HYPERTENSION

1
HYPERTENSION Workshop
September, 2007
Information was produced and/or compiled by the
Alberta Provincial Stroke Strategy and written
permission is required prior to reprinting any of
the material located within this document.
09/0709/08R
2
High Blood PressureGet the Low Down!
3
Average Canadian
4
Who Has Hypertension?

• What is the chance he has hypertension?
• What is the chance he will get hypertension if
  not already?
• If he has hypertension, what is the chance he
  knows his BP is high?
• If he has hypertension, what is the chance he is
  treated and controlled?

5
The Challenge In Canada

• Hypertension is a problem which increases with
  age
• Hypertension is often unidentified
• if identified - is poorly treated.
• Recent data is showing that identification and
  management of hypertension in Canada has improved
  over the past few years.

6
We Need to Make a Difference!
7
What can be the result of hypertension?Hypertens
ion increases the risk of what health problems?
8
Hypertension is a Major Risk Factor

• Untreated high blood pressure increases risk of
• Stroke (4 times gt risk hemorrhagic stroke)
• Coronary Artery Disease
• Congestive heart failure
• Chronic Kidney Disease
• Peripheral vascular disease
• Dementia
• Atrial Fibrillation
• Effective treatment has been shown to reduce the
  risk of recurrent stroke and to reduce cognitive
  decline in patients with dementia
• Source
  2007 CHEP Recommendations

9
Hypertension

• Stroke mortality doubles for every 20 mmHg
  increase in SBP or 10 mmHg increase in
  DBP
• Prospective Studies Collaboration. Age-specific
  relevance of usual blood pressure to vascular
  mortality A meta-analysis of individual data for
  one million adults in 61 prospective studies.
• Lancet 20023601903-13.

10
Benefits of Treating Hypertension

• Younger than 60
• reduces the risk of stroke by 42
• reduces the risk of coronary event by 14
• Older than 60
• reduces overall mortality by 20
• reduces cardiovascular mortality by 33
• reduces incidence of stroke by 40
• reduces coronary artery disease by 15

Source 2007 CHEP Recommendations
11
What Are the Benefits of Treating Hypertension?
For a decrease of 10/5 mm Hg (one medication or
a change in lifestyle)

• Heart attack by 15
• Heart failure by 50
• Stroke by 38
• Death by 10

Source 2007 CHEP Recommendations
12
Lets get the Low Down on Hypertension

• What is blood pressure?
• Causes of hypertension
• How to measure blood pressure
• Diagnosis of hypertension
• Types of hypertension
• Lifestyle and Pharmaceutical treatment
• BP target values
• Review highlights of 2007 CHEP recommendations

13
What Is Blood Pressure?

• Blood pressure is the amount of force on the
  walls of the arteries as the blood circulates
  around the body.

14
What is Blood Pressure?

• Systolic
• Pressure in the blood vessels
• as the heart beats or contracts
• fills them with blood (i.e. 130)
• Diastolic
• The pressure in the blood vessels as the
  heart relaxes in between beats. (i.e. 80)

15
What is Blood Pressure?

• Blood pressure goes up and down naturally
  throughout the day, and from one day to another.
• A healthy blood pressure reading is
• less than 130/80 mmHg on a regular basis.
• A client has high blood pressure if average or
  usual
• readings are 140/90
• readings are 130/80 ( for those with diabetes
  or chronic kidney disease)
• High blood pressure hypertension

16
5 Factors Controlling Blood Pressure

• Cardiac output
• Peripheral Vascular Resistance
• Volume of circulating blood
• Viscosity
• Elasticity of vessel walls

17
Classification of Hypertension
The category pertains to the highest risk blood
pressure ISHInternational Society of
Hypertension. Chalmers J et al. J Hypertens
199917151-85.
Source 2007 CHEP Recommendations
18
Blood pressure target values for treatment of
hypertension
Source 2007 CHEP Recommendations
19
What Causes HYPERTENSION ?

• POOR LIFESTYLE!!
• - interaction between genetics and environment.
• 1 in 20 people a disease such as of the kidneys
  

20
Factors that affect Blood Pressure

• Age
• Sex
• Race
• Diurnal Rhythm
• Genetics
• Obesity
• Exercise
• Emotions
• Stress
• Diet
• Alcohol

21
Symptoms of High Blood Pressure

• Called the Silent Killer
• Usually no symptoms until initial event (Stroke
  or cardiac event)
• If symptoms are present this may be due to
  secondary hypertension or complications of
  hypertension

22
BP Measurement Technique
Demonstrate What is good technique? What should
have been done?
23
BP Measurement Technique

• 1) Client should rest for 5 minutes in a quiet
  comfortable room prior to the measurement.
• Should be in a sitting position with back
  supported and legs not crossed.
• 2) Select the appropriate cuff size as
  follows

24
BP Measurement Technique

• 3) Bare arm in a supported position, with
  antecubital fossa _at_ heart level.
• 4) Find brachial pulse (inner part of the arm
  near the elbow) using index middle fingers.

25
BP Measurement Technique

• 5) Apply the appropriate size cuff to the arm by
  positioning the center of the inflatable bladder
  directly over the brachial artery secure
  snugly.
• Ensure the lower edge of the cuff is 2cm above
  the elbow crease.
• NOTE The bladder inside the cuff should
  encircle
• 80 of the arm in adults
• 100 of the arm in children lt 13years.

