Download 2001 Canadian Recommendations for the Management of

Focus on the 2001 Canadian
Recommendations for the
Management of Hypertension
Version: April 25, 2002
2001 Canadian Hypertension Education Program Recommendations
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Recommendations for the
Management and Treatment of
Hypertension
The Canadian Hypertension Education Program
April 25, 2002
2001 Canadian Hypertension Education Program Recommendations
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2001 Canadian Recommendations
for the Management of Hypertension
•
•
•
•
•
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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
2001 Canadian Hypertension Education Program Recommendations
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The Canadian Hypertension Recommendations Working Group:
Subgroups for the 2001 recommendations:
2001 Canadian Recommendations for
the Management of Hypertension
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
2001 Canadian Hypertension Education Program Recommendations
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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.
2001 Canadian Hypertension Education Program Recommendations
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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
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Proportion of Deaths Attributable to
Leading Risk Factors
World Health Organization Global Burden of Disease Study
14%
11.7%
12%
10%
% of
8%
Global
Disability 6%
6.0%
5.8%
5.3%
3.9%
4%
2%
0%
Malnutrition
Tobacco Use Hypertension
2001 Canadian Hypertension Education Program Recommendations
Poor Water
Supply
Physical
Inactivity
Murray et al. 1996
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Hypertension and Target Organ
Damage
Eyes
Brain
Retinal hemorrhage,
exudate, optical disc
edema, arteriolar
constriction, etc.
Stroke, TIA,
hypertensive
encephalopathy,
etc.
Blood vessels
Aneurysm, arterial
occlusive disease,
etc.
Heart
Angina, MI, CHF,
LVH, etc.
Kidney
ESRF, etc.
2001 Canadian Hypertension Education Program Recommendations
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BP and Risk of CAD Mortality
Risk of CAD mortality per 10,000
person-years
40
Diastolic
35
Systolic
30
25
20
15
10
5
0
75-79
80-89
90-99
100+
<120
120-139 140-159
160+
Blood pressure (mm Hg)
Multiple Risk Factor Intervention Trial (MRFIT); n=347,978 men. Neaton et al. Arch Intern Med 1992;152:56-64
2001 Canadian Hypertension Education Program Recommendations
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BP and Risk of Stroke Mortality
Risk of stroke mortality per
10,000 person-years
10
Diastolic
Systolic
8
6
4
2
0
<85
85-89
90-99
100+
<130
130-139 140-159
160+
Blood pressure (mm Hg)
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
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Blood Pressure Distribution in the
Population According to Age
Men
Women
150
150
130
130
PP
110
80
80
70
70
30-39 40-49 50-59 60-69 70-79  80
PP
110
30-39 40-49 50-59 60-69 70-79  80
Age
Age
PP=Pulse Pressure.
Adapted from : Third National Health and Nutrition. Examination Survey, Hypertension 1995;25:305-13
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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%
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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
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The Challenge In Canada
22% of Canadians 18-70 years of age have hypertension
50% of Canadians >65 years of age have hypertension
Hypertensive patients
who are treated
and BP controlled
Hypertensive patients
who are treated
but BP uncontrolled
21%
22%
13%
43%
Patients who are aware
but remain untreated
and BP uncontrolled
9%
Diabetic patients
Who are treated and
BP controlled
Hypertensive patients
who are unaware
Joffres et al. Am J Hyper 2001;14:1099 –1105
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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.
2001 Canadian Hypertension Education Program Recommendations
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2001 Canadian Recommendations for
the Management of Hypertension
A slide kit and clinical practice algorithms
supporting the full recommendations can be
downloaded from the CHS website at:
www.chs.md
2001 Canadian Hypertension Education Program Recommendations
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2001 Canadian Recommendations for
the Management of Hypertension
DIAGNOSIS
AND FOLLOW-UP
OF HYPERTENSION
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Classification of Hypertension
According to WHO/ISH*
Category
Systolic
Diastolic
Optimal
<120
<80
Normal
<130
<85
High-Normal
130-139
85-89
Grade 1 (mild hypertension )
140-159
90-99
- Subgroup: borderline
140-149
90-94
Grade 2 (moderate hypertension)
160-179
100-109
Grade 3 (severe hypertension)
 180
 110
Isolated Systolic Hypertension (ISH)
140
<90
140-149
<90
- Subgroup: borderline
*ISH=International Society of Hypertension. Chalmers J et al. J Hypertens 1999;17:151-85.
