1. 2001 Canadian Hypertension Education Program Recommendations 1 Focus on the 2001 Canadian Recommendations for the Management of Hypertension Version: April 25, 2002

2. 2001 Canadian Hypertension Education Program Recommendations 2 Recommendations for the Management and Treatment of Hypertension The Canadian Hypertension Education Program April 25, 2002

3. 2001 Canadian Hypertension Education Program Recommendations 3 2001 Canadian Recommendations for the Management of Hypertension Systematic review of the literature supplemented by personal files to Nov 2001 Application of an evidence-based grading scheme Use of a Central Review Committee comprised of methodologists to improve consistency of grading 1 day conference to discuss recommendations and evidence National presentation Voting with removal of recommendations that >30% disagree with

4. 2001 Canadian Hypertension Education Program Recommendations 4 Office Measurement of BP: C Abbott (Chair), K Mann; Follow-up of BP: P Bolli; Risk Assessment: S Grover Self-measurement of BP: D McKay (Chair), B Ens; Ambulatory BP Monitoring: M Myers, S Rabkin; Routine Laboratory Testing: T Wilson; Echocardiography: G Honos; Lifestyle Modification: E Burgess (Chair), R Petrella, R Touyz; Pharmacotherapy of Uncomplicated Hypertension: R Lewanczuk (Chair); B Culleton, J Wright; sub group Hypertension in the Elderly: G. Fodor, P Hamet, R Herman Pharmacotherapy for Hypertension in patients with Cardiovascular Disease: F Leenen (Chair); S Rabkin, J Stone; Diabetes: J Mahon, P Larochelle, R Ogilvie, C Jones, S Tobe; Renal and Renovascular HTN: M Lebel (Chair), E Burgess, S Tobe; Endocrine forms of hypertension: E Schiffrin Concordance Strategies for Patients: RD Feldman (Chair), J Irvine The Canadian Hypertension Recommendations Working Group: Subgroups for the 2001 recommendations: 2001 Canadian Recommendations for the Management of Hypertension

5. 2001 Canadian Hypertension Education Program Recommendations 5 2001 Canadian Recommendations for the Management of Hypertension Working Group for slides development: Dr. Norm Campbell, Dr. Denis Drouin, Dr. Ross Feldman, Dr. Alain Milot, Dr. Guy Tremblay.

6. 2001 Canadian Hypertension Education Program Recommendations 6 Hypertension as a Risk Factor Hypertension is a significant risk factor for: –cerebrovascular disease –coronary artery disease –congestive heart failure –renal failure –peripheral vascular disease –dementia –atrial fibrillation

7. 2001 Canadian Hypertension Education Program Recommendations 7 Murray et al. 1996 Proportion of Deaths Attributable to Leading Risk Factors World Health Organization Global Burden of Disease Study

8. 2001 Canadian Hypertension Education Program Recommendations 8 Brain Stroke, TIA, hypertensive encephalopathy, etc. Eyes Retinal hemorrhage, exudate, optical disc edema, arteriolar constriction, etc. Blood vessels Aneurysm, arterial occlusive disease, etc. Heart Angina, MI, CHF, LVH, etc. Kidney ESRF, etc. Hypertension and Target Organ Damage

9. 2001 Canadian Hypertension Education Program Recommendations 9 BP and Risk of CAD Mortality Multiple Risk Factor Intervention Trial (MRFIT); n=347,978 men. Neaton et al. Arch Intern Med 1992;152:56-64

10. 2001 Canadian Hypertension Education Program Recommendations 10 BP and Risk of Stroke Mortality Multiple Risk Factor Intervention Trial (MRFIT); n=347,978 men. Neaton et al. In: Laragh et al (eds). Hypertension: Pathophysiology, Diagnosis, and Management.2 ed. NY: Raven, 1995:127

