1. Hypertension Dr. J. Antony Gagnon, Pharm.D., CDE, CAE Part I
Pharmacy Program Coordinator
Hamilton Family Health Team

2. Hypertension is a Major Risk Factor
Untreated individuals with high blood pressure have an increased risk of:
Stroke (four times greater risk of hemorrhagic stroke)
Atherosclerotic cardiovascular events
Congestive heart failure
Renal failure
Peripheral vascular disease
Dementia
Effective treatment has been shown to reduce the risk of recurrent stroke and to reduce cognitive decline in patients with dementia
Woo D, Haverbusch M, Sekar P, Kissela B, Khoury J, Schneider A, Kleindorfer D, Szaflarski J, Pancioli A, Jauch E, Moomaw C, Sauerbeck L, Gebel J, Broderick J. Effect of untreated hypertension on hemorrhagic stroke. Stroke 2004;35:

3. 2006 Canadian Hypertension Education Program Recommendations
Scope of the problem
More than 90% of Canadians are estimated to develop hypertension during adulthood
Approximately one half of adult Canadians are hypertensive by age 60.
Even normotensive 55 or 65 year olds have a 90% chance of developing hypertension over the next 20 years
2006 Canadian Hypertension Education Program Recommendations

4. Awareness, Treatment and Control
~ 2.4 million Ontarians have BP >140/90mmHg (22%)
HTN treated but uncontrolled
Aware but untreated
& BP uncontrolled
21%
22%
13%
43%
Chart from CHEP 2004 Recommendations p.16 in slide package. It comes from Joffres MR et al. Distribution of blood pressure and hypertension in Canada and the United States. Am J Hyper 2001;14: This pie chart shows the results of the Canadian Heart Health Survey regarding hypertension awareness, treatment and control. While one study can highlight concerns for discussion and further study, there is a need for further evidence (in particular Canadian) to validate this pattern and understand if lack of awareness is truly an issue.
The Canadian Heart Health Survey is due to be repeated in 2006.
“2.4 million figure comes from Towards an Integrated Stroke Strategy, Report of the Joint Working Group, June 2000.
Speakers please note: Of the 13% of patients who are treated and BP controlled, 9% are diabetic patients who are treated and BP controlled.
Hypertensive
and unaware
HTN Treated & BP controlled
Source: Joffres et al. Am J Hyper 2001;14:

5. Impact of High-Normal BP on Risk of Cardiovascular Disease
Cumulative incidence of CV events in women without hypertension according to baseline blood pressure
SBP
DBP 85-89
SBP
SBP <120 mmHg
Data from the Framingham Heart Study’s long-term follow-up indicate that the lifetime risk of developing hypertension is about 90%. The data are from a community-based prospective cohort study of 1,298 participants from the Framingham Heart Study who were between 55 and 65 years old and free of hypertension at baseline ( ). The residual life-time risk for developing hypertension was estimated for participants who reached the age of 65 free of hypertension.
A study investigating association between BP category and CVD risk in the Framingham Heart Study concluded that those with BP <120 had fewer vascular events than those with blood pressure in the range of High normal BP (SBP DBP 85-89) was associated with an increased risk of CVD.
Vasan, RS et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. NEJM 2001;345:
The JNC 7 Report identified a new category—pre-hypertension—to address the future risk of cardiovascular disease associated with blood pressures previous classified as high normal. The JNC 7 Report stresses the importance of recommending lifestyle modification for individuals with systolic BP mmHg or diastolic mmHg and classifies this as pre-hypertension
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, JAMA 2003;289:
Source: Vasan, RS et al. NEJM 2001;345:

