What’s New?

CHEP

2015
Canadian Recommendations for
the Management of Hypertension

Canadian Hypertension Education Program Programme éducatif canadien sur l’hypertension

What’s New?
Are you and your patients armed with the
latest hypertension management resources?
Sign up at www.hypertension.ca to be notified by
email when new resources are developed or updated
or to download current resources. Your patients can
also sign up at www.hypertension.ca for 2015 annual
membership where they will receive email notices of
updated and new educational resources.
Prevention and Attaining Treatment Targets
are Key
Prevention is a key goal. In this regard, healthcare
professionals should continue to assess blood pressure
at all appropriate visits. Lifestyle modifications to
achieve a healthy lifestyle and optimize weight can
lower blood pressure and prevent the development
of hypertension. Healthcare providers are advised
to encourage smoking cessation, physical activity,
healthy diets and sodium restriction.
In patients with documented hypertension,
attaining blood pressure targets is vital to prevent
cardiovascular and cerebrovascular complications.
Therefore, a <140/90 mmHg blood pressure target
should be attained in most hypertensive patients
(other than those at very low risk of events or frail
elderly patients aged 80 years or older). In persons
with diabetes a blood pressure <130/80 mmHg
Measure Blood Pressure in All Adults at All Appropriate Visits
Elevated BP Reading(s) – office, home or pharmacy
Hypertension Visit 1
History, Physical Examination
and Diagnostic Tests
AOBP ≥ 135/85
OBPM ≥ 140/90
YES
Out of Office Assessment
– ABPM (preferred)
– HBPM Diagnostic Series
Hypertension Visit 2
(Within 1 Month)
Daytime ABPM or HBPM ≥135/85
24-hour ABPM ≥130/80
YES
Hypertension
is recommended. This can be done using lifestyle Smoking Cessation is a Priority
modification and, if necessary, medication. • The tobacco status of all patients should be
As a whole, all healthcare professionals should updated regularly.
advocate for prevention of hypertension by modifying • Health care providers should clearly advise
exposures to behavioural, environmental and societal smokers to quit.
risk factors. • Pharmacotherapy should be offered to all smokers
Continuously update your knowledge with to help them quit.
educational resources for the prevention and control
Additional Changes for 2015
of hypertension and also by registering at www.
• Patients with hypertension attributable to renal
hypertension.ca
artery stenosis should be primarily managed
What is New in 2015? medically.
Accurate Blood Pressure Measurement is of
What’s still really important in 2015?
Critical Importance
Key messages relating to the management of
• Office blood pressure measurement using
hypertension that continue to be important and
electronic (oscillometric) upper arm devices is
relevant include:
preferred to auscultation because the latter is not
• Lifestyle changes are a critical component of
performed accurately in clinical practice.
hypertension management and prevention
• Out-of-office measurement should be used after
• The most important step in prescription of
the first hypertension visit to confirm the diagnosis
antihypertensive therapy is achieving patient
of hypertension because it more accurately reflects
“buy-in”
prognosis and identifies white coat effect.
• Global cardiovascular risk assessment and
• Two out-of-office modalities exist – 24-hour
optimization is important in all hypertensive
ambulatory blood pressure monitoring and home
patients.
blood pressure monitoring. 24-hour ambulatory
monitoring is the preferred modality because it
assesses BP throughout day and night.
Measurement using electronic (oscillometric) upper
BP arm devices is preferred over auscultation
≥180/110 Hypertension
ABPM: Ambulatory Blood Pressure Measurement
AOBP: Automated Office Blood Pressure
No Hypertension HBPM: Home Blood Pressure Measurement
NO (Annual BP Measurement
Recommended)
OBPM: Office Blood Pressure Measurement
OBPM:
Hypertension Visit 2
Alternate Method ≥ 140 SBP or ≥ 90 DBP
(If ABPM or HBPM is not available)
Hypertension Visit 3
≥ 160 SBP or
Hypertension
≥ 100 DBP
White Coat Hypertension
< 160/100
If the average HBPM <135/85,
NO
it is advisable to perform ABPM
or repeat HBPM to confirm
Hypertension Visit 4-5
≥ 140 SBP or
Hypertension
≥ 90 DBP
No Hypertension No Hypertension
(Annual BP Measurement < 140/90 (Annual BP Measurement
Recommended) Recommended)
Treatment of Adults with Systolic/Diastolic Hypertension
Without Compelling Indications for a Specific Agent
Target <140/90 mmHg
Initial Treatment and Monotherapy
Health Behaviour
Modification

