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Canadian Recommendations for the Management of Hypertension Prepared by Lianne Tile MD FRCPC Septemb

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Title: Canadian Recommendations for the Management of Hypertension Prepared by Lianne Tile MD FRCPC Septemb

1
Canadian Recommendations for the Management of
Hypertension Prepared by Lianne Tile MD
FRCPC September 2003
2
HypertensionPart II

Pharmacological Management

3
References

Feldman RD, Campbell NRC, Larochelle P et al.
1999 Canadian recommendations for the management
of hypertension. CMAJ 1999 161 (supp 12)1-17.
Feldman R et al. The Canadian Hypertension
Education Program Recommendations whats new,
whats old but still important in 2003. Journal
of Hypertension 2003.
August, P. Initial Treatment of Hypertension.
NEJM 2003 3487 610-17.

4
Outline

At the end of this seminiar you will be familiar
with
Indications for drug treatment
Which drugs should be prescribed as first-line
therapy? Subsequent therapy?
Goals of treatment
Individualization of therapy

5
Levels of Evidence

A - the recommendation was based on 1 or more
studies at level I (RCT or equivalent with a
significant result)
B - the best evidence available is at level II
(RCT that does not meet level I criteria)
C - the best evidence available is at level III
(nonrandomized trial)
D - the best evidence available was lower than
level III (i.e. case series) and included expert
opinion

6
Case

Mrs. X, our 54-year old, moderately obese but
otherwise healthy patient, is seen in follow up.
Remember
Both her father and her mother are hypertensive.
Her father had a stroke at the age of 64.
There is no target organ damage, and lipids,
glucose, and EKG are normal.
Her blood pressure is now gt155/95 over 5 visits
and at home, despite lifestyle changes.
What (if any) antihypertensive medication would
you start?
What is the target BP?

7
Lifestyle Modifications

They can work!
In selected patients, these can lower BP similar
to a single antihypertensive medication
Intervention Targeted change SBP/DBP
Sodium reduction 100 mmol/day -5.8 / -2.5
Weight loss -4.5 kg -7.2 / -5.9
Alcohol reduction lt2.7 drinks/day -4.6 / -2.3
Exercise 3 times/week -10.3 / -7.5
Dietary DASH diet -11.4 / -5.5

8
Indications for drug treatment adults lt 60 y.o.

sustained diastolic blood pressure of 90 mm Hg or
higher, especially with cardiovascular disease or
risk factors, or target-organ damage (grade A)
diastolic BP of 100 mm Hg or higher even when no
other cardiovascular risk factors are present
(grade A)
medication should be considered in isolated
systolic hypertension (systolic BP gt 160 mm Hg),
particularly in those with target-organ damage or
cardiovascular risk factors (grade D)

9
Indications for drug treatment adults gt 60 y.o.

drug therapy should be prescribed for systolic BP
? 160 mmHg (grade A)
NOTE 2001 guidelines have removed age as a guide
to choice of therapy those over 60 should be
treated as those under 60

10
Choice of medication hypertension w.out other
compelling indications

Initial therapy should be monotherapy with
low-dose thiazide (ALLHAT), beta-blocker,
ACE-inhibitor, ARB or long acting dihydropyridine
CCB (grade A).
Beta-blockers are not recommended as first-line
therapy in patients over 60 y.o. (grade A).
Thiazide, ARB, or long acting dihydropyridine CCB
recommended for isolated systolic HTN (grade A).

Combination therapy is recommended (and often
needed) if goals not reached with monotherapy
(grade A).
Useful Antihypertensive Drug Combinations
For additive hypotensive effect in dual therapy,
combine an agent from Column 1 with any in Column
2.
Column 1 Column 2
Thiazide diuretic Beta-blocker
Long-acting dihydropyridine ACE Inhibitor
calcium channel blocker ARB

12
Choice of medication hypertension w.out other
compelling indications

Centrally acting agents and alpha-adrenergic
antagonists are effective in decreasing BP and
reducing cardiovascular events (grade B), but
should not be used as initial therapy or in the
elderly due to
Cognitive impairment (methyldopa)
Postural hypotension (alpha-antagonists)
Drowsiness, depression (reserpine)
ACEI are not recommended in blacks