6. Cardiovascular Risk Factors
Assessment of the overall cardiovascular risk
Cardiovascular Risk Factors
Presence of Risk Factors
Increasing age (Men > 55, Women > 65)
Male gender
Smoking
Family history of premature cardiovascular disease
(age< 55 in men and < 65 in women)
Dyslipidemia (TC > 6.5 or LDL > 4
HDL Men < 1.0 and Women < 1.3)
Sedentary lifestyle
Abdominal obesity
Presence of Diabetes
Presence of Target Organ Damage
Microalbuminuria or proteinuria
Left ventricular hypertrophy
Chronic kidney disease (glomerular filtration rate < 60 ml/min/1.73 m2)
Presence of atherosclerotic vascular disease
Previous stroke or TIA
CHD
Peripheral arterial disease
CV Risk Factors that may alter thresholds and targets in the treatment of HTN
2006 Canadian Hypertension Education Program Recommendations

7. Assessment of the overall cardiovascular risk
Search for exogenous potentially modifiable factors that can induce/aggravate hypertension
Presription Drugs:
NSAIDs, including Coxibs
Corticosteroids and anabolic steroids
Oral contraceptive and sex hormones
Vasoconstricting/sympathomimetic decongestants
Calcineurin inhibitors (cyclosporin, tacrolimus)
Erythropoietin and analogues
Monoamine oxidase inhibitors (MAOIs)
Midodrine
Other:
Licorice root
Stimulants including cocaine
Salt
Excessive alcohol use
Sleep apnea
2006 Canadian Hypertension Education Program Recommendations

8. Assessment of the overall cardiovascular risk
Assessing global risk: the interaction between blood pressure and risk factors
Blood pressure (mmHg)
Other risk factors and disease history
Normal
SBP or DBP 80-84
High normal
SBP or DBP 85-89
Grade 1
SBP or DBP 90-99
Grade 2
SBP or DBP
Grade 3
SBP ≥180 or DBP ≥110
I. No other risk factors
Average risk
Low added risk
Moderate added risk
High added risk
II. 1-2 risk factors
Very high added risk
III. ≥3 risk factors or target organ damage or diabetes
IV. Associated clinical conditions
Adapted from WHO/ISH Recommendations on Hypertension. Journal of Hypertension 2003, Vol 21 No 6
2006 Canadian Hypertension Education Program Recommendations

9. 2006 Canadian Hypertension Education Program Recommendations
Criteria for the diagnosis of hypertension and recommendations for follow-up
2006 Canadian Hypertension Education Program Recommendations

10. Blood pressure target values for treatment of hypertension
Goals of Therapy
Blood pressure target values for treatment of hypertension
Condition
Target
SBP / DBP mmHg
Isolated systolic hypertension
<140
Systolic/Diastolic Hypertension
• Systolic BP
• Diastolic BP
<90
Diabetes and Chronic Kidney disease
• Systolic
• Diastolic
<130
<80
Proteinuria
<125
<75
2006 Canadian Hypertension Education Program Recommendations

11. 2006 Canadian Hypertension Education Program Recommendations
Clinic, Home/Self, Ambulatory (ABP) Blood Pressure Measurement equivalence numbers
A clinic blood pressure of 140/90 mmHg
has the equivalent risk of a:
Description
Blood Pressure mmHg
Home/Self pressure average
135 / 85
Daytime average ABP
24-hour average ABP
130 / 80
2006 Canadian Hypertension Education Program Recommendations

12. 2006 Canadian Hypertension Education Program Recommendations
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.
2006 Canadian Hypertension Education Program Recommendations

13. Treatment of hypertension
Reducing hypertension-related complications in the “general” population of patients with hypertension depends more on the extent of blood pressure lowering achieved than on the choice of any specific “first-line” drug class
Treat to target
The treatment of hypertension is all about global atherosclerotic risk reduction
Monotherapy is not (usually) enough
Lifestyle modifications are the cornerstone of both antihypertensive and anti-atherosclerotic therapy
2006 Canadian Hypertension Education Program Recommendations

