Part 2: Recommendations for Hypertension Treatment

1
Part 2 Recommendations for Hypertension Treatment
2
2009 Canadian Hypertension Education Program
(CHEP)

• A red flag has been posted where
  recommendations were updated for 2009.
• Slide kits for health care professional and
  public education can be downloaded (English and
  French versions) from http//www.hypertension.ca

3
2009 Canadian Hypertension Education Program
(CHEP)

• Treatment Approaches
• Lifestyle
• Pharmacological

4
Key CHEP messages for the management of
hypertension

• Assess blood pressure at all appropriate visits.
• Encourage people with hypertension to use
  approved devices and proper technique to measure
  blood pressure at home.
• Ensure people with hypertension are screened for
  diabetes (and vice versa). Treat hypertension in
  people with diabetes with a combination of
  lifestyle changes and pharmacotherapy to control
  blood pressure to less than 130/80 mmHg. Many
  require use of three or more antihypertensive
  drugs including diuretics to achieve blood
  pressure targets.
• Assess and manage overall cardiovascular risk in
  all people with hypertension including smoking,
  dyslipidemia, dysglycemia, abdominal obesity,
  unhealthy eating and physical inactivity.
• Sustained lifestyle modification is the
  cornerstone for the prevention and management of
  hypertension and cardiovascular disease (CVD).
• Treat blood pressure to less than 140/90 mmHg in
  most people and to less than 130/80 mmHg in
  people with diabetes or chronic kidney disease.
  More than one drug is usually required.

5
Whats New for 2009The Hypertensive Diabetic

• Patients with diabetes are at high cardiovascular
  risk
• Up to 80 of diabetic patients die of
  cardiovascular disease
• Most patients with diabetes have hypertension
• Between 35 and 75 of diabetic complications have
  been attributed to hypertension.
• Treatment of hypertension in patients with
  diabetes reduces total mortality, myocardial
  infarction, stroke, retinopathy and progressive
  renal failure rates.
• More intensive reduction in blood pressure
  reduces major cardiovascular events and total
  mortality by 25

Treating hypertension in the diabetic patient
reduces death and disability and reduces health
care system costs TARGET lt130 systolic and lt80
mmHg diastolic
6
Whats New for 2009The Hypertensive Diabetic

• 2/3rds of hypertensive diabetic patients have
  uncontrolled hypertension (gt 130/80 mmHg)
• There is underutilization of diuretic therapy in
  treating hypertension in diabetic patients. In
  general a diuretic is required for blood pressure
  control in multi drug regimes.
• A combination of lifestyle changes and 3 or more
  medications are often required.
• More intensive reduction in blood pressure in the
  hypertensive diabetic is one a few medical
  interventions where the cost of treatment is less
  than the cost of the complications prevented

Treating hypertension in the diabetic patient
reduces death and disability and reduces health
care system costs TARGET lt130 systolic and lt80
mmHg diastolic
7
Whats New for 2009

• Increased age on its own should not be a
  consideration in determining the need for
  antihypertensive drug therapy. Drug therapy for
  the elderly should be based on the same criteria
  as in younger adults however caution should be
  exercised in elderly patients who are frail or
  have postural hypotension.

N Engl J Med 20083581887-98
8
Whats New for 2009

• The combination of an ACE inhibitor with an ARB
  is not recommended in patients with
• hypertension without compelling indications,
• coronary artery disease who do not have heart
  failure,
• prior stroke,
• non proteinuric chronic kidney disease or
• diabetes mellitus without micro albuminuria

N Engl J Med 20083581547-59 Lancet 2008 372
54753
9
Whats New for 2009

• The use of combination of ACE inhibitor with an
  ARB should only be considered in selected and
  closely monitored people with advanced heart
  failure or proteinuric nephropathy.

