1. 2007 Part 1: Recommendations for Hypertension Diagnosis Assessment and Follow up January, 2007

2. 2 2007 Canadian Hypertension Education Program Recommendations The Canadian Hypertension Education Program (CHEP) is jointly sponsored by the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the Heart and Stroke Foundation of Canada, the Canadian Council of Cardiovascular Nurses, the Canadian Pharmacists Association, the College of Family Physicians of Canada

3. 2007 Canadian Hypertension Education Program Recommendations 3 A red flag has been posted where recommendations were updated for 2007. This slide kit for medical education, health care professional, patient and public information can be downloaded (English and French versions) from the Canadian Hypertension Society website at: http://www.hypertension.ca The 2007 Canadian Hypertension Education Program

4. 4 2007 Canadian Hypertension Education Program Recommendations The 2007 Canadian Hypertension Education Program What's New for 2007 Approximately 95% of Canadians will develop hypertension if they live an average lifespan Most overweight patients with high normal blood pressure (130-139/85-89 mmHg) develop within 4 years and almost 1/2 within 2 years. Annual follow-up of patients with high normal blood pressure is recommended.

5. 5 2007 Canadian Hypertension Education Program Recommendations What percent of Canadians have hypertension? CCHS CMAJ 1992

6. 6 2007 Canadian Hypertension Education Program Recommendations Life time risk of Hypertension in Normotensive Women and Men aged 65 years Risk of Hypertension % 0 2 4681012 14161820 Years to Follow-up Women Risk of Hypertension % Years to Follow-up 0 2 4681012 14161820 Men JAMA 2002: Framingham data. 100 80 60 40 20 0 100 80 60 40 20 0

7. 7 2007 Canadian Hypertension Education Program Recommendations High risk of developing hypertension in those with high normal blood pressure 40% of patients with systolic 130-139 or diastolic 85-89 mmHg developed hypertension in 2 years and 63% in 4 years NEJM 2006;354:1685-97 Annual follow-up of patients with high normal blood pressure is recommended.

8. 8 2007 Canadian Hypertension Education Program Recommendations Reversible risks for developing hypertension Obesity Poor dietary habits High sodium intake Sedentary High alcohol consumption High stress High normal blood pressure

9. 2007 The Canadian Hypertension Education Program: 2007 Recommendations What’s old but still important?

10. 2007 Canadian Hypertension Education Program Recommendations 10 Assess blood pressure at all appropriate visits. Almost one half of those with blood pressure 130-139/85-89 will develop hypertension within 2 years. They require annual reassessment. Assess global cardiovascular risk in all hypertensive patients. Lifestyle modification is the cornerstone for the prevention and management of hypertension and CVD. Key CHEP messages for the management of hypertension

11. 2007 Canadian Hypertension Education Program Recommendations 11 Key CHEP messages for the management of hypertension Treat to target (<140/90 mmHg; <130/80 mmHg in patients with diabetes or chronic kidney disease). To achieve targets sustained lifestyle modification and more than one drug is usually required. Follow patients with uncontrolled blood pressure at least monthly until blood pressure targets are achieved. Strategies to improve patient adherence to lifestyle modifications and antihypertensive therapy need to be incorporated in every patients management

12. 12 2007 Canadian Hypertension Education Program Recommendations The 2007 Canadian Hypertension Education Program Table of contents HYPERTENSION DIAGNOSIS, ASSESSMENT AND FOLLOW-UP I.Assess blood pressure at all appropriate visits II.Criteria for the diagnosis of hypertension and recommendations follow-up III.Assessment of overall cardiovascular risk in hypertensive patients IV.Routine and optional laboratory tests for the investigation of patients with hypertension V.Assessment of renovascular hypertension VI.Endocrine hypertension VII.Home measurement of blood pressure VIII.Ambulatory blood pressure measurement IX.Role of Echocardiography

13. 13 2007 Canadian Hypertension Education Program Recommendations I. Assess blood pressure at all appropriate visits 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 60% of those who are overweight and have high normal blood pressure will develop hypertension in 4 years

14. 14 2007 Canadian Hypertension Education Program Recommendations I. Assess blood pressure at all appropriate visits Blood pressure of all adults should be measured whenever it is appropriate by trained healthcare professionals using standardized techniques. To screen for hypertension To assess cardiovascular risk To monitor antihypertensive treatment

15. 15 2007 Canadian Hypertension Education Program Recommendations I. Assess blood pressure at all appropriate visits Assess blood pressure annually in those with high normal blood pressure.