26
BP Measurement Technique

• 6) Locate the clients radial pulse on the thumb
  side of the wrist.

27
BP Measurement Technique

• 7) Place manometer so center of the mercury
  column, or aneroid dial, is easily visible
• - Ensure tubing is unobstructed.
• 8) Take the clients pulse rapidly increase the
  cuff pressure. Note the reading when the radial
  pulse disappears while deflating the cuff by
  releasing the valve all the way

28
BP Measurement Technique

• 8) Locate brachial artery place stethoscope
  gently but firmly over the artery,
• just below the lower
• edge of the cuff.
• 9) The column of mercury must be _at_ zero before
  the procedure begins, or the needle on the
  aneroid devise must be opposite zero when the
  cuff is deflated.

29
BP Measurement Technique

• 10) Inflate the cuff rapidly to a pressure
• 20-30 mmHg above the previously
• determined level (based on the
  disappearance
• of the radial pulse).
• 11) Let the cuff deflate by slowly releasing the
  
• valve and allowing the mercury or needle
• to drop _at_ a rate of 2-3mmHg per second or
• per pulse beat while listening for audible
  
• Korotkoff sounds.

30
BP Measurement Technique

• Systolic The 1st appearance of a clear tapping
  sound on the manometer (phase 1 Korotkoff). Note
  the reading on the manometer.
• Diastolic The point _at_ which the sound disappears
  on the manometer (phase V Korotkoff). Note the
  reading on the manometer.

31
BP Measurement Technique

• Once BP completed, record the Systolic
  Diastolic numbers immediately.
• Explain target values for BP to the client
  provide education regarding the clients BP value
  and/or lifestyle modifications that may be
  helpful.
• Contact the physician as required to report
  elevated BP values.

32
Tips to Ensure an Accurate BP Measurement

• Rest for 5 minutes prior to measurement
• Calm, comfortable environment
• No tight clothing on arm or forearm
• No crossing of legs
• No talking during measurement

• No smoking 15-30 minutes prior
• No caffeine 1 hour prior
• No strenuous exercise
• 1 hour prior
• Ensure bladder is empty
• Appropriate cuff size

33
What is your Blood Pressure Measurement?
34
Sources of Potential Errors in BP Measurement
35
Sources of Potential Errors in BP Measurement

• No waiting time prior to measurement
• Arm positioned inappropriately
• Presence of background noise or conversation
• Rounding figures up or down

• Inappropriate cuff size or position of cuff
• Inadequate deflation of the cuff (too quickly or
  slowly)
• Instrument not calibrated

36
Types of BP Monitors

• 1) Mercury Manometer Usually fixed to a wall
  mount, or a portable unit on wheels.
• 2) Electronic Device A portable unit which is
  most often used for home BP monitoring.

37
Types of BP Monitors

• 3) Aneroid Manometer Can be fixed to a wall
  mount, a portable hand held unit, or a portable
  unit on wheels.

• Not Recommended
• May go out of calibration
• 40 used are out of calibration
• Require regular assessment of calibration every
  6 - 12 months
• A systematic process should be in place to
  ensure accuracy

38
2007 Canadian Hypertension Education Program
Recommendations

• Annual process to develop and update
  evidence-based recommendations for HTN management
• Incorporated all trials and meta-analyses
  published in the past year felt to have relevance
  for individuals with hypertension
• The 2007 unabridged and bottom line reports
  available at www.hypertension.ca
• CHEP is jointly sponsored by the Canadian
  Hypertension Society, Blood Pressure Canada, the
  Public Health Agency of Canada, the Heart and
  Stroke Foundation of Canada, the College of
  Family Physicians of Canada, the Canadian Council
  of Cardiovascular Nurses, the Canadian
  Pharmacists Association

39
Treat Hypertension in the Context of Overall
Cardiovascular Risk

• Assess global cardiovascular risk
• The management plan for patients with
  hypertension must be based on their global
  cardiovascular risk
• Consider informing patients of their global risk
  to improve the effectiveness of risk modification
• Shared decision-making may improve the
  effectiveness of preventive health interventions.
  
• Simply counting risk factors may be misleading
• Source 2007 Canadian Hypertension Education
  Program Recommendations

40
Diagnosing Hypertension
41
Assess blood pressure at all appropriate visits

• Blood pressure of all adults should be measured,
  whenever appropriate, by trained healthcare
  professionals using standardized techniques.
• To screen for hypertension
• To assess cardiovascular risk
• To monitor antihypertensive treatment
• Assess blood pressure annually in those with high
  normal blood pressure.

Source 2007 Canadian Hypertension Education
Program Recommendations
42
Criteria for the diagnosis of hypertension and
recommendations for follow-up
Hypertension Visit 1 BP Measurement, History and
Physical examination
Diagnostic tests ordering at visit 1 or 2
Hypertension Visit 2 within 1 month
Source 2007 CHEP Recommendations
43
Criteria for the diagnosis of hypertension and
recommendations for follow-up
BP 140-179 / 90-109
Patients with high normal blood pressure (clinic
SBP 130-139 and/or DBP 85-89) should be followed
annually.
Source 2007 CHEP Recommendations
44
Case 1

• Mr. W. is a 58 year old Sr. Administrator for a
  Health Region in Alberta. Seen in clinic to
  follow-up on BP 164/92 taken at a pharmacy
• BPs during this visit 156/90 160/92
• Interview and review of the medical chart
  reveals
• Height 6 1 and weight 215 lbs (BMI 28.4 kg/m2)
• Review of systems normal
• Social drinker (4 glasses of wine/week)
• Quit smoking 10 years ago
• No routine physical activity
• Family history of CVD (father died at age 50 from
  MI)
• Married, four children
• Is he hypertensive?