Thiazide/
Long-acting
thiazide-like ACEI ARB Beta-blocker*
CCB
diuretic

A combination of two first-line drugs may be considered as initial therapy if the

blood pressure is ≥ 20 mmHg systolic or ≥10 mmHg diastolic above target.

* Beta-blockers 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

Combination Therapy Suspected Resistant Hypertension

To achieve optimal blood pressure targets:
• Multiple drugs are often required to reach target levels,
especially in patients with type 2 diabetes.
• Replace multiple antihypertensive agents with fixed-
dose combination therapy.
• Low doses of multiple drugs may be more effective and
better tolerated than higher doses of fewer drugs.
• Reassess patients with uncontrolled blood pressure at
least every 2 months.
• A combination of two first-line agents may also be
considered as initial treatment of hypertension if systolic
blood pressure is 20 mmHg above target or if diastolic
blood pressure is 10 mmHg above target.
• The combination of ACE inhibitors and ARBs should not
be used.
• In selected high-risk patients in whom combination
therapy is being considered, an ACE inhibitor plus a
long-acting dihydropyridine CCB is preferable to an
ACE inhibitor plus a thiazide or thiazide-like diuretic.
• Consider white coat hypertension, white coat effect and
non-adherence.
• If not used as first-line or second-line therapy, triple
drug therapy should include a diuretic when not
contraindicated.
• Two-drug combinations of beta-blockers, ACE inhibitors
and angiotensin receptor blockers have not been proven
to have clinically important antihypertensive effect.
• Monitor creatinine and potassium when combining
potassium sparing diuretics, ACE inhibitors, angiotensin
receptor blockers and/or direct renin inhibitors.
• Consider referral to a hypertension specialist if blood
pressure is still not controlled after treatment with 3
antihypertensive medications.
Routine Lab Testing
Preliminary Investigations of patients with hypertension
1. Urinalysis
2. Blood chemistry (potassium, sodium and creatinine)
3. Fasting blood glucose and/or glycated hemoglobin (A1c)
4. Fasting total cholesterol and high density lipoprotein cholesterol (HDL),
low density lipoprotein cholesterol (LDL), triglycerides
5. Standard 12-lead ECG
Currently there is insufficient evidence, for or against, to recommend routine testing of
microalbuminuria in patients with hypertension but without diabetes or renal disease.

Follow-up investigations of patients with hypertension

During the maintenance phase of hypertension management, tests (including electrolytes,
creatinine, glucose/A1c, and fasting lipids) should be repeated with a frequency reflecting
the clinical situation.
Diabetes develops in 1-3% per year of those with drug-treated hypertension. The risk is
higher in those with one or more of the following: treated with a diuretic or beta-blocker,
impaired fasting glucose or impaired glucose tolerance, obesity (especially abdominal),
dyslipidemia, sedentary lifestyle and poor dietary habits. Screen hypertensives with
annual fasting plasma glucose testing and follow the screening recommendations.
For diabetes management see: Can J Diabetes. 2013;37(suppl 1):S1-S212