14. Lifestyle Therapies in Hypertensive Adults
Intervention
Target
Exercise
30-60 minutes at least 4x/week
Sodium reduction
mMol/day
Diet
DASH diet
Weight loss
Waist circumference
BMI <25 kg/m2
Men 102 cm (40 in) & women  88 cm (35 in)
Alcohol reduction
<2 drinks/day
Smoking
Smoke free environment .
Source: Adapted from CHEP 2005 Recommendations
2006 Canadian Hypertension Education Program Recommendations

15. Lifestyle Recommendations for Hypertension Dietary
Dietary Sodium
Restrict to target range of mmol/day
(Most of the salt in food is hidden and comes from processed food)
Dietary Potassium
If required, daily dietary intake >80 mmol
Calcium supplementation
No conclusive studies for hypertension
Magnesium supplementation
• Fresh Fruits
• Vegetables
• Low Fat dairy products
• Low saturated fat diet in accordance with the DASH diet
2006 Canadian Hypertension Education Program Recommendations

16. Impact of Lifestyle Therapies on BP in Hypertensive Adults
Intervention
Targeted Change
SBP/DBP
Sodium reduction
100 mMol or 1 tsp/day
5.8/-2.5
Weight loss
 4.5 kg
 7.2/-5.9
Alcohol reduction
 2.7 drinks/day
 4.6/-2.3
Exercise*
3 times/week
 -7.4/-5.8
Dietary Patterns
DASH diet
 11.4/-5.5
Note: the extent of blood pressure change from each intervention should not be compared because the participants, the type and duration of the intervention, and the basic design of the trials differed substantially.
Miller ER et al. Results of aggregate and meta analysis of short term trials.
J Clin Hyper 1999;3:191-8.
Pescatello, LS, Franklin, B A, Fagard, R, Farquhar, W B. Kelley, G A., Ray, CA. Exercise and hypertension. Medicine and Science in Sports & Exercise 2004;36(3).
Source: Miller ER et al. Results of aggregate and meta analysis of short term trials.
J Clin Hyper 1999;3:191-8.
* Exercise and Hypertension, Medicine and Science in Sports & Exercise 2004;36(3).
2006 Canadian Hypertension Education Program Recommendations

17. Indications for Pharmacotherapy
Usual blood pressure threshold values for initiation of pharmacological treatment of hypertension
Condition
Initiation
SBP / DBP mmHg
• Systolic/Diastolic hypertension
140/90
• Diabetes
• Chronic Kidney Disease
130/80
2006 Canadian Hypertension Education Program Recommendations

18. Indications for Pharmacotherapy
In low risk patients with stage 1 hypertension ( /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.
Patients with target organ damage (e.g. proteinuria) are recommended to be treated with pharmacotherapy if blood pressure is equal to or above 140/90
Patients with known atherosclerotic disease (e.g. past stroke) are recommended to be treated with pharmacotherapy even if the blood pressure is normal (see compelling indications)
Patients with diabetes or chronic kidney disease should be considered for pharmacotherapy if the blood pressure is equal or over 130/80 mmHg
2006 Canadian Hypertension Education Program Recommendations

19. Choice of Pharmacological Treatment: Uncomplicated
Associated risk factors? or
Target organ damage/complications?
Concomitant diseases/conditions?
Treatment in the
absence of specific
indication NO
Individualized
Treatment
(and compelling indications)
YES
2006 Canadian Hypertension Education Program Recommendations

20. Lifestyle modification Triple or Quadruple Therapy
Treatment of Diastolic-Systolic Hypertension without Other Compelling Indications For Specific Agents
TARGET <140/90 mmHg
Lifestyle modification
therapy
Thiazide
diuretic
ACE-I
ARB
Long-acting
CCB
Beta- blocker*
* Not indicated as first line therapy over 60
CONSIDER
Nonadherence?
Secondary HTN?
Interfering drugs or lifestyle?
White coat effect?
Dual Combination
Triple or Quadruple Therapy
2006 Canadian Hypertension Education Program Recommendations