45
Diagnostic Work-Up

• Check BP at all appropriate visits
• Use standardized measurement technique
• Have patient rest for 5 minutes
• Use a validated calibrated device
• Cuff encircles 80 of upper arm
• Measure both arms at initial visit
• Thereafter take 2 measurements on the side where
  BP is higher

46
Diagnostic Work-Up, cont

• History and physical
• Review for CV risk factors, evidence of Target
  Organ Damage and HTN, monitor treatment
• Routine laboratory tests
• Urinalysis
• blood chemistry (potassium, sodium, creatinine),
  fasting glucose, fasting TC, HDL, LDL,
  triglycerides
• Standard 12-lead ECG
• Lab tests for specific subgroups
• Diabetes renal disease urinary albumin
  excretion
• increased creatinine, hx of renal disease or
  proteinuria - renal ultrasound

47
Search for Cardiovascular Risk Factors

• Family history of premature CVD
• Chronic kidney disease
• Abnormal lipid profile
• Sedentary lifestyle
• Left ventricular hypertrophy
• Abdominal obesity
• Coronary Artery Disease

• Hypertension
• Male
• Increasing age
• Peripheral arterial disease
• Previous stroke or TIA
• Microalbuminuria or proteinuria
• Diabetes mellitus
• Smoking

Source 2007 CHEP Recommendations
48
Search for Target Organ Damage

• Cerebrovascular
• TIA
• Ischemic or Hemorrhagic Stroke
• Hypertensive retinopathy
• Left ventricular dysfunction
• Coronary artery disease
• Angina or prior MI
• CHF
• Chronic kidney disease
• Peripheral arterial disease

Source 2007 CHEP Recommendations
49
Case 1

• Visit 2

50
Case 1 Visit 2

• LDL3.1 mmol/L
• TC 4.85 mmol/L
• TG2.2 mmol/L
• HDL 1.32 mmol/L
• Normal 12 lead ECG
• Weight ?7.5 lbs since first visit
• No routine physical activity

• BP 158/100 mmHg
• No evidence of Target Organ Damage
• Normal urinalysis
• Serum potassium4.5 mmol/L (3.5-5.0)
• Serum creatinine 97 mmol/L (50-120)
• Fasting glucose5.1 mmol/L

Is he hypertensive? What are the treatment and
management options?
51
Use any of three validated technologies to
diagnose hypertension office,ambulatory and
home
52
Ambulatory BP Monitoring Who?

• Role in diagnosis and management of patients with
  HTN
• Patients with suspected office-induced elevations
  in BP
• Untreated patients with mild to moderate clinic
  BP elevation and no target organ damage
• Treated patients with
• BP not below target values despite receiving
  appropriate chronic hypertensive therapy
• Symptoms that may be suggestive of hypotension
• Fluctuating office readings

53
Ambulatory BP Monitoring

• BP is monitored during daily activities and
  during sleep
• Mean daytime BP 135/85 or mean nocturnal
  BP 125/75 is considered elevated
• Mean 24 hour ambulatory BP 130/80 mmHg is
  considered elevated
• A drop in nocturnal BP lt10 is associated with an
  increased risk of cardiovascular events

Source 2007 CHEP Recommendations
54
Follow up algorithm for high Blood Pressure
Ambulatory Blood Pressure Measurement
24-h ABPM
Awake BP gt135 SBP or gt85 DBP or 24-hour gt130 SBP
or gt80 DBP
Awake BP lt 135/85 and 24-hour lt 130/80
Consistent with HTN
Continue to follow-up
Patients with high normal blood pressure should
be followed annually.
Source 2007 CHEP Recommendations
55
Home Blood Pressure Monitoring

• Patients who
• May wish to take an active role in BP management
• May need help with adherence
• Are not adherent with treatment
• Have hypertension and diabetes
• May have office induced (white coat)
  hypertension
• Target lt135/85 mmHg (unless diabetes, renal
  disease, or proteinuria)
• A blood pressure contract and BP monitoring tools
  are available from the BP Action Plan
• Have chronic kidney disease
• Have masked hypertension

56
Home Blood Pressure Monitoring Protocol

• Assessment of white coat or sustained
  hypertension based on the following protocol
• Two daily measures
• Morning and evening
• An initial 7-day period
• Do not consider single and first day home BP
  values
• Ask patient to bring device and BP record to
  appointment
• Demonstrate/review how to measure and record BP
  (arm, position, time of day).
• Refer to the BP ACTION Plan for monitoring tools
• Review treatment goals and personal BP targets
  with patient at visits (daytime average BP?135/85
  considered elevated)

