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2012心房颤动：目前的认识和治疗建议

来源：乌哈旅游

CanadianJournalofCardiology28(2012)270–287

Guidelines

The2012CanadianHypertensionEducationProgramRecommendationsfortheManagementofHypertension:BloodPressureMeasurement,Diagnosis,Assessmentof

Risk,andTherapy

StellaS.Daskalopoulou,MD,PhD,aNadiaA.Khan,MD,MSc,bRobertR.Quinn,MD,PhD,cMarcelRuzicka,MD,PhD,dDonaldW.McKay,PhD,eDanielG.Hackam,MD,PhD,fSimonW.Rabkin,MD,gDoreenM.Rabi,MD,MSc,hRichardE.Gilbert,MD,PhD,iRajS.Padwal,MD,MSc,jMartinDawes,MBBS,MD(Lond),kRhianM.Touyz,MD,PhD,lTavisS.Campbell,PhD,mLyneCloutier,RN,PhD,nStevenGrover,MD,MPA,oGeorgeHonos,MD,pRobertJ.Herman,MD,qErnestoL.Schiffrin,MD,PhD,rPeterBolli,MD,sThomasWilson,MD,tRossD.Feldman,MD,uM.PatriceLindsay,BScN,PhD,vBrendaR.Hemmelgarn,MD,PhD,cMichaelD.Hill,MD,MSc,wMarkGelfer,MD,xKevinD.Burns,MD,dMichelVallée,MD,PhD,yG.V.RameshPrasad,MBBS,MSc,zMarcelLebel,MD,aaDonnaMcLean,RN,MN,NP,PhD(c),bbJ.MalcolmO.Arnold,MD,ccGordonW.Moe,MD,MSc,ddJonathanG.Howlett,MD,eeJean-MartinBoulanger,MD,ffPierreLarochelle,MD,ggLawrenceA.Leiter,MD,hhCharlotteJones,MD,PhD,iiRichardI.Ogilvie,MD,jjVincentWoo,MD,kkJanuszKaczorowski,PhD,llLucTrudeau,MD,mmSimonL.Bacon,PhD,nnRobertJ.Petrella,MD,PhD,ooAlainMilot,MD,MSc,ppJamesA.Stone,MD,PhD,qqDenisDrouin,MD,rrMaximeLamarre-Cliché,MD,ssMarshallGodwin,MD,MSc,ttGuyTremblay,MD,uuPavelHamet,MD,PhD,vvGeorgeFodor,MD,PhD,wwS.GeorgeCarruthers,MD,xxGeorgePylypchuk,MD,yyEllenBurgess,MD,cRichardLewanczuk,MD,zzGeorgeK.Dresser,MD,PhD,aaaBrianPenner,MD,bbbRobertA.Hegele,MD,cccPhilipA.McFarlane,MD,PhD,dddMukulSharma,MD,MSc,eeeNormanR.C.Campbell,MD,fffDebraReid,PhD,RD,gggLucPoirier,BPharm,MSc,hhhand

SheldonW.Tobe,MD;iiifortheCanadianHypertensionEducationProgram

ReceivedforpublicationFebruary11,2012.AcceptedFebruary24,2012.Correspondingauthor:DrStellaS.Daskalopoulou,McGillUniversity,McGillUniversityHealthCentre,MontrealGeneralHospital,1650CedarAvenue,B2.101.4,Montreal,QuébecH3G1A4,Canada.Tel.:ϩ514-934-1934ϫ42295;fax:ϩ514-934-8564.

E-mail:stella.daskalopoulou@mcgill.ca

Seepage285fordisclosureinformation.

Aversionofthehypertensionrecommendationsdesignedforpatientandpubliceducationhasbeendevelopedtoassisthealthcarepractitionersmanaginghypertension.Thesummaryisavailableelectronically(gotohttp://www.hypertension.caorhttp://www.heartandstroke.ca).

Daskalopoulouetal.

2012CanadianRecommendationsforHighBP

DivisionofGeneralInternalMedicine,McGillUniversity,Montreal,Québec,Canada;bDivisionofGeneralInternalMedicine,UniversityofBritishColumbia,Vancouver,BritishColumbia,Canada;cDivisionofNephrology,UniversityofCalgary,Calgary,Alberta,Canada;dDivisionofNephrology,UniversityofOttawa,Ottawa,Ontario,Canada;eFacultyofMedicine,MemorialUniversityofNewfoundland,StJohn’s,NewfoundlandandLabrador,Canada;fDepartmentofMedicineandEndocrinology,UniversityofWesternOntario,London,Ontario,Canada;gDivisionofCardiology,UniversityofBritishColumbia,Vancouver,BritishColumbia,Canada;hDepartmentsofMedicine,CommunityHealthandCardiacSciences,UniversityofCalgary,Calgary,Alberta,Canada;iStMichael’sHospital,UniversityofToronto,Toronto,Ontario,Canada;jDivisionofGeneralInternalMedicine,UniversityofAlberta,Edmonton,Alberta,Canada;kDepartmentofFamilyMedicine,UniversityofBritishColumbia,Vancouver,BritishColumbia,Canada;lOttawaHospitalResearchInstitute,UniversityofOttawa,Ottawa,Ontario,Canada;mDepartmentofPsychology,UniversityofCalgary,Calgary,Alberta,Canada;nDepartmentofNursing,UniversitéduQuébecàTrois-Rivières,Québec,Canada;oDivisionofClinicalEpidemiology,MontrealGeneralHospital,Montreal,Québec,Canada;pDivisionofCardiology,SirMortimerB.Davis-JewishGeneralHospital,Montreal,Québec,Canada;qDepartmentofMedicine,UniversityofCalgary,Calgary,Alberta,Canada;rDepartmentofMedicine,SirMortimerB.Davis-JewishGeneralHospital,McGillUniversity,Montreal,Québec,Canada;sAmbulatoryInternalMedicineTeachingClinic,StCatharines,Ontario,Canada;tDepartmentofMedicine,UniversityofSaskatchewan,Saskatoon,Saskatchewan;Canada;uDepartmentofMedicine,UniversityofWesternOntario,London,

Ontario,Canada;vCanadianStrokeNetwork,Toronto,Ontario,Canada;wDepartmentsofClinicalNeurosciences,MedicineandCommunityHealthSciences,UniversityofCalgary,Calgary,Alberta,Canada;xVancouver,BritishColumbia,Canada;yDivisionofNephrology,HôpitalMaisonneuve-Rosemont,UniversitédeMontréal,Montreal,Québec,Canada;zDivisionofNephrology,UniversityofToronto,Toronto,Ontario,Canada;aaCHUQ,L’Hôtel-DieudeQuébec,DepartmentofMedicine,l’UniversitéLaval,Québec,Québec,Canada;bbFacultyofNursing,UniversityofAlberta,Edmonton,Alberta,Canada;ccLondonHealthSciencesCentre,UniversityofWesternOntario,London,Ontario,Canada;ddUniversityHealthNetwork,UniversityofToronto,Toronto,Ontario,Canada;eeQueenElizabethIIHealthSciencesCentre,Halifax,NovaScotia,Canada;ffCharlesLeMoyneHospitalResearchCentre,UniversityofSherbrooke,Sherbrooke,Québec,Canada;ggInstitutderecherchéCliniquedeMontréal,Montréal,Québec,Canada;hhDivisionofEndocrinologyandMetabolismand

KeenanResearchCentreattheLiKaShingKnowledgeInstitute,StMichael’sHospital,Toronto,Ontario,Canada;iiDivisionofEndocrinology,DepartmentofMedicine,UniversityofCalgary,Calgary,Alberta,Canada;jjUniversityHealthNetwork,UniversityofToronto,Toronto,Ontario,Canada;kkDivisionofEndocrinology&Metabolism,UniversityofManitoba,Winnipeg,Manitoba,Canada;llDépartementdemédecinefamilialeetmédecined’urgence,UniversitédeMontréal,Montréal,Québec,Canada;mmDepartmentofMedicine,McGillUniversity,Montréal,Québec,Canada;nnDepartmentofExerciseScience,ConcordiaUniversity,Montréal,Québec,Canada;ooLawsonHealthResearchInstitute,UniversityofWesternOntario,London,Ontario,Canada;ppDepartmentofMedicine,UniversiteLaval,Québec,Québec,Canada;qqDivisionofCardiology,DepartmentofMedicine,UniversityofCalgary,Calgary,Alberta,Canada;rrDepartmentofFamilyMedicine,UniversitéLaval,Québec,Québec,Canada;ssInstitutderecherchéCliniquedeMontréal,Montréal,Québec,Canada;ttPrimaryHealthcareResearchUnit,MemorialUniversityofNewfoundland,StJohn’s,NewfoundlandandLabrador,Canada;uuUniversitéLaval,DirectiondelaSantépubliqueϪ03,Québec,Québec,Canada;vvFacultédeMédicine,UniversitédeMontréal,Montréal,Québec,Canada;wwPreventionandRehabilitationCentre,UniversityofOttawaHeartInstitute,Ottawa,Ontario,Canada;xxLisburn,NorthernIreland;yyDivisionofNephrology,StPaul’sHospital,UniversityofSaskatchewan,Saskatoon,Saskatchewan,Canada;zzUniversityofAlberta,

Edmonton,Alberta,Canada;aaaDepartmentofMedicine,UniversityofWesternOntario,London,Ontario,Canada;bbbDepartmentofPharmacologyandTherapeutics,UniversityofManitoba,Winnipeg,Manitoba,Canada;cccSchulichSchoolofMedicineandDentistry,UniversityofWesternOntario,London,Ontario,Canada;dddDivisionofNephrology,StMichael’sHospital,UniversityofToronto,Toronto,

Ontario,Canada;eeeTheCanadianStrokeNetwork,TheOttawaHospital,Ottawa,Ontario,Canada;fffDepartmentsofMedicine,CommunityHealthSciences,andPharmacologyandTherapeutics,UniversityofCalgary,Calgary,Alberta,Canada;gggCanadianForcesHealthServicesGroup,DepartmentofNationalDefence,Ottawa,Ontario,Canada;hhhHypertensionUnitandPharmacyDepartment,

CHUQ,Québec,Québec,Canada;iiiDivisionofNephrology,UniversityofToronto,Toronto,Ontario,Canada

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ABSTRACT

Weupdatedtheevidence-basedrecommendationsforthediagnosis,assessment,prevention,andtreatmentofhypertensioninadultsfor2012.Thenewrecommendationsare:(1)useofhomebloodpressuremonitoringtoconﬁrmadiagnosisofwhitecoatsyndrome;(2)miner-alocorticoidreceptorantagonistsmaybeusedinselectedpatientswithhypertensionandsystolicheartfailure;(3)ahistoryofatrialﬁbrillationinpatientswithhypertensionshouldnotbeafactorindecidingtoprescribeanangiotensin-receptorblockerforthetreat-mentofhypertension;and(4)thebloodpressuretargetforpatientswithnondiabeticchronickidneydiseasehasnowbeenchangedtoϽ140/90mmHgfromϽ130/80mmHg.Wealsoreviewedtherecentevidenceonbloodpressuretargetsforpatientswithhypertensionanddiabetesandcontinuetorecommendabloodpressuretargetoflessthan130/80mmHg.

