Part 2: Recommendations for Hypertension Treatment

1. Part 2: Recommendations for Hypertension Treatment January 2007

2. Key CHEP messages for the management of hypertension • 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.

3. 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

4. 2007 Canadian Hypertension Education Program • A red flaghas been posted where recommendations were updated for 2007. • A slide kit for medical education can be downloaded (English and French versions) from http://www.hypertension.ca

5. 2007 Canadian Hypertension Education Program • Treatment Approaches: • Lifestyle • Pharmacological

6. 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) will develop hypertension within 4 years and almost 1/2 within 2 years. • Annual follow-up of patients with high normal blood pressure is recommended.

7. 2007 Canadian Hypertension Education Program What's New for 2007 • Up to 17% of hypertension can be attributed to high sodium diets • Reduce sodium intake to less than 100 mmol in normotensive patients to prevent hypertension

8. Recommendations 2007Table of contents • Indications for drug therapy • Goal for therapy • Adherence • Lifestyle • Uncomplicated • CV – IHD • CHF • Cerebrovascular / Stroke • LVH X. Chronic kidney disease • Renovascular • Diabetes • Smoking • Global risk reduction

9. Usual blood pressure threshold values for initiation of pharmacological treatment of hypertension I. Indications for Pharmacotherapy

10. I. Indications for Pharmacotherapy • In low risk patients with stage 1 hypertension (140-159/90-99 mmHg) lifestyle modification can be the sole therapy. • Over 90% of Canadians with hypertension have other risk factors and pharmacotherapy should be considered in these patients if blood pressure remains equal to or above 140/90 mmHg with lifestyle modification. • Patients with target organ damage (e.g. left ventricular hypertrophy) are recommended to be treated with pharmacotherapy if blood pressure is equal to or above 140/90 • Patients with known atherosclerotic disease (e.g. past stroke) are recommended to be treated with pharmacotherapy even if the blood pressure is normal (see compelling indications) • Patients with diabetes or chronic kidney disease should be considered for pharmacotherapy if the blood pressure is equal or over 130/80 mmHg

11. II. Goals of Therapy Blood pressure target values for treatment of hypertension

12. II. Goals of Therapy • To optimally reduce cardiovascular risk reduce the blood pressure to specified targets. • This usually requires two or more drugs and lifestyle changes • The systolic target is more difficult to achieve however controlling systolic blood pressure is as important if not more important than controlling diastolic blood pressure

13. Follow-up of blood pressure above targets • Patients with blood pressure at target are recommended to be followed at least every 2nd month • Follow-up visits are used to increase the intensity of lifestyle and drug therapy, monitor the response to therapy and assess adherence

14. Part 2: Recommendations for Hypertension Treatment January, 2007

15. IV. Lifestyle management

16. Lifestyle Recommendations for Prevention of Hypertension for NON-Hypertensive Individuals. To reduce the possibility of becoming hypertensive, Restriction of sodium intake to less than 100 mmol (2300 mg) / day Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary and soluble fiber, whole grains and protein from plant sources, low in saturated fat, cholesterol and salt in accordance with Canada's Guide to Healthy Eating. Regular physical activity: accumulation of 30-60 minutes of moderate intensity cardiorespiratory activity 4-7/week Low risk alcohol consumption (≤2 standard drinks/day and less than 14/week for men and less than 9/week for women) Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2) Waist Circumference < 102 cm for men < 88 cm for women Smoke free environment

17. Lifestyle Recommendations for the Treatment of Hypertension Restriction of sodium intake to less than 100 mmol (2300 mg) / day Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary and soluble fiber, whole grains and protein from plant sources, low in saturated fat, cholesterol and salt in accordance with Canada's Guide to Healthy Eating. Regular physical activity: accumulation of 30-60 minutes of moderate intensity cardiorespiratory activity 4-7/week Low risk alcohol consumption (≤2 standard drinks/day and less than 14/week for men and less than 9/week for women) Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2) Weight loss (> 5 Kg) in those who are over weight (BMI>25) Waist Circumference < 102 cm for men < 88 cm for women Smoke free environment

18. Dietary Sodium Restrict to target range of 65-100 mmol/day (Most of the salt in food is hidden and comes from processed food) Dietary Potassium If required, daily dietary intake >80 mmol Calcium supplementation No conclusive studies for hypertension Magnesium supplementation No conclusive studies for hypertension Lifestyle Recommendations for Hypertension: Dietary • • High in fresh fruits • • High in vegetables • • High in low fat dairy products • High in dietary and soluble fibre • High in plant protein • • Low in saturated fat and cholesterol http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_guide_rainbow_e.html