10
2009 Canadian Hypertension Education Program
(CHEP)

• Important messages from past recommendations
• IMPORTANT ROLE FOR HOME MEASUREMENT OF BLOOD
  PRESSURE
• Encourage hypertensive patients to use an
  approved blood pressure measuring device and use
  proper technique to assess blood pressure at
  home.
• Home measurement can help to confirm the
  diagnosis of hypertension, improve blood pressure
  control, reduce the need for medications,
  identify patients with white coat and masked
  hypertension and improve medication adherence

11
2009 Canadian Hypertension Education Program
(CHEP)

• IMPORTANT ROLE FOR HOME MEASUREMENT OF BLOOD
  PRESSURE
• An internet based toolkit for home blood pressure
  measurement including recording and tracking of
  blood pressures can be found at
  www.heartandstroke.ca/BP.
• Patient information on selecting an approved
  device, and how to measure and track home blood
  pressure can be found at www.hypertension.ca.
• More information on home monitoring is in the
  CHEP diagnostic slide set and the BP measurement
  slide set

12
2009 Canadian Hypertension Education Program
(CHEP)

• Important messages from past recommendations
• High dietary sodium is estimated to increase
  blood pressure in the Canadian population to the
  extent that 1,000,000 Canadians meet the
  diagnostic criteria for hypertension who would
  otherwise have normal blood pressure
• Most of the sodium in Canadian diets comes from
  processed foods and restaurants.
• Pizza, breads, soups and sauces usually have high
  amounts of sodium
• Patient information on how to achieve a reduced
  sodium diet can be found at www.hypertension.ca
• Aim to reduce sodium intake to less than 2300
  mg/day to prevent and control hypertension

13
TO REDUCE DIETARY SODIUM

• Advise patients to
• Buy and eat more fresh foods, especially fruit
  and vegetables
• Choose processed foods look with low salt labels
  or brands with the lowest percentage of sodium on
  the food label
• Wash canned foods or other salty foods in water
  before eating or cooking
• If desired, use unsalted spices to make foods
  taste better
• Eat less food at restaurants and fast food
  outlets and ask for less salt to be added in food
  orders
• Use less sauces on food
• Eat foods with less than 200 mg of sodium or less
  than 10 of the daily value per serving
• Advise patients not to
• Buy or eat heavily salted foods (e.g. pickled
  foods, salted crackers or chips, processed meats,
  etc).
• Add salt in cooking and at the table
• Eat foods with more than 400 mg of sodium or more
  than 20 of the daily value per serving

14
Recommendations 2009Table of contents

• Indications for drug therapy
• Goal for therapy
• Adherence
• Lifestyle
• Uncomplicated
• CV IHD
• CHF
• Cerebrovascular / Stroke
• LVH
• X. Chronic kidney disease
• Renovascular
• Diabetes
• Smoking
• Overall risk reduction

15
Usual blood pressure threshold values for
initiation of pharmacological treatment of
hypertension
I. Indications for Pharmacotherapy
16
I. Indications for Pharmacotherapy

• In low risk patients with stage 1 hypertension
  (140-159/90-99 mmHg) lifestyle modification can
  be the sole therapy.
• Over 90 of Canadians with hypertension have
  other risk factors and pharmacotherapy should be
  considered in these patients if blood pressure
  remains equal to or above 140/90 mmHg with
  lifestyle modification.
• In particular many younger hypertensive Canadians
  with multiple cardiovascular risks are currently
  not treated with pharmacotherapy. Health care
  professionals need to be alert to this important
  care gap and recommend pharmacotherapy.
• Patients with target organ damage (e.g. left
  ventricular hypertrophy) are recommended to be
  treated with pharmacotherapy if blood pressure is
  equal to or above 140/90 mmHg
• Patients with diabetes or chronic kidney disease
  should be considered for pharmacotherapy if the
  blood pressure is equal or over 130/80 mmHg

17
Blood pressure target values for treatment of
hypertension
II. Goals of Therapy
18
II. 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
• The systolic target is more difficult to achieve
  however controlling systolic blood pressure is as
  important if not more important than controlling
  diastolic blood pressure