RÉSUMÉ

Nousavonsmisàjourlesrecommandationsfactuellesencequiatraitaudiagnostic,àl’évaluation,àlapréventionetautraitementdel’hypertensionchezlesadultespour2012.Lesnouvellesrecomman-dationssont:1)l’utilisationdelamesuredelapressionartérielleàdomicilepourconﬁrmerundiagnosticde«syndromedelablouseblanche»;2)lesantagonistesdurécepteurminéralocorticoïdepeu-ventêtreutiliséschezdespatientsayantdel’hypertensionetuneinsufﬁsancecardiaquesystolique;3)unantécédentdeﬁbrillationau-riculairechezlespatientsayantdel’hypertensionnedevraitpasêtreunfacteurdedécisionpourprescrireuninhibiteurdurécepteurdel’angiotensinedansletraitementdel’hypertension;4)lapressionartériellecibledespatientsnondiabétiquesayantunemaladierénalechroniqueestmaintenantdeϽ140/90mmHgaulieudeϽ130/90mmHg.Nousavonsaussirevulesdonnéesrécentessurlapressionartériellecibledespatientsayantdel’hypertensionetundiabète,etnouscontinuonsderecommanderunepressionartériellecibledemoinsde130/80mmHg.

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ExecutiveSummary

Objective:Toupdatetheevidence-basedrecommenda-tionsfortheprevention,diagnosis,assessment,andtreatmentofhypertensioninadultsfor2012.

OptionsandOutcomes:Forlifestyleandpharmacologicin-terventions,randomizedtrialsandsystematicreviewsoftrialswerepreferentiallyreviewed.Changesincardiovascularmorbidityandmortality,aswellastotalmortalityweretheprimaryoutcomesofinterest.However,forlifestyleinterventions,bloodpressurelow-eringwasacceptedasaprimaryoutcome,andprogressiverenalimpairmentwasalsoacceptedasaclinicallyrelevantprimaryout-comeamongpatientswithchronickidneydisease.

Evidence:ACochraneCollaborationlibrarianconductedanindependentMEDLINEsearchuptoAugust2011toupdatethe2011recommendations.Toidentifyadditionalstudies,referencelistswerereviewedandexpertswerecontacted.Allrelevantarticleswerereviewedandappraisedindependentlybybothcontentandmethodologyexpertsusingprespeciﬁedlevelsofevidence.RecommendationsDiagnosisandassessment

Anewrecommendationthisyearrelatestothediagnosisofwhitecoathypertension,whichcouldbeconﬁrmedeitherbyreliablerepeatedhomebloodpressure(BP)monitoringor24-hourambulatoryBPmonitoring(ABPM).RecommendationsforBPmeasurement,criteriaforhypertensiondiagnosisandfollow-up,assessmentofglobalcardiovascularrisk,diagnostictesting,diagnosisofrenovascularandendocrinecausesofhy-pertension,ambulatorymonitoring,andtheuseofechocardi-ographyinhypertensiveindividualsareunchanged.Preventionandtreatment

Newrecommendationsinclude:(1)aldosteroneantagonistsarerecommendedforhypertensionandsystolicheartfailureinadditiontothesuggestedtherapy;(2)ahistoryofatrialﬁbril-lation(AF)inpatientswithhypertensionshouldnotbeafactorindecidingtoprescribeanangiotensin-receptorblocker(ARB)forthetreatmentofhypertension;(3)fromarereviewoftheevidence,BPtargetsforpatientswithnondiabeticchronickid-neydisease(CKD)isnowϽ140/90mmHginsteadofϽ130/80mmHg;(4)TheBPtargetforpatientswithhyperten-sionanddiabetesmellitusdidnotchange(Ͻ130/80mmHg)basedonevaluationofrecentmeta-analyses.Recommenda-tionsonlifestylemodiﬁcationstopreventandtreathyperten-sion,indicationsforpharmacologicmanagementofhyperten-sion,treatmentthresholdsandtargets,choiceoftherapyforadultswithhypertensionandwithoutcompellingindicationsforotheragents,isolatedsystolichypertension,cerebrovasculardisease,proteinuricnondiabeticCKD,ischemicheartdisease,leftventricularhypertrophy,diabetes,andglobalvascularpro-tectionhavenotchanged.Treatmentforpheochromocytoma,primaryhyperaldosteronism,andstrategiestoimproveantihy-pertensivemedicationadherenceareunchanged.Validation

Allrecommendationsweregradedaccordingtothestrengthoftheevidenceandvotedonbythe65membersoftheCana-dianHypertensionEducationProgram(CHEP)Recommen-dationsTaskForce.Allrecommendationsreportedherein

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achievedatleast80%consensus.CHEPwillcontinuetoup-daterecommendationsannually.Allrecommendationsareoutlinedinthisdocument.

Introduction

Hypertensionaffects27%oftheCanadianadultpopula-tionaged35-64years1andover50%ofpeopleaged65yearsandolder.2,3HypertensionremainsoneofthemostcommonmodiﬁableriskfactorsforcardiovasculardiseaseinCanadaandglobally.4,5Eachyear,numerousstudiesarepublishedthatmayaffecttheclinicalpracticeofhypertension.TheobjectiveoftheannualupdatesontheCHEPrecommendationsistoprovidetimelyevidence-basedrecommendationstoprimarycarepro-viderstoimprovehypertensionprevention,detection,andcontrolinCanadians.Keyclinicalquestionsaddressedinclude:(1)Howishypertensiondiagnosed?(2)Howdowediagnosewhitecoathypertension?(3)Whatfrequencyoffollow-upandlaboratorytestingisnecessaryforhypertensivepatients?(4)Howisriskassessedforfuturecardiovasculareventsinthesepatients?(5)Whenshouldwestartpharmacologicaltherapytocontrolhypertension?(6)WhatBPlevelshouldbeattainedinhypertensivepatientsandinpatientswithcoexistingdiabetesorCKD?(7)Whatlifestyleinterventionsareeffectiveinpre-ventinghypertensionandreducingBP?(8)Whataretheopti-malpharmacologicalagentsfortreatmentofhypertension,aswellashypertensionoccurringinpatientswithspeciﬁccomor-bidconditions,includingdiabetes,cardiovasculardisease,stroke,orkidneydisease?(9)Howcanweimproveadherencetoantihypertensivemedications?(10)Howdowediagnoseandtreatsecondarycausesofhypertension,renovascularhy-pertension,pheochromocytoma,andhyperaldosteronism?Inthisdocument,weoutlinealloftherecommendationsanddiscusstheevidenceandrationaleonthoserecommenda-tionsthatareneworupdated.MoredetaileddiscussionofpreviouschangestotheCanadianrecommendationsisavail-ableinpriorpublications.6-17Thisyear,therecommendationsunderwentsigniﬁcantrevisionbasedonrecentlypublishedtrialsandrereviewofearlierstudies:EplerenoneinMildPatientsHos-pitalizationandSurvivalStudyinHeartFailure(EMPHASIS-HF)trial,18EplerenonePost-AcuteMyocardialInfarctionHeartFailureEfﬁcacyandSurvivalStudy(EPHESUS),1920andRandomizedAldactoneEvaluationStudy(RALES)fortheheartfailurerecommendation;AtrialFibrillationClopidogrelTrialWithIrbesartanforPreventionofVascularEvents(ACTIVEI),21AngiotensinIIAntagonistinParoxysmalAtrialFibrillation(ANTIPAF)22andGruppoItalianoperloStudiodellaSopravvivenza23nell’InfartoMiocardico-AtrialFibrillation(GISSI-AF),forAF;AfricanAmericanStudyofKidneyDis-easeandHypertension(AASK)follow-upextensiontrial,24-26RamiprilEfﬁcacyinNephropathy-2(REIN-2),27andModiﬁ-cationofDietinRenalDisease(MDRD)28,29trialsfortheBPtargetsforCKD;and2meta-analysesoflargeclinicaltrialsrecentlypublished30,31onBPtreatmenttargetsforpatientswithdiabetes.Also,theevidencebasefordiagnosingwhitecoathypertensionusinghomeBPmonitoringwasreviewed.

Theserecommendationsaretargetedtowardprimarycareprovidersandapplytoadultsatriskfororwithhypertension.ForissuesrelatedtothediagnosisandevaluationofhighBPinchildrenand32adolescents,thereaderisreferredtoseparateguidelines.Aversionofthehypertensionrecommendations

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2012CanadianRecommendationsforHighBP

designedforpatientandpubliceducationhasbeendevelopedtoassisthealthcarepractitionersmanaginghypertension.Thesummaryisfreelyavailableat:http://www.hypertension.ca.Althoughwementionindividualantihypertensiveagentswhendiscussingtrials,thereadermayassumethatalldrug-speciﬁcrec-ommendationsareapplicabletotheentiredrugclassinquestion,unlessotherwisestated.Finally,althoughtheserecommendationsarebasedonbestevidence,healthcareprovidersmustalsousetheirownclinicaljudgementandconsiderpatientpreferenceswhenapplyingtheserecommendationsfortheirpatients.Methods

ACochraneCollaborationlibrarianconductedaMEDLINE/PubMedsearchusingtextwordsandMeSHheadings(copiesofthedifferentstrategiesareavailableuponrequest).Commonsearchtermswerehypertension[MeSH],hypertens*[ti,ab],andbloodpressure,whichwerethencombinedwithtermsforthespeciﬁcconcepteachsubgroupinvestigated.AhighlysensitivesearchstrategyforrandomizedtrialsandsystematicreviewspublisheduptoAugust2011wasused,andinordertoensurethatallrelevantstudieswereincluded,bibliogra-phiesofidentiﬁedarticleswerealsomanuallysearched(de-tailsofsearchstrategiesandretrievedarticlesareavailableonrequest).Studieswereselectediftheyincludedtherelevantoutcomes.Theoutcomesprimarilyconsideredincludedchangesincardiovascularmorbidityandmortalityaswellastotalmortality.However,BPloweringwasacceptedasaprimaryoutcomeforlifestylemodiﬁcationrecommenda-tionsandprogressiverenalimpairmentwasalsoacceptedforpatientswithCKD.Randomizedcontrolledtrials(RCTs)andsystematicreviewsofrandomizedtrialswereselectedfortreatmentrecommendationsandcrosssectionalandcohortstudieswerereviewedforassessingdiagnosisandprognosis.Studycharacteristicsandstudyqualitywereassessedusingpre-speciﬁed,standardizedalgorithmsforRCTsandcohortstudiesdevelopedbyCHEP.33Draftrecommendationsweredevelopedforeachsectionbynationalandinternationalhypertensionexpertsbasedonreviewofallidentiﬁedarticlesrelevanttotheirtopicarea(seeSupplementalAppendixS1).MembersoftheCanadianDiabetesAssociationGuidelinesCommittee,CanadianSo-cietyofNephrology,CanadianStrokeNetwork,andtheCanadianCardiovascularHarmonizedNationalGuidelineEndeavourInitiativealsocollaboratedwithCHEPsub-groupmembersforthedevelopmentof2012draftrecom-mendationstoensureharmonizedhypertensionrecommen-dationsbetweenguidelines.Cardiovascularandmortalitybeneﬁtsaswellasadverseeffectsandriskswereconsideredwhenformulatingthedraftrecommendations.Costswerenotconsidered.Subsequently,thecentralreviewcommitteecomposedofclinicalepidemiologists,revieweddraftrecom-mendationsfromeachsubgroupand,inaniterativeprocess,helpedtoreﬁneandstandardizeallrecommendationsandtheirgradingacrosssubgroups;recommendationswereclas-siﬁedaccordingtothestrengthofevidence(fordetails,seeTable1),rangingfromA(strongestevidence,high-preci-sionrandomizedclinicaltrials)toD(expertopinionalone).CHEPmembersthendiscussedandvettedthedraftrecom-mendationsandevidencefromeachsubgroupatthe2012consensusconferenceheldinAlliston,Ontario.Basedon

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Table1.GradingschemeforrecommendationsGradeA

Recommendationsarebasedonrandomizedtrials(orsystematicreviewsoftrials)withhighlevelsofinternalvalidityandstatisticalprecision,andforwhichthestudyresultscanbedirectlyappliedtopatientsbecauseofsimilarclinicalcharacteristicsandtheclinicalrelevanceofthestudyoutcomes.