19. Recommendations for daily salt intake Less than: • 100 mmol sodium (Na) • or 2,3 g sodium (Na) • or 5,8 g of salt (NaCl) • or 1 teaspoon of table salt 2,300 mg sodium = 1 teaspoon of table salt

20. Salt 2007: Meta-analyses Hypertensives Reduction of BP 5.1 / 2.7 mmHg with a average reduction of 78 mmol sodium/day (162 to 87mmol/day) 7.2/3.8 mmHg with a average reduction of 100 mmol sodium/day Normotensives Reduction of BP 2.0 / 1.0 mmHg with a average reduction of sodium 74 mmol/day 3.6/1.7 mmHg with a average reduction of 100 mol/day sodium The Cochrane Library 2006;3:1-41;

21. Salt 2007: Meta analysis on different reduction in sodium on blood pressure Hypertension 2003;42:1093-1099

22. Epidemiologic impact on mortality of blood pressure reduction in the population After Intervention Before Intervention Prevalence % Reduction in BP Adapted from Whelton, P. K. et al. JAMA 2002;288:1882-1888

23. F I Intensity - Moderate T Time - 30-60 minutes T Lifestyle Recommendations for Hypertension. Physical Activity Should be prescribed to reduce blood pressure Frequency - Four to seven days per week Type cardiorespiratory activity - Walking, jogging - Cycling - Non-competitive swimming Exercise should be prescribed as adjunctive to pharmacological therapy

24. Lifestyle Recommendations for Hypertension: Alcohol Low risk alcohol consumption • 0-2 standard drinks/day • Men: maximum of 14 standard drinks/week • Women: maximum of 9 standard drinks/week A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or 12 oz of beer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).

25. Lifestyle Recommendations for Hypertension Stress Management Stress management Hypertensive patients in whom stress appears to be an important issue Behavior Modification Individualized cognitive behavioral interventions are more likely to be effective when relaxation techniques are employed.

26. Hypertensive and all patients • BMI over 25 • - Encourage weight reduction • Healthy BMI: 18.5-24.9 kg/m2 • Waist Circumference • < 102 cm for men • < 88 cm for women • For patients prescribed pharmacological therapy: weight loss has additional antihypertensive effects. Weight loss strategies should employ a multidisciplinary approach and include dietary education, increased physical activity and behavioural modification Lifestyle Recommendations for Hypertension Weight LossHeight, weight, and waist circumference (WC) should be measured and body mass index (BMI) calculated for all adults.

27. Waist circumference measurement Last rib margin Mid distance Iliac crest Courtesy J.P. Després 2006

28. Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults Applying the 2005 Canadian Hypertension Education Program recommendations: 3. Lifestyle modifications to prevent and treat hypertension Padwal R. et al. CMAJ ･ SEPT. 27, 2005; 173 (7) 749-751

29. Lifestyle Therapies in Hypertensive Adults: Summary

30. Pharmacotherapy

31. 2007 Canadian Hypertension Education Program Table of contents • Indications for drug therapy • Goal for therapy • Adherence • Lifestyle • Uncomplicated • CV – IHD • CHF • Cerebrovascular / Stroke • LVH X. Chronic kidney disease • Renovascular • Diabetes • Smoking • Global risk reduction

32. NO YES Treatment in the absence of specific indication Individualized Treatment (and compelling indications) V. Choice of Pharmacological Treatment Uncomplicated Associated risk factors? or Target organ damage/complications? or Concomitant diseases/conditions?

33. V. Choice of Pharmacological Treatment 1. Treatment of Systolic/Diastolic hypertension without other compelling indications 2. Treatment of Isolated Systolic hypertension without other compelling indications

34. ARB ACE-I V. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling Indications TARGET <140/90 mmHg INITIAL TREATMENT AND MONOTHERAPY Lifestyle modification therapy Thiazide Long-acting CCB Beta-blocker* * BBs are not indicated as first line therapy for age 60 and above ACEI and ARB are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential

35. V.Considerations Regarding the Choice of First-Line Therapy • ACE inhibitors and ARBs are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential • Beta adrenergic blockers are not recommended for patients age 60+ without another compelling indication • Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agent • ACE-I are not recommended (as monotherapy)for black patients without another compelling indication

36. Major Congenital Malformations after First Trimester Exposure to ACE inhibitors • Cardiovascular and neurological defects • ACEI risk ratio 2.71 (1.72-4.27) vs. other drugs 0.66 (0.25-1.75) vs. no drug NEJM 2006;354:2443-51

37. 1. Add-on Therapy • CONSIDER • Nonadherence? • Secondary HTN? • Interfering drugs or lifestyle? • White coat effect? • Resistant Hypertension? 2. Triple or Quadruple Therapy V. Add-on Therapy for Systolic/Diastolic Hypertension without Other Compelling Indications If partial response to monotherapy If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers or centrally acting agents).