16. 16 2007 Canadian Hypertension Education Program Recommendations Incidence of hypertension in those identified with borderline hypertension 772 subjects, mean age 48.5 Not receiving tx for HTN Avg of 3 BPs at baseline: SBP 130-139 and DBP < 89 OR SBP < 139 and DBP 85-89 Primary endpoint – new onset HTN NEJM 2006;354:1685-97

17. 17 2007 Canadian Hypertension Education Program Recommendations Kaplan-Meier Plot of New Onset HTN NEJM 2006;354:1685-97

18. 18 2007 Canadian Hypertension Education Program Recommendations Other evidence from the Framingham cohort Outcome: progression to HTN: –BP > 140/90 or –treatment for HTN Vasan. Lancet 2001

19. 19 2007 Canadian Hypertension Education Program Recommendations Incidence rates of hypertension at 1, 2 and 3 yrs Optimum < 120/80 Normal 120-129/80-84 High normal 130-139/85-89 Vasan. Lancet 2001

20. 20 2007 Canadian Hypertension Education Program Recommendations Impact of high-normal BP on risk of cardiovascular disease. Framingham cohort (n=6859) High normal BP at baseline 10-year cumulative incidence of CVD (CV death, MI, stroke, CHF) 35-64 years65-90 years Men 8% (6% - 10%)25% (17% - 34%) Women 4% (2% - 5%)18% (12% - 23%) NEJM 2001;345:1291-7

21. 21 2007 Canadian Hypertension Education Program Recommendations II. Criteria for the diagnosis of hypertension and recommendations for follow-up BP: 140-179 / 90-109 ABPM (If available) Clinic BPM Home BPM (If available) Yes Hypertension Visit 2 Target Organ Damage or Diabetes or Chronic Kidney Disease or BP > 180/110? Hypertension Visit 2 Target Organ Damage or Diabetes or Chronic Kidney Disease or BP > 180/110? Hypertension Visit 1 BP Measurement, History and Physical examination Hypertension Visit 1 BP Measurement, History and Physical examination Hypertensive Urgency / Emergency Hypertensive Urgency / Emergency Diagnosis of HTN Diagnosis of HTN No

22. 22 2007 Canadian Hypertension Education Program Recommendations II. Criteria for the diagnosis of hypertension and recommendations for follow-up Hypertension Visit 1 BP Measurement, History and Physical examination Hypertension Visit 1 BP Measurement, History and Physical examination Hypertension Visit 2 within 1 month Yes BP >140/90 mmHg and Target organ damage or Diabetes or Chronic Kidney Disease or BP >180/110? Diagnostic tests ordering at visit 1 or 2 Diagnostic tests ordering at visit 1 or 2 Hypertensive Urgency / Emergency Hypertensive Urgency / Emergency Diagnosis of HTN Diagnosis of HTN BP: 140-179 / 90-109mmHg No Elevated Out of the Office BP measurement Elevated Random Office BP Measurement

23. 23 2007 Canadian Hypertension Education Program Recommendations II. Criteria for the diagnosis of hypertension and recommendations for follow-up BP: 140-179 / 90-109 24-h ABPM (If available) Diagnosis of HTN Awake BP >135 SBP or > 85 DBP or 24-hour > 130 SBP or > 80 DBP Awake BP >135 SBP or > 85 DBP or 24-hour > 130 SBP or > 80 DBP Awake BP <135/85 and 24-hour <130/80 Awake BP <135/85 and 24-hour <130/80 Continue to follow-up Clinic BP Diagnosis of HTN Hypertension visit 3 > 160 SBP or > 100 DBP > 140 SBP or > 90 DBP < 140 / 90 Diagnosis of HTN Continue to follow-up <160 / 100 Hypertension visit 4-5 ABPM or S/H BPM if available or Home BPM (If available) > 135/85 < 135/85 Diagnosis of HTN Continue to follow- up or Patients with high normal blood pressure (clinic SBP 130-139 and/or DBP 85-89) should be followed annually.

