ damage
- •Fundi, cardiovascular, and neurologic systems
- Evaluation for underlying cause of hypertension
III Assessment of overall cardiovascular risk in hypertensive children
- 1.Cardiovascular risk factors should be assessed in hypertensive children (Grade C).
IV Routine laboratory tests for the investigation of children with hypertension
- 1.Routine tests that should be performed for the investigation of all children with hypertension include:
- i.Blood chemistry (sodium, potassium, chloride, total CO2, and creatinine; Grade D);
- ii.Urinalysis (Grade D);
- iii.Renal ultrasound (Grade D);
- 2.Routine laboratory tests that should be performed for the assessment of cardiovascular risk in all children with hypertension include the following:
- i.For diabetes screening refer to Diabetes Canada clinical practice guidelines (https://www.diabetes.ca/health-care-providers/clinical-practice-guidelines/chapter-35#panel-tab_FullText) (chapters on children and adolescence) (revised recommendation);
- ii.Serum total cholesterol and HDL cholesterol, low-density lipoprotein cholesterol, non-HDL cholesterol, and triglycerides (Grade C; revised recommendation).
- 3.Routine tests that should be performed for the assessment of target organ damage in all children with hypertension include:
- i.Echocardiogram (Grade C);
- ii.Retinal examination (Grade C);
- iii.Albumin/creatinine ratio (first morning; Grade D).
V Ambulatory BP measurement in children
- 1.For children with elevated office BP readings, ABPM should be guided by a physician with expertise in pediatric hypertension; ABPM is useful to classify BP (Supplemental Table S7; Grade C).
- 2.Physicians should use only ABPM devices that have been validated independently in children using established protocols. A standard approach to obtaining ABPM readings should be used (Supplemental Table S7; Grade D).
- 3.ABPM levels should be interpreted with appropriate pediatric normative data for children 5 years of age or older or height of ≥ 120 cm (Grade D).
VI Role of echocardiography
- 1.Routine echocardiographic evaluation in children with confirmed hypertension is recommended (Grade D).
- 2.The echocardiographic assessment should include measurements of left ventricular mass index, systolic and diastolic left ventricular function, and evaluation of the aortic arch (Grade D).
VII Health behaviour management
- 1.Height and weight should be measured and body mass index calculated for all children at routine health visits (Grade D).
- 2.Achieving a healthy body weight (body mass index percentile < 85%) is recommended for nonhypertensive individuals to prevent hypertension and for hypertensive children to reduce BP (Grade C).
- 3.A comprehensive approach should include dietary education and increased physical activity (Grade C).
VIII Indications for drug therapy for children with hypertension
- 1.Pharmacological therapy should be initiated when patients have:
- i.Symptomatic hypertension (Grade D);
- ii.Hypertensive target organ damage (Grade C);
- iii.Stage 2 hypertension (Grade D);
- iv.BP ≥ 90th percentile associated with diabetes mellitus type 1 or 2, chronic kidney disease, or heart failure (Grade D);
- v.Stage 1 hypertension without target organ damage that persists (≥ 6 months) despite a trial of nonpharmacologic therapy (Grade D).
- 2.In children with proven secondary hypertension, specific treatment of the underlying disease must be initiated by an expert in pediatric hypertension (Grade D).
IX Choice of drug therapy for children with hypertension
- A.Recommendations for children with systolic and/or diastolic hypertension
- 1.Initial therapy should be monotherapy.
- i.Recommended monotherapy choices are:
- a.An ACE inhibitor (Grade C);
- b.An ARB (Grade C); or
- c.A long-acting dihydropyridine CCB (Grade D).
- ii.An alternate option is a β-blocker (Grade D) although they are less preferable because of the side effect profile in children.
- iii.If there are adverse effects, another drug from this group should be substituted.
- 2.If BP goals are not achieved with standard-dose monotherapy for ≥ 6 months, children should be referred to an expert in pediatric hypertension (Grade D).
- 3.ACE inhibitors (Grade C) and ARBs (Grade D) are not recommended as first-line agents in black patients and β-blockers are not recommended as first-line agents in children with asthma or diabetes (type 1 or type 2), and high-performance athletes (Grade D).
X Goals of therapy for children with hypertension
- 1.The treatment goal is office BP (systolic and diastolic) < 95th percentile (Grade D). The goal for ABPM is BP (systolic and diastolic) < 95th percentile (Grade D).
- 2.For patients with risk factors or target organ damage the goal is BP (systolic and diastolic) < 90th percentile (Grade D).
3. Hypertension and Pregnancy
- •Up to 7% of pregnancies are complicated by a hypertensive disorder of pregnancy, and approximately 5% of women will have chronic hypertension when they become pregnant.