21. Considerations Regarding the Choice of First-Line Therapy
Beta adrenergic blockers are not recommended for patients age 60+ without another compelling indication
Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agent
ACE-I are not recommended (as monotherapy) for black patients without another compelling indication
2006 Canadian Hypertension Education Program Recommendations

22. Going Beyond First- Line Therapy
2006 Canadian Hypertension Education Program Recommendations

23. Useful Dual Combinations
For additive hypotensive effect in add-on therapy Combine an agent from Column 1 with any in Column 2
Column 1
Column 2
• Thiazide diuretic
• Long-acting calcium channel blocker *
• Beta adrenergic blocker
• ACE Inhibitor
• ARB
Dual combination of agents within column 1 and within column 2 have less than additive hypotensive effect but may be indicated in specific settings (e.g. column 2 drugs in patients following myocardial infarction)
* Caution should be exercised when using a non DHP-CCB and a beta-blocker
2006 Canadian Hypertension Education Program Recommendations

24. Lifestyle modification
Treatment of Isolated Systolic Hypertension without Other Compelling Indications For Specific Agents
TARGET <140 mmHg
Lifestyle modification
therapy
Thiazide diuretic
ARB
Long-acting
DHP CCB
CONSIDER
Nonadherence?
Secondary HTN?
Interfering drugs or lifestyle?
White coat effect?
Dual 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 blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).
Triple therapy
2006 Canadian Hypertension Education Program Recommendations

25. 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
2006 Canadian Hypertension Education Program Recommendations

26. 2006 Canadian Hypertension Education Program Recommendations
Pharmacological Treatment of Hypertension with Compelling Indications For Specific Agents
2006 Canadian Hypertension Education Program Recommendations

27. 2006 Canadian Hypertension Education Program Recommendations
Pharmacological Treatment of Hypertension with Compelling Indications For Specific Agents
2006 Canadian Hypertension Education Program Recommendations

28. Global Vascular Protection for Hypertensive Patients: Statins
Statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria:
• Male
• age 55 or older
• Smoking
• Type 2 Diabetes
• Total-C/HDL-C ratio of 6 mMol/L or higher
• Family History of Premature CV disease
• Previous Stroke or TIA
• LVH
• ECG abnormalities
• Microalbuminuria or Proteinuria
• Peripheral Vascular Disease
ASCOT-LLA Lancet 2003;361:
2006 Canadian Hypertension Education Program Recommendations

29. Global Vascular Protection for Hypertensive Patients: ASA
Consider low dose ASA
Caution should be exercised if BP is not controlled.
2006 Canadian Hypertension Education Program Recommendations

30. Global Vascular Protection for Hypertensive Patients: ACE inhibitors
ACE-inhibitors are recommended for all patients with established atherosclerotic disease (e.g., stroke, TIA, coronary artery disease or PAD) even if another antihypertensive agent already controls BP
2006 Canadian Hypertension Education Program Recommendations

31. 2006 Canadian Hypertension Education Program Recommendations
Summary I
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
alone if effective to reach the goal value or in combination with pharmacological treatment
2006 Canadian Hypertension Education Program Recommendations

32. 2006 Canadian Hypertension Education Program Recommendations
Summary II
PROMOTING ADHERENCE
a multi-faceted approach should be used to improve adherence with both non pharmacological and pharmacological strategies
TREATING TO TARGET BP
treat aggressively using combinations of drugs and lifestyle modification to achieve individualized targets
2006 Canadian Hypertension Education Program Recommendations

33. Key CHEP messages for the management of hypertension
Assess global cardiovascular risk in all hypertensive patients
Lifestyle modifications are the cornerstone of both antihypertensive and antiatherosclerotic therapy
Treat to target (<140/90 mmHg; <130/80 mmHg in patients with diabetes or chronic kidney disease)
Combinations of drugs are usually required to achieve blood pressure targets
Focus on patient adherence to lifestyle modifications and antihypertensive therapy
2006 Canadian Hypertension Education Program Recommendations

34. 2006 Canadian Hypertension Education Program Recommendations