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Blood Pressure Assessment
• Patients should be assessed at all
appropriate visits
– To determine cardiovascular risk
– To monitor antihypertensive treatment
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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
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Recommended Technique
for Measuring Blood Pressure (cont.)
– Position cuff appropriately
– Support arm with antecubital fossa at
heart level
– Place stethoscope over the brachial
artery
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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
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Diagnosis of Hypertension: Summary
140/90
BP
180/105
Visit 1
- Hypertensive
urgency?
History-taking,
physical examination
Visit 2
Visit 3
- Target organ
damage or
BP >180/105?
(Visit 3)
Hypertension
diagnosis
confirmed
Visit 4
Visit 5
Blood pressure
measurement
every year
BP >threshold
for initiation of
treatment
No
2001 Canadian Hypertension Education Program Recommendations
Yes
Validated technique and
BP measurement device
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Blood Pressure Threshold Values for Initiation of
Pharmacological Treatment of Hypertension
Condition
Initiation
SBP / DBP mmHg
Diastolic ± systolic hypertension
Isolated systolic hypertension
140/90
160
Diabetes
130/80
Renal disease
130/80
Proteinuria >1 g/day
125/75
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Target Values for Blood Pressure
Condition
Target
SBP / DBP mmHg
Isolated systolic hypertension
<140/90
<140
Home BP measurement
<135/85
Diastolic ± systolic hypertension
(No diabetes, renal disease or proteinuria)
Diabetes
<130/80
Renal disease
<130/80
Proteinuria >1 g/day
<125/75
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Threshold for Initiation of Treatment
and Target Values
Condition
Initiation
Target
SBP / DBP mmHg
SBP / DBP mmHg
>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
Diastolic ± systolic hypertension
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Routine and Optional Laboratory Tests
Investigation of all patients with hypertension
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
New recommendations for investigation of endocrine and renal
hypertension syndromes
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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
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Screening for Hyperaldosteronism
should be considered for patients with the
following characteristics:
• Spontaneous hypokalemia
• Profound diuretic-induced hypokalemia (<3.0
mmol/L)
• Hypertension refractory to treatment with 3 or
more drugs
• Incidental adrenal adenomas.
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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.
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Screening for Pheochromocytoma
should be considered for patients with the following
characteristics:
• 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.
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Screening for Pheochromocytoma
 Screening for pheochromocytoma should include a 24
hour urine for metanephrines and creatinine
 Assessment of urinary VMA is inadequate
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WHO/ISH Recommendations for
Risk Assessment
Stratification of risk to quantify prognosis
–Other Risk Factors &
Disease History
I. No other risk
factors
II. 1-2 risk factors
III. 3 risk factors or
TOD or diabetes
IV. ACC
Grade 1
Grade 2
Grade 3
–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)
–Low risk
Medium risk
High risk
Medium risk
Medium risk
V high risk
High risk
High risk
V high risk
V high risk
V high risk
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.
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Home (Self) Measurement of BP:
Specific Role in Selected Patients
Which patients?
Non adherence
Hypertension and
diabetes
Office-induced blood
pressure elevation
Normal
Home BP?
Further assess
using
ambulatory
blood pressure
monitoring
BP >135/85 mm Hg should be considered elevated
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Home (Self) Measurement of BP:
Patient Education
How to?
Use devices:
- appropriate for the individual (cuff size)
- have met the standards of the AAMI
and/or the BHS
Adequate patient training in:
- measuring their BP
- interpreting these readings
Values over
135 / 85 mm Hg
should be
considered elevated
AAMI=Association for the Advancement of Medical
Instrumentation; BHS=British Hypertension Society
Regular verifications
- accuracy of the device
- measuring techniques
Self measurement can help to
improve patient adherence
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Ambulatory BP Monitoring:
Specific Role in Selected Patients*
Which patients?
Those with suspected office-induced BP elevation
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
* When available
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Ambulatory BP Monitoring
Specific Role in Selected Patients
How to ?
Use validated devices
How to interpret?
Mean daytime ambulatory blood pressure
>135/85 mm Hg
is considered elevated
* A drop in nocturnal BP of <10% is associated with increased risk of CV events
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The Role of Echocardiography:
Specific Role in Selected Patients
Assessment of
Left ventricular
dysfunction
Routine Evaluation
Presence of
Tracking of the
therapeutic regression
Coronary artery disease
Most antihypertensives regress LVH over 6 months treatment period except arterial vasodilators
(eg. Hydralazine)
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Recommendations for Follow-up
Diagnosis of hypertension
Non Pharmacological treatment
With or without Pharmacological treatment
Are BP readings below target during 2 consecutive visits*?