24. 24 2007 Canadian Hypertension Education Program Recommendations The concept of masked hypertension From Pickering, Hypertension 1992 Office SBP mmHg Ambulatory SBP mmHg True hypertensive True Normotensive White Coat HTN Masked HTN White Coat HTN True Normotensive Masked HTN True hypertensive 200 180 160 140 120 100 120140160180200 135

25. 25 2007 Canadian Hypertension Education Program Recommendations The prognosis of masked hypertension Prevalence is approximately 10% in hypertensive patients. 0 5 10 15 20 25 30 35 Normal 23/685 White coat 24/656 Uncontrolled 41/462 Masked 236/3125 Bobrie et al. JAMA 2004;291:1342-9 CV events per 1000 patient- year CV Events

26. 26 2007 Canadian Hypertension Education Program Recommendations Symptoms, Severe hypertension, Intolerance to anti-hypertensive treatment or Target Organ Damage II. Criteria for the diagnosis of hypertension and 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 * NoYes More frequent visits * Visits every 1 to 2 months* * Consider Home measurement in hypertension management, to rule out masked hypertension or white coat effect and to enhance adherence. No

27. 27 2007 Canadian Hypertension Education Program Recommendations Search for target organ damage Cerebrovascular disease - transient ischemic attacks - ischemic or hemorrhagic stroke - vascular dementia Hypertensive retinopathy Left ventricular dysfunction Coronary artery disease - myocardial infarction - angina pectoris - congestive heart failure Chronic kidney disease - hypertensive nephropathy (GFR < 60 ml/min/1.73 m 2 ) - albuminuria Peripheral artery disease - intermittent claudication III. Assessment of the overall cardiovascular risk

28. 28 2007 Canadian Hypertension Education Program Recommendations 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 III. Assessment of the overall cardiovascular risk

29. 29 2007 Canadian Hypertension Education Program Recommendations Treat Hypertension in the Context of Overall Cardiovascular Risk 1. Global cardiovascular risk should be assessed. In hypertensive patients consider using calculations that include cerebrovascular events 2. In the absence of Canadian data to determine the accuracy of risk calculations, avoid using absolute levels of risk to support treatment decisions at specific risk thresholds. Simply counting risk factors may be misleading III. Assessment of the overall cardiovascular risk

30. 30 2007 Canadian Hypertension Education Program Recommendations Cardiovascular Risk Factors Presence of Risk Factors - Increasing age -Male gender -Smoking -Family history of premature cardiovascular disease (age< 55 in men and < 65 in women) -Dyslipidemia -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 m 2 ) 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 III. Assessment of the overall cardiovascular risk

31. 31 2007 Canadian Hypertension Education Program Recommendations Systematic Coronary Risk Evaluation 10-Year Risk of Fatal CVD in High-Risk Regions like Canada Adapted from De Backer et al. Eur Heart J. 2003;24:1601-1610. SC  RE 10-year risk of fatal CVD in populations at high CVD risk Calibrated according to the 2002 Canadian mortality data 15% and over 10%–14% 5%–9% 3%–4% 2% 1% <1% (Total Cholesterol / HDL-Cholesterol) Ratio Systolic blood pressure (mmHg) WomenMen Canada

32. 32 2007 Canadian Hypertension Education Program Recommendations IV. Routine Laboratory Tests 1. Urinalysis 2. Blood chemistry (potassium, sodium and creatinine) 3. Fasting glucose 4. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides 5. Standard 12-leads ECG Investigation of all patients with hypertension During the maintenance phase of hypertension management, tests (including electrolytes, creatinine, glucose, and fasting lipids) should be repeated with a frequency reflecting the clinical situation. Deleted routine CBC as a recommendation