11. 2001 Canadian Hypertension Education Program Recommendations 11 PP=Pulse Pressure. Adapted from : Third National Health and Nutrition. Examination Survey, Hypertension 1995;25:305-13 30-3940-4950-5960-6970-79  80 70 80 110 130 150 Age 30-3940-4950-5960-6970-79  80 70 80 110 130 150 Age MenWomen PP Blood Pressure Distribution in the Population According to Age

12. 2001 Canadian Hypertension Education Program Recommendations 12 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%

13. 2001 Canadian Hypertension Education Program Recommendations 13 Benefits of Treating to Target Older than 60 with isolated systolic hypertension (SBP  160 mm Hg and DBP <90 mm Hg) –36% reduction in the risk of stroke –25% reduction in the risk of coronary events

14. 2001 Canadian Hypertension Education Program Recommendations 14 Joffres et al. Am J Hyper 2001;14:1099 –1105 21% 13% 43% 22% Hypertensive patients who are treated but BP uncontrolled Hypertensive patients who are treated and BP controlled Hypertensive patients who are unaware Patients who are aware but remain untreated and BP uncontrolled 22% of Canadians 18-70 years of age have hypertension 50% of Canadians >65 years of age have hypertension 9% Diabetic patients Who are treated and BP controlled The Challenge In Canada

15. 2001 Canadian Hypertension Education Program Recommendations 15 Results of a survey on awareness on hypertension (Canada) 67% of aware hypertensive patients believe that their BP was their own primary responsibility HOWEVER two thirds of these patients stated that high BP was not a serious concern. Thus the mandate to improve public awareness of the consequences of hypertension is clear. R. Petrella MD, Perspective in Cardiology, March 2002.

16. 2001 Canadian Hypertension Education Program Recommendations 16 A slide kit and clinical practice algorithms supporting the full recommendations can be downloaded from the CHS website at: www.chs.md 2001 Canadian Recommendations for the Management of Hypertension

17. 2001 Canadian Hypertension Education Program Recommendations 17 DIAGNOSIS AND FOLLOW-UP OF HYPERTENSION 2001 Canadian Recommendations for the Management of Hypertension

18. 2001 Canadian Hypertension Education Program Recommendations 18 Classification of Hypertension According to WHO/ISH * CategorySystolicDiastolic Optimal <120<80 Normal <130<85 High-Normal 130-13985-89 Grade 1 (mild hypertension ) 140-15990-99 - Subgroup: borderline 140-14990-94 Grade 2 (moderate hypertension) 160-179100-109 Grade 3 (severe hypertension)  180  110 Isolated Systolic Hypertension (ISH)  140 <90 - Subgroup: borderline 140-149<90 *ISH=International Society of Hypertension. Chalmers J et al. J Hypertens 1999;17:151-85.

19. 2001 Canadian Hypertension Education Program Recommendations 19 Blood Pressure Assessment Patients should be assessed at all appropriate visits –To determine cardiovascular risk –To monitor antihypertensive treatment

20. 2001 Canadian Hypertension Education Program Recommendations 20 Recommended Technique for Measuring Blood Pressure Standardized technique: –Have the patient rest for 5 minutes –Use an appropriate cuff size –Use a mercury manometer or a recently calibrated aneroid or electronic device

21. 2001 Canadian Hypertension Education Program Recommendations 21 Recommended Technique for Measuring Blood Pressure (cont.) –Position cuff appropriately –Support arm with antecubital fossa at heart level –Place stethoscope over the brachial artery

22. 2001 Canadian Hypertension Education Program Recommendations 22 Recommended Technique for Measuring Blood Pressure (cont.) –To exclude possibility of auscultatory gap, increase cuff pressure rapidly to 30 mmHg above level of disappearance of radial pulse –Drop pressure by 2 mmHg / beat: appearance of sound (phase I Korotkoff) = systolic pressure disappearance of sound (phase V Korotkoff) = diastolic pressure –Take 2 blood pressure measurements, 1 minute apart