57
Do You Have White Coat Hypertension?
Demonstration?
58
The Concept of Masked Hypertension
200
180
True hypertensive
Masked HTN
160
Ambulatory SBP mmHg
140
True Normotensive
120
White Coat HTN
100
100
120
140
160
180
200
Office SBP mmHg
From Pickering, Hypertension 1992
59
The prognosis of masked hypertension
Prevalence is approximately 10 in hypertensive
patients.
35
CV Events
30
25
20
CV events per 1000 patient-year
15
10
5
0
Normal
White coat
Uncontrolled
Masked
23/685
24/656
41/462
236/3125
Bobrie et al. JAMA 20042911342-9
60
Some recommended electronic blood pressure
monitors for home blood pressure measurement
Monitors AD or LifeSource Models 767,
767PAC, 774AC, 779, 787AC Monitor Omron
Models HEM-705 PC, HEM-711,
HEM-741CINT Monitor Microlife Model BP 3BTO-A
Models with memory are preferred
Source 2007 CHEP Recommendations
61
Clinic, Home, Ambulatory (ABP) Blood Pressure
Measurement equivalence numbers
A clinic blood pressure of 140/90 mmHg has a
similar risk of a
Source 2007 CHEP Recommendations
62
Criteria for the diagnosis of hypertension and
recommendations for follow-up
Source 2007 CHEP Recommendations
63
Criteria for the diagnosis of hypertension and
recommendations for follow-up
BP 140-179 / 90-109
Patients with high normal blood pressure (clinic
SBP 130-139 and/or DBP 85-89) should be followed
annually.
Source 2007 CHEP Recommendations
64
Criteria for the diagnosis of hypertension and
recommendations for follow-up
Diagnosis of hypertension
Non Pharmacological treatment With or without
Pharmacological treatment
Are BP readings below target during 2 consecutive
visits?
No
Yes
Symptoms, Severe hypertension, Intolerance to
anti-hypertensive treatment or Target Organ Damage
Follow-up at 3-6 month intervals
Yes
No
Visits every 1 to 2 months
More frequentvisits
Consider Home measurement in hypertension
management, to rule out masked hypertension or
white coat effect and to enhance adherence.
65
Key CHEP messages for the management of
hypertension

• Assess blood pressure at all appropriate visits.
• Almost one half of those with blood pressure
  130-139/85-89 will develop hypertension within 2
  years. They require annual reassessment.
• Assess global cardiovascular risk in all
  hypertensive patients.
• Lifestyle modification is the cornerstone for the
  prevention and management of hypertension and CVD.

66
Key CHEP messages for the management of
hypertension

• Treat to target (lt140/90 mmHg lt130/80 mmHg in
  patients with diabetes or chronic kidney
  disease).
• To achieve targets sustained lifestyle
  modification and more than one drug is usually
  required.
• Follow patients with uncontrolled blood pressure
  at least every 2 months until blood pressure
  targets are achieved.
• Strategies to improve patient adherence to
  lifestyle modifications and antihypertensive
  therapy need to be incorporated in every patients
  management

67
Lifestyle Management Recommendations

• Case 2

68
Reversible risks for developing hypertension

• Obesity
• Poor dietary habits
• High sodium intake
• Sedentary
• High alcohol consumption
• High stress
• High normal blood pressure

Source 2007 CHEP Recommendations
69
Case 2

• Mr. J is a 45 year old mechanic
• Several recent office visits pre/post inguinal
  hernia repair
• BP range 140/90-154/90 mmHg at recent office
  visits
• Previous documented BP 122/70 mmHg
• Nonsmoker
• Drinks 3-4 beers/day (more on W/E)
• Saturday night hockey league, no other exercise
• Weight increased 20 lbs over past 5 years (BMI 28
  kg/m2 )
• Eats fast food for lunch 3-4 times/week

70
Lifestyle Strategies

• Prevent HTN
• Eat a healthy diet Canadas Guide to Healthy
  Eating
• High in fresh fruits, vegetables, low fat dairy
  products, low in saturated fat and cholesterol
• Restrict sodium (lt100 mmol/day)
• Physical activity 30-60 min moderate intensity
  4-7x/week
• Maintain healthy body weight (BMI 18.5-24.9
  kg/m2) WClt102cm men, lt88 cm women
• Alcohol consumption (?2 drinks /day)
• Smoke free environment

• Treat HTN
• Eat healthy DASH diet
• High in fresh fruits, vegetables, low fat dairy
  products, low in saturated fat
• Restrict sodium (lt100 mmol/day)
• Physical activity 30-60 min moderate intensity
  4x/week or more
• Weight loss (gt5 Kg) in those who are overweight
  (BMI ?25) and WClt102cm men, lt88 cm women
• Reduce alcohol consumption in those who drink
  excessively
• Smoke free environment

Source 2007 CHEP Recommendations
71
Dietary Approaches to Stop Hypertension DASH
Diet

• Rich in fruits, vegetables, low fat dairy foods,
  and low in fat, total fat, cholesterol and salt
• The low sodium DASH diet evaluated the effect of
  reducing sodium intake in combination with a DASH
  diet. BP fell 11.4/5.5 mmHg in hypertensive
  persons compared to 3.5/2.1 in normotensives
• Source Appel et al. N Engl J Med 19973361117.
• The DASH eating plan is available at
  www.nhlbi.nih.gov/health/public/heart/hbp/dash

72
Lifestyle Recommendations for Hypertension
Dietary

• High in fresh fruits
• High in vegetables
• High in low fat dairy products
• High in dietary and soluble fibre
• High in plant protein
• Low in saturated fat and cholesterol

http//www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_g
uide_rainbow_e.html
Source 2007 CHEP Recommendations
73
Sodium Reduction

