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Focus on the 2001 Canadian Recommendations for the Management of Hypertension Version: April 25, 2002 2001 Canadian Hypertension Education Program Recommendations 1 Recommendations for the Management and Treatment of Hypertension The Canadian Hypertension Education Program April 25, 2002 2001 Canadian Hypertension Education Program Recommendations 2 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 2001 Canadian Hypertension Education Program Recommendations 3 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 4 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 5 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 2001 Canadian Hypertension Education Program Recommendations 6 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 7 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 8 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 9 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 2001 Canadian Hypertension Education Program Recommendations 10 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 2001 Canadian Hypertension Education Program Recommendations 11 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% 2001 Canadian Hypertension Education Program Recommendations 12 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 2001 Canadian Hypertension Education Program Recommendations 13 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 2001 Canadian Hypertension Education Program Recommendations 14 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 15 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 16 2001 Canadian Recommendations for the Management of Hypertension DIAGNOSIS AND FOLLOW-UP OF HYPERTENSION 2001 Canadian Hypertension Education Program Recommendations 17 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. 2001 Canadian Hypertension Education Program Recommendations 18 Blood Pressure Assessment • Patients should be assessed at all appropriate visits – To determine cardiovascular risk – To monitor antihypertensive treatment 2001 Canadian Hypertension Education Program Recommendations 19 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 2001 Canadian Hypertension Education Program Recommendations 20 Recommended Technique for Measuring Blood Pressure (cont.) – Position cuff appropriately – Support arm with antecubital fossa at heart level – Place stethoscope over the brachial artery 2001 Canadian Hypertension Education Program Recommendations 21 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 2001 Canadian Hypertension Education Program Recommendations 22 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 23 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 2001 Canadian Hypertension Education Program Recommendations 24 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 2001 Canadian Hypertension Education Program Recommendations 25 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 2001 Canadian Hypertension Education Program Recommendations 26 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 2001 Canadian Hypertension Education Program Recommendations 27 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 2001 Canadian Hypertension Education Program Recommendations 28 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. 2001 Canadian Hypertension Education Program Recommendations 29 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. 2001 Canadian Hypertension Education Program Recommendations 30 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. 2001 Canadian Hypertension Education Program Recommendations 31 Screening for Pheochromocytoma Screening for pheochromocytoma should include a 24 hour urine for metanephrines and creatinine Assessment of urinary VMA is inadequate 2001 Canadian Hypertension Education Program Recommendations 32 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. 2001 Canadian Hypertension Education Program Recommendations 33 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 2001 Canadian Hypertension Education Program Recommendations 34 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 2001 Canadian Hypertension Education Program Recommendations 35 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 2001 Canadian Hypertension Education Program Recommendations 36 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 2001 Canadian Hypertension Education Program Recommendations 37 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) 2001 Canadian Hypertension Education Program Recommendations 38 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 40 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 2001 Canadian Hypertension Education Program Recommendations 41 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 2001 Canadian Hypertension Education Program Recommendations 42 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 2001 Canadian Hypertension Education Program Recommendations 43 Lifestyle Recommendations for Hypertension: Alcohol Low risk alcohol consumption • 0-2 drinks/day • Men: <14 drinks/week • Women: <9 drinks/week 2001 Canadian Hypertension Education Program Recommendations 44 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 45 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 2001 Canadian Hypertension Education Program Recommendations 46 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 47 2001 Canadian Recommendations for the Management of Hypertension PHARMACOLOGICAL TREATMENT 2001 Canadian Hypertension Education Program Recommendations 48 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 2001 Canadian Hypertension Education Program Recommendations 49 Choice of Treatment Associated risk factors? or Target organ damage/complications? or Concomitant diseases/conditions? NO Standardized treatment YES Individualized treatment 2001 Canadian Hypertension Education Program Recommendations 50 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 2001 Canadian Hypertension Education Program Recommendations 51 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 2001 Canadian Hypertension Education Program Recommendations 52 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 2001 Canadian Hypertension Education Program Recommendations 53 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 54 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 55 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 2001 Canadian Hypertension Education Program Recommendations 56 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 2001 Canadian Hypertension Education Program Recommendations 57 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 58 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 2001 Canadian Hypertension Education Program Recommendations 60 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 62 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 2001 Canadian Hypertension Education Program Recommendations 63 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 2001 Canadian Hypertension Education Program Recommendations 64 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) 2001 Canadian Hypertension Education Program Recommendations 65 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 2001 Canadian Hypertension Education Program Recommendations 66 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 67 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 2001 Canadian Hypertension Education Program Recommendations 68 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 69 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. 2001 Canadian Hypertension Education Program Recommendations 70