19
Follow-up of blood pressure above targets

• Patients with blood pressure above target are
  recommended to be followed at least every 2nd
  month
• Follow-up visits are used to increase the
  intensity of lifestyle and drug therapy, monitor
  the response to therapy and assess adherence

20
IV. Lifestyle management
21
Lifestyle Recommendations for Prevention and
Treatment of Hypertension

• To reduce the possibility of becoming
  hypertensive,
• Reduce sodium intake to less than 2300 mg / day
• Healthy diet high in fresh fruits, vegetables,
  low fat dairy products, dietary and soluble
  fiber, whole grains and protein from plant
  sources, low in saturated fat, cholesterol and
  sodium in accordance with Canada's Guide to
  Healthy Eating.
• Regular physical activity accumulation of 30-60
  minutes of moderate intensity cardiorespiratory
  activity (e.g. a brisk walk)
• 4-7 days/week in addition to routine activities
  of daily living
• Low risk alcohol consumption (2 standard
  drinks/day and less than 14/week for men and less
  than 9/week for women)
• Maintenance of ideal body weight (BMI 18.5-24.9
  kg/m2)
• Waist Circumference
  Men Women
• - Europid, Sub-Saharan African, Middle Eastern
  lt94 cm lt80 cm
• - South Asian, Chinese lt90 cm lt80 cm
• - Smoke free environment

22
Lifestyle Recommendations for Hypertension
Dietary

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

www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng
.php
23
Potential Benefits of a Wide Spread Reduction in
Dietary Sodium in Canada

• REDUCTION IN AVERAGE DIETARY SODIUM FROM ABOUT
  3500 MG TO 1700 MG
• 1 million fewer hypertensives
• 5 million fewer physicians visits a year for
  hypertension
• Health care cost savings of 430 to 540 million
  per year related to fewer office visits, drugs
  and laboratory costs for hypertension
• Improvement of the hypertension treatment and
  control rate
• 13 reduction in CVD
• Total health care cost savings of over 1.3
  billion/year

24
Recommendations for daily salt intake

• Less than
• 2,300 mg sodium (Na)
• 100 mmol sodium (Na)
• 5.8 g of salt (NaCl)
• 1 teaspoon of table salt

2,300 mg sodium 1 level teaspoon of table salt
however, 80 of average sodium intake is in
processed foods and only 10 is added at the
table or in cooking
25
Sodium Meta-analyses

• Hypertensives
• Reduction of BP
• 5.1 / 2.7 mmHg with a average reduction of 1800
  mg sodium/day
• 7.2/3.8 mmHg with a average reduction of 2300 mg
  sodium/day
• Normotensives
• Reduction of BP
• 2.0 / 1.0 mmHg with a average reduction of sodium
  1700 mg/day
• 3.6/1.7 mmHg with a average reduction of 2300
  mg/day sodium