• For hypertensive patients
• Ask patients how much fresh foods and unprocessed
  foods they consume
• Ask about processed and fast foods
• ? dietary sodium to target range
• 65-100mmol/day (2/3-1 tsp table
  salt/day).
• Counsel all patients to avoid excessive salt
  intake
• Avoid fast and processed foods and minimize use
  of salt at the table and during cooking

74
2007 Canadian Hypertension Education Program

• What's New for 2007
• Up to 30 of hypertension can be attributed to
  high sodium diets
• Reduce sodium intake to less than 100 mmol in
  normotensive patients to prevent hypertension

75
Physical Activity

• Evidence that mild hypertension can be treated
  with moderate physical activity alone
• Of particular note
• Significant ? BP after 4 to 5 wks
• Effect persisted as long as patient exercised,
  reversible if training stopped
• Daily physical activity not essential to get
  antihypertensive effect
• Age, race, sex has no effect on the benefit
  derived

76
Physical Activity

• The Heart and Stroke Foundation recommends that
  clients be prescribed exercise to reduce blood
  pressure
• Think FITT
• Frequent (4 or more days of the week)
• Intensity (moderate)
• Time (optimum 30-60 minutes)
• Type (dynamic walking, cycling, swimming)
• Physical activity should be prescribed as
  adjunctive therapy for those patients prescribed
  pharmacotherapy

77
Weight Loss

• Healthy BMI 18.5-24.9 kg/m2
• Waist circumference
• lt102 cm for men, lt88 cm for women
• Encourage weight reduction for hypertensive and
  all patients with BMI gt25
• Additional anti-hypertensive effects for patients
  prescribed pharmacological therapy
• Weight loss strategies should use a
  multidisciplinary approach and include dietary
  education, increased physical activity and
  behavior modification

78
Waist circumference measurement
Last rib margin
Mid distance
Iliac crest
Courtesy J.P. Després 2006
Source 2007 CHEP Recommendations
79
Alcohol Consumption

• Ask how much alcohol clients drink
• For those who choose to drink
• Limit to ? 2 standard drinks/day as per low risk
  drinking guidelines (www.lrdg.net)
• 14 standard drinks/wk for men
• 9 standard drinks/week for women 1 standard
  drink 1 can beer or 1.5 oz liquor or spirits or
  5 oz of wine
• Advise hypertensive patients to limit alcohol

80
Stress Management

• There is no evidence that stress management
  prevents hypertension, but there is some evidence
  that stress management can reduce BP in
  hypertensive patients.
• Consider how stress contributes to hypertension
  (e.g., unhealthy lifestyle choices such as
  smoking, drinking and binge eating)
• Consider exercise as a treatment for stress
  management
• In patients whom stress is an important issue,
  individualized cognitive behavioural
  interventions are more likely to be effective
  when relaxation techniques are employed

CMAJ 1999160 (9 Suppl)S47 S48.
81
Smoking Cessation
82
Health Professionals Role in Smoking Cessation

• Ask systematically identify all tobacco users
• Implement an office wide system that ensures that
  tobacco use is queried and documented at every
  visit
• Advise strongly urge all tobacco users to quit
• In a clear and personalized manner, urge every
  tobacco user to quit
• Assess determine willingness to make a quit
  attempt
• Ask every tobacco user if he/she is willing to
  make a quit attempt at this time (based on the
  Stages of Change)
• Assist aid the patient in quitting
• Provide a quit plan
• Arrange follow up support with links to the
  local community

Adapted from Anderson et al, Chest
2002121932-941.
83
Suggested Smoking Cessation Approach Using the
Stages of Change

• Pre-contemplation
• Not thinking seriously about quitting
• Goal Encourage smoker to think about the
  personal impact of smoking
• Contemplation
• Thinking about quitting in the next six months
• Goal Discuss health effects of smoking and
  benefits of quitting. Offer follow-up and set
  date for next appointment.
• Preparation
• Preparing to quit in next month and has tried to
  quit in the past year
• Goal Assist the patient to select the best plan
  to be smoke free. Set date for next appointment.

84
Suggested Approach, cont

• Action
• Receptive to cessation advice. Actively trying to
  quit.
• Goal Assist the patient in efforts to quit.
  Discuss relapse prevention and replacing smoking
  with other behaviours (physical activity,
  hobbies, etc.) Set date for next appointment.
• Maintenance
• Continues to remain smoke free for more than six
  months. May slip and have occasional cigarette.
• Goal Congratulate patient. Assist patient to
  find strategies to prevent relapse.
• Source Prochaska JO, Diclemente CC.
  Understanding and using the stages of change.
  Program Training Consultation Centre, Ontario
  Tobacco Strategy, 1995.