13
Goals of treatment

Uncomplicated hypertension
Diastolic BP lt 90 mm Hg (grade A)
Systolic BP lt 140 mm Hg (grade D)
Home BP lt 135/85 mm Hg
Diabetes or renal disease
BP lt 130/80 mm Hg
Renal disease and proteinuria gt 1g/24hrs
BP lt 125/75 mm Hg

14
Individualization of antihypertensive therapy

Diabetes Mellitus
Coronary Artery Disease
Heart Failure
Stroke/TIA
Renal Disease
Left Ventricular Hypertrophy
Peripheral Vascular Disease
Dyslipidemia
Gout

15
Diabetes

Target blood pressure lt 130/80 mm Hg
Hypertensives without nephropathy
Initial therapy ACE-I or ARB
low dose thiazide an alternative
second line
addition of beta-blockers or long-acting
dihydropyridine CCB
combination of above medications

16
Diabetes

Hypertensives with nephropathy
Initial therapy ACE-I or ARB
second line addition of thiazide, beta-blockers,
long acting dihydropyridine CCBs, or ACEI/ARB
combination
if renal impairment and volume overload, add loop
diuretic (grade C)

17
Coronary Artery Disease

Stable angina
Beta-blocker (grade D), consider ACE-I
alternatively Long-acting CCB (grade B)
Prior MI
Beta-blocker, ACE-I or both (grade A)

18
Heart Failure

Systolic dysfunction
ACE-I (grade A)
thiazide or loop diuretics, beta-blockers
(metoprolol or carvedilol), or spironolactone as
additional therapy (grade A)
alternatively combination of hydralazine and
isosorbide dinitrate (grade A) or ARB
If still hypertensive amlodipine (grade A) or
felodipine (Grade B)

19
Stroke/TIA

Blood pressure reduction recommended after the
acute phase, even in normotensive patients
Initial therapy diuretic/ACE-I combinations

20
Renal disease

Target BP
lt130/80 mm Hg (grade C)
if proteinuria gt 1 g/day lt 125/75 mm Hg (grade C)
Preferred agent ACE-I (grade A)
add diuretic if necessary (grade D)
Dihydropyridine CCB is an alternative in
nondiabetic renal disease (grade B)
Avoid ACE-I in suspected renal artery stenosis

21
Left ventricular hypertrophy

Initial therapy ACE-I, ARB, dihydropyridine CCBs
or diuretics
Beta-blockers for agelt55
hydralazine and minoxidil should be avoided

22
Peripheral vascular disease

Same recommendations as for uncomplicated
hypertension, but
Avoid beta-blockers in severe disease
Raynauds Use vasodilators such as CCB, ACE-I,
ARB, alpha-blocker (grade B)

23
Dyslipidemia

At present there is insufficient evidence to base
therapy on reported effects of specific drugs on
lipid profile

24
Hyperuricemia and gout

Asymptomatic hyperuricemia is not a
contraindication to diuretic use (grade D)
Avoid diuretics in patients with a history of
gout, or significant risk factors. If diuretics
are essential for BP control, consider
allopurinol (grade D).

25
Response to Therapy

If BP still uncontrolled, consider reasons
Non-adherence
Secondary causes
Diet
Other medications
To Improve Adherence
Simplify medication regimens to once daily dosing
Tailor pill-taking to fit patients daily habits
Encourage greater patient responsibility in BP
management (including home BP monitoring)
Educate patients and families about hypertension
and their treatment regimens

26
Back to our patient

Mrs. X, our 54-year old, moderately obese but
otherwise healthy patient, with a family hx of
stroke, was started on Hydrochlorothiazide 12.5
mg OD, and this was increased to 25 mg OD.
Her BP remained at 145/95, so Ramipril 2.5 mg OD
was added.
Her BP stabilized at 135/85.
She was seen for follow up in 6 months. Her BP
remained controlled, and lytes and creatinine
were normal. Lifestyle changes were encouraged

27
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28
Take Home Messages