GradeB

Recommendationsarebasedonrandomizedtrials,systematicreviewsorpre-speciﬁedsubgroupanalysesofrandomizedtrialsthathavelowerprecision,orthereisaneedtoextrapolatefromstudiesbecauseofdifferingpopulationsorreportingofvalidatedintermediate/surrogateoutcomesratherthanclinicallyimportantoutcomes.

GradeC

Recommendationsfromtrialsthathavelowerlevelsofinternalvalidityand/orprecision,orreportunvalidatedsurrogateoutcomes,orresultsfromnonrandomizedobservationalstudies.

GradeD

Recommendationsarebasedonexpertopinionalone.

thedeliberationsattheconsensusconference,the2012rec-ommendationswereﬁnalizedandthensubmittedtoall65votingmembersoftheCHEPEvidence-BasedRecommen-dationsTaskForceforapproval.ExternalobserversfromtheCanadianAgencyforDrugsandHealth,theBrazilianSocietyofCardiology,andthePublicHealthAgencyofCanadawerealsopresentattheconsensusmeeting.Memberswithconﬂictsofinterestwererecusedfromvotingonthespeciﬁcrec-ommendations(alistofconﬂictscanbefoundinSupplementalAppendixS2).Recommendationswereﬁnalizedafterachievingconsensus,deﬁnedasrecommendationsapprovedbyϾ70%ofthetaskforce.Intheactualvote,allrecommendationsreceivedatleast80%approval.

The2012CHEPDiagnosisandAssessmentRecommendations

I.AccuratemeasurementofBPRecommendations1.HealthcareprofessionalswhohavebeenspeciﬁcallytrainedtomeasureBPaccuratelyshouldassessBPinalladultpa-tientsatallappropriatevisitstodeterminecardiovascularriskandmonitorantihypertensivetreatment(GradeD).2.Useofstandardizedmeasurementtechniques(seeSupple-mentalTableS1)isrecommendedwhenassessingBP(GradeD).

3.AutomatedofﬁceBPmeasurements(OBPM)canbeusedintheassessmentofofﬁceBP(GradeD).

4.Whenusedinproperconditions,automatedofﬁcesystolicBP(SBP)ofՆ135mmHgordiastolicBP(DBP)ofՆ85mmHgshouldbeconsideredanalogoustomeanawakeambulatorySBPofՆ135mmHgandDBPofՆ85mmHg,respectively(GradeD).

Background.SeveralautomatedOBPMdeviceshavebeenin-dependentlyvalidatedforclinicalaccuracy,includingtheBpTRUautomaticBPmonitor,theBPM-100electronicoscillo-metricofﬁceBPmonitor(VSMMedTechLtd,Vancouver,BC),andtheOmronofﬁcedigitalBPHEM-907monitor(OmronHealthcareInc,LakeForest,IL).34-36However,furtherresearchisneededtodeterminewhetherautomatedOBPMaccuratelypre-dictfuturetargetorgandamageandcardiovasculareventsbetterthanmanualOBPM.CHEPisactivelyevaluatingthisarea.

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Figure1.Theexpeditedassessmentanddiagnosisofpatientswithhypertension:focusonvalidatedtechnologiesforBPassessment.**ThresholdsrefertoBPvaluesaveragedacrossthecorrespondingnumberofvisitsandnotjustthemostrecentofﬁcevisit.ABPM,ambulatoryBPmeasurement;BP,bloodpressure(mmHg);DBP,diastolicBP(mmHg);HBPM,homeBPmeasurement;HTN,hypertension;OBPM,ofﬁceBPmeasurement;SBP,systolicBP(mmHg).ReprintedwithpermissionfromtheCanadianHypertensionEducationProgram.

II.Criteriafordiagnosisofhypertensionandrecommendationsforfollow-up(Fig.1)Recommendations1.Atinitialpresentation,patientsdemonstratingfeaturesofahypertensiveurgencyoremergency(Table2)shouldbedi-agnosedashypertensiveandrequireimmediatemanage-ment(GradeD).

2.IfSBPisՆ140mmHgand/orDBPisՆ90mmHg,aspeciﬁcvisitshouldbescheduledfortheassessmentofhy-pertension(GradeD).IfBPishigh-normal(SBP130-139mmHgand/orDBP85-89mmHg),annualfollow-upisrecommended(GradeC).

3.Attheinitialvisitfortheassessmentofhypertension,ifSBPisՆ140and/orDBPisՆ90mmHg,morethan2addi-tionalreadingsshouldbetakenduringthesamevisitusingavalidateddeviceandaccordingtotherecommendedpro-cedureforaccurateBPdetermination(seeSupplementalTableS1).Theﬁrstreadingshouldbediscardedandthelatter2readingsaveraged.Ahistoryandphysicalexamina-

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2012CanadianRecommendationsforHighBP

Table2.ExamplesofhypertensiveurgenciesandemergenciesAsymptomaticdiastolicBPՆ130mmHgSevereelevationofBPinthesettingofanyof:HypertensiveencephalopathyAcuteaorticdissection

AcuteleftventricularfailureAcutecoronarysyndromeAcutekidneyinjuryIntracranialhemorrhageAcuteischemicstrokeEclampsiaofpregnancy

BP,bloodpressure.

ReprintedwithpermissionoftheCanadianHypertensionEducationProgram.

tionshouldbeperformedand,ifclinicallyindicated,diag-nosticteststosearchfortargetorgandamage(Table3)andassociatedcardiovascularriskfactors(Table4)shouldbearrangedwithin2visits.Exogenousfactorsthatcaninduceoraggravatehypertensionshouldbeassessedandremovedifpossible(Table5).Visit2shouldbescheduledwithin1month(GradeD).

4.Atvisit2fortheassessmentofhypertension,patientswithmacrovasculartargetorgandamage,diabetesmellitus,orCKD(glomerular2ﬁltrationrate[GFR]Ͻ60mLpermin-uteper1.73m5.ՆAt140visitmm2forHg)theand/orcanbeassessmentDBPdiagnosedofishypertension,Ն90ashypertensivemmHgpatients(GradeifSBPwithoutD).ismacrovasculartargetorgandamage,diabetesmellitus,orCKDcanbediagnosedashypertensiveiftheSBPisՆ180mmHgand/ortheDBPisՆ110mmHg(GradeD).Patientswithoutmacrovasculartargetorgandamage,diabetesmellitus,orCKDbutwithlowerBPlevelsshouldundergofurtherevaluationusinganyofthe3approachesoutlinednext:

i.OBPM:UsingmanualOBPM,patientscanbediagnosedasՆhypertensive100mmHgifaveragedtheSBPisacrossՆ160themmﬁrstHg3visits,ortheorDBPifthe

isTable3.Examplesoftargetorgandamage

CerebrovasculardiseaseStroke

IschemicstrokeandtransientischemicattackIntracerebralhemorrhage

AneurysmalsubarachnoidhemorrhageDementia

Vasculardementia

MixedvasculardementiaanddementiaoftheAlzheimer’stypeHypertensiveretinopathyLeftventriculardysfunctionLeftventricularhypertrophyCoronaryarterydiseaseMyocardialinfarctionAnginapectoris

CongestiveheartfailureRenaldisease

Chronickidneydisease(GFRϽ60mLperminuteper1.73m2)Albuminuria

PeripheralarterydiseaseIntermittentclaudicationGFR,glomerularﬁltrationrate.

ReprintedwithpermissionoftheCanadianHypertensionEducationProgram.

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Table4.Examplesofkeycardiovascularriskfactorsforatherosclerosis

NonmodiﬁableAgeՆ55yearsMale

Familyhistoryofprematurecardiovasculardisease(ageϽ55inmenandϽ65inwomen)Modiﬁable

SedentarylifestylePoordietaryhabitsAbdominalobesityDysglycemiaSmokingDyslipidemiaStress

NonadherencePriorhistoryofclinicallyovertatheroscleroticdiseaseindicatesaveryhighriskforarecurrentatheroscleroticevent(eg,peripheralarterialdisease,previ-ousstroke,ortransientischemicattack).

ReprintedwithpermissionoftheCanadianHypertensionEducationProgram.

SBPaveragesՆ140mmHgortheDBPaveragesՆ90mmHgaveragedacross5visits(GradeD).

ii.ABPM:UsingABPM(seeRecommendationinsectionVIII.ABPM),patientscanbediagnosedashypertensiveifՆthemeanawakeSBPisՆ135mmHgortheDBPHg85ormmtheHgDBPorisifՆthe80meanmm24-hourHg(GradeSBPC).

isՆ130mmisiii.HomeBPmonitoring(HBPM):UsingHBPM(see

RecommendationinsectionVII.HBPM),patientscanbediagnosedashypertensiveiftheaverageSBPisՆ135mmHgortheDBPisՆ85mmHg(GradeC).IftheaverageHBPMisϽ135/85mmHg,itisadvisabletoeitherrepeathomemonitoringtoconﬁrmtheHBPMisϽ135/85mmHgorperform24-hourABPMtoconﬁrmthatthemean24-hourABPMisϽ130/80mmHgandthemeanawakeABPMisϽ135/85mmHgbeforediagnosingwhitecoathypertension(GradeD).

6.Investigationsforsecondarycausesofhypertensionshouldbeinitiatedinpatientswithsuggestiveclinicaland/orlabo-ratoryfeatures(outlinedlater)(GradeD).

Table5.Examplesofexogenousfactorsthatcaninduce/aggravatehypertension

Prescriptiondrugs

NSAIDs,includingcoxibs

CorticosteroidsandanabolicsteroidsOralcontraceptiveandsexhormones

Vasoconstricting/sympathomimeticdecongestantsCalcineurininhibitors(cyclosporin,tacrolimus)Erythropoietinandanalogues

Antidepressants:MAOIs,SNRIs,SSRIsMidodrineOthersubstancesLicoriceroot

StimulantsincludingcocaineSalt

Excessivealcoholuse

MAOIs,monoamineoxidaseinhibitors;NSAIDs,nonsteroidalanti-inﬂammatorydrugs;SNRIs,serotonin-norepinephrinereuptakeinhibi-tors;SSRIs,selectiveserotoninreuptakeinhibitors.

ReprintedwithpermissionoftheCanadianHypertensionEducationProgram.

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7.Ifatthelastdiagnosticvisitthepatientisnotdiagnosedashyper-tensiveandhasnoevidenceofmacrovasculartargetorgandamage,thepatient’sBPshouldbeassessedatyearlyintervals(GradeD).8.Hypertensivepatientsreceivinglifestylemodiﬁcationadvicealone(nonpharmacologicaltreatment)shouldbefollowedupat3-to6-monthintervals.Shorterintervals(every1or2months)areneededforpatientswithhigherBP(GradeD).9.Patientsgivenantihypertensivedrugtreatmentshouldbeseenmonthlyorevery2months,dependingonthelevelofBP,untilreadingson2consecutivevisitsarebelowtheirtarget(GradeD).Shorterintervalsbetweenvisitswillbeneededforsymp-tomaticpatientsandthosewithseverehypertension,intoler-ancetoantihypertensivedrugs,ortargetorgandamage(gradeD).WhenthetargetBPhasbeenreached,patientsshouldbeseenat3-to6-monthintervals(gradeD).