- •The prevalence of hypertension in pregnancy is expected to increase with women becoming pregnant later in their reproductive years and the increasing prevalence of cardiovascular comorbidities such as increased preconception body mass index and maternal diabetes.96,Public Health Agency of Canada
Maternal hypertension in Canada.97,Government of Canada
Chapter 2: preconception care.98
Fertility: overview, 2012 to 2016. Statistics Canada.https://www.150.statcan.gc.ca/n1/pub/91-209-x/2018001/article/54956-eng.htmDate accessed: January 8, 2020
- Provencher C.
- Milan A.
- Hallman S.
- D’Aoust C.
- •The possibility of pregnancy should be considered when managing women with hypertension who are of reproductive age.
- •Preconception counselling should be offered to all women with hypertension who are considering pregnancy.
- •ACE inhibitor and ARB therapy should be avoided before conception and during pregnancy unless there is a compelling indication for their use (ie, proteinuric kidney disease).
- •Hypertension during pregnancy can increase the risk of adverse maternal and fetal outcomes, including an increased risk of preeclampsia, placental abruption, prematurity, small for gestational age infants, stillbirth, and maternal renal and retinal injury,99thus generally requires involvement of an interdisciplinary team including obstetrical care providers.
- •Women with hypertension should be managed as per the Hypertension Canada guidelines for adults with hypertension before and immediately after pregnancy, except if they are breastfeeding. In breastfeeding women, only certain antihypertensive medications should be considered because their concentration in the breastmilk has been shown to be low. During pregnancy refer to Figure 3: Management of Hypertension in Pregnancy.
- •Antihypertensive medications commonly used in pregnancy and lactation are presented in Table 18.Table 18Antihypertensive medications commonly used in pregnancy and lactation
Pregnancy Lactation First-line oral drugs (Grade C) Second-line oral drugs (Grade D) Medications to avoid (Grade C) Oral drugs (Grade D) Labetalol Clonidine ACE inhibitors∗ Labetalol Methyldopa Hydralazine ARBs∗ Methyldopa Long-acting oral nifedipine Thiazide diuretics Long-acting oral nifedipine Other β-blockers (acebutolol, metoprolol, pindolol, and propranolol) Enalapril
CaptoprilACE, angiotensin converting enzyme; ARB, angiotensin receptor blocker.∗ Fetotoxicity of renal system.
I Preconception care
- •Consider preconception counselling for women with hypertension considering pregnancy.
- •Consider discontinuing ACE inhibitor and ARB therapy before conception.
- •Consider certain antihypertensive medications for safe management of hypertension in breastfeeding women.
- 1.Preconception counselling is recommended for women with prepregnancy hypertension to advise on individualized antihypertensive medication management during pregnancy (Grade D; new recommendation).
- 2.Consider discontinuing ACE inhibitors and ARBs in women planning pregnancy (Grade D, new recommendation).
II Management of nonsevere hypertension (BP 140-159/90-109 mm Hg) in pregnancy
- 1.Antihypertensive therapy is recommended for average SBP measurements of ≥ 140 mm Hg or DBP measurements of ≥ 90 mm Hg in pregnant women with chronic hypertension, gestational hypertension, or preeclampsia (Grade C).
- i.Initial antihypertensive therapy should be monotherapy from the following first-line drugs: oral labetalol, oral methyldopa, long-acting oral nifedipine, or other oral β-blockers (acebutolol, metoprolol, pindolol, and propranolol; Grade C).
- ii.Other antihypertensive drugs can be considered as second-line drugs including: clonidine, hydralazine, and thiazide diuretics (Grade D).
- iii.ACE inhibitors and ARBs should not be used in pregnant women (Grade C; revised grade for entire recommendation).
- 2.A DBP of 85 mm Hg should be targeted for pregnant women receiving antihypertensive therapy with chronic hypertension or gestational hypertension (Grade B). A similar target could be considered for pregnant women with preeclampsia (Grade D).
- 3.Additional antihypertensive drugs should be used if target BP levels are not achieved with standard-dose monotherapy (Grade C). Add-on drugs should be from a different drug class chosen from first-line or second-line options (Grade D).
III Management of severe hypertension (BP ≥ 160/110 mm Hg) in pregnancy and postpartum
- 1.Women with severe hypertension with SBP ≥ 160 mm Hg or DBP ≥ 110 mm Hg in pregnancy or postpartum require urgent antihypertensive therapy because it is considered an obstetrical emergency (Grade D; revised recommendation).
IV Management of postpartum (up to 6 weeks postpartum) hypertension
- 1.Antihypertensive drugs used in breastfeeding women include: labetalol, methyldopa, long-acting nifedipine, enalapril, or captopril (Grade D; new recommendation).
|Pediatric guidelines||Adult guidelines|
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