Part 2: Recommendations for Hypertension Treatment

1. Part 2: Recommendations for HypertensionTreatment

2. 2009 Canadian Hypertension Education Program (CHEP) • A red flag has been posted where recommendations were updated for 2009. • Slide kits for health care professional and public education can be downloaded (English and French versions) from http://www.hypertension.ca

3. 2009 Canadian Hypertension Education Program (CHEP) Treatment Approaches: • Lifestyle • Pharmacological

4. Key CHEP messages for the management of hypertension • Assess blood pressure at all appropriate visits. • Encourage people with hypertension to use approved devices and proper technique to measure blood pressure at home. • Ensure people with hypertension are screened for diabetes (and vice versa). Treat hypertension in people with diabetes with a combination of lifestyle changes and pharmacotherapy to control blood pressure to less than 130/80 mmHg. Many require use of three or more antihypertensive drugs including diuretics to achieve blood pressure targets. • Assess and manage overall cardiovascular risk in all people with hypertension including: smoking, dyslipidemia, dysglycemia, abdominal obesity, unhealthy eating and physical inactivity. • Sustained lifestyle modification is the cornerstone for the prevention and management of hypertension and cardiovascular disease (CVD). • Treat blood pressure to less than 140/90 mmHg in most people and to less than 130/80 mmHg in people with diabetes or chronic kidney disease. More than one drug is usually required.

5. What’s New for 2009The Hypertensive Diabetic • Patients with diabetes are at high cardiovascular risk • Up to 80% of diabetic patients die of cardiovascular disease • Most patients with diabetes have hypertension • Between 35 and 75% of diabetic complications have been attributed to hypertension. • Treatment of hypertension in patients with diabetes reduces total mortality, myocardial infarction, stroke, retinopathy and progressive renal failure rates. • More intensive reduction in blood pressure reduces major cardiovascular events and total mortality by 25% Treating hypertension in the diabetic patient reduces death and disability and reduces health care system costs TARGET <130 systolic and <80 mmHg diastolic

6. What’s New for 2009The Hypertensive Diabetic • 2/3rds of hypertensive diabetic patients have uncontrolled hypertension (> 130/80 mmHg) • There is underutilization of diuretic therapy in treating hypertension in diabetic patients. In general a diuretic is required for blood pressure control in multi drug regimes. • A combination of lifestyle changes and 3 or more medications are often required. • More intensive reduction in blood pressure in the hypertensive diabetic is one a few medical interventions where the cost of treatment is less than the cost of the complications prevented Treating hypertension in the diabetic patient reduces death and disability and reduces health care system costs TARGET <130 systolic and <80 mmHg diastolic

7. What’s New for 2009 Increased age on its own should not be a consideration in determining the need for antihypertensive drug therapy. Drug therapy for the elderly should be based on the same criteria as in younger adults however caution should be exercised in elderly patients who are frail or have postural hypotension. N Engl J Med 2008;358:1887-98

8. What’s New for 2009 The combination of an ACE inhibitor with an ARB is not recommended in patients with • hypertension without compelling indications, • coronary artery disease who do not have heart failure, • prior stroke, • non proteinuric chronic kidney disease or • diabetes mellitus without micro albuminuria N Engl J Med 2008;358:1547-59 Lancet 2008; 372: 547–53

9. What’s New for 2009 • The use of combination of ACE inhibitor with an ARB should only be considered in selected and closely monitored people with advanced heart failure or proteinuric nephropathy.

10. 2009 Canadian Hypertension Education Program (CHEP) Important messages from past recommendations IMPORTANT ROLE FOR HOME MEASUREMENT OF BLOOD PRESSURE Encourage hypertensive patients to use an approved blood pressure measuring device and use proper technique to assess blood pressure at home. Home measurement can help to confirm the diagnosis of hypertension, improve blood pressure control, reduce the need for medications, identify patients with white coat and masked hypertension and improve medication adherence

11. 2009 Canadian Hypertension Education Program (CHEP) IMPORTANT ROLE FOR HOME MEASUREMENT OF BLOOD PRESSURE • An internet based toolkit for home blood pressure measurement including recording and tracking of blood pressures can be found at www.heartandstroke.ca/BP. • Patient information on selecting an approved device, and how to measure and track home blood pressure can be found at www.hypertension.ca. • More information on home monitoring is in the CHEP diagnostic slide set and the BP measurement slide set

12. 2009 Canadian Hypertension Education Program (CHEP) Important messages from past recommendations • High dietary sodium is estimated to increase blood pressure in the Canadian population to the extent that 1,000,000 Canadians meet the diagnostic criteria for hypertension who would otherwise have ‘normal’ blood pressure • Most of the sodium in Canadian diets comes from processed foods and restaurants. • Pizza, breads, soups and sauces usually have high amounts of sodium • Patient information on how to achieve a reduced sodium diet can be found at www.hypertension.ca • Aim to reduce sodium intake to less than 2300 mg/day to prevent and control hypertension

13. TO REDUCE DIETARY SODIUM Advise patients to • Buy and eat more fresh foods, especially fruit and vegetables • Choose processed foods look with low salt labels or brands with the lowest percentage of sodium on the food label • Wash canned foods or other salty foods in water before eating or cooking • If desired, use unsalted spices to make foods taste better • Eat less food at restaurants and fast food outlets and ask for less salt to be added in food orders • Use less sauces on food • Eat foods with less than 200 mg of sodium or less than 10% of the daily value per serving Advise patients not to • Buy or eat heavily salted foods (e.g. pickled foods, salted crackers or chips, processed meats, etc). • Add salt in cooking and at the table • Eat foods with more than 400 mg of sodium or more than 20% of the daily value per serving

