Canadian Hypertension Education Program: Sound Bite Version – Treat to Target

8 Nov
2010

Education Program

The following targets are currently recommended for reducing blood pressure:

• in general, less than 140 mm Hg systolic and less than 90 mm Hg diastolic

• for patients with diabetes or chronic kidney disease, less than 130/80 mm Hg

Use Combinations of Medications and Lifestyle Modifications to Achieve Blood Pressure Targets

Most patients require 2 or more drugs to achieve recommended blood pressure targets. Individualization of antihypertensive therapy should always be consid­ered (Table 1). In general, the average reduction in blood pressure with a single blood-pressure-lowering medication is 10/5 mm Hg. Combining medications is therefore to be expected in therapy for hypertension. Using lifestyle modifications can reduce the number and doses of medications required for blood pressure con­trol and should be recommended for all hypertensive patients. The systolic blood pressure target is usually more difficult to achieve; however, the patient’s cardio­vascular prognosis is at least as closely associated (if not more closely associated) with systolic blood pressure as with diastolic blood pressure.

Table 1. Considerations in the Individualization of Antihypertensive Therapy


Condition


Initial Therapy


Second-Line Therapy


Notes and Cautions


Hypertension without
compelling indications for other medications



Thiazide diuretics,
6- blockers
(for patients under
60
years of age), ACE inhibitors (for
nonblack patients), ARBs, or long-acting CCBs (consider ASA and/or
statins in selected patients)


Combinations of
first-line drugs



a-Blockers are not recommended as
initial monotherapy. 6-Blockers are not recommended as initial
monotherapy in those
60
years of age or older. Hypokalemia
should be avoided in those who are receiving diuretics. ACE inhibitors
are not recommended as initial monotherapy for black patients. ACE
inhibitors and ARBs are contraindicated in pregnancy.


Isolated systolic
hypertension without other compelling indications


Thiazide diuretics,
ARBs, or long-acting dihydropyridine CCBs


Combinations of
first-line drugs


Hypokalemia should be
avoided by using potassium-sparing agents in those who are receiving
diuretics.


Diabetes mellitus with
nephropathy


ACE inhibitors or ARBs


Addition of one or more
of thiazide diuretics, cardioselective 6-blockers, or