38. Drug Combinations • When combining drugs, use first-line therapies • Two drug combinations of beta blockers, ACE inhibitors and angiotensin receptor blockers have not been proven to have additive hypotensive effects. • Therefore these potential two drug combinations should not be used unless there is a compelling (non blood pressure lowering) indication such as ischemic heart disease, post myocardial infarction, congestive heart failure or chronic kidney disease with proteinuria.

39. Drug Combinations cont’d • Caution should be exercised in combining a non dihydropyridine CCB and a beta blocker to reduce the risk of bradycardia or heart block. • Monitor creatinine and potassium when combining K sparing diuretics, ACE inhibitors and/or angiotensin receptor blockers. • If a diuretic is not used as first or second line therapy, triple dose therapy should include a diuretic, when not contraindicated.

40. Most HTN Pts need more than 1 drug (data from ALLHAT)

41. Most HTN Pts need more than 1 drug 5 4 3 Number of drugs 2 1 0 HOT IDNT AASK ABCD MDRD UKPDS ALLHAT

42. BP Effects from antihypertensive therapy Law. BMJ 2003 (SR of 354 RCTs) • Dose response curves for efficacy are relatively flat • 80% of the BP lowering efficacy is achieved at half-standard dose • Combinations of high standard dose have additive blood pressure lowering effects

43. Long-acting CCB Beta-blocker* Thiazide diuretic ACE-I ARB V. Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications TARGET <140/90 mmHg Lifestyle modification therapy * Not indicated as first line therapy over 60 Dual Combination • CONSIDER • Nonadherence? • Secondary HTN? • Interfering drugs or lifestyle? • White coat effect? ACEI and ARB are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential Triple or Quadruple Therapy

44. Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications TARGET <140 mmHg INITIAL TREATMENT AND MONOTHERAPY Lifestyle modification therapy Thiazide diuretic ARB Long-acting DHP CCB

45. V. Add-on therapy for Isolated Systolic Hypertension without Other Compelling Indications If partial response to monotherapy Dual combination Combine first line agents Thiazide diuretic ARB Long-acting DHP CCB • CONSIDER • Nonadherence? • Secondary HTN? • Interfering drugs or lifestyle? • White coat effect? Triple therapy If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha adrenergic blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).

46. V. Summary: Treatment of Isolated Systolic Hypertension without Other Compelling Indications TARGET <140 mmHg Lifestyle modification therapy Thiazide diuretic ARB Long-acting DHP CCB Dual therapy • CONSIDER • Nonadherence? • Secondary HTN? • Interfering drugs or lifestyle? • White coat effect? *If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker). Triple therapy

47. V. Choice of Pharmacological Treatment 1. Treatment of systolic-diastolic hypertension without other compelling indications 2. Treatment of isolated systolic hypertension without other compelling indications

48. Choice of Pharmacological Treatment for Hypertension Individualized treatment • Compelling indications: • Ischemic Heart Disease • Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI • Left Ventricular Systolic Dysfunction • Cerebrovascular Disease • Left Ventricular Hypertrophy • Non Diabetic Chronic Kidney Disease • Renovascular Disease • Smoking • Diabetes Mellitus • With Diabetic Nephropathy • Without Diabetic Nephropathy • Global Vascular Protection for Hypertensive Patients • Statins if 3 or more additional cardiovascular risks • Aspirin once blood pressure is controlled

49. 1. Beta-blocker 2. Long-acting CCB Stable angina ACE-I are recommended for most patients with established CAD* Short-acting nifedipine VI. Treatment of Hypertension in Patients with Ischemic Heart Disease • Caution should be exercised when combining a non DHP-CCB and a beta-blocker • If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or Diltiazem) Those at low risk with well controlled risk factors may not benefit from ACEI therapy

50. VI. Treatment of Hypertension in Patients with Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI An ARB can be used if the patient is intolerant to ACE-I Beta-blocker and ACE-I Recent myocardial infarction If beta-blocker contraindicated or not effective Long-acting DHP CCB (Amlodipine, Felodipine) YES Heart Failure ? NO Long-acting CCB