Background.Whitecoathypertensionisassociatedwithabet-tercardiovascularprognosiscomparedwiththosewithelevatedBPattheofﬁceandinnonofﬁcesettings.37However,diagnos-ingwhitecoathypertensionischallengingandhasreliedon24-hourABPMtoconﬁrmitsdiagnosis.Thereisnowcumu-lativeevidencetoindicatethatrepeatedHBPMprovidessig-niﬁcantprognosticaccuracytobeusedinconﬁrmingwhitecoathypertension.Recentevidencefrom163subjectsenrolledinanobservationalstudysuggeststhatHBPMdemonstratedthelowestvariability38whencomparedwithofﬁceandambula-torymonitoring.Within-personvariabilityimprovedwithlongerself-monitoringdurationandlowerintervalsbetweenmonitoring;thelowestcoefﬁcientsofvariation(2.7%)wasachievedafter4weeksofmonitoringwithoutintervals,andthehighest(6.1%)whentherewasa10-weekintervalinatotalof1weekdurationofmeasurements.AlthoughitisrecognizedthatneitherHBPMnorABPMareperfectlyreproducibleandhavemoderatediagnosticagreement,patientswithwhitecoathypertensiondiagnosedbyeitherHBPMorawake-ABPMwereshowntohaveamorefavourableriskproﬁleandlesstargetorgandamagethanthosewithsustainedhypertension,withthepercent-ageofpatientswithhighorveryhighcardiovascularriskdecreas-ingprogressivelyfromsustainedhypertensiontowhitecoathyper-tensionconﬁrmedbybothtechniques(PϽ0.005fortrend).39Furthermore,longitudinalevidencesuggeststhatHBPMhasabetterprognosticaccuracythanOBPM;theincidenceofcardio-vasculareventsinpatientswithwhitecoatsyndromewashighandnotsigniﬁcantlydifferentfromtheincidenceofcardiovasculareventsinpatientswithcontrolledhypertension(hazardratio[HR],1.18,95%conﬁdenceinterval[CI],0.67-2.10).40III.hypertensiveAssessmentpatientsofoverallcardiovascularriskinRecommendations1.Globalcardiovascularriskshouldbeassessed.Multifactorialriskassessmentmodelscanbeusedtopredictmoreaccu-ratelyanindividual’sglobalcardiovascularrisk(GradeA)andtouseantihypertensivetherapymoreefﬁciently(GradeD).IntheabsenceofCanadiandatatodeterminetheaccu-racyofriskcalculations,avoidusingabsolutelevelsofrisktosupporttreatmentdecisions(GradeC).

2.Considerinformingpatientsoftheirglobalrisktoimprovetheeffectivenessofriskfactormodiﬁcation(GradeB).Consider

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alsousinganalogiesthatdescribecomparativerisksuchas“car-diovascularage,”“vascularage,”or“heartage”toinformpa-tientsoftheirriskstatus(GradeB).

Background.Riskcalculatorsarefreelyavailableat:www.myhealthcheckup.com,andwww.monbilansante.com.TheSystematicCerebrovascularandCoronaryRiskEvaluation(SCORE)riskcalculationwasupdatedusingCanadiandataandisnowavailableathttp://www.scorecanada.ca.Therearenochangestotheserecommendationsfor2012.IV.investigationRoutineandofpatientsoptionalwithlaboratoryhypertensiontestsfortheRecommendations1.Routinelaboratoryteststhatshouldbeperformedfortheinvestigationofallpatientswithhypertensionincludethefollowing:

i.Urinalysis(GradeD);

ii.Bloodchemistry(potassium,sodium,andcreatinine)(GradeD);

iii.Fastingbloodglucose(GradeD);

iv.Fastingserumtotalcholesterolandhigh-densitylipo-proteincholesterol,low-densitylipoproteincholesterol,andtriglycerides(GradeD);

v.Standard12-leadelectrocardiography(GradeC).

2.Assessurinaryalbuminexcretioninpatientswithdiabetes(GradeD).

3.Alltreatedhypertensivepatientsshouldbemonitoredac-cordingtothecurrentCanadianDiabetesAssociationguidelinesforthenewappearanceofdiabetes(GradeB).4.Duringthemaintenancephaseofhypertensionmanage-ment,tests(includingthoseforelectrolytes,creatinine,andfastinglipids)shouldberepeatedwithafrequencyreﬂectingtheclinicalsituation(GradeD).Background.Therearenochangestotheserecommendationsfor2012.

V.AssessmentforrenovascularhypertensionRecommendations1.PatientspresentingwithՆ2oftheclinicalclueslistednext,suggestingrenovascularhypertension,shouldbeinvesti-gated(GradeD):

i.SuddenonsetorworseningofhypertensionandageϾ55orϽ30years;

ii.Presenceofanabdominalbruit;iii.HypertensionresistanttoՆ3drugs;

iv.RiseinserumcreatininelevelՆ30%associatedwithuseofanangiotensin-convertingenzyme(ACE)inhibitororARB;v.Otheratheroscleroticvasculardisease,particularlyinpa-tientswhosmokeorhavedyslipidemia;

vi.Recurrentpulmonaryedemaassociatedwithhypertensivesurges.Whenavailable,thefollowingtestsarerecom-mendedtoaidintheusualscreeningforrenalvasculardisease:captopril-enhancedradioisotoperenalscan,Dopp-lersonography,magneticresonanceangiography,andcomputedtomographyangiography(forthosewithnor-malrenalfunction)(GradeB).Captopril-enhancedradio-

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isotoperenalscanisnotrecommendedforthosewithCKD(GFRϽ60mLperminuteper1.73m2)(GradeD).Background.Therearenochangestotheserecommendationsfor2012.

VI.Endocrinehypertension

RecommendationsA.Hyperaldosteronism:screeninganddiagnosis

1.Screeningforhyperaldosteronismshouldbeconsideredforthefollowingpatients(GradeD):

i.Hypertensivepatientswithspontaneoushypokalemia(Kϩii.HypertensiveϽ3.5mmol/L);

patientswithmarkeddiuretic-inducedhypokalemia(Kϩiii.PatientsϽiv.ՆHypertensive3drugs;

withhypertension3.0mmol/L);

refractorytotreatmentwith

patientsfoundtohaveanincidentalad-renaladenoma.

2.Screeningforhyperaldosteronismshouldincludeassess-mentofplasmaaldosteroneandplasmareninactivity(Sup-plementalTableS2).

3.Forpatientswithsuspectedhyperaldosteronism(onthebasisofthescreeningtest,SupplementalTableS2,Item3),adiagnosisofprimaryaldosteronismshouldbeestab-lishedbydemonstratinginappropriateautonomoushy-persecretionofaldosteroneusingatleastoneofthema-noeuvreslistedinSupplementalTableS2,Item4.Whenthediagnosisisestablished,theabnormalityshouldbelocalizedusinganyofthetestsdescribedinSupplementalTableS2,Item5.B.Pheochromocytoma:screeninganddiagnosis1.Ifpheochromocytomaisstronglysuspected,thepatientshouldbereferredtoaspecializedhypertensioncentre,par-ticularlyifbiochemicalscreeningtests(SupplementalTableS3)havealreadybeenfoundtobepositive(GradeD).2.Thefollowingpatientsshouldbeconsideredforscreeningforpheochromocytoma(GradeD):

i.Patientswithparoxysmaland/orsevere(BPՆ180/110mmHg)sustainedhypertensionrefractorytousualan-tihypertensivetherapy;

ii.Patientswithhypertensionandmultiplesymptomssuggestiveofcatecholamineexcess(eg,headaches,pal-pitations,sweating,panicattacks,andpallor);

iii.Patientswithhypertensiontriggeredbyinhibitors,micturition,␤-blockers,

monoamineoxidaseorchangesinabdominalpressure;

iv.Patientswithincidentallydiscoveredadrenalmassandpatientswithhypertensionandmultipleendocrineneo-plasia2Aor2B,vonRecklinghausen’sneuroﬁbroma-tosis,orvonHippel-Lindaudisease;

v.Forpatientswithpositivebiochemicalscreeningtests,lo-calizationofpheochromocytomasshouldinvolvetheuseofmagneticresonanceimaging(preferable),computedto-mography(ifmagneticresonanceimagingunavailable),and/oriodineI-131meta-iodobenzylguanidinescintigra-phy(GradeCforeachmodality).

Background.Therearenochangestotheserecommendationsfor2012.

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VII.HBPMRecommendations1.HBPMcanbeusedinthediagnosisofhypertension(GradeC).

2.TheuseofHBPMonaregularbasisshouldbeconsideredforpatientswithhypertension,particularlythosewith:i.Diabetesmellitus(GradeD);ii.CKD(GradeC);

iii.Suspectednonadherence(GradeD);

iv.Demonstratedwhitecoateffect(GradeC);

v.BPcontrolledintheofﬁcebutnotathome(maskedhypertension)(GradeC).

3.WhenwhitecoathypertensionissuggestedbyHBPM,itspresenceshouldbeconﬁrmedbyrepeatHBPM(seeRec-ommendation8)orABPMbeforetreatmentdecisionsaremade(GradeD).

4.PatientsshouldbeadvisedtopurchaseanduseonlyHBPMdevicesthatareappropriatefortheindividualandhavemetstandardsoftheAssociationfortheAdvancementofMedicalInstrumentation,themostrecentrequirementsoftheBritishHypertensionSocietyprotocol,ortheIn-ternationalProtocolforvalidationofautomatedBPmeasuringdevices.PatientsshouldbeencouragedtousedeviceswithdatarecordingcapabilitiesorautomaticdatatransmissiontoincreasethereliabilityofreportedHBPM(GradeD).

5.HomeSBPvaluesՆ135mmHgorDBPvaluesՆ85mmHgshouldbeconsideredelevatedandassociatedwithanincreasedoverallmortalityriskanalogoustoofﬁceSBPreadingsofՆ140mmHgorDBPՆ90mmHg(GradeC).

6.HealthcareprofessionalsshouldensurethatpatientswhomeasuretheirBPathomehaveadequatetrainingand,ifnecessary,repeattraininginmeasuringtheirBP.PatientsshouldbeobservedtodeterminethattheymeasureBPcor-rectlyandshouldbegivenadequateinformationaboutin-terpretingthesereadings(GradeD).

7.Theaccuracyofallindividualpatients’validateddevices(includingelectronicdevices)mustberegularlycheckedagainstadeviceofknowncalibration(GradeD).

8.HBPMforassessingwhitecoathypertensionorsustainedhypertensionshouldbebasedonduplicatemeasures,morn-ingandevening,foraninitial7-dayperiod.First-dayhomeBPvaluesshouldnotbeconsidered(GradeD).Background.InformationonvalidatedBPmonitorscanbefoundat:http://www.hypertension.ca/devices-endorsed-by-hypertension-canada-dp1.

Updatedbackgroundinformationonwhitecoathyperten-sionisprovidedinsectionII.CriteriaforDiagnosisofHyper-tensionandRecommendationsforFollow-up.Therearenootherchangestotheserecommendationsfor2012.VIII.ABPMRecommendations1.BPmonitoringcanbeusedinthediagnosisofhyperten-sion(GradeC).ABPMshouldbeconsideredwhenanofﬁce-inducedincreaseinBPissuspectedintreatedpa-tientswith:

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i.BPthatisnotbelowtargetdespitereceivingappropriatechronicantihypertensivetherapy(GradeC);ii.Symptomssuggestiveofhypotension(GradeC);iii.FluctuatingofﬁceBPreadings(GradeD).

2.PhysiciansshoulduseonlyABPMdevicesthathavebeenval-idatedindependentlyusingestablishedprotocols(GradeD).3.Therapyadjustmentshouldbeconsideredinpatientswithamean24-hourambulatorySBPofՆ130mmHgorDBPofՆ80mmHgorameanawakeSBPofՆ135mmHgorDBPofՆ85mmHg(GradeD).