33. 33 2007 Canadian Hypertension Education Program Recommendations IV. Optional Laboratory Tests Investigation for specific patient subgroups For those with diabetes or chronic kidney disease: assess urinary albumin excretion, since therapeutic recommendations differ if proteinuria is present. For those suspected of having an endocrine cause for the high blood pressure, or renovascular hypertension, see following slides. Other secondary forms of hypertension require specific testing. albumin:creatinine ratio [ACR] > 30 mg/mmol is abnormal

34. 34 2007 Canadian Hypertension Education Program Recommendations V. Screening for Renovascular Hypertension Patients presenting with two or more of the following clinical clues listed below suggesting renovascular hypertension should be investigated. i)sudden onset or worsening of hypertension and > age 55 or < age 30 ii)the presence of an abdominal bruit iii)hypertension resistant to 3 or more drugs iv)a rise in creatinine of 30% or more associated with use of an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker v)other atherosclerotic vascular disease, particularly in patients who smoke or have dyslipidemia vi)recurrent pulmonary edema associated with hypertensive surges

35. 35 2007 Canadian Hypertension Education Program Recommendations V. Screening for Renovascular Hypertension The following tests are recommended, when available, to aid in the usual screening for renal vascular disease: captopril-enhanced radioisotope renal scan* Doppler sonography magnetic resonance angiography CT-angiography (for those with normal renal function * captopril-enhanced radioisotope renal scan is not recommended for those with glomerular filtration rates <60 mL/min)

36. 36 2007 Canadian Hypertension Education Program Recommendations VI. Screening for Hyperaldosteronism Spontaneous hypokalemia (<3.5 mmol/L). 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:

37. 37 2007 Canadian Hypertension Education Program Recommendations VI. Screening for hyperaldosteronism Screening for hyperaldosteronism should include plasma aldosterone and plasma renin activity (or renin concentration) - measured in morning samples. - taken from patients in a sitting position after resting at least 15 minutes. Aldosterone antagonists, ARBs, beta-blockers and clonidine should be discontinued prior to testing. A positive screening test should lead to referral or further testing.

38. 38 2007 Canadian Hypertension Education Program Recommendations VI.Renin, Aldosterone and Ratio Conversion factors A. To estimate: B. From: Multiply (B) by: Renin Concentration (ng/mL) Plasma Renin Activity (ng/mL/hr) 0.206 Plasma Renin Activity (g/L/sec) Plasma Renin Activity (ng/mL/hr) 0.278 Aldosterone concentration (pmol/L) Aldosterone concentration (ng/dL) 28

39. 39 2007 Canadian Hypertension Education Program Recommendations VI. Screening for Pheochromocytoma Paroxysmal and/or severe sustained hypertension refractory to usual antihypertensive therapy; Hypertension and symptoms suggestive of catecholamine 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 mass; 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:

40. 40 2007 Canadian Hypertension Education Program Recommendations VI. Screening for Pheochromocytoma Screening for pheochromocytoma should include a 24 hour urine for metanephrines and creatinine. Assessment of urinary VMA is inadequate. A normal plasma metanephrine level can be used to exclude pheochromocytoma in low risk patients but the test is performed by few laboratories.

41. 41 2007 Canadian Hypertension Education Program Recommendations VII. Home measurement of blood pressure Uncomplicated hypertension Diabetes mellitus Chronic kidney disease Suspected nonadherence Hypertension and diabetes Office-induced blood pressure elevation (white coat effect) Masked hypertension Which patients? Further assess using 24-h ambulatory blood pressure monitoring If office BP measurement is elevated and Home BP is normal Daytime average BP equal to or over 135/85 mm Hg should be considered elevated Home BP measurement should be encouraged to increase patient involvement in care

42. 42 2007 Canadian Hypertension Education Program Recommendations VII. Suggested Protocol for Home Measurement of Blood Pressure Home blood pressure values should be based on: - duplicate measures, - morning and evening, - for an initial 7-day period. Singular and first day home BP values should not be considered. Daytime average BP equal to or over 135/85 mmHg should be considered elevated