Yes
Follow-up at 3-6
month intervals
No
Symptoms, Severe
hypertension, Intolerance to
anti-hypertensive treatment
or Target Organ Damage
Yes
More frequent
visits
2001 Canadian Hypertension Education Program Recommendations
No
Monthly visits
39
2001 Canadian Recommendations for
the Management of Hypertension
LIFESTYLE MANAGEMENT
2001 Canadian Hypertension Education Program Recommendations
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Lifestyle Recommendations for
Hypertension
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
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Lifestyle Recommendations for
Hypertension: Dietary
Dietary Sodium
Fresh fruits,
Restrict to target range of 90-130 mmol/day
(Limitation of salt additives and foods with
excessive added salt)
Vegetables,
Low fat dairy
products,
Low fat diet,
in accordance with
Canada's Guide
Dietary Potassium
Daily dietary intake >60 mmol
Calcium supplementation
No conclusive studies for hypertension
to Healthy Eating
Magnesium supplementation
No conclusive studies for hypertension
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Lifestyle Recommendations for
Hypertension: Physical Activity
Should be prescribed to reduce blood pressure
F
Frequency
- Four or five times per week
I
Intensity
- Moderate
T
Time
- 45-60 minutes
Type
Dynamic exercise
- Walking
- Cycling
- Non-competitive swimming
T
For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapy
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Lifestyle Recommendations for
Hypertension: Alcohol
Low risk alcohol consumption
• 0-2 drinks/day
• Men: <14 drinks/week
• Women: <9 drinks/week
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Lifestyle Recommendations for
Hypertension: Stress Management
Stress management
Hypertensive patients
in whom stress appears to be an important issue
Behaviour Modification
- Individualized
- Cognitive
2001 Canadian Hypertension Education Program Recommendations
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Lifestyle Recommendations for
Hypertension: Weight Loss
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
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Impact of Lifestyle Therapies on BP in
Hypertensive Adults
Intervention
Sodium reduction
Weight loss
Alcohol reduction
Exercise
Dietary patterns
Potassium increase
Targeted change
SBP/DBP
100 mmol/day
-5.8 / -2.5
-4.5 kg
-7.2 / -5.9
-2.7 drinks/day
-4.6 / -2.3
3 times/week
-10.3 / -7.5
DASH diet
-11.4 / -5.5
75 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.
2001 Canadian Hypertension Education Program Recommendations
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2001 Canadian Recommendations for
the Management of Hypertension
PHARMACOLOGICAL
TREATMENT
2001 Canadian Hypertension Education Program Recommendations
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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
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Choice of Treatment
Associated risk factors?
or
Target organ damage/complications?
or
Concomitant diseases/conditions?
NO
Standardized
treatment
YES
Individualized
treatment
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Recommendations for Improving Adherence
to Antihypertensive Prescription
• Adherence can be improved by a multipronged 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
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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
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Treatment Algorithm
for Systolic-Diastolic Hypertension
TARGET <140/90 mmHg
Lifestyle modification
therapy
Low-dose
thiazides
CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or
lifestyle?
• White coat effect?
ACE-I
Long-acting
DHP-CCB
Alpha-blocker
as initial
monotherapy
Betablockers
Combination
Combine adjacent classes
Triple or quadruple therapy
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Treatment algorithm
for Isolated Systolic Hypertension
TARGET <140 mmHg
Lifestyle modification
therapy
Long-acting
DHP CCB
Low-dose
Thiazide
CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or
lifestyle?
• White coat effect?
Alpha-blockers and
beta-blockers as
initial monotherapy
Combination
Effective 2-drug combination
(Add ACE-I or beta blocker)
Combination
Triple or quadruple therapy
2001 Canadian Hypertension Education Program Recommendations
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Global Treatment Algorithm
for Hypertension
TARGET <140/90 mm Hg
Lifestyle modification
therapy
Low-dose
thiazides
CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or
lifestyle?
• White coat effect?
ACE-I
*
Long-acting
DHP-CCB
Alpha-blocker
as initial
monotherapy
Betablockers **
Combination
Combine adjacent classes
Triple or quadruple therapy
*Not recommended for ISH; **Not recommended for patients >60 years or ISH
2001 Canadian Hypertension Education Program Recommendations
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Rationale for Drug Combination Therapy
Many patients require multiple
drugs to achieve BP targets
• Even higher proportion of
hypertensive patients with
diabetes require multi-drug
therapy
50%
50%
1 Drug
2 Drugs
33%
• Low doses of multiple
drugs may be more
effective and better
tolerated than higher doses
of fewer drugs
3 Drugs
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Useful Combinations
For additive hypotensive effect in dual therapy
combine an agent from
Column 1 with any in Column 2
Column 1
Column 2
• Low dose thiazide
diuretics
• Beta-blocker
• Long-acting
dihydropyridine calcium
channel blocker
• ACE Inhibitor
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Treatment of Hypertension With
Associated Risk Factors
Dyslipidemia
Treatment of uncomplicated
hypertension,
hypertension associated with
other conditions or
concomitant risk factors.
2001 Canadian Hypertension Education Program Recommendations
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Treatment of Hypertension With
Associated Risk Factors
Smoking
Beta-blocker
2001 Canadian Hypertension Education Program Recommendations
The benefits of treating
smokers with beta-blockers
remain uncertain
in the absence
of a specific indication
like angina or post-MI
59
Treatment of Hypertension with Diabetes
TARGET <130/80 mmHg
with
Nephropathy
1. ACE Inhibitor
2. ARB
Alpha-blockers
Diabetes
without
Nephropathy
Isolated
Systolic
Hypertension
ACE-Inhibitor
Combination
Effective 2-drug combination
ACE-Inhibitor
Long-acting
dihydropyridine
CCB
Low-dose thiazide
COMBINATION
Cardioselective BB
Long-acting CCB
Low-dose thiazide diuretic
More than 3 drugs may be needed to reach target values for diabetic patients
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Treatment of Hypertension
with Ischemic Heart Disease
Combination
Stable
angina
1. Beta-blocker
2. Long-acting CCB
Beta-blocker
and long-acting
Dihydropyridine CCB
ACE-I,
Beta-blocker
or both
Normal systolic
left ventricular
function
Ischemic
cardiopathy
Prior
myocardial
infarction
Alternate
ACE-I should be
strongly considered in
all patients with CAD
Short-acting
nifedipine
2001 Canadian Hypertension Education Program Recommendations
Verapamil
or
Diltiazem
61
Treatment of Hypertension
with Peripheral Vascular Diseases
mild
Atherosclerotic
PVD
Treatment of uncomplicated hypertension,
hypertension associated with other
conditions or concomitant risk factors.
severe
± ACE-I ?
Peripheral
vascular
disease
Renal artery
stenosis
Raynaud’s
syndrome
Beta-blocker
ACE-I/ARB
(use with caution)
Vasodilators:
Alpha-blockers, CCB,
ACE-I, ARB
May aggravate
symptoms
May induce renal
insufficiency
May have
beneficial effects
Beta-blocker
2001 Canadian Hypertension Education Program Recommendations
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Treatment of Hypertension
with Systolic Dysfunction
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
NYHA class II - IV
* Diuretics:
- Thiazides
- Loop diuretics
Add
Bisoprolol, Carvedilol,
Metoprolol
Additional
therapy
Amlodipine or
Felodipine
NYHA class III - IV
Add Spironolactone
Non
dihydropyridine
CCB or nifedipine
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
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Treatment of Hypertension
with Arrhythmia*
Atrial fibrillation and
supraventricular
tachycardia
Beta-blocker
Verapamil
Diltiazem
May inhibit
ventricular
response
Caution if systolic
dysfunction is
present
Arrhythmia
and
conduction
problems
Sinoatrial node
dysfunction and
atrioventricular
conduction problems
Beta-blocker
Verapamil
Diltiazem
Clonidine
Methyldopa
* Caution is recommended when diuretics are used with class 1A, 1C or III antiarrythmic drugs
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Treatment of Hypertension
with Left Ventricular Hypertrophy
Most
antihypertensives
Can reduce LVH
over a 6 months
treatment period
Vasodilators:
Hydralazine, Minoxidil
Can Increase
LVH
Left ventricular
hypertrophy
Most antihypertensives regress LVH over 6 months treatment period except arterial vasodilators
(eg. hydralazine)
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Treatment of Hypertension
with Nondiabetic Renal Disease
ACE-I
Renal
disease
Additive therapy:
Diuretic
Combination
with other agents
Target BP
Nondiabetic: < 130/80
Proteinuria > 1 g/day: < 125/ 85
ACE-I: Bilateral
renal artery
stenosis
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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
2001 Canadian Hypertension Education Program Recommendations
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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
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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
2001 Canadian Hypertension Education Program Recommendations
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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.
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