4.ThemagnitudeofchangesinnocturnalBPshouldbetakenintoaccountinanydecisiontoprescribeorwithholddrugtherapybaseduponABPM(GradeC)becauseadecreaseinnocturnalBPofϽ10%isassociatedwithincreasedriskofcardiovascularevents.Background.Therearenochangestotheserecommendationsfor2012.

IX.RoleofechocardiographyRecommendations1.Routineechocardiographicevaluationofallhypertensivepatientsisnotrecommended(GradeD).

2.Anechocardiogramforassessmentofleftventricularhyper-trophyisusefulinselectedcasestohelpdeﬁnethefutureriskofcardiovascularevents(GradeC).

3.Echocardiographicassessmentofleftventricularmass,aswellasofsystolicanddiastolicleftventricularfunctionisrecom-mendedforhypertensivepatientssuspectedtohaveleftven-triculardysfunctionorcoronaryarterydisease(GradeD).4.PatientswithhypertensionandevidenceofheartfailureshouldhaveanobjectiveassessmentofleftventricularEF,eitherbyechocardiogramornuclearimaging(GradeD).Background.Therearenochangestotheserecommendationsfor2012.

TheCHEP2012PreventionandTreatmentRecommendationsI.LifestylemanagementRecommendationsA.Physicalexercise

1.Fornonhypertensiveindividuals(toreducethepossibilityofbecominghypertensive)orforhypertensivepatients(toreducetheirBP),prescribetheaccumulationof30-60minutesofmoderateintensitydynamicexercise(eg,walking,jogging,cy-clingorswimming)4-7daysperweekinadditiontotherou-tineactivitiesofdailyliving(GradeD).Higherintensitiesofexercisearenotmoreeffective(GradeD).B.Weightreduction

1.Height,weight,andwaistcircumferenceshouldbemeasured,andbodymassindexcalculatedforalladults(GradeD).2.Maintenanceofahealthybodyweight(bodymassindex18.5to24.9,andwaistcircumferenceϽ102cmformenandϽ88cmforwomen)isrecommendedfornonhyper-tensiveindividualstopreventhypertension(GradeC)andforhypertensivepatientstoreduceBP(GradeB).Allover-

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weighthypertensiveindividualsshouldbeadvisedtoloseweight(GradeB).

3.Weightlossstrategiesshouldemployamultidisciplinaryap-proachthatincludesdietaryeducation,increasedphysicalac-tivity,andbehaviouralintervention(GradeB).C.Alcoholconsumption

1.ToreduceBP,alcoholconsumptionshouldbeinaccor-dancewithCanadianlow-riskdrinkingguidelinesinbothnormotensiveandhypertensiveindividuals.HealthyadultsshouldlimitalcoholconsumptiontoՅ2drinksperday,andconsumptionshouldnotexceed14standarddrinksperweekformenand9standarddrinksperweekforwomen(GradeB).(Note:Onestandarddrinkisconsideredtobeequivalentof13.6gor17.2mLofethanolorapproximately44mL[1.5oz]of80proof[40%]spirits,355mL[12oz]of5%beer,or148mL[5oz]of12%wine).D.Dietaryrecommendations

1.Itisrecommendedthathypertensivepatientsandnormo-tensiveindividualsatincreasedriskofdevelopinghyperten-sionconsumeadietthatemphasizesfruits,vegetables,low-fatdairyproducts,dietaryandsolubleﬁbre,wholegrains,andproteinfromplantsourcesthatisreducedinsatu-ratedfatandcholesterol(DietaryApproachestoStopHypertension[DASH]diet41-44)(SupplementalTableS4)(GradeB).E.Sodiumintake

1.Forpreventionandtreatmentofhypertension,adietarysodiumintakeof1500mg(65mmol)perdayisrecom-mendedforadultsagedՅ50years;1300mg(57mmol)perdayforage51-70years;and1200mg(52mmol)perdayforageϾ70years(GradeB).F.Potassium,calcium,andmagnesiumintake

1.Supplementationofpotassium,calcium,andmagnesiumisnotrecommendedforthepreventionortreatmentofhy-pertension(GradeB).G.Stressmanagement

1.Inhypertensivepatientsinwhomstressmaybecontribut-ingtoBPelevation,stressmanagementshouldbeconsid-eredasanintervention(GradeD).Individualizedcogni-tive-behaviouralinterventionsaremorelikelytobeeffectivewhenrelaxationtechniquesareused(GradeB).

Background.Therearenochangestotheserecommendationsfor2012.

II.hypertensionIndicationsspeciﬁcagentswithoutfordrugcompellingtherapyforindicationsadultswithforRecommendations1.AntihypertensivetherapyshouldbeprescribedforaverageDBPmeasurementsofՆ100mmHg(GradeA)oraverageSBPmeasurementsofՆ160mmHg(GradeA)inpatientswithoutmacrovasculartargetorgandamageorothercardio-vascularriskfactors.

2.AntihypertensivetherapyshouldbestronglyconsideredifDBPreadingsaverageՆ90mmHginthepresenceof

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macrovasculartargetorgandamageorotherindependentcardiovascularriskfactors(GradeA).

3.AntihypertensivetherapyshouldbestronglyconsideredifSBPreadingsaverageՆ140mmHginthepresenceofmacrovasculartargetorgandamage(GradeCfor140-160mmHg;GradeAforϾ160mmHg).

4.Antihypertensivetherapyshouldbeconsideredinallpa-tientsmeetingtheaboveindicationsregardlessofage(GradeB).Cautionshouldbeexercisedinelderlypatientswhoarefrail.Background.Therearenochangestotheserecommendationsfor2012.

III.withoutChoicecompellingoftherapyindicationsforadultsforwithspeciﬁchypertensionagentsRecommendationsA.Recommendationsforindividualswithdiastolicand/orsystolichypertension

1.Initialtherapyshouldbemonotherapywithathiazidedi-uretic(GradeA),a␤-blocker(inpatientsyoungerthan60years,GradeB),anACEinhibitor(innonblackpatients,GradeB),along-actingcalciumchannelblocker(CCB)(GradeB);oranARB(GradeB).Ifthereareadverseeffects,anotherdrugfromthisgroupshouldbesubstituted.Hypo-kalemiashouldbeavoidedinpatientstreatedwiththiazidediureticmonotherapy(GradeC).

2.AdditionalantihypertensivedrugsshouldbeusediftargetBPlevelsarenotachievedwithstandard-dosemonotherapy(GradeB).Add-ondrugsshouldbechosenfromﬁrst-linechoices.UsefulchoicesincludeathiazidediureticorCCBwitheither:ACEinhibitor,ARB,ordiuretic␤-blocker(GradeBforthecombinationofthiazideandadihydropyridineCCB;GradeCforthecombinationofdihydropyridineCCBandACEinhibitor;andGradeDforallothercom-binations).CautionshouldbeexercisedincombininganondihydropyridineCCBanda␤-blocker(GradeD).ThecombinationofanACEinhibitorandanARBisnotrec-ommended(GradeA).

3.Combinationtherapyusing2ﬁrst-lineagentsmayalsobeconsideredasinitialtreatmentofhypertension(GradeC)ifSBPis20mmHgabovetargetorifDBPis10mmHgabovetarget.However,cautionshouldbeexercisedinpa-tientsinwhomasubstantialfallinBPfrominitialcombi-nationtherapyismorelikelytooccurorinwhomitwouldbepoorlytolerated(eg,elderlypatients).

4.IfBPisstillnotcontrolledwithacombinationof2ormoreﬁrst-lineagents,orthereareadverseeffects,otherantihy-pertensivedrugsmaybeadded(GradeD).

5.Possiblereasonsforpoorresponsetotherapy(Table6)shouldbeconsidered(GradeD).

6.␣-Blockersarenotrecommendedasﬁrst-lineagentsforun-complicatedhypertension(GradeA);␤-blockersarenotrecommendedasﬁrst-linetherapyforuncomplicatedhy-pertensioninpatients60yearsofageorolder(GradeA);andACEinhibitorsarenotrecommendedasﬁrst-linether-apyforuncomplicatedhypertensioninblackpatients(GradeA).However,theseagentsmaybeusedinpatientswithcertaincomorbidconditionsorincombinationtherapy.

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Table6.Possiblereasonsforpoorresponsetoantihypertensivetherapy

NoncomplianceDietaryMedication

AssociatedconditionsObesity

Cigarettesmoking

ExcessivealcoholconsumptionSleepapneaChronicpainDruginteractions

Nonsteroidalanti-inﬂammatorydrugs(includingcyclo-oxygenase-2inhibitors)

Oralcontraceptives

CorticosteroidsandanabolicsteroidsSympathomimeticsanddecongestantsCocaine

AmphetaminesErythropoietin

Cyclosporine,tacrolimusLicorice

Over-the-counterdietarysupplements(eg,ephedra,mahuang,bitterorange)

Monoamineoxidaseinhibitors,certainselectiveserotoninreuptakeinhibitorsandserotonin-norepinephrinereuptakeinhibitorsSuboptimaltreatmentregimensDosagetoolow

InappropriatecombinationsofantihypertensiveagentsVolumeoverload

Excessivesaltintake

Renalsodiumretention(pseudotolerance)SecondaryhypertensionRenalinsufﬁciencyRenovasculardisease

PrimaryhyperaldosteronismThyroiddisease

PheochromocytomaandotherrareendocrinecausesObstructivesleepapneaNotethatcausesof‘pseudo-resistance’(suchaswhitecoathypertensionorpseudo-hypertensionintheelderly)shouldberuledoutﬁrst.AdaptedfromMcAlisteretal.45B.Recommendationsforindividualswithisolatedsystolichypertension

1.Initialtherapyshouldbemonotherapywithathiazidedi-uretic(GradeA),along-actingdihydropyridineCCB(GradeA),oranARB(GradeB).Ifthereareadverseeffects,anotherdrugfromthisgroupshouldbesubstituted.Hypo-kalemiashouldbeavoidedinpatientstreatedwiththiazidediureticmonotherapy(GradeC).

2.AdditionalantihypertensivedrugsshouldbeusediftargetBPlevelsarenotachievedwithstandard-dosemonotherapy(GradeB).Add-ondrugsshouldbechosenfromﬁrst-lineoptions(GradeD).

3.IfBPisstillnotcontrolledwithacombinationof2ormoreﬁrst-lineagents,orthereareadverseeffects,otherclassesofdrugs(suchas␣-blockers,ACEinhibitors,centrallyactingagentsornondihydropyridineCCBs)maybeaddedorsub-stituted(GradeD).

4.Possiblereasonsforpoorresponsetotherapy(Table6)shouldbeconsidered(GradeD).

5.␣-Blockersarenotrecommendedasﬁrst-lineagentsforun-complicated␤isolatedsystolichypertensionisolated-blockerssystolicarenothypertensionrecommendedinpatientsasﬁrst-line(GradeA);andagedtherapyՆ60years

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Table7.Cardiovascularriskfactorsforconsiderationofstatintherapyinnondyslipidemicpatientswithhypertension

Malesex

AgeՆ55years

Leftventricularhypertrophy

Otherelectrocardiogramabnormalities:leftbundlebranchblock,left

ventricularstrainpattern,abnormalQ-wavesorST-TchangescompatiblewithischemicheartdiseasePeripheralarterialdisease

PreviousstrokeortransientischemicattackMicroalbuminuriaorproteinuriaDiabetesmellitusSmoking

FamilyhistoryofprematurecardiovasculardiseaseTotalcholesteroltohigh-densitylipoproteinratio6

IfhypertensivepatientshaveՆ3oftheseriskfactors,statinsshouldbeconsidered.