Health Behaviour Recommendations for Prevention and Treatment of Hypertension

Objective Recommendation Comment

Being More An accumulation of 30-60 minutes of dynamic exercise of moderate intensity (such Should be prescribed to both hypertensive and
Physically as walking, cycling, swimming) four to seven days per week in addition to the routine normotensive individuals for prevention and
Active activities of daily living. Higher intensities of exercise are no more effective at BP management of hypertension.
lowering but may produce other cardiovascular benefits. For non-hypertensive or stage
1 hypertensive individuals, the use of resistance or weight training exercise (such as free
weight lifting, fixed weight lifting, or hand grip exercise) does not adversely influence BP.
Weight A healthy BMI (18.5 - 24.9 kg/m2) and waist circumference (<102 cm for men and Encourage multidisciplinary approach to
Reduction <88 cm for women) is recommended for non-hypertensive individuals to prevent weight loss, including dietary education,
hypertension and for hypertensive patients to reduce BP. increased physical activity and behavior
modification.
Moderation in Limited consumption: 0-2 standard drinks/day Should be prescribed to both hypertensive and
Alcohol Intake normotensive individuals for prevention and
• Men: < 14 drinks/week
• Women: < 9 drinks/week management of hypertension
Eating DASH-like diet: Should be prescribed to both hypertensive
Healthier and and normotensive individuals for prevention/
Reducing
• High in fresh fruits, vegetables, dietary fibre, non-animal protein (e.g. soy) and low-fat
dairy products. Low in saturated fat and cholesterol. management of hypertension.
Sodium Intake
• To decrease BP, consider reducing dietary sodium intake towards 2000 mg per day.
Relaxation Individualized cognitive behavior interventions are more likely to be effective when For selected patients in whom stress plays a
Therapies relaxation techniques are employed. role in elevating BP.
Smoking Advise smokers to quit and offer them specific pharmacotherapy to help them quit. A global cardiovascular risk reduction strategy.
Cessation Abstinence from smoking. A smoke-free environment.
 Hypertension Care Pearls
Interprofessional team care
• Involvement of an interprofessional team improves
adherence

Health behaviour changes are important to make

• Frequent brief interventions double the rate of lifestyle
changes
• All hypertensives require lifestyle assessment and
ongoing support to initiate and maintain lifestyle changes

Younger patients remain undertreated and older

women are less likely to achieve target.
• Start pharmacotherapy for hypertensives with multiple
cardiovascular risks factors immediately, in addition to
lifestyle changes
• In particular, reduce risk factors in smokers who
cannot quit

Combination therapy of ACE inhibitor with ARB

• Reassess all patients on this combination
• Consider other combinations

Measurement using electronic (oscillometric)

upper arm devices is preferred over auscultation.

Hypertension Canada Resources

Hypertension Canada
www.hypertension.ca
• Get the CHEP recommendations, slide decks and the CHEP app
• Find patient and health care provider resources, including how
to measure blood pressure at home and how to reduce sodium
consumption
• Access accredited online training
• Sign up for the monthly eINFO newsletter to get resource
updates and the latest news
• View a list of endorsed devices to measure blood pressure
at home
Canadian Diabetes Association
www.guidelines.diabetes.ca
• 2013 Clinical Practice Guidelines