23. 2001 Canadian Hypertension Education Program Recommendations 23 Diagnosis of Hypertension: Summary Visit 1 Visit 2 Visit 3 Visit 5 Blood pressure measurement every year - Hypertensive urgency? - Target organ damage or BP >180/105? (Visit 3) Hypertension diagnosis confirmed BP >threshold for initiation of treatment Yes No Validated technique and BP measurement device Visit 4 History-taking, physical examination BP 140/90 180/105

24. 2001 Canadian Hypertension Education Program Recommendations 24 Blood Pressure Threshold Values for Initiation of Pharmacological Treatment of Hypertension ConditionInitiation SBP / DBP mmHg Diastolic ± systolic hypertension  140/90 Isolated systolic hypertension  160 Diabetes  130/80 Renal disease  130/80 Proteinuria >1 g/day  125/75

25. 2001 Canadian Hypertension Education Program Recommendations 25 Target Values for Blood Pressure ConditionTarget SBP / DBP mmHg Diastolic ± systolic hypertension Isolated systolic hypertension <140/90 <140 Home BP measurement (No diabetes, renal disease or proteinuria) <135/85 Diabetes <130/80 Renal disease <130/80 Proteinuria >1 g/day <125/75

26. 2001 Canadian Hypertension Education Program Recommendations 26 Threshold for Initiation of Treatment and Target Values ConditionInitiationTarget SBP / DBP mmHg Diastolic ± systolic hypertension >140/90<140/90 Isolated systolic hypertension SBP >160<140 Home BP measurement (no diabetes, renal disease or proteinuria) >135/85<135/85 Diabetes >130/80<130/80 Renal disease >130/80<130/80 Proteinuria >1 g/day >125/75<125/75

27. 2001 Canadian Hypertension Education Program Recommendations 27 Routine and Optional Laboratory Tests 1. Urinalysis 2. Complete blood count 3. Blood chemistry (Potassium, Sodium and creatinine) 4. Fasting glucose 5. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides 6. Standard 12 leads ECG Investigation of all patients with hypertension New recommendations for investigation of endocrine and renal hypertension syndromes

28. 2001 Canadian Hypertension Education Program Recommendations 28 Screening for Renovascular Hypertension Should be considered for patients with the following characteristics: –Patients who are candidates for angioplasty or revascularization and who have Uncontrolled hypertension despite therapy with  3 drugs Or deteriorating renal function Or recurrent episodes of flash pulmonary edema Screening should include a post captopril renogram

29. 2001 Canadian Hypertension Education Program Recommendations 29 Screening for Hyperaldosteronism Spontaneous hypokalemia Profound diuretic-induced hypokalemia (<3.0 mmol/L) Hypertension refractory to treatment with 3 or more drugs Incidental adrenal adenomas. should be considered for patients with the following characteristics:

30. 2001 Canadian Hypertension Education Program Recommendations 30 Screening for Hyperaldosteronism Screening for hyperaldosteronism should include a plasma aldosterone and plasma renin activity measured in morning samples taken from patients in a sitting position after resting at least 15 minutes. Antihypertensive drugs with the exception of aldosterone antagonists may be continued prior to testing.

31. 2001 Canadian Hypertension Education Program Recommendations 31 Screening for Pheochromocytoma Paroxysmal and/or severe sustained hypertension refractory to usual antihypertensive therapy; Hypertension and symptoms suggestive of catacholamine excess (two or more of headaches, palpitations, sweating, etc); Hypertension triggered by beta-blockers, monoamine oxidase inhibitors, micturition, or changes in abdominal pressure; Incidentally discovered adrenal adenoma; Multiple endocrine neoplasia (MEN) 2A or 2B; von Recklinghausen’s neurofibromatosis, or von Hippel-Lindau disease. should be considered for patients with the following characteristics:

32. 2001 Canadian Hypertension Education Program Recommendations 32 Screening for Pheochromocytoma  Screening for pheochromocytoma should include a 24 hour urine for metanephrines and creatinine  Assessment of urinary VMA is inadequate