DatafromSeveretal.47(GradeA).However,bothagentsmaybeusedinpatientswithcertaincomorbidconditionsorincombinationtherapy.

Background.Recentconcernwasraisedregardingthepoten-tialassociationofcancerwithARBsamidpublicationofseveralrecentposthocanalyses.The2012guidelinescontinuetorec-ommendtheuseofARBsinappropriateclinicalsituationsgiventhecompletedsafetyanalysiscommissionedbytheUSFoodandDrugAdministrationof31clinicaltrialsand156,000patientsﬁndingnoevidenceofanincreasedriskofcancerinpatientswhotakeanARB.46Therearenochangestotheserecommendations.

IV.hypertensionGlobalvascularspeciﬁcagentswithoutprotectioncompellingtherapyindicationsforadultsforwithRecommendations1.Statintherapyisrecommendedinhypertensivepatientswith3ormorecardiovascularriskfactorsasdeﬁnedinTa-ble7(GradeAinpatientsϾ40years),orwithestablishedatheroscleroticdisease(GradeAregardlessofage).

2.Strongconsiderationshouldbegiventotheadditionoflow-doseacetylsalicylicacidtherapyinhypertensivepa-tients(GradeAinpatientsϾ50years).CautionshouldbeexercisedifBPisnotcontrolled(GradeC).

Background.Therearenochangestotheserecommendationsfor2012.Forfurtherguidanceinthemanagementofpatientswithdyslipidemia,readersarereferredtothe2009CanadianCardiovascularSociety/Canadianguidelinesforthediagnosisandtreatmentofdyslipidemiaandpreventionofcardiovascu-lardiseaseintheadult.48V.withoutGoalcompellingoftherapyforindicationsadultswithforhypertensionspeciﬁcagentsRecommendations1.TheSBPtreatmentgoalisapressurelevelofϽ140mmHg(GradeC).TheDBPtreatmentgoalisapressurelevelofϽ90mmHg(GradeA).

Background.Therearenochangestotheserecommendationsfor2012.

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VI.ischemicTreatmentheartofdisease

hypertensioninassociationwithRecommendationsA.Recommendationsforhypertensivepatientswithcoro-naryarterydisease

1.AnACEinhibitororARBisrecommendedformostpatientswithhypertensionandcoronaryarterydisease(GradeA).2.Forpatientswithstableangina,␤-blockersarepreferredasinitialtherapy(GradeB).CCBsmayalsobeused(GradeB).3.Short-actingnifedipineshouldnotbeused(GradeD).4.Forpatientswithcoronaryarterydisease,butwithoutco-existingsystolicheartfailure,thecombinationofanACEinhibitorandARBisnotrecommended(GradeB).

5.Inhigh-riskpatients,whencombinationtherapyisbeingused,choicesshouldbeindividualized.ThecombinationofanACEinhibitorandadihydropyridineCCBispreferabletoanACEinhibitorandadiureticinselectedpatients(GradeA).B.Recommendationsforpatientswithhypertensionwhohavehadarecentmyocardialinfarction

1.Initialtherapyshouldincludebothainhibitor(GradeA).

␤-blockerandanACE2.AnARBcanbeusedifthepatientisintolerantofanACEinhibitor(GradeAinpatientswithleftventricularsystolicdysfunction).

3.CCBsmaybeusedinpostmyocardialinfarctionpatientswhen␤-blockersarecontraindicatedornoteffective.Non-dihydropyridineCCBsshouldnotbeusedwhenthereisheartfailure,asevidencedbypulmonarycongestiononex-aminationorradiography(GradeD).

Background.Therearenochangestotheserecommendationsfor2012.

VII.heartTreatmentfailureofhypertensioninassociationwithRecommendations1.Inpatientswithsystolicdysfunction(ejectionfraction[EF]Ͻ40%),ACEinhibitors(GradeA)andarerecommendedforinitialtherapy.␤-blockers(GradeA)Aldoste-roneantagonists(mineralocorticoidreceptorantagonists)maybeaddedforpatientswitharecentcardiovascularhos-pitalization,acutemyocardialinfarction,elevatedB-typenatriureticpeptideorN-terminalpro–B-typenatriureticpeptidelevel,orNewYorkHeartAssociation(NYHA)classIItoIVsymptoms(GradeA).Carefulmonitoringforhy-perkalemiaisrecommendedwhenaddinganaldosteroneantagonisttoACEinhibitororARB.Otherdiureticsarerecommendedasadditionaltherapyifneeded(GradeBforthiazidediureticsforBPcontrol,GradeDforloopdiureticsforvolumecontrol).BeyondconsiderationsofBPcontrol,dosesofACEinhibitorsorARBsshouldbetitratedtothosefoundtobeeffectiveintrialsunlessadverseeffectsbecomemanifest(GradeB).

2.AnARBisrecommendedifACEinhibitorsarenottoler-ated(GradeA).

3.AcombinationofhydralazineandisosorbidedinitrateisrecommendedifACEinhibitorsandARBsarecontraindi-catedornottolerated(GradeB).

Daskalopoulouetal.

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4.ForhypertensivepatientswhoseBPisnotcontrolled,anARBmaybeaddedtoanACEinhibitorandotherantihy-pertensivedrugtreatment(GradeA).CarefulmonitoringshouldbeusedifcombininganACEinhibitorandanARBduetopotentialadverseeffectssuchashypotension,hyper-kalemia,andworseningrenalfunction(GradeC).Addi-tionaltherapiesmayalsoincludedihydropyridineCCBs(GradeC).Background.Thisyear,wehaveexpandedourrecommenda-tionformineralocorticoidreceptorantagonistsinpatientswithbothhypertensionandchronicsystolicheartfailure(EFϽ40%)onthebasisofcompellingevidencefrom3RCTs.Ourpreviousrecommendationwasguidedby2earliertrials,RALES19andEPHESUS.20Thisyear,theEMPHASIS-HFprovideddeﬁniteevidencethatestablishesthebeneﬁcialeffectofmineralocorticoidreceptorantagonistsonmorbidityandmortality18acrossabroadspectrumofsystolicheartfailurepa-tients.EMPHASIS-HFenrolled2737patientswithheartfailure,whowererandomizedtoreceiveeitherthemineralo-corticoidreceptorantagonisteplerenone(upto50mgdaily)orplaceboinadditiontorecommendedtherapy.Patientswereincludediftheywereatleast55yearsofage,hadNYHAfunc-tionalclassIIsymptoms,anEFofnomorethan30%(or,ifϾ30%to35%,aQRSdurationϾ130msonelectrocardiogram)and␤treatmentwithanACEinhibitor,anARBorboth,andaor-blockermaximal(unlesstoleratedcontraindicated)dose.Thetrialatwasthestoppedrecommendedprematurelydoseafteramedianfollow-upperiodof21months.Theprimaryoutcome,acompositeofdeathfromcardiovascularcausesorhospitalizationforheartfailure,wassigniﬁcantlyreducedintheeplerenonegroupwhencomparedwiththeplacebogroup(HR,0.63;95%CI,0.54-0.74)aswasriskofdeath(HR,0.76;95%CI,0.62-0.93).Importantly,excludedfromthetrialwerepatientswithabaselineserumpotassiumlevelϾ5.0mmol/LandabaselineestimatedGFRϽ30mLperminuteper1.73m2.Despitethis,comparedwithplacebotherewasamorethan2-foldincreasedriskofhyperkalemiaintheeplerenonegroup(3.7%vs8.0%,respectively,PϽ0.001).Thisﬁnding,coupledwithearlierconcernsregardingtheriskofhyperkale-miawithspironolactoneinmoreseverestagesofheartfailure,andincombinationwithotherreninangiotensinantagonistsunderscoretheimportanceofregularelectrolytemonitoringinpatientswhoreceivemineralocorticoidreceptorantagonists.Thus,mostpatientswithCKDandthosewithahistoryofseverehyperkalemiashouldnotreceiveamineralocorticoidre-ceptorantagonist.

Thisyear,datafrom3ARBRCTsincludingpatientswithhypertensionandAF(ACTIVEI,ANTIPAF,andGISSI-AF)wereexaminedindetail.21-23InACTIVEI,irbesartandidnotreduceeithercoprimaryendpointcomprisingmajorcardio-vasculareventsinpatientswithAFandatleast1additionalstrokeriskfactor(HR,0.99;95%CI,0.91-1.08;andHR,0.94;95%CI,0.87-1.02).21Althoughirbesartanreducedtheriskofhospitalizationforheartfailure(HR,0.86;95%CI,0.76-0.98),itdidnotsigniﬁcantlyreducetheriskofhospital-izationforAF(HR,0.95;95%CI,0.85-1.07).Furthermore,symptomatichypotensionwasmorecommonintheirbesartangroup(PϽ0.001)aswasanyrenaldysfunctionleadingtodrugdiscontinuation(Pϭ0.02).Asimilarlackofbeneﬁtforolm-esartanwasnotedintheANTIPAFtrial(inpatientswithpar-

281

oxysmalAFwithoutstructuralheartdiseaseinsinusrhythmatrecruitment)22andforvalsartanintheGISSI-AFtrial(inpa-tientswithahistoryofrecurrentAFinsinusrhythmatrecruit-ment).23Basedonthisevidence,theTaskForceconcludedthatARBsdidnotpreventrecurrentAFormajorcardiovasculareventsinpatientswithAF.Therefore,thepresenceofAFinpatientswithhypertensionshouldnotmandateselectionofanARBforthetreatmentofhypertension.

VIII.stroke

TreatmentofhypertensioninassociationwithRecommendationsA.BPmanagementinacutestroke(onsetto72hours)1.Forpatientswithischemicstrokenoteligibleforthrombo-lytictherapy,treatmentofhypertensioninthesettingofacuteischemicstrokeortransientischemicattackshouldnotberoutinelyundertaken(GradeD).ExtremeBPeleva-tion(eg,SBPϾ220mmHgorDBPϾ120mmHg)maybetreatedtoreducetheBPbyapproximately15%(GradeD),andnotmorethan25%,overtheﬁrst24hourswithgradualreductionthereafter(GradeD).AvoidexcessiveloweringofBPasthismayexacerbateexistingischemiaormayinduceischemia,particularlyinthesettingofintracra-nialarterialocclusionorextracranialcarotidorvertebralarteryocclusion(GradeD).Pharmacologicalagentsandroutesofadministrationshouldbechosentoavoidprecip-itousfallsinBP(GradeD).

2.Forpatientswithischemicstrokeeligibleforthrombolytictherapy,veryhighBP(Ͼ185/110mmHg)shouldbetreatedconcurrentlyinpatientsreceivingthrombolytictherapyforacuteischemicstroketoreducetheriskofsec-ondaryintracranialhemorrhage(GradeB).B.BPmanagementafteracutestroke

1.Strongconsiderationshouldbegiventotheinitiationofantihypertensivetherapyaftertheacutephaseofastrokeortransientischemicattack(GradeA).

2.Aftertheacutephaseofastroke,BP-loweringtreatmentisrecommendedtoatargetofconsistentlyϽ140/90mmHg(GradeC).

3.TreatmentwithanACEinhibitor/diureticcombinationispreferred(GradeB).

4.Forpatientswithstroke,thecombinationofanACEinhib-itorandARBisnotrecommended(GradeB).

Background.Therearenochangestotheserecommendationsfor2012.