14. Recommendations 2009Table 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 Overall risk reduction

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

16. 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. • In particular many younger hypertensive Canadians with multiple cardiovascular risks are currently not treated with pharmacotherapy. Health care professionals need to be alert to this important care gap and recommend pharmacotherapy. • 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 mmHg • Patients with diabetes or chronic kidney disease should be considered for pharmacotherapy if the blood pressure is equal or over 130/80 mmHg

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

18. 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

19. Follow-up of blood pressure above targets • Patients with blood pressure above 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

20. IV. Lifestyle management

21. Lifestyle Recommendations for Prevention and Treatment of Hypertension To reduce the possibility of becoming hypertensive, Reduce sodium intake to less than 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 sodium in accordance with Canada's Guide to Healthy Eating. Regular physical activity:accumulation of 30-60 minutes of moderate intensity cardiorespiratory activity (e.g. a brisk walk) 4-7 days/week in addition to routine activities of daily living Low risk alcohol consumption(≤2 standard drinks/dayandless 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 Men Women - Europid, Sub-Saharan African, Middle Eastern <94 cm <80 cm - South Asian, Chinese <90 cm <80 cm - Smoke free environment

22. Dietary Sodium Less than 2300mg / day (Most of the salt in food is ‘hidden’ and comes from processed food) Dietary Potassium 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 fresh vegetables • • High in low fat dairy products • High in dietary and soluble fibre • High in plant protein • • Low in saturated fat and cholesterol • Low in sodium www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php

23. Potential Benefits of a Wide Spread Reduction in Dietary Sodium in Canada REDUCTION IN AVERAGE DIETARY SODIUM FROM ABOUT 3500 MG TO 1700 MG • 1 million fewer hypertensives • 5 million fewer physicians visits a year for hypertension • Health care cost savings of $430 to 540 million per year related to fewer office visits, drugs and laboratory costs for hypertension • Improvement of the hypertension treatment and control rate • 13% reduction in CVD • Total health care cost savings of over $1.3 billion/year

24. Recommendations for daily salt intake Less than: • 2,300 mg sodium (Na) • 100 mmol sodium (Na) • 5.8 g of salt (NaCl) • 1 teaspoon of table salt 2,300 mg sodium = 1 level teaspoon of table salt however, 80% of average sodium intake is in processed foods and only 10% is added at the table or in cooking

25. Sodium: Meta-analyses Hypertensives Reduction of BP 5.1 / 2.7 mmHg with a average reduction of 1800 mg sodium/day 7.2/3.8 mmHg with a average reduction of 2300 mg sodium/day Normotensives Reduction of BP 2.0 / 1.0 mmHg with a average reduction of sodium 1700 mg/day 3.6/1.7 mmHg with a average reduction of 2300 mg/day sodium The Cochrane Library 2006;3:1-41

26. Meta analysis on different reductions in dietary sodium intake on blood pressure Hypertension 2003;42:1093-1099

27. 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

28. Hypertensive and all patients • BMI over 25 • - Encourage weight reduction • Healthy BMI: 18.5-24.9 kg/m2 • Waist Circumference Men Women • - Europid, Sub-Saharan African, Middle Eastern <94 cm <80 cm • - South Asian, Chinese, Japanese <90 cm <80 cm • 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 behaviour modification Lifestyle Recommendations for Hypertension: Weight LossHeight, weight, and waist circumference (WC) should be measured and body mass index (BMI) calculated for all adults. CMAJ 2007;176:1103-6

29. Waist Circumference Measurement Last rib margin Mid distance Iliac crest Courtesy J.P. Després 2006

30. 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).

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

32. 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

33. Lifestyle Therapies in Hypertensive Adults: Summary

34. 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

35. Pharmacotherapy

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

37. 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

38. ARB ACEI V. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling Indications TARGET <140/90 mmHg INITIAL TREATMENT AND MONOTHERAPY Lifestyle modification therapy A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target Thiazide Long-acting CCB Beta-blocker* • BBs are not indicated as first line therapy for age 60 and above ACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential

39. V.Considerations Regarding the Choice of First-Line Therapy • Use caution in initiating therapy with 2 drugs in whom adverse events are more likely (e.g. frail elderly, those with postural hypotension or who are dehydrated). • ACE inhibitors, renin 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 and over without another compelling indication. • Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agent if required. • The use of combination of ACE inhibitor with a ARB should only be considered in selected and closely monitored people with advanced heart failure or proteinuric nephropathy. • ACE-I are not recommended (as monotherapy)for black patients without another compelling indication.

40. 1. Add-on Therapy • IF BLOOD PRESSURE IS NOT CONTROLLED CONSIDER • Nonadherence • Secondary HTN • Interfering drugs or lifestyle • White coat effect 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).

41. 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 Combinations of an ACEI with an ARB do not reduce cardiovascular events more than the ACEI alone and have more adverse effects therefore are not generally recommended

42. 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 serum 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.

43. Medication Use and BP Control in ALLHAT  <140/90 mm Hg Cushman et al. J Clin Hypertens 2002;4:393-404.

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

45. BP lowering effects from antihypertensive drugs Dose response curves for efficacy are relatively flat 80% of the BP lowering efficacy is achieved at half-standard dose Combinations of standard doses have additive blood pressure lowering effects Law. BMJ 2003

46. V. Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications Long-acting CCB Beta-blocker* Thiazide diuretic ACEI ARB TARGET <140/90 mmHg Lifestyle modification A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target Initial therapy Dual Combination • CONSIDER • Nonadherence • Secondary HTN • Interfering drugs or lifestyle • White coat effect *Not indicated as first line therapy over 60 y Triple or Quadruple Therapy

47. 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

48. 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).

49. 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

50. 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