85
Smoking Cessation Pharmacotherapy

• Effective pharmacotherapies exist for smoking
  cessation.
• Except in the presence of contraindications these
  should be considered as part of the quit plan for
  all patients willing to quit smoking
• Nicotine replacement therapy
• Nicotine patch (Habitrol, Nicoderm, Nicotrol)
• Nicotine gum (Nicorette)
• Bupropion SR (Zyban)
• Varenicline (Champix)
• Combined use of the Nicotine patch and Bupropion
  SR are more effective than either alone in
  patients who are willing to quit

86
Impact of Lifestyle Therapies on Blood Pressure
in Hypertensive Adults
Applying the 2005 Canadian Hypertension Education
Program recommendations 3. Lifestyle
modifications to prevent and treat hypertension
Padwal R. et al. CMAJ ? SEPT. 27, 2005 173 (7)
749-751
Source 2007 CHEP Recommendations
87
Lifestyle Therapies in Hypertensive Adults
Summary
Source 2007 CHEP Recommendations
88
BP ACTION PLAN

• The BP ACTION PLAN is a free, confidential,
  customized action plan for healthy living.
• This plan will give your patients access to
  practical tips, tools and other resources that
  are relevant to them. Then they can take the next
  steps to reducing their risks and improving their
  health.
• Self-administered, evidence-based, health risk
  assessment questionnaire
• Patients receive customized tips, resources and
  information links to help them reduce their
  risks.
• www.heartandstroke.ca or 1-888-HSF-INFO

89
BP ACTION PLAN for Mr. J.

• Your Risks
• Sex (male)
• Activity level
• Weight (BMI gt25)
• Alcohol (gt2 drinks per day)
• Fat (diet high in fat)
• Salt (diet high in salt)
• Blood pressure (elevated blood pressure)

• Your Plan
• Activity think about ? activity
• see Health Goals Chart and Physical Activity Log
• Weight think about losing weight
• Salt ? dietary salt
• Alcohol think about ?alcohol
• Fat ? dietary fat
• ? Blood Pressure

90
BP ACTION PLAN for Mr. J.

• Blood Pressure
• Set goals and a start date for changing your
  lifestyle
• See your doctor if you have a lot of weight to
  lose or havent been active for a while
• Bring your Health Action Report to your next
  visit and discuss risk factors.
• You may want to print and fill out a Blood
  Pressure Management Contract
• Check out resources
• Heart and Stroke HeartWalk Workout and Healthy
  Weight program
• Health Canadas Physical Activity site
  www.hcsc.gc.ca/english/healthy_living/physical_ac
  tivty.html

91
2007 Canadian Hypertension Education Program

• What's New for 2007
• Approximately 95 of Canadians will develop
  hypertension if they live an average lifespan
• Most overweight patients with high normal blood
  pressure (130-139/85-89 mmHg) will develop
  hypertension within 4 years and almost 1/2 within
  2 years.
• Annual follow-up of patients with high normal
  blood pressure is recommended.

92
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93
Integrating Canadian Hypertension Education
Program Recommendations intoPractice
94
Systolic-Diastolic Hypertension in the Absence of
Specific DiseaseNo other compelling
indications such as associated risk factors,
target organ damage or co-morbid
conditions/diseases

• When to Consider Pharmacotherapy

95
Strongly Consider Pharmacotherapy If

• BP remains ? 140/90 mmHg with lifestyle
  modification
• Client has Target Organ Damage (e.g. LVH) and BP
  ? 140/90 mmHg
• Client has Diabetes or chronic kidney disease and
  BP is ? 130/80 mmHg
• Patient has known atherosclerotic disease
• (e.g. past stroke) even if BP is normal
• Source 2007 CHEP Recommendations

96
Blood pressure target values for treatment of
hypertension
Goals of Therapy
97
Goals of Therapy

• To optimally reduce cardiovascular risk reduce
  the blood pressure to specified targets.
• This usually requires two or more drugs and
  lifestyle changes
• Systolic target is more difficult to achieve
  however controlling systolic blood pressure is as
  important if not more important than controlling
  diastolic blood pressure

98
Treatment of Adults with Systolic/Diastolic
Hypertension without Other Compelling Indications
TARGET lt140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy
Beta-blocker
Long-acting CCB
Thiazide
BBs are not indicated as first line therapy for
age 60 and above
ACEI and ARB are contraindicated in pregnancy and
caution is required in prescribing to women of
child bearing potential
99
Combination Therapy for Systolic-Diastolic
Hypertension With No Other Compelling Indications

• If partial response to dual combination therapy
• May be necessary to try triple or quadruple
  therapy
• Consider possibility of one or more of the
  following
• Nonadherence
• Secondary hypertension
• Interfering drugs or lifestyle
• White coat hypertension
• Resistant hypertension

Source 2007 CHEP Recommendations
100
Factors That Induce and/or Aggravate HTN

• Alcohol
• Recreation drugs (e.g., cocaine)
• Some herbal remedies
• Non steroidal anti-inflammatory drugs
• Oral contraceptive pill
• Corticosteroids
• Anabolic steroids
• Erythropoietin
• Calcineurin inhibitors (Cyclosporin, Tacrolimus)
• Ephedrine/pseudo-ephedrine
• licorice
• Sleep apnea
• Source CHEP 2005 Recommendations

101
Summary Treatment of Systolic-Diastolic
Hypertension without Other Compelling Indications
TARGET lt140/90 mmHg
Lifestyle modification therapy
Not indicated as first line therapy over 60
Dual Combination

• CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?

ACEI and ARB are contraindicated in pregnancy and
caution is required in prescribing to women of
child bearing potential
Triple or Quadruple Therapy
Source 2007 CHEP Recommendations
102
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103
Isolated Systolic Hypertension with No Other
Compelling Indication

• Case 1b
• How would you treat Mr. W if his SBP was
  consistently higher than 160 mmHg?