IX.ventricularTreatmenthypertrophyofhypertensioninassociationwithleftRecommendations1.Hypertensivepatientswithleftventricularhypertrophyshouldbetreatedwithantihypertensivetherapytolowertherateofsubsequentcardiovascularevents(GradeC).

2.Thechoiceofinitialtherapycanbeinﬂuencedbythepres-enceofleftventricularhypertrophy(GradeD).Initialther-apycanbedrugtreatmentusingACEinhibitors,ARBs,long-actingCCBs,orthiazidediuretics.Directarterialva-sodilatorssuchashydralazineorminoxidilshouldnotbeused.

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Background.Therearenochangestotheserecommendationsfor2012.

X.nondiabeticTreatmentCKDofhypertensioninassociationwithRecommendations1.ForpatientswithnondiabeticCKD,targetBPisϽ140/90mmHg(GradeB).

2.ForpatientswithhypertensionandproteinuricCKD(uri-naryproteinϾ500mg/24hoursoralbumin-to-creatinineratioϾ30mg/mmol),initialtherapyshouldbeanACEinhibitor(GradeA)oranARBifthereisintolerancetoACEinhibitors(GradeB).

3.Thiazidediureticsarerecommendedasadditiveantihy-pertensivetherapy(GradeD).ForpatientswithCKDandvolumeoverload,loopdiureticsareanalternative(GradeD).

4.Inmostcases,combinationtherapywithotherantihyper-tensiveagentsmaybeneededtoreachtargetBPlevels(GradeD).

5.ThecombinationofanACEinhibitorandARBisnotrecommendedforpatientswithnonproteinuricCKD(GradeB).

Background.Thisyear,theresultsof3RCTswereexaminedindetailandledtotherevisionofthepreviousBPtargetforhypertensivepatientswithnondiabeticCKD.

TheMDRDtrialincludedpatientswithGFRbetween13and55mLperminuteper1.73m2whowererandomlyas-signedtoeitherausualBPtarget(meanarterialpressure[MAP],107mmHg,equivalentto140/90mmHg)oralowBPtarget(MAP92mmHg,equivalentto125/75mmHg).28,29,49Intheprimaryanalysis,therewasnodifferencebetweentheusualandlowBPgroupswithrespecttotheslopeofdeclineinGFR.Secondaryoutcomesincludingkidneyfail-ure,death,acompositeofkidneyfailureordeath,andcardio-vasculareventswerealsonotsigniﬁcantlydifferentbetweengroups.Aposthoc,subgroupanalysisshowedthattherateofGFRdeclineappearedtoincreaseaboveaMAPof98mmHginpatientswithproteinuriabetween0.25-3.0gr/day,whileinpatientswithproteinuriaofՆ3.0gr/day,therateofGFRdeclineincreasedaboveaMAPof92mmHg.However,thisposthocanalysiswaslimitedbythefactthattherewasnostratiﬁcationbasedonprespeciﬁedlevelsofproteinuria,aprioripowercalculationswerenotperformedforsubgroups,baselinepatientcharacteristicswerenotpresentedaccordingtosub-groups,andadjustmentformultipletestingwasnotper-formed.Furthermore,theuseofACEinhibitorswashigherinthelowBPtargetgroup.

IntheAASKtrial,African-Americanindividualswithhy-pertensiveCKDandGFRbetween20and65mLperminuteper1.73m2wererandomlyassignedtoausualBPtarget(MAP,102-107mmHg)oralowBPtarget(MAP,92mmHg).24-26Inaddition,patientswererandomlyassignedtotreatmentwithramipril,metoprolol,oramlodipineina2ϫ3factorialdesign.TherewasnosigniﬁcantdifferenceinthechronicslopeortheoverallrateofdeclineinGFRperyearbetweengroups.PatientsinthelowBPgroupexperienceda17%reductioninprotein-uriaascomparedwithanincreaseof7%intheusualBPgroup.Therewasnodifferenceintheriskofothersecondaryout-comesincludingkidneyfailure,thecompositeofkidneyfailure

CanadianJournalofCardiology

Volume282012

ordeath,thecompositeofaGFReventordeath,orthecom-binedendpointofGFRevent,kidneyfailure,ordeath.Therewasnodifferenceincardiovascularmortalityornonfatalcar-diovascularevents.IntheoriginalAASKtrialtherewasaninteractionbetweenbaselineproteinuriaandBPtarget,whichwasnotreportedintheoriginalanalysisbutinasubsequentanalysis.SimilartotheMDRDtrial,thiswasaposthocsub-groupanalysisandrandomizationwasnotstratiﬁedbasedonprespeciﬁedlevelsofproteinuria,therewerenoaprioripowercalculationsforthesubgroups,andadjustmentformultipletestingwasnotperformed.ThesuggestionthatpatientswithproteinuriaofϾ300mgrperdayatbaselinemayderivebeneﬁtfromalowerBPtarget,andthatthosewithlessproteinuriamayexperienceworseoutcomes,shouldbeinterpretedashypothesis-generating.

TheREIN-2trialrandomlyassignedpatientswithnondia-beticCKDandϾ1gr/dayofproteinuriatousualBPtarget(targetDBPϽ90mmHg)orlowBPtarget(targetBPϽ130/80mmHg).27AllpatientsweretreatedwithramiprilandthelowBPgroupreceivedfelodipine5-10mg/daytogetherwithadditionalagentsasneededtoachievetargets.Thetrialwasstoppedearlyduetofutilityafteramedianfollow-upof19months;thiswasdeﬁnedapriori.MeanachievedBPwas134/82mmHgintheusualBPgroupcomparedwith130/80mmHginthelowBPgroup.Therewasnodiffer-enceintheriskofprogressiontokidneyfailurebetweengroups(adjustedHR,1.0;95%CI,0.61-1.64).SigniﬁcantlimitationsofthisstudyincludeduseofdihydropyridineCCBinthelowBPgroup,thesmalldifferenceinachievedBP(4/2mmHg)betweengroups,limitedfollow-up,aswellasthefactthatallpatientsreceivedtherapywithaﬁxeddoseofanACEinhibitor.

Overall,thereisnocompellingevidencetosupportalowBPtargetofϽ130/80mmHginallpatientswithhyperten-sionandnondiabeticCKD.DespiteobservationalevidencesuggestingthatmoreintensiveBPcontrolmaybebeneﬁcialinindividualswithϾ300mgrorϾ1gr/dayofproteinuria,theonlyRCTexaminingthisissuewasnegative.Althoughasmallerbeneﬁtcannotberuledout,thecurrentevidencebasedoesnotsupportamoreintensiveBPtargetinthisgroup.Therefore,theTaskForcevotedtoremovethepreviouslowBPtargetandresumethegeneralBPtarget(Ͻ140/90mmHg)recommendedforpatientswithhypertension.XI.renovascularTreatmentdiseaseofhypertensioninassociationwithRecommendations1.Renovascularhypertensionshouldbetreatedinthesamemannerashypertensionwithoutcompellingindications,exceptforcautionintheuseofACEinhibitorsorARBsduetotheriskofacuterenalfailureinbilateraldiseaseoruni-lateraldiseasewithasolitarykidney(GradeD).

2.Closefollow-upandearlyintervention(angioplastyandstentingorsurgery)shouldbeconsideredforpatientswithuncontrolledhypertensiondespitetherapywithՆ3drugs,deterioratingkidneyfunction,bilateralatheroscleroticrenalarterylesions(ortightatheroscleroticstenosisinasinglekidney),orrecurrentepisodesofﬂashpulmonaryedema(GradeD).

Daskalopoulouetal.

2012CanadianRecommendationsforHighBP

Background.Therearenochangestotheserecommendationsfor2012.

XII.diabetesTreatmentmellitusofhypertensioninassociationwithRecommendations1.PersonswithdiabetesmellitusshouldbetreatedtoattainSBPsofϽ130mmHg(GradeC)andDBPsofϽ80mmHg(GradeA).(ThesetargetBPlevelsarethesameastheBPtreatmentthresholds.)Combinationtherapyusing2ﬁrst-lineagentsmayalsobeconsideredasinitialtreatmentofhypertension(GradeB)ifSBPis20mmHgabovetargetorifDBPis10mmHgabovetarget.However,cautionshouldbeexercisedinpatientsinwhomasubstantialfallinBPismorelikelyorpoorlytolerated(eg,elderlypatientsandpa-tientswithautonomicneuropathy).

2.Forpersonswithcardiovascularorkidneydisease,includingmicroalbuminuriaorwithcardiovascularriskfactorsinad-ditiontodiabetesandhypertension,anACEinhibitororanARBisrecommendedasinitialtherapy(GradeA).

3.Forpersonswithdiabetesandhypertensionnotincludedintheaboverecommendation,appropriatechoicesinclude(inalphabeticalorder):ACEinhibitors(GradeA),ARBs(GradeB),dihydropyridineCCBs(GradeA),andthiazide/thiazide-likediuretics(GradeA).

4.IftargetBPlevelsarenotachievedwithstandard-dosemonotherapy,additionalantihypertensivetherapyshouldbeused.ForpersonsinwhomcombinationtherapywithanACEinhibitorisbeingconsidered,adihydropyridineCCBispreferabletohydrochlorothiazide(GradeA).

Background.Thisyear,2meta-analysesthataddressedthequestionsaboutrelativebeneﬁtsandrisksofachievinglowerSBPinpatientswithdiabetesmellitusandhypertensionwerepublished.

TheBangaloreetal.meta-analysisincludedtrialsthatcom-paredachievedSBPlevelsofϽ135mmHg,Ͻ130mmHg,andϽ140mmHg50inpatientswithdiabetesorimpairedfastingglucose(IFG).Theprimaryoutcomewasmajoradversecardiovasculareventsincludingmortality,cardiovascularmor-tality,myocardialinfarction,stroke,andheartfailure.SBPlev-elsofϽ135mmHgwereassociatedwithreducedmortality(oddsratio[OR],0.87;95%CI,0.79-0.95),andlevelsϽ130mmHgwereassociatedwithreducedriskofstroke(OR,0.53;95%CI,0.38-0.75).Importantly,althoughsigniﬁcantadverseevents,suchashypotensionandhyperkalemiawereinconsis-tentlyreportedacrosstrials,therewasasigniﬁcantincreaseintheoddsofadverseeventswithSBPbelowboth135mmHgand130mmHg.

Themeta-analysisbyReboldietal.includedallantihyper-tensivetrialsthatenrolledpatientswithhypertensionanddia-betesbutnotimpairedfastingglucose,anddidaseriesofstrat-iﬁedmeta-analysesandmeta-regressionanalysestodeterminethebeneﬁtassociatedwithdifferentlevelsofSBPonmyocar-dialinfarctionandstroke.51DecreasinglevelsofSBPwereas-sociatedwithincreasingbeneﬁtintermsofstroke,butnotintermsofmyocardialinfarction.Ameta-regressionexaminingtheassociationbetweenthedegreeofSBPloweringandstrokefoundthatforevery5%reductioninSBP,theriskofstrokewasreducedby13%.SuchalinearassociationbetweenSBPreduc-tionandmyocardialinfarctionriskreductionwasnotnoted.

283

BothofthesereviewswerelimitedbythefactthattheydidnotexaminetargetSBPsbutratherSBPsachievedinthecon-textofaclinicaltrial.Further,thesereviewscouldnotcontrolfordifferencesindurationofdiabetesorglycemiccontrol.AstheActiontoControlCardiovascularRiskinDiabetesBloodPressure(ACCORDBP)trialsuggestedthataninteractionbetweenglycemiccontrolandSBPloweringmayexist,theinabilitytoaccountfordifferencesindiabetesmanagementshouldbenoted.45,52AlthoughtheoptimalBPtargetremainsuncertain,thesemeta-analysesandresultsfromACCORDBPdonotprovideanycompellingevidencetoalterthepresentrecommendation(Ͻ130/80mmHg).Thiswasmainlysupportedbytheasso-ciationbetweenSBPlevelsϽ130mmHgandreductioninstrokeon1hand,andtheincreasedriskofadverseevents,suchashypotensionandhyperkalemiawithlowerSBPtargetsontheotherhand,withthemajorityofadverseeffectsassociatedwithSBPϽ120mmHg.