33. 2001 Canadian Hypertension Education Program Recommendations 33 WHO/ISH Recommendations for Risk Assessment Stratification of risk to quantify prognosis Grade 1Grade 2Grade 3 –Other Risk Factors & Disease History –SBP 140-159 or DBP 90-99 (mild hypertension) –SBP 160-179 or DBP 100-109 (moderate hypertension) –SBP ≥ 180 or DBP ≥ 110 (severe hypertension) I. No other risk factors –Low riskMedium riskHigh risk II. 1-2 risk factors Medium risk V high risk III.  3 risk factors or TOD or diabetes High risk V high risk IV. ACC V high risk Risk strata (typical 10 year risk of stroke, myocardial infarction and cardiovascular mortality) Chalmers J et al. J Hyper 1999;17:151-85.

34. 2001 Canadian Hypertension Education Program Recommendations 34 Hypertension and diabetes Non adherence Which patients? Further assess using ambulatory blood pressure monitoring Normal Home BP? Office-induced blood pressure elevation BP >135/85 mm Hg should be considered elevated Home (Self) Measurement of BP: Specific Role in Selected Patients

35. 2001 Canadian Hypertension Education Program Recommendations 35 Home (Self) Measurement of BP: Patient Education Values over 135 / 85 mm Hg should be considered elevated How to? Adequate patient training in: - measuring their BP - interpreting these readings Regular verifications - accuracy of the device - measuring techniques Use devices: - appropriate for the individual (cuff size) - have met the standards of the AAMI and/or the BHS AAMI=Association for the Advancement of Medical Instrumentation; BHS=British Hypertension Society Self measurement can help to improve patient adherence

36. 2001 Canadian Hypertension Education Program Recommendations 36 Ambulatory BP Monitoring: Specific Role in Selected Patients* Untreated - Mild (Grade 1) to moderate (Grade 2) clinic BP elevation and without target organ damage Treated patients - Apparent resistance to drug therapy - Symptoms suggestive of hypotension - Fluctuating office blood pressure readings Which patients? Those with suspected office-induced BP elevation * When available

37. 2001 Canadian Hypertension Education Program Recommendations 37 Ambulatory BP Monitoring Specific Role in Selected Patients How to interpret? Mean daytime ambulatory blood pressure >135/85 mm Hg is considered elevated Use validated devices * A drop in nocturnal BP of <10% is associated with increased risk of CV events How to ?

38. 2001 Canadian Hypertension Education Program Recommendations 38 The Role of Echocardiography: Specific Role in Selected Patients Presence of Coronary artery disease Routine Evaluation Tracking of the therapeutic regression Assessment of Left ventricular dysfunction Most antihypertensives regress LVH over 6 months treatment period except arterial vasodilators (eg. Hydralazine)

39. 2001 Canadian Hypertension Education Program Recommendations 39 Recommendations for Follow-up Are BP readings below target during 2 consecutive visits*? Non Pharmacological treatment With or without Pharmacological treatment Diagnosis of hypertension Follow-up at 3-6 month intervals Symptoms, Severe hypertension, Intolerance to anti-hypertensive treatment or Target Organ Damage NoYes NoYes More frequent visits Monthly visits

40. 2001 Canadian Hypertension Education Program Recommendations 40 LIFESTYLE MANAGEMENT 2001 Canadian Recommendations for the Management of Hypertension

41. 2001 Canadian Hypertension Education Program Recommendations 41 Healthy diet; High in fresh fruits, vegetables and low fat dairy products, low in saturated fat, and salt in accordance with Canada's Guide to Healthy Eating Regular physical activity: optimum 45-60 minutes of moderate cardiorespiratory activity 4-5/week Reduction in alcohol consumption in those who drink excessively (<2 drinks/ day Weight loss (> 5 Kg) in those who are over weight (BMI>25) Smoke free environment Lifestyle Recommendations for Hypertension