104
Isolated Systolic Hypertension with No Other
Compelling Indication
Initial Treatment
Lifestyle Modification Therapy
Target BP lt140 mmHg
Monotherapy with
Thiazide Diuretics
Long acting DHP-CCB
ARB
or
or
Dual therapy Combine agents from adjacent classes
Source Adapted from CHEP 2007 Recommendations
105
Add-on therapy for Isolated Systolic Hypertension
without Other Compelling Indications
If partial response to monotherapy
Dual combination Combine first line agents
Thiazide diuretic
ARB
Long-acting DHP CCB

• CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?

If blood pressure is still not controlled, or
there are adverse effects, other classes of
antihypertensive drugs may be combined (such as
ACE inhibitors, alpha adrenergic blockers,
centrally acting agents, or nondihydropyridine
calcium channel blocker).
Source Adapted from CHEP 2007 Recommendations
106
Summary Treatment of Isolated Systolic
Hypertension without Other Compelling Indications
TARGET lt140 mmHg
Initial Treatment
Lifestyle modification therapy
Thiazide diuretic
ARB
Long-acting DHP CCB
Dual therapy

• CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?

If blood pressure is still not controlled, or
there are adverse effects, other classes of
antihypertensive drugs may be combined (such as
ACE inhibitors, alpha blockers, centrally acting
agents, or nondihydropyridine calcium channel
blocker).
Triple therapy
Source Adapted from CHEP 2007 Recommendations
107
Barriers
108
Barriers to HTN Diagnosis and Treatment
109
Barriers to HTN Diagnosis and Treatment

• Patient related factors
• Low level of awareness about diagnosis
• Lack of compliance/adherence to therapy
• Belief that HTN is self limiting (dont know that
  they need to stay on the medication)
• Cost of medications
• Lack of knowledge about seriousness of
  uncontrolled BP
• Side effects of the medications
• White coat hypertension
• Source Clinical problem-solving
  based on the 1999 Canadian recommendations for
  the
• management of hypertension. CMAJ
  1999161 (12 Suppl)S18-22.

110
Barriers, cont

• System related factors
• Time constraints in practice settings
• Complexity of prescribing and/or monitoring
  existing drug regimens
• Drug adverse effects
• Lack of awareness of new lower BP target values
• Practice patterns
• Lack of awareness of up-to-date guidelines
• Source Clinical problem-solving
  based on the 1999 Canadian recommendations for
  the
• management of hypertension. CMAJ
  1999161 (12 Suppl)S18-22.

111
Economic Considerations

• 2007 CHEP recommendations are based solely on
  efficacy data
• Individual patient/physician preferences and
  costs of different drug classes have not been a
  part of the process
• Pharmaceutical costs are a significant barrier
  for many Albertans without drug coverage
• Cost may be a deciding factor when choosing an
  anti-hypertensive pharmaceutical treatment

112
Adherence

• Adherence is the single most important modifiable
  factor that compromises treatment outcome (WHO)
• Defined as the extent to which a patients
  behaviour corresponds with recommendations from
  the health care provider
• The term adherence is intended to be non
  judgemental, a statement of fact rather than of
  blame of the prescriber, patient or treatment
• Level 1a evidence exists to support a number of
  methods to promote adherence

113
Suggestions for Improving Adherence

114
Suggestions for Improving Adherence

• Health professionals can encourage adherence
  using a number of approaches
• Provide quality information about the risks of
  increased BP and the benefits of lifestyle and
  pharmaceutical treatment
• Explain that more than one drug may be necessary
• Explain that will probably take medication for
  life
• Counsel on side effects of treatment
• Take BP and talk about targets at every available
  visit
• Maintain regular BP follow up
• Refer to BP ACTION PLAN to encourage greater
  awareness, responsibility and involvement in BP
  and health management
• Adapted from 2005 CHEP Recommendations, JNC 7,
  and the Heart and Stroke BP Action Plan

115
Suggestions for Improving Adherence, cont

• Assess adherence at every visit
• Encourage responsibility/autonomy in monitoring
  BP and prescriptions
• Write prescriptions for exercise
• Simplify medication dosing
• Tailor pill taking to fit daily habits (same
  place/time/situation)
• Ask patient to bring pill vials (including OTCs)
  to medical visits
• Record medications and side effects
• Explore options for patients who have no drug
  coverage
• Work with worksite to improve monitoring of
  adherence to medications lifestyle changes

Adapted from WHO, CHEP 2007, JNC 7, and the
Heart and Stroke BP Action Plan
116
Treatment of Systolic-Diastolic Hypertension with
other compelling Indications

• Case Studies

117
Treatment of Systolic-Diastolic Hypertensionin a
Diabetic Patient

• Case 3

118
Case 3

• Mr. M is a 57 year old labourer with NIDDM and
  mild hypertension that is untreated
• New patient to the area
• Smokes 1½ ppd
• Weight has increased over past 5 years (BMI 27.4
  kg/m2)
• Total cholesterol elevated at 6.25 mmol/L
• HDL cholesterol 0.97 mmol/L
• Fasting serum glucose 7.3 mmol/L
• Urinalysis, serum electrolytes, creatinine normal
• BP ranges from 140/90-150/96 mmHg