43. 43 2007 Canadian Hypertension Education Program Recommendations Some recommended electronic blood pressure monitors for home blood pressure measurement Monitors A&D® or LifeSource® Models: 767*, 767PAC*, 774AC*, 779, 787AC* Monitor Omron® Models: HEM-705 PC*, HEM-711*, HEM-741CINT* Monitor Microlife® Model: BP 3BTO-A * Models with memory are preferred

44. 44 2007 Canadian Hypertension Education Program Recommendations VII. Home Measurement of BP:Patient Education AAMI=Association for the Advancement of Medical Instrumentation; BHS=British Hypertension Society; IP: International Protocol. Use devices: appropriate for the individual (cuff size) have met the standards of the AAMI and or the BHS and or IP Adequate patient training in: measuring their BP interpreting these readings Regular verifications accuracy of the device measuring techniques How to? Home measurement can help to improve patient adherence Values equal to or over 135 / 85 mm Hg should be considered elevated

45. 45 2007 Canadian Hypertension Education Program Recommendations VIII. Ambulatory BP Monitoring: Untreated - Mild (Grade 1) to moderate (Grade 2) clinic BP elevation and without target organ damage. Treated patients - Blood pressure that is not below target values despite receiving appropriate chronic antihypertensive therapy. - Symptoms suggestive of hypotension. -Fluctuating office blood pressure readings. Which patients? Beyond the diagnosis of hypertension, ABPM measurement may also be considered for selected patients for the management of HTN

46. 46 2007 Canadian Hypertension Education Program Recommendations VIII. Ambulatory BP Monitoring Specific Role in Selected Patients A drop in nocturnal BP of <10% is associated with increased risk of CV events Use validated devices How to interpret? Mean daytime ambulatory blood pressure > 135/85 mmHg is considered elevated. Mean 24 h ambulatory blood pressure > 130/80 mmHg is considered elevated. How to ?

47. 47 2007 Canadian Hypertension Education Program Recommendations DescriptionBlood Pressure mmHg Home pressure average135 / 85 Daytime average ABP135 / 85 24-hour average ABP130 / 80 A clinic blood pressure of 140/90 mmHg has a similar risk of a: Clinic, Home, Ambulatory (ABP) Blood Pressure Measurement equivalence numbers

48. 48 2007 Canadian Hypertension Education Program Recommendations Follow up algorithm for high Blood Pressure using Ambulatory Blood Pressure Measurement 24-h ABPM Consistent with HTN Awake BP > 135 SBP or > 85 DBP or 24-hour > 130 SBP or > 80 DBP Awake BP > 135 SBP or > 85 DBP or 24-hour > 130 SBP or > 80 DBP Awake BP < 135/85 and 24-hour < 130/80 Awake BP < 135/85 and 24-hour < 130/80 Continue to follow-up Patients with high normal blood pressure should be followed annually.

49. 49 2007 Canadian Hypertension Education Program Recommendations IX. The Role of Echocardiography: Specific Roles Echocardiography is not useful for routine evaluation Echocardiography is useful for: Assessment of Left ventricular dysfunction Presence of left ventricular hypertrophy may influence management

50. 50 2007 Canadian Hypertension Education Program Recommendations Assess blood pressure at all appropriate visits. Almost one half of those with blood pressure 130-139/85-89 will develop hypertension within 2 years. They require annual reassessment. Assess global cardiovascular risk in all hypertensive patients. Lifestyle modification is the cornerstone for the prevention and management of hypertension and CVD. Key CHEP messages for the management of hypertension

51. 51 2007 Canadian Hypertension Education Program Recommendations Key CHEP messages for the management of hypertension Treat to target (<140/90 mmHg; <130/80 mmHg in patients with diabetes or chronic kidney disease). To achieve targets sustained lifestyle modification and more than one drug is usually required. Follow patients with uncontrolled blood pressure at least monthly until blood pressure targets are achieved. Strategies to improve patient adherence to lifestyle modifications and antihypertensive therapy need to be incorporated in every patients management