42. 2001 Canadian Hypertension Education Program Recommendations 42 Dietary Potassium Dietary Sodium Magnesium supplementation Calcium supplementation Restrict to target range of 90-130 mmol/day (Limitation of salt additives and foods with excessive added salt) Daily dietary intake >60 mmol Fresh fruits, Vegetables, Low fat dairy products, Low fat diet, in accordance with Canada's Guide to Healthy Eating No conclusive studies for hypertension Lifestyle Recommendations for Hypertension: Dietary

43. 2001 Canadian Hypertension Education Program Recommendations 43 Should be prescribed to reduce blood pressure For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapy Lifestyle Recommendations for Hypertension: Physical Activity Type Dynamic exercise - Walking - Cycling - Non-competitive swimming Time - 45-60 minutes Intensity - Moderate Frequency - Four or five times per week F I T T

44. 2001 Canadian Hypertension Education Program Recommendations 44 Low risk alcohol consumption Women: <9 drinks/week Men: <14 drinks/week 0-2 drinks/day Lifestyle Recommendations for Hypertension: Alcohol

45. 2001 Canadian Hypertension Education Program Recommendations 45 Lifestyle Recommendations for Hypertension: Stress Management Hypertensive patients in whom stress appears to be an important issue - Individualized - Cognitive Stress management Behaviour Modification

46. 2001 Canadian Hypertension Education Program Recommendations 46 Hypertensive and all patients BMI over 25 - Encourage weight reduction - Lose a minimum of 4.5 kg For patients prescribed pharmacological therapy: weight loss has additional antihypertensive effects Lifestyle Recommendations for Hypertension: Weight Loss

47. 2001 Canadian Hypertension Education Program Recommendations 47 Impact of Lifestyle Therapies on BP in Hypertensive Adults InterventionTargeted changeSBP/DBP Sodium reduction100 mmol/day-5.8 / -2.5 Weight loss-4.5 kg-7.2 / -5.9 Alcohol reduction-2.7 drinks/day-4.6 / -2.3 Exercise3 times/week-10.3 / -7.5 Dietary patternsDASH diet-11.4 / -5.5 Potassium increase75 mmol/day-4.4 / -2.5 Result of aggregate and metaanalyses of short term trials. Miller ER et al. J Clin Hyper 1999:Nov/Dec:191-8.

48. 2001 Canadian Hypertension Education Program Recommendations 48 PHARMACOLOGICAL TREATMENT 2001 Canadian Recommendations for the Management of Hypertension

49. 2001 Canadian Hypertension Education Program Recommendations 49 Indications for Pharmacotherapy Strongly consider prescription if: –Sustained DBP >90 mm Hg and: Target-organ damage or CVD OR concomitant diseases such as diabetes mellitus OR other cardiovascular risk factors if no other risk factors, prescribe if: DBP >100 mm Hg and/or SBP >160 mm Hg

50. 2001 Canadian Hypertension Education Program Recommendations 50 Associated risk factors? or Target organ damage/complications? or Concomitant diseases/conditions? Individualized treatment Standardized treatment YES NO Choice of Treatment

51. 2001 Canadian Hypertension Education Program Recommendations 51 Recommendations for Improving Adherence to Antihypertensive Prescription Adherence can be improved by a multi- pronged approach –Simplify medication regimens to once daily dosing –Tailor pill-taking to fit patients’ daily habits –Encourage greater patient responsibility/autonomy in monitoring their BP and adjusting their prescriptions –Coordinate with worksite health care givers to improve monitoring of adherence with pharmacological and lifestyle modification prescriptions –Educate patients and patients’ families about their disease/treatment regimens