Canadian Cardiovascular Society

www.ccsguidelineprograms.ca
For professionals: • Clinical practice guidelines for dyslipidemia, atrial fibrilliation,
• Access an accredited 15 ½ hour interdisciplinary heart failure and many cardiovascular illnesses
training program
• Sign up for free monthly news updates, featured
research and educational resources
• Become a member for special privileges and savings
Considerations in the Individualization of Antihypertensive Therapy
Hypertension Without Other Compelling Indications for a Specific Agent
Diastolic hypertension
with or without systolic
hypertension (target BP
<140/90 mmHg)
Isolated systolic
hypertension without other
compelling indications
(target BP for age <80 is
<140/90 mmHg; for age ≥
80 the target systolic BP is
<150 mmHg)
Diabetes Mellitus — Target <130/80 mmHg
Diabetes mellitus with
microalbuminuria*, renal
disease, cardiovascular
disease or additional
cardiovascular risk factors
Diabetes mellitus not
included in the above
category
Cardiovascular Disease — Target <140/90 mmHg
Coronary artery disease
Recent myocardial infarction
Heart failure
Left ventricular hypertrophy
Past stroke or TIA
Non-diabetic chronic kidney disease — Target <140/90 mmHg
Nondiabetic chronic kidney
disease with proteinuria†
Renovascular disease
Initial Therapy
Thiazide/thiazide-like diuretics, beta-
blockers, ACE inhibitors, ARBs, or
long-acting calcium channel blockers
(consider ASA and statins in selected
patients). Consider initiating therapy with a
combination of first- line drugs if the blood
pressure is ≥20 mmHg systolic or ≥10
mmHg diastolic above target.
Thiazide/thiazide-like diuretics, ARBs
or long-acting dihydropyridine calcium
channel blockers.
ACE inhibitors or ARBs
ACE inhibitors, ARBs, dihydropyridine
CCBs or thiazide/thiazide-like diuretics
Initial Therapy
ACE inhibitors or ARBs; beta blockers for
patients with stable angina
Beta-blockers and ACE inhibitors
(ARBs if ACE inhibitor intolerant)
ACE inhibitors (ARBs if ACE inhibitor
intolerant) and beta- blockers.
Aldosterone antagonists (mineral corticoid
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 to IV symptoms.
ACE inhibitor, ARB, long acting CCB or
thiazide /thiazide-like diuretics.
ACE inhibitor and a thiazide /thiazide-like
diuretic combination.
ACE inhibitors (ARBs if ACE inhibitor
intolerant) if there is proteinuria. Diuretics
as additive therapy
Does not affect initial treatment
recommendations
Second-line Therapy
Combinations of first-line drugs
Combinations of first-line drugs
Addition of dihydropyridine CCB is preferred
over thiazide/thiazide-like diuretic.
Combination of first-line drugs. If combination
with ACE-inhibitor is being considered, a
dihydropyridine CCB is preferable to a thiazide/
thiazide-like diuretic
Second-line Therapy
Long-acting CCBs. When combination therapy
is being used for high risk patients, an ACE
inhibitor/ dihydropyridine CCB is preferred.
Long-acting CCBs if beta blocker
contraindicated or not effective
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.
Combination of additional agents
Combination of additional agents
Combinations of additional agents
Combinations of additional agents
Notes and/or Cautions
Not recommended for monotherapy: Alpha blockers, Beta-
blockers in those ≥60 years of age, ACE inhibitors in black people.
Hypokalemia should be avoided in those prescribed diuretics. ACE
inhibitors, ARBs and direct renin inhibitors are potential teratogens,
and caution is required if prescribing to women with child-bearing
potential. Combination of an ACE inhibitor with an ARB is not
recommended.
Same as diastolic hypertension with or without systolic hypertension
A loop diuretic could be considered in hypertensive CKD patients
with extracellular fluid overload.
Normal albumin to creatinine ratio [ACR] <2.0 mg/mmol in men
and women
Notes and/or Cautions
Avoid short-acting nifedipine. Combination of an ACE-inhibitor with
an ARB is specifically not recommended. Exercise caution when
lowering SBP to target if DBP is ≤60 mmHg.
Non-dihydropyridine CCBs should not be used with concomitant-
heart failure.
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.
Hydralazine and minoxidil should not be used.
Treatment of hypertension should not be routinely undertaken in
acute stroke unless extreme BP elevation. Combination of an ACE
inhibitor with an ARB is not recommended.
Carefully monitor renal function and potassium for those on an ACE
inhibitor or ARB. Combinations of an ACE-inhibitor and ARB are not
recommended in patients without proteinuria.
Avoid ACE inhibitors or ARBs if bilateral renal artery stenosis or
unilateral disease with solitary kidney
Considerations in the Individualization of Antihypertensive Therapy* (continued)

Initial Therapy Second-line Therapy Notes and/or Cautions

Other Conditions — Target <140/90 mmHg
Peripheral arterial disease Does not affect initial treatment Combinations of additional agents Avoid beta-blockers with severe disease
recommendations
Dyslipidemia Does not affect initial treatment Combinations of additional agents
recommendations
Overall vascular protection Statin therapy for patients with 3 or Caution should be exercised with the ASA recommendation if blood
more cardiovascular risk factors or pressure is not controlled.
atherosclerotic disease. Low dose ASA in
hypertensive patients ≥ 50 years

* Microalbuminuria is defined as persistent albumin to creatinine ratio [ACR] Target BP Levels for Hypertension
>2.0 mg/mmol in men and women.
† P roteinuria is defined as urinary protein >500 mg/24hr or albumin to
Setting Location or Condition Target
creatinine ratio [ACR] >30 mg/mmol. (SBP/DBP mmHg)