The Cochrane Library 200631-41
26
Meta analysis on different reductions in dietary
sodium intake on blood pressure
Hypertension 2003421093-1099
27
Lifestyle Recommendations for Hypertension
Physical Activity
Should be prescribed to reduce blood pressure
Frequency - Four to seven days per week
Type cardiorespiratory activity - Walking,
jogging - Cycling - Non-competitive swimming
Exercise should be prescribed as adjunctive to
pharmacological therapy
28
Lifestyle Recommendations for Hypertension
Weight LossHeight, weight, and waist
circumference (WC) should be measured and body
mass index (BMI) calculated for all adults.
CMAJ 20071761103-6
29
Waist Circumference Measurement
Last rib margin
Mid distance
Iliac crest
Courtesy J.P. Després 2006
30
Lifestyle Recommendations for Hypertension
Alcohol
Low risk alcohol consumption
0-2 standard drinks/day
Men maximum of 14 standard drinks/week
Women maximum of 9 standard drinks/week
A standard drink is about 142 ml or 5 oz of wine
(12 alcohol). 341 mL or 12 oz of beer (5
alcohol) 43 mL or 1.5 oz of spirits (40 alcohol).
31
Lifestyle Recommendations for Hypertension
Stress Management
Stress management
Hypertensive patients in whom stress appears to
be an important issue
Behaviour Modification
Individualized cognitive behavioural
interventions are more likely to be effective
when relaxation techniques are employed.
32
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
33
Lifestyle Therapies in Hypertensive Adults
Summary
34
Epidemiologic impact on mortality of blood
pressure reduction in the population
After Intervention
Before Intervention
Prevalence
Reduction in BP
Adapted from Whelton, P. K. et al. JAMA
20022881882-1888
35
Pharmacotherapy
36
V. Choice of Pharmacological Treatment
Uncomplicated
Associated risk factors? or Target organ
damage/complications? or Concomitant
diseases/conditions?
37
V. Choice of Pharmacological Treatment

• 1. Treatment of Systolic/Diastolic hypertension
  without other compelling indications
• 2. Treatment of Isolated Systolic hypertension
  without other compelling indications

38
V. Treatment of Adults with Systolic/Diastolic
Hypertension without Other Compelling Indications
TARGET lt140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy
A combination of 2 first line drugs may be
considered as initial therapy if the blood
pressure is gt20 mmHg systolic or gt10 mmHg
diastolic above target
Thiazide
Beta-blocker
Long-acting CCB

• BBs are not indicated as first line therapy for
  age 60 and above

ACEI, ARB and direct renin inhibitors are
contraindicated in pregnancy and caution is
required in prescribing to women of child bearing
potential
39
V. Considerations Regarding the Choice of
First-Line Therapy

• Use caution in initiating therapy with 2 drugs in
  whom adverse events are more likely (e.g. frail
  elderly, those with postural hypotension or who
  are dehydrated).
• ACE inhibitors, renin inhibitors and ARBs are
  contraindicated in pregnancy and caution is
  required in prescribing to women of child bearing
  potential.
• Beta adrenergic blockers are not recommended for
  patients age 60 and over without another
  compelling indication.
• Diuretic-induced hypokalemia should be avoided
  through the use of potassium sparing agent if
  required.
• The use of combination of ACE inhibitor with a
  ARB should only be considered in selected and
  closely monitored people with advanced heart
  failure or proteinuric nephropathy.
• ACE-I are not recommended (as monotherapy) for
  black patients without another compelling
  indication.

40
V. Add-on Therapy for Systolic/Diastolic
Hypertension without Other Compelling Indications
If partial response to monotherapy
If blood pressure is still not controlled, or
there are adverse effects, other classes of
antihypertensive drugs may be combined (such as
alpha blockers or centrally acting agents).
41
Drug Combinations

• When combining drugs, use first-line therapies.
• Two drug combinations of beta blockers, ACE
  inhibitors and angiotensin receptor blockers have
  not been proven to have additive hypotensive
  effects. Therefore these potential two drug
  combinations should not be used unless there is a
  compelling (non blood pressure lowering)
  indication
• Combinations of an ACEI with an ARB do not reduce
  cardiovascular events more than the ACEI alone
  and have more adverse effects therefore are not
  generally recommended

42
Drug Combinations contd

• Caution should be exercised in combining a non
  dihydropyridine CCB and a beta blocker to reduce
  the risk of bradycardia or heart block.
• Monitor serum creatinine and potassium when
  combining K sparing diuretics, ACE inhibitors
  and/or angiotensin receptor blockers.
• If a diuretic is not used as first or second line
  therapy, triple dose therapy should include a
  diuretic, when not contraindicated.