52. 2001 Canadian Hypertension Education Program Recommendations 52 Suggestions: Improving Adherence to Antihypertensive Prescription Provide quality information on the consequences of hypertension and the benefits of lifestyle and drug therapy Ask about side effects and record any that occur Tailor pill taking into a usual daily routine (same time/place/situation) Simplify drug and lifestyle regime Ensure regime is affordable Involve family and friends in lifestyle and medication adherence Maintain regular BP follow-up Consider Dosett ® or other adherence aids Consider self measurement of blood pressure Record prescription refill dates on calendar and consider self monitoring pill counts Campbell 2002

53. 2001 Canadian Hypertension Education Program Recommendations 53 ACE-I Beta- blockers Low-dose thiazides Combination Combine adjacent classes Lifestyle modification therapy Long-acting DHP-CCB Alpha-blocker as initial monotherapy Triple or quadruple therapy Treatment Algorithm for Systolic-Diastolic Hypertension TARGET <140/90 mmHg CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect?

54. 2001 Canadian Hypertension Education Program Recommendations 54 Low-dose Thiazide Long-acting DHP CCB CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect? Combination Effective 2-drug combination (Add ACE-I or beta blocker) Alpha-blockers and beta-blockers as initial monotherapy Combination Triple or quadruple therapy Treatment algorithm for Isolated Systolic Hypertension TARGET <140 mmHg Lifestyle modification therapy

55. 2001 Canadian Hypertension Education Program Recommendations 55 ACE-I * Beta- blockers ** Low-dose thiazides Combination Combine adjacent classes Lifestyle modification therapy Long-acting DHP-CCB Alpha-blocker as initial monotherapy *Not recommended for ISH; ** Not recommended for patients >60 years or ISH Triple or quadruple therapy Global Treatment Algorithm for Hypertension TARGET <140/90 mm Hg CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect?

56. 2001 Canadian Hypertension Education Program Recommendations 56 Rationale for Drug Combination Therapy Even higher proportion of hypertensive patients with diabetes require multi-drug therapy Low doses of multiple drugs may be more effective and better tolerated than higher doses of fewer drugs Many patients require multiple drugs to achieve BP targets 3 Drugs 2 Drugs 1 Drug 50%

57. 2001 Canadian Hypertension Education Program Recommendations 57 Useful Combinations Column 1Column 2 Low dose thiazide diuretics Long-acting dihydropyridine calcium channel blocker Beta-blocker ACE Inhibitor For additive hypotensive effect in dual therapy combine an agent from Column 1 with any in Column 2

58. 2001 Canadian Hypertension Education Program Recommendations 58 Dyslipidemia Treatment of uncomplicated hypertension, hypertension associated with other conditions or concomitant risk factors. Treatment of Hypertension With Associated Risk Factors

59. 2001 Canadian Hypertension Education Program Recommendations 59 SmokingBeta-blocker The benefits of treating smokers with beta-blockers remain uncertain in the absence of a specific indication like angina or post-MI Treatment of Hypertension With Associated Risk Factors

60. 2001 Canadian Hypertension Education Program Recommendations 60 Diabetes with Nephropathy without Nephropathy 1. ACE Inhibitor 2. ARB ACE-Inhibitor Long-acting dihydropyridine CCB Low-dose thiazide More than 3 drugs may be needed to reach target values for diabetic patients Alpha-blockers COMBINATION Cardioselective BB Long-acting CCB Low-dose thiazide diuretic Treatment of Hypertension with Diabetes TARGET <130/80 mmHg Combination Effective 2-drug combination Isolated Systolic Hypertension

61. 2001 Canadian Hypertension Education Program Recommendations 61 Ischemic cardiopathy Stable angina Prior myocardial infarction Normal systolic left ventricular function 1. Beta-blocker 2. Long-acting CCB Combination Beta-blocker and long-acting Dihydropyridine CCB ACE-I, Beta-blocker or both Verapamil or Diltiazem Alternate Short-acting nifedipine Treatment of Hypertension with Ischemic Heart Disease ACE-I should be strongly considered in all patients with CAD