ACE: Angiotensin-converting enzyme Home: Home blood pressure and daytime ABPM* <135/85
ARB: Angiotensin receptor blocker Systolic ± diastolic hypertension <140/90
ASA: Acetylsalicylic acid
CCB: Calcium channel blocker Isolated systolic hypertension <140
NYHA: New York Heart Association Very elderly (age ≥ 80 y) with isolated
Office: <150
TIA: Transient ischemic attack. systolic hypertension
Diabetes <130/80
Non-DM Chronic kidney disease <140/90
*ABPM: Ambulatory Blood Pressure Monitoring

Interventions That Can Help Improve Medication Adherence

Adherence can be improved by a multi-pronged approach:

1) At every visit, assist your patient to adhere using a multi-pronged approach

a) Tailor and simplify pill-taking to fit your patient’s daily habits
b) Utilize single pill combinations
c) Utilize unit-of-use packaging (e.g. blister packaging)
2) Assist your patient in getting more involved in his/her treatment
a) Encourage greater responsibility/autonomy in monitoring his/her blood pressure and
reporting the results, so you may adjust his/her prescriptions as needed
3) Improve your management in the office and beyond
a) Educate your patient and his/her family about hypertension and its treatment
b) Inform your patient of their global risk to improve the effectiveness of risk factor
modification using vascular or cardiovascular age
c) Adherence to an antihypertensive prescription can be improved by an
interprofessional team approach
The Role of Sodium

13% of CV events in Canada are attributed to

excess dietary sodium.
Beyond the Salt Shaker:
Key Messages for Healthcare Professionals
1. Dietary sodium is an important contributor to
high blood pressure.
2. Canadian sodium intake is well above recommended levels.
3. Lowering sodium intake is good for public health.
4. Processed foods are our main source of dietary sodium.
5. Healthcare professionals can play a key role.

Guidelines for Sodium Intake

To decrease blood pressure, consider
reducing sodium intake towards
2,000 mg per day.

The benefits of being a Hypertension Canada Member

Become a member at www.hypertension.ca to gain access to valuable benefits that
include discounted registration for our annual accredited Congress, trainee travel
awards, the promotion of member publications, free resources and opportunities to
make a difference as an expert volunteer and advocate.

Be a part of the Hypertension Canada community

Hypertension Canada offers many programs and services that can be accessed both
by members and non-members. Please join us.
• Sign up for the eINFO monthly newsletter at http://hypertension.ca/en/einfo
• Get 15.5 hours of accredited, interdisciplinary online training with PEP online:
https://hypertension.ca/en/professional/pep-online
• Follow us on Twitter @HTNCanada and Like our Facebook page

Information For Patients

Hypertension recommendations designed for the public have been developed and can
be accessed by patients and healthcare professionals at www.hypertension.ca.
Bulk orders of 25 or more copies can be requested at www.hypertension.ca/resources.
Hypertension recommendations for patients with diabetes are also available.
2015 Key Messages
All Canadian adults should have their blood pressure
assessed at all appropriate clinical visits. Electronic
(oscillometric) measurement methods are preferred to
manual measurement.
Out-of-office measurement should be performed to
confirm the initial diagnosis of hypertension.
Health behaviour modification is effective in preventing
hypertension, treating hypertension and reducing
cardiovascular risk.
Combinations of both health behaviour changes and
drugs are generally necessary to achieve target blood
pressures.

Optimum management of the hypertensive patient Advise smokers to quit and offer them specific
requires assessment and communication of overall pharmacotherapy to help them quit.
cardiovascular risk using an analogy like ‘vascular age’.
Focus on adherence.
Home BP monitoring is an important tool in self-
monitoring and self-management. Treat to target.

COHDO8115E

For the complete version of the 2015 CHEP Recommendations please refer to our website at www.hypertension.ca
Published by Hypertension Canada as a professional service with unrestricted support from Servier Canada Inc.

Hypertension Canada Tel : 905-943-9400 www.hypertension.ca

3780 14th Avenue, Suite 211
Markham ON L3R 9Y5
Fax : 905-943-9401
Email : info@hypertension.ca
HCP1030EN
CHEP