119
Treatment of Hypertension in association with
Diabetes Mellitus
Threshold equal or over 130/80 mmHg and Target
below 130/80 mmHg
Urinary albumin to creatinine ration gt 2.0
mg/mmol in men or gt 2.8mg/mmol in women or
chronic kidney disease
Urinary albumin to creatinine ratio lt2.0
mg/mmol in men or lt2.8mg/mmol in women
based on at least 2 of 3 measurements
Source Adapted from CHEP 2007 Recommendations
120
Treatment of Hypertension in association with
Diabetes Mellitus Summary
Threshold equal or over 130/80 mmHg and TARGET
below 130/80 mmHg
ACE Inhibitor or ARB
1. ACE-Inhibitor or ARB or 2. Thiazide diuretic
or DHP-CCB
Combination (Effective 2-drug combination)
without Nephropathy
Monitor potassium and creatinine carefully in
patients with CKD prescribed an ACEI or ARB
More than 3 drugs may be needed to reach target
values for diabetic patients If Creatinine over
150 µmol/L or creatinine clearance below 30
ml/min ( 0.5 ml/sec), a loop diuretic should be
substituted for a thiazide diuretic if control of
volume is desired
Source Adapted from CHEP 2007 Recommendations
121
Treatment of Systolic-Diastolic Hypertension with
other compelling Indications

• Case Studies

122
Treatment of Hypertension in Patients with Recent
ST Segment Elevation-MI or non-ST Segment
Elevation-MI
An ARB can be used if the patient is intolerant
to ACE-I
Beta-blocker and ACE-I
Recent myocardial infarction
If beta-blocker contraindicated or not effective
Long-acting DHP CCB (Amlodipine, Felodipine)
YES
Heart Failure ?
NO
Long-acting CCB
Source Adapted from CHEP 2007 Recommendations
123
Treatment of Hypertensionfor Patients with
Cerebrovascular Disease
Source Adapted from CHEP 2007 Recommendations
124
Treatment of Hypertension for Patients Who Use
Tobacco
Source Adapted from CHEP 2007 Recommendations
125
Vascular Protection withHypertension
126
Vascular Protection for Hypertensive Patients
Statins

• In addition to current Canadian recommendations
  on management of dyslipidemia, statins are
  recommended in high-risk hypertensive patients
  with established atherosclerotic disease or with
  at least 3 of the following criteria

ASCOT-LLA Lancet 20033611149-58
ASCOT-LLA Lancet 20033611149
127
Vascular Protection for Hypertensive Patients
ASA
Consider low dose ASA
Caution should be exercised if BP is not
controlled.
Source Adapted from CHEP 2007 Recommendations
128
Summary I

• Regarding the treatment of hypertension, the
  recommendations endorse
• ASSESSMENT OF BLOOD PRESSURE AT ALL APPROPRIATE
  VISITS
• Most Canadians will develop hypertension during
  their lives. Routine assessment of blood pressure
  is required for early detection and risk
  management
• ANNUAL FOLLOW-UP OF PATIENTS WITH HIGH NORMAL
  BLOOD PRESSURE
• Most overweight patients with high normal blood
  pressure (130-139/85-89 mmHg) will develop within
  4 years and almost 1/2 within 2 years.

Source CHEP 2007 Recommendations
129
Summary II

• Regarding the treatment of hypertension, the
  recommendations endorse
• INDIVIDUALIZING THERAPY
• consider concomitant risk factors and/or
  concurrent diseases, other patient
  characteristics and preferences (e.g. age,
  diabetes, CVD) and other considerations e.g.
  costs
• LIFESTYLE MODIFICATION
• To prevent hypertension
• In those with hypertension alone if effective to
  reach the goal value or in combination with
  pharmacological treatment

Source CHEP 2007 Recommendations
130
Summary III

• Regarding the treatment of hypertension, the
  recommendations endorse
• TREATING TO TARGET BP
• treat aggressively using combinations of drugs
  and lifestyle modification to achieve
  individualized target
• PROMOTING ADHERENCE
• a multi-faceted approach should be used to
  improve adherence with both non pharmacological
  and pharmacological strategies

Source CHEP 2007 Recommendations
131
Key CHEP messages

• Assess blood pressure at all appropriate visits.
• Almost one half of those with blood pressure
  130-139/85-89 will develop hypertension within 2
  years. They require annual reassessment.
• Assess global cardiovascular risk in all
  hypertensive patients.
• Lifestyle modification is the cornerstone for the
  prevention and management of hypertension and CVD.

Source CHEP 2007 Recommendations
132
Key CHEP messages

• Treat to target (lt140/90 mmHg lt130/80 mmHg in
  patients with diabetes or chronic kidney
  disease).
• To achieve targets sustained lifestyle
  modification and more than one drug is usually
  required.
• Follow patients with uncontrolled blood pressure
  at least monthly until blood pressure targets are
  achieved.
• Strategies to improve patient adherence to
  lifestyle modifications and antihypertensive
  therapy need to be incorporated in every patients
  management

Source CHEP 2007 Recommendations
133

• Impending Doom!

134
High Blood PressureGet the Low Down!
135
HYPERTENSION

• Prepared by
• Carolyn Walker, RN, BN
• Education Coordinator
• Alberta Provincial Stroke Strategy
• September 2007
• Reviewers
• Dr. Norm Campbell, MD, FRCPCF
• Professor of Medicine, Community Health Sciences
  and Pharmacology and Therapeutics at the
  University of Calgary
• CIHR Canadian Chair in Hypertension Prevention
  and Control
• Chair of the Canadian Hypertension Education
  Program (CHEP) Steering Committee and the CHEP
  Executive Committee
• President of Blood Pressure Canada.
• Recognition of the Canadian Stroke Strategy for
  information utilized in the development of this
  presentation