43
Medication Use and BP Control in ALLHAT
?
lt140/90 mm Hg
Cushman et al. J Clin Hypertens 20024393-404.
44
Most HTN Pts need more than 1 drug
5
4
3
Number of drugs
2
1
0
HOT
IDNT
AASK
ABCD
MDRD
UKPDS
ALLHAT
45
BP lowering effects from antihypertensive drugs

• Dose response curves for efficacy are relatively
  flat
• 80 of the BP lowering efficacy is achieved at
  half-standard dose
• Combinations of standard doses have additive
  blood pressure lowering effects

Law. BMJ 2003
46
V. Summary Treatment of Systolic-Diastolic
Hypertension without Other Compelling Indications
TARGET lt140/90 mmHg
Lifestyle modification
A combination of 2 first line drugs may be
considered as initial therapy if the blood
pressure is gt20 mmHg systolic or gt10 mmHg
diastolic above target
Initial therapy
Dual Combination

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

Not indicated as first line therapy over 60 y
Triple or Quadruple Therapy
47
Treatment Algorithm for Isolated Systolic
Hypertension without Other Compelling Indications
TARGET lt140 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy
Thiazide diuretic
ARB
Long-acting DHP CCB
48
V. 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

Triple therapy
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).
49
V. Summary Treatment of Isolated Systolic
Hypertension without Other Compelling Indications
TARGET lt140 mmHg
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
50
Choice of Pharmacological Treatment for
Hypertension

• Individualized treatment
• Compelling indications
• Ischemic Heart Disease
• Recent ST Segment Elevation-MI or non-ST Segment
  Elevation-MI
• Left Ventricular Systolic Dysfunction
• Cerebrovascular Disease
• Left Ventricular Hypertrophy
• Non Diabetic Chronic Kidney Disease
• Renovascular Disease
• Smoking
• Diabetes Mellitus
• With Diabetic Nephropathy
• Without Diabetic Nephropathy
• Global Vascular Protection for Hypertensive
  Patients
• Statins if 3 or more additional cardiovascular
  risks
• Aspirin once blood pressure is controlled

51
VI. Treatment of Hypertension in Patients with
Ischemic Heart Disease

• Caution should be exercised when combining a
  non DHP-CCB and a beta-blocker
• If abnormal systolic left ventricular
  function avoid non DHP-CCB (Verapamil or
  Diltiazem)
• Combinations of an ACEI with an ARB are not
  recommended in the absence of heart failure

Those at low risk with well controlled risk
factors may not benefit from ACEI therapy
52
VI. Treatment of Hypertension in Patients with
Recent ST Segment Elevation-MI or non-ST Segment
Elevation-MI
Beta-blocker and ACEI or ARB (if ACEI not
tolerated)
Recent myocardial infarction
If beta-blocker contraindicated or not effective
Long-acting Dihydropyridine CCB (e.g.
Amlodipine)
YES
Heart Failure ?
NO
Long-acting CCB
Avoid non dihydropyridine CCBs (diltiazem,
verapamil)
53
VII. Treatment of Hypertension with Left
Ventricular Systolic Dysfunction
ACEI and Beta blocker if ACEI intolerant
ARB Titrate doses of ACEI or ARB to those used in
clinical trials
Systolic cardiac dysfunction

• If additional therapy is needed
• Diuretic (Thiazide for hypertension Loop for
  volume control)
• for CHF class III-IV or post MI Aldosterone
  Antagonist

If ACEI and ARB are contraindicated Hydralazine
and Isosorbide dinitrate in combination
If additional antihypertensive therapy is
needed ACEI / ARB Combination
Long-acting DHP-CCB (Amlodipine)
Beta-blockers used in clinical trials were
bisoprolol, carvedilol and metoprolol.
54
VIII. Treatment of Hypertensionfor Patients
with Cerebrovascular Disease
Combinations of an ACEI with an ARB are not
recommended
55
IX. Treatment of Hypertension in Patients with
Left Ventricular Hypertrophy
Hypertensive patients with left ventricular
hypertrophy should be treated with
antihypertensive therapy to lower the rate of
subsequent cardiovascular events.