62. 2001 Canadian Hypertension Education Program Recommendations 62 ACE-I/ARB (use with caution) Peripheral vascular disease Atherosclerotic PVD Renal artery stenosis Raynaud’s syndrome Treatment of uncomplicated hypertension, hypertension associated with other conditions or concomitant risk factors. Beta-blocker Vasodilators: Alpha-blockers, CCB, ACE-I, ARB May aggravate symptoms May induce renal insufficiency May have beneficial effects severe mild Beta-blocker ± ACE-I ? Treatment of Hypertension with Peripheral Vascular Diseases

63. 2001 Canadian Hypertension Education Program Recommendations 63 Physicians who are not yet experienced in the use of beta-blockers should consider initiation of treatment in conjunction with a physician experienced in heart failure management- particularly for NYHA Class III-IV patients * Diuretics: - Thiazides - Loop diuretics Systolic cardiac dysfunction ACE-I + Additional therapy, if abnormal water retention: Diuretic* If ACE-I are contraindicated or not tolerated: Hydralazine and Isosorbide dinitrate in combination Or ARB Add Bisoprolol, Carvedilol, Metoprolol Additional therapy Amlodipine or Felodipine NYHA class II - IV Non dihydropyridine CCB or nifedipine Add Spironolactone Treatment of Hypertension with Systolic Dysfunction NYHA class III - IV

64. 2001 Canadian Hypertension Education Program Recommendations 64 Arrhythmia and conduction problems Atrial fibrillation and supraventricular tachycardia Sinoatrial node dysfunction and atrioventricular conduction problems Beta-blocker Verapamil Diltiazem Beta-blocker Verapamil Diltiazem Clonidine Methyldopa May inhibit ventricular response * Caution is recommended when diuretics are used with class 1A, 1C or III antiarrythmic drugs Caution if systolic dysfunction is present Treatment of Hypertension with Arrhythmia*

65. 2001 Canadian Hypertension Education Program Recommendations 65 Left ventricular hypertrophy Vasodilators: Hydralazine, Minoxidil Most antihypertensives Can Increase LVH Most antihypertensives regress LVH over 6 months treatment period except arterial vasodilators (eg. hydralazine) Can reduce LVH over a 6 months treatment period Treatment of Hypertension with Left Ventricular Hypertrophy

66. 2001 Canadian Hypertension Education Program Recommendations 66 ACE-I Additive therapy: Diuretic Renal disease Combination with other agents Nondiabetic: < 130/80 Proteinuria > 1 g/day: < 125/ 85 Target BP ACE-I: Bilateral renal artery stenosis Treatment of Hypertension with Nondiabetic Renal Disease

67. 2001 Canadian Hypertension Education Program Recommendations 67 Treatment of Hypertension After the Acute Phase of Nondisabling Stroke or TIA Stroke, TIA Strongly consider blood pressure reduction after the acute phase An ACE-I should be strongly considered in all patients with stroke and TIA

68. 2001 Canadian Hypertension Education Program Recommendations 68 Summary I Regarding the treatment of hypertension, the recommendations endorse: –Individualizing therapy consider concomitant risk factors and/or concurrent diseases (i.e., diabetes, CVD, renal disease) –Treating to target BP treat aggressively to achieve individualized targets –Using nonpharmacological strategies lifestyle modifications

69. 2001 Canadian Hypertension Education Program Recommendations 69 Summary II Regarding the treatment of hypertension, the recommendations endorse: –Using combination therapy addition of medications in combination to achieve BP targets is preferred to maximal dose titration or serially switching drugs –Promoting adherence a multi-pronged approach should be used to improve adherence with both non pharmacological and pharmacological strategies

70. 2001 Canadian Hypertension Education Program Recommendations 70 Summary III Regarding the treatment of hypertension, the recommendations endorse:  Hypertension is a major factor responsible for progression of atherosclerotic disease.  Therefore, a comprehensive treatment of hypertension should include all associated risk factors.