XIII.AdherencestrategiesforpatientsRecommendations1.Adherencetoanantihypertensiveprescriptioncanbeim-provedbyamultiprongedapproach(Table8).

Background.Therearenochangestotheserecommendationsfor2012.

XIV.endocrineTreatmentcausesofsecondaryhypertensionduetoRecommendations1.TreatmentofhyperaldosteronismandpheochromocytomaareoutlinedinSupplementalTablesS2andS3.

Background.Therearenochangestotheserecommendationsfor2012.

Table8.Strategiestoimprovepatientadherence

Assist●●Tailoringyourpatient●Simplifyingpill-takingtoadhereby:

Replacingmedicationtoﬁtregimenspatients’todailyonce-dailyhabitsdosing(GradeD)

●Utilizingcombinationsmultipleunit-of-use(GradepillpackagingC)

antihypertensivecombinations(GradewithsingleD)pill(ofseveralmedicationstobetaken●Usingtogether)(GradeD)

antihypertensiveamultidisciplinaryprescriptionteam(GradeapproachB)

toimproveadherencetoanAssist●Encouragingyourpatientgreateringettingmoreinvolvedintheirtreatmentby:

●Educatingtheirbloodpressurepatientandadjustingresponsibility/autonomytheirprescriptionsin(GrademonitoringC)treatmentpatientsregimensand(Gradepatients’C)

familiesabouttheirdiseaseandImprove●Assessingyourmanagementadherencetoinpharmacologicaltheofﬁceandbeyondby:

●Encouragingtherapyateveryphoneormail),adherencevisit(GradeandnonpharmacologicalparticularlywithD)

duringtherapythebyﬁrstout-of-ofﬁcethreemonthscontactoftherapy(eitherby●Coordinating(GradeD)

improvemonitoringwithpharmacistsofadherenceandwithwork-sitepharmacologicalhealthcareandgiverslifestyleto●Utilizingmodiﬁcationelectronicprescriptionsmedication(GradecomplianceD)

aids(GradeD)ReprintedwithpermissionoftheCanadianHypertensionEducationProgram.

284

Table9.Considerationsintheindividualizationofantihypertensivetherapy

Initialtherapy

Diastolicwithorwithoutsystolichypertension

Second-linetherapy

CanadianJournalofCardiology

Volume282012

Notesand/orcautions

Hypertensionwithoutothercompellingindications(targetBP<140/90mmHg)

Thiazidediuretics,␤-blockers,ACECombinationsofﬁrst-lineNotrecommendedformonotherapy:

inhibitors,ARBs,orlong-actingdrugs␣-blockers,␤-blockersinthoseCCBs(considerASAandstatinsinՆ60yearsofage,ACEinhibitorsselectedpatients).Considerinblacks.Hypokalemiashouldbeinitiatingtherapywithaavoidedinthoseprescribedcombinationofﬁrst-linedrugsifthediureticmonotherapy.ACEBPisՆ20mmHgsystolicorՆ10inhibitors,ARBs,anddirectreninmmHgdiastolicabovetargetinhibitorsarepotentialteratogens,

andcautionisrequiredif

prescribingtowomenofchild-bearingpotential.CombinationofanACE-inhibitorwithanARBisnotrecommended.

IsolatedsystolichypertensionwithoutotherThiazidediuretics,ARBs,orlong-actingCombinationsofﬁrst-lineSameasdiastolicwithorwithoutcompellingindicationsdihydropyridineCCBsdrugssystolichypertension

Diabetesmellitus(targetBP<130/80mmHg)

Diabetesmellituswithmicroalbuminuria,*ACEinhibitorsorARBsAdditionofAloopdiureticcouldbeconsideredrenaldisease,cardiovasculardisease,ordihydropyridineCCBinhypertensiveCKDpatientsadditionalcardiovascularriskfactorsispreferredoverwithextracellularﬂuidvolume

thiazideoverload

DiabetesmellitusnotincludedintheaboveACEinhibitors,ARBs,dihydropyridineCombinationofﬁrst-lineNormalACRϽ2.0mg/mmolincategoryCCBs,orthiazidediureticsdrugs.IfcombinationmenandϽ2.8mg/mmolin

withanACEinhibitorwomenisbeingconsidered,adihydropyridineCCBispreferabletothiazidediuretic

Cardiovasculardisease(targetBP<140/90mmHg)

CoronaryarterydiseaseACEinhibitorsorARBs(exceptinlow-Long-actingCCBs.WhenAvoidshort-actingnifedipine.

riskpatients);␤-blockersforpatientscombinationtherapyisCombinationofanACEwithstableanginabeingusedforhighinhibitorwithanARBis

riskpatients,anACEspeciﬁcallynotrecommendedinhibitor/dihydropyridineCCBispreferred

Recentmyocardialinfarction␤-BlockersandACEinhibitors(ARBsifLong-actingCCBsif␤-NondihydropyridineCCBsshould

ACEinhibitor-intolerant)blockernotbeusedwithconcomitant

contraindicatedornotheartfailureeffective

HeartfailureACEinhibitors(ARBsifACEinhibitor-ACEinhibitorandARBTitratedosesofACEinhibitorsand

intolerant)and␤-blockers.combined.ARBstothoseusedinclinicalAldosteroneantagonistsHydralazine/isosorbidetrials.Carefullymonitor(mineralocorticoidreceptordinitratecombinationpotassiumandrenalfunctionifantagonists)maybeaddedforifACEinhibitorandcombininganyofACEinhibitor,patientswitharecentcardiovascularARBcontraindicatedARB,and/oraldosteronehospitalization,acutemyocardialornottolerated.antagonistinfarction,elevatedB-typeThiazideorloopnatriureticpeptideorN-terminal-diureticsare

proBNPlevel,orNYHAclassIItorecommendedasIVsymptomsadditivetherapy.

DihydropyridineCCB

LeftventricularhypertrophyACEinhibitor,ARB,long-actingCCB,CombinationofadditionalHydralazineandminoxidilshould

orthiazidediuretics.agentsnotbeused

PaststrokeorTIAACEinhibitor/diureticcombinationsCombinationofadditionalTreatmentofhypertensionshould

agentsnotberoutinelyundertakenin

acutestrokeunlessextremeBPelevation.CombinationofanACEinhibitorwithanARBisnotrecommended

NondiabeticCKD(targetBP<140/90mmHg)

NondiabeticCKDwithproteinuria†ACEinhibitors(ARBsifACEinhibitor-CombinationsofCarefullymonitorrenalfunctionand

intolerant)ifthereisproteinuria.additionalagentspotassiumforthosetakinganDiureticsasadditivetherapyACEinhibitororARB.

CombinationsofanACEinhibitorandARBarenot

recommendedinpatientswithoutproteinuria

RenovasculardiseaseDoesnotaffectinitialtreatmentCombinationsofAvoidACEinhibitorsorARBif

recommendationsadditionalagentsbilateralrenalarterystenosisor

unilateraldiseasewithsolitarykidney

Daskalopoulouetal.

2012CanadianRecommendationsforHighBPTable9.Continued.

Initialtherapy

PeripheralarterialdiseaseDyslipidemia

Overallvascularprotection

Second-linetherapy

Notesand/orcautions

Otherconditions(targetBP<140/90mmHg)DoesnotaffectinitialtreatmentCombinationsofrecommendationsadditionalagentsDoesnotaffectinitialtreatmentCombinationsofrecommendationsadditionalagentsStatintherapyforpatientswith3or—morecardiovascularriskfactorsoratheroscleroticdisease.LowdoseASAinpatientswithcontrolledBP

285

Avoid␤-blockerswithseveredisease—

CautionshouldbeexercisedwiththeASArecommendationifBPisnotcontrolled

ACE,angiotensin-convertingenzyme;ACR,albumin-to-creatinineratio;ARB,angiotensin-receptorblocker;ASA,acetylsalicylicacid;BNP,B-typenatriureticpeptide;BP,bloodpressure;CCB,calciumchannelblocker;CKD,chronickidneydisease;NYHA,NewYorkHeartAssociation;TIA,transientischemicattack.*AlbuminuriaisdeﬁnedaspersistentACRϾ2.0mg/mmolinmenandϾ2.8mg/mmolinwomen.†ProteinuriaisdeﬁnedasurinaryproteinϾ500mgper24hoursorACRϾ30mg/mmol.ReprintedwithpermissionoftheCanadianHypertensionEducationProgram.

Implementation

Theimplementationtaskforceconductsanextensiveknowledgetranslationefforttoenhanceuptakeandapplicabil-ityoftheserecommendations.Theseeffortsbrieﬂyincludeknowledgeexchangeforums,targetededucationalmaterialsforprimarycareproviders,aswellaspatients,andfreelyavailableslidekitsandsummarydocumentsofallrecommendationsontheCa-nadianHypertensionSocietyWebsite(www.hypertension.ca).DocumentsareavailableinFrenchandEnglish,andsomedoc-umentsaretranslatedintootherlanguages.TheCHEPout-comestaskforceconductshypertensionsurveillancestudiesandreviewofexistingCanadianhealthsurveystoidentifygapsbetweencurrentandbestpractices.Theimplementationtaskforcealsoregularlyreceivesfeedbackfromenduserstoimproveguidelineprocessesandcontent.Althoughthenumberofpri-marycareprovidersthatdirectlyreceiveCHEPmaterialsonaregularbasishasdramaticallyincreased,CHEPiscontinuingtoaddressthebarrierandchallengeofidentifyingandreachingallactiveprimarycareprovidersacrossCanadafordissemina-tionofCHEPmaterials.

FutureDirections

Thepresentreport(seeTable9forthesummaryofphar-macologicalmanagementofhypertension)representsthe13thiterationoftheannuallyupdatedCHEPrecommendationsforthemanagementofhypertension,andwewillcontinuetocon-ductyearlysystematicreviewsoftheclinicaltrialevidencetoupdateourrecommendationsfortherapyannually.Theprev-alenceofhypertensioninCanadacontinuestoincreaseandispredictedtoreach7,500,000peoplein2012/2013withover1000peoplenewlydiagnosedwithhypertensioneveryday.53Therefore,thereisaneedtofocusoureffortsonpreventionofhypertension,whichistheCHEPthemefor2012.TheoverallgoaloftheCHEPistoimproveawareness,treatment,andcontrolofhypertensioninCanada.

FundingSources

TheCHEPprocessissponsoredbyHypertensionCanada,theCollegeofFamilyPhysiciansofCanada,theCanadianPharmacyAssociation,theCanadianCouncilofCardiovascu-larNurses,andtheHeartandStrokeFoundationofCanada.CHEPmembersareunpaidvolunteers.AlthoughmeetingsponsorsarealsostakeholdersintheCHEP,theviewsorinter-

estsofthesponsorshavenotinﬂuencedtheﬁnalrecommen-dations.

Disclosures

DisclosurescanbefoundinSupplementalAppendixS2availableonlineatwww.onlinecj.ca.References

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Toaccessthesupplementarymaterialaccompanyingthisarti-cle,visittheonlineversionoftheCanadianJournalofCardiologyatwww.onlinecjc.ca,andatdoi:10.1016/j.cjca.2012.02.018.

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