• ACEI
• ARB,
• CCB
• Thiazide Diuretic
• - BB (if age below 60)

56
X. Treatment of Hypertension in Patients with Non
Diabetic Chronic Kidney Disease
albumincreatinine ratio ACR gt 30 mg/mmol or
urinary protein gt 500 mg/24hr
Monitor serum potassium and creatinine carefully
in patients with CKD prescribed an ACEI or
ARB Combinations of a ACEI and a ARB are
specifically not recommended in the absence of
proteinuria
57
XI. Treatment of Hypertension in Patients with
Renovascular Disease
58
XII. Treatment of Hypertension in association
with Diabetes Mellitus
59
XII. 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 ratio gt 2.0
mg/mmol in men or gt 2.8mg/mmol in women or
chronic kidney disease
A combination of 2 first line drugs may be
considered as initial therapy if the blood
pressure is gt20 mmHg systolic or gt10 mmHg
diastolic above target
Combinations of an ACEI with an ARB are
specifically not recommended in the absence of
proteinuria
based on at least 2 of 3 measurements
60
XII. Treatment of Hypertension in association
with Diabetic Nephropathy
Monitor serum potassium and creatinine carefully
in patients with CKD prescribed an ACEI or ARB
61
XII. Treatment of Systolic-Diastolic Hypertension
without Diabetic Nephropathy
Threshold equal or over 130/80 mmHg and TARGET
below 130/80 mmHg
1. ACE Inhibitor or ARB or 2. Thiazide diuretic
or Dihydropyridine CCB
Diabetes without Nephropathy
Combination of first line agents
IF ACE Inhibitor and ARB and DHP-CCB and Thiazide
are contraindicated or not tolerated,
SUBSTITUTE Cardioselective BB or
Long-acting NON DHP-CCB
DHP dihydropyridine
Addition of one or more of Cardioselective BB
or Long-acting CCB
Combinations of an ACE Inhibitor with an ARB are
specifically not recommended in the absence of
proteinuria
Cardioselective BB Acebutolol, Atenolol,
Bisoprolol , Metoprolol
More than 3 drugs may be needed to reach target
values for diabetic patients
62
XII. Treatment of Hypertension in association
with Diabetes Mellitus Summary
Threshold equal or over 130/80 mmHg and TARGET
below 130/80 mmHg
A combination of 2 first line drugs may be
considered as initial therapy if the blood
pressure is gt20 mmHg systolic or gt10 mmHg
diastolic above target
ACE Inhibitor or ARB
1. ACEInhibitor or ARB or 2. Thiazide diuretic or
DHP-CCB
without Nephropathy
gt 2-drug combinations
Monitor serum potassium and creatinine carefully
in patients with CKD prescribed an ACEI or
ARB Combinations of an ACEI with an ARB are
specifically not recommended in the absence of
proteinuria
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
63
XIII. Treatment of Hypertension for Patients Who
Use Tobacco
64
XIV. Overall Vascular Protection for Patients
with Hypertension
65
Most hypertensive Canadians have other
cardiovascular risks

• Assess and manage hypertensive patients for
  smoking, dyslipidemia and dysglycemia (impaired
  fasting glucose or diabetes) abdominal obesity,
  unhealthy eating and physical inactivity.

66
XIV. 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
67
XIV. Vascular Protection for Hypertensive
Patients ASA
Consider low dose ASA
Caution should be exercised if BP is not
controlled.
68
Adherence to anti-hypertensive management can be
improved by a multi-pronged approach

• Assess adherence to pharmacological and
  non-pharmacological therapy at every visit
• Teach patients to take their pills on a regular
  schedule associated with a routine daily activity
  e.g. brushing teeth.
• Simplify medication regimens using long-acting
  once-daily dosing
• Utilize fixed-dose combination pills
• Utilize unit-of-use packaging e.g. blister
  packaging

69
Adherence to anti-hypertensive management can be
improved by a multi-pronged approach

• Encourage greater patient responsibility/autonomy
  in regular monitoring of their blood pressure
• Educate patients and patients' families about
  their disease/treatment regimens verbally and in
  writing
• Use an interdisciplinary care approach if
  available to improve adherence to therapy

70
Focusing on care gaps

• CHEP utilizes several different surveillance
  mechanisms to look for areas where patient care
  can be improved.
• In 2009 we highlight 3 important care gaps
• Lifestyle change after a diagnosis of
  hypertension
• Pharmacotherapy in younger patients who have
  multiple cardiovascular risk factors
• Achieving blood pressure targets in people with
  diabetes

71
NPHS (1994-2002) More Lifestyle Changes After
Hypertension Diagnosis Are Needed
Small decreases in smoking and physical
inactivity along with increases in BMI were
observed in newly diagnosed patients in the
longitudinal National Population Health Survey
(NPHS). This trend was largely seen in patients
who were taking antihypertensive medication. A is
the survey cycle prior to diagnosis and B is the
survey cycle following hypertension diagnosis.
Can J Cardiol, 2008. 24 3 199-204.
72
Lifestyle change

• Single lifestyle changes can have a similar blood
  pressure lowering effect as an antihypertensive
  drug and most lifestyle changes also reduce other
  cardiovascular risk factors
• Brief health care professional interventions are
  effective in promoting lifestyle change
• More extensive interdisciplinary team approaches
  are more effective in promoting lifestyle change.

73
Treating younger patients with pharmacotherapy

• Most patients with hypertension have other
  cardiovascular risks.
• Multiple risk factors can dramatically increase
  the probability of an adverse cardiovascular
  outcome

74
The Proportion of Aware Adult Hypertensive
Canadians Not Receiving Antihypertensive
Treatment by Number of Cardiovascular Disease
(CVD) Risk Factors
(risks include male, smoking, obese (BMI gt30),
diabetes, and physically inactive)
Can J Cardiol 200824485-90
75
Treating younger patients with pharmacotherapy

• Be aware that many young hypertensive patients
  are not currently prescribed antihypertensive
  therapy
• Those with additional cardiovascular risk factors
  are recommended for pharmacotherapy
• In particular, hypertensive patients who smoke
  and are unable to stop should be prescribed
  antihypertensive therapy.

76
Hypertension in the Diabetic patient

• Two thirds of Ontarians with hypertension and
  diabetes have blood pressure above target.
• Only 25 were prescribed a thiazide like
  diuretic.
• Very large reductions in cardiovascular disease
  and death occur from treating hypertension in
  diabetic patients.
• Many require lifestyle change and three or more
  drugs

CMAJ 20081781441-9, Am J Hypertens
2008211210-5.
77
NEW PATIENT RESOURCES FOR HYPERTENSION ON LINE

• www.heartandstroke.ca/BP
• To monitor home blood pressure and encourage self
  management of lifestyle
• www.hypertension.ca
• To access up to date downloadable patient
  information on hypertension

78
Public translation of CHEP recommendations
Download at www.hypertension.ca/bpc
79
Educate patients and patients' families about
their disease/treatment regimens verbally and in
writing
Useful patient information can be obtained in
recent publications from the Canadian
Hypertension Society.
Available by order from CHS Secretariat-Canadian
Hypertension Society. Tel [phone], Fax
613-533-6927 Email HYPERTENSION_at_QUEENSU.CA
80
Encourage greater patient responsibility/autonomy
Can be ordered at www.hypertension.qc.ca
81
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
• Encourage appropriate patients to properly
  measure blood pressure at home
• Most can assess blood pressure at home. Home
  measurement can confirm a diagnosis of
  hypertension, improve adherence to drug
  treatment, improve control rates and detect
  patients with white coat hypertension and masked
  hypertension.

82
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 treatment target or in combination with
  pharmacological treatment

83
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