The 2015 CHEP Recommendations

1. The 2015 CHEP Recommendations What’s new in the treatment of hypertension? What’s still really important?

2. Hypertension Canada • Mission: • Advancing health through the prevention and control of high blood pressure and its complications. • Vision: • Canadians will have the healthiest blood pressurein the world.

3. Evidence-based Annual Recommendations • Canada has the world’s highest reported national blood pressure control rates • CHEP is known as the most credible source for evidence-based chronic disease management recommendations, with annual updates, a well-validated review process and effective dissemination techniques across Canada

4. 2015 CHEP Recommendations Task Force

5. Hypertension Canada Knowledge Translation Organizational Chart Recommendations Task Force

6. Hypertension Canada’s Annual KT Cycle for developing management recommendations Adapted from Graham ID, Logan, J., Harrison MB, Straus, S., Tetroe, JM, Caswell, W. et al. (2006). Lost in knowledge translation: Time for a map? Journal of Continuing Education in Health Professions, 26, 13-24.

7. CHEP 2015 Recommendations What’s new? • Assess clinic blood pressures using electronic (oscillometric) monitors • The diagnosis of hypertension should be based on out-of-office measurements • The management of hypertension is all about global cardiovascular risk management and vascular protection including advice and treatment for smoking cessation • Treatment of atherosclerotic renal artery stenosis is primarily medical

8. CHEP 2015 Recommendations What’s still important? • Know the BP threshold and treat to target • Adopting healthy behaviours is integral to the management of hypertension • The most important step in prescription of antihypertensive therapy is achieving patient “buy-in”

9. Usual blood pressure threshold values for initiation of pharmacological treatment TOD = target organ damage *This higher treatment target for the very elderly reflects current evidence and heightened concerns of precipitating adverse effects, particularly in frail patients. Decisions regarding initiating and intensifying pharmacotherapy in the very elderly should be based upon an individualized risk-benefit analysis.

10. Recommended Treatment Targets Treatment consists of health behaviour ±pharmacological management In patients with coronary artery disease be cautious when lowering blood pressure if diastolic blood pressures are < 60mmHg

11. CHEP 2015 Recommendations What’s still important? • Know the BP threshold and treat to the target • Adopting healthy behaviours is integral to the management of hypertension • The most important step in prescription of antihypertensive therapy is achieving patient “buy-in”

12. Impact of health behaviour managementon blood pressure Clinical Guideline: Methods, evidence and recommendations National Institute for Health and Clinical Excellence (NICE) May 2011

13. Health Behaviour Management: Summary

14. CHEP 2015 Recommendations What’s still important? • Know the BP threshold and treat to the target • Adopting healthy behaviours is integral to the management of hypertension • The most important step in prescription of antihypertensive therapy is achieving patient “buy-in”

15. Adherence to antihypertensive management can be improved by a multi-pronged approach • Encourage greater patient responsibility/autonomy in regular monitoring of their blood pressure • Educate patients and patients' families about their disease/treatment regimens verbally and in writing • Use an interdisciplinary care approach coordinating with work-site health care givers and pharmacists if available • Encouraging adherence to therapy by healthcare practitioner-based telephone contact, particularly, over the first three months of therapy

16. Adherence to antihypertensive management can be improved by a multi-pronged approach-II • Assess adherence to pharmacological and health behaviour therapies at every visit • Teach patients to take their pills on a regular schedule associated with a routine daily activity e.g. brushing teeth. • Simplify medication regimens using long-acting once-daily dosing • Utilize single pill combinations • Utilize unit-of-use packaging e.g. blister packaging

17. CHEP 2015 Recommendations What’s new? • Monitor blood pressures in clinic using an electronic (oscillometric) device • The diagnosis of hypertension should be based on out-of-office measurements • The management of hypertension is all about global cardiovascular risk management and vascular protection including advice and treatment for smoking cessation • Treatment of atherosclerotic renal artery stenosis is primarily medical

18. Criteria for the diagnosis of hypertension and recommendations for follow-up: overview Measurement using electronic (oscillometric) upper arm devices is preferred over auscultation ABPM: Ambulatory Blood Pressure Measurement AOBP: Automated Office Blood Pressure HBPM: Home Blood Pressure measurement OBPM: Office Blood Pressure measurement

19. BP measurement methods • Office (attended, OBPM) • Auscultatory (mercury, aneroid) • Oscillometric (electronic) • Office Automated (unattended, AOBP) • Oscillometric (electronic) • Ambulatory (ABPM) • Home (HBPM) For information on blood pressure measurement devices: • http://www.dableducational.org/sphygmomanometers.html • http://www.bhsoc.org/bp-monitors/bp-monitors/

20. BP measurement methods Office (attended, OBPM) Auscultatory (mercury, aneroid) Oscillometric(electronic) http://www.dableducational.org/sphygmomanometers.html http://www.bhsoc.org/bp-monitors/bp-monitors/

21. BP measurement methods Office Automated (unattended, AOBP) Oscillometric (electronic) http://www.dableducational.org/sphygmomanometers.html http://www.bhsoc.org/bp-monitors/bp-monitors/

22. New 2015 Recommendation: BP Measurement Office BP measurement (OBPM): • Measurement using electronic (oscillometric) upper arm devices is preferred to auscultatory devices (Grade C).

23. Auscultatory OBPM is inaccurate • In the real world, the accuracy of auscultatory OBPM can be adversely affected by provider, patient and device factors such as: • too rapid deflation of the cuff • digit preference with rounding off of readings to 0 or 5 • also, mercury sphygmomanometers are being phased out and aneroid devices are less likely to remain calibrated • Consequence: Routine auscultatory OBPMs are 9/6 mm Hg higher than standardized research BPs (primarily using oscillometric devices)

24. Keys to accurate OBPM • Use standardized measurement techniques and validated equipment • Measurement using electronic (oscillometric) upper arm devices is preferred over auscultation • The first reading should be discarded and the latter two averaged.

25. Out of office assessment is the preferred means of diagnosing hypertension Clinic BP as alternate method

26. Out of office BP measurement methods:Ambulatory (ABPM) http://www.dableducational.org/sphygmomanometers.html http://www.bhsoc.org/bp-monitors/bp-monitors/

27. Out of office BP measurement methods:Home (HBPM) http://www.dableducational.org/sphygmomanometers.html http://www.bhsoc.org/bp-monitors/bp-monitors/

28. Out-of-office BP Measurements • ABPM has better predictive ability than OBPM and is the recommended out-of-office measurement method. • HBPM has better predictive ability than OBPM and is recommended if ABPM is not tolerated, not readily available or due to patient preference. • Identifies white coat hypertension (as well as diagnosing masked hypertension)

29. Out-of-office BP measurements are more highly correlated with BP-related risk SBP DBP Mule et al. J Cardiovasc Risk 2002;9:123-9.

30. 135 Only relying on office pressures misses out on white coat and masked hypertension 200 180 True Hypertension Masked Hypertension 160 Ambulatory BP mmHg 140 Normotension White Coat Hypertension 120 100 100 120 140 160 180 200 Manual Office BP mmHg From Pickering et al. Hypertension 2002;40:795-796

31. The prognosis of white coat and masked hypertension 35 CV Events 30 25 20 CV events per 1000 patient-year 15 10 5 0 Normal Whitecoat Uncontrolled Masked 23/685 24/656 41/462 236/3125 Okhubo et al. J. Am. Coll. Cardiol. 2005;46;508-515

32. White coat hypertension: risk factors • women • older adults • non-smokers • subjects recently diagnosed with hypertension with a limited number of routine OBPM • subjects with mild hypertension • pregnant women • subjects without evidence of target organ damage Franklin SS, et al. Hypertension 2013;62:982-7 Lovibond K, et al. Lancet 2011;378:1219-30

33. Masked hypertension: risk factors • high normal clinic BPs • older adults • males • higher BMI • smoker • excess alcohol consumption • diabetes • peripheral arterial disease • orthostatic hypotension • LVH Hanninen MR et al, J Hypertens. 2011;29:1880-88 Barochiner J et al. Am J Hypertens. 2013;28:872-78 Andalib A et al. Intern M ed J. 2012;42:260-66

34. Summary of evidence • Out-of-office is needed to identify white coat hypertension (and to rule out masked hypertension) • ABPM has better predictive ability than OBPM • HBPM has better predictive ability than OBPM

35. Criteria for the diagnosis of hypertension and recommendations for follow-up: summary Measurement using electronic (oscillometric) upper arm devices is preferred over auscultation ABPM: Ambulatory Blood Pressure Measurement AOBP: Automated Office Blood Pressure HBPM: Home Blood Pressure measurement OBPM: Office Blood Pressure measurement

36. CHEP 2015 Recommendations What’s new? • Assess clinic blood pressures using electronic (oscillometric) monitors • The diagnosis of hypertension should be based on out-of-office measurements • The management of hypertension is all about global cardiovascular risk management and vascular protection including advice and treatment for smoking cessation • Treatment of atherosclerotic renal artery stenosis is primarily medical .

37. Assess global cardiovascular risk in all hypertensive patients 8 out of 10 hypertensive patients have at least 1 additional risk factor  Risk factors =  Global CV risk Gee ME, Bienek A, McAlister FA, et al. Factors Associated With Lack of Awareness and Uncontrolled High Blood Pressure Among Canadian Adults With Hypertension. Can J Cardiol. 2012;28:375-382.

38. Informing patients of their global risk improves the effectiveness of risk factor modification Grover SA , et al. J Gen Intern Med. 2009;24(1);33–39

39. Impact on blood pressure treatment of discussing coronary risk with patients Grover SA, et al. J Gen Intern Med 2009;24(1);33-9

40. Previous Stroke or TIA LVH ECG abnormalities Microalbuminuria or Proteinuria Peripheral Vascular Disease The treatment of hypertension is all about vascular protection Statins are recommended in high risk hypertensive patients based on having established atherosclerotic disease or at least 3 of the following: • Male • 55 y or older • Smoking • Type 2 Diabetes • Total-C/HDL-C ratio of 6 or higher • Premature Family History of CV disease ASCOT-LLA Lancet 2003;361:1149-58

41. Vascular Protection for Hypertensive Patients: ASA Low dose ASA in hypertensive patients >50 years Caution should be exercised if BP is not controlled. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998;351:1755-1762.

42. New 2015 Recommendation: Vascular Protection Tobacco use status of all patients should be updated on a regular basis and health care providers should clearly advise patients to quit smoking.

43. Effect of advice on smoking cessation rates Cochrane Database Syst Rev. 2013 May 31;5:CD000165. doi: 10.1002/14651858.CD000165.pub4 2015

44. New 2015 Recommendation: Vascular Protection Advicein combination with pharmacotherapy (e.g., varenicline, bupropion, nicotine replacement therapy) should be offered to all smokers with a goal of smoking cessation.

45. Cochrane network meta-analysis 2014Kate Cahill et al • Nicotine replacement therapy (NRT), antidepressant bupropion, and nicotine receptor partial agonist varenicline • Impact on long term abstinence- 6 months or longer • Synthesis of 12 Cochrane reviews • 267 studies • Over 10,000 participants

46. Network meta-analysis of smoking cessation pharmacotherapies studies Cochrane Database Syst Rev. 2013 May 31;5:CD000165. doi: 10.1002/14651858.CD000165.pub4

47. CHEP 2015 Recommendations What’s new? • Clinic blood pressures should be using electronic (oscillometric) monitors • The diagnosis of hypertension should be based on out-of-office measurements • The management of hypertension is all about global cardiovascular risk management and vascular protection including advice and treatment supporting smoking cessation • Treatment of atherosclerotic renal artery stenosis is primarily medical

48. CHEP Recommendations 2015: Therapy Patients with hypertension attributable to atherosclerotic renal artery stenosis (RAS) should be primarily medically managed because renal angioplasty and stenting offer no benefits over optimal medical therapy alone.

49. CORAL: Cooper et al, Stenting & Medical Rx for Atherosclerotic RAS 947 Patients: HT with SBP≥155 while on ≥2 drugs; OR CKD: GFR <60 mL/min/1.73 m2AND RAS ≥80% or ≥60% with SBP gradient ≥20 mmHg Intervention (1:1): Palmaz Genesis stent (Cordis) Concurrent Medical Rx: antiplatelet; Anti-HT to <140/90 (DM: 130/80) with candesartan, HCT, amlodipine; lipid Rx (atorvastatin); glucose Primary Outcome: Composite: Death (CV/renal), stroke, MI, stroke, HFhosp, prog renal insuff, perm RRT NEJM 2014; 370; 13-22.

50. CORAL: Cooper et al, Stenting & Medical Rx for Atherosclerotic RAS • Conclusion: • Renal-artery stenting did not confer a significant benefit with respect to the prevention of clinical events when added to comprehensive, multifactorial medical therapy in people with atherosclerotic RAS and HT or CKD. NEJM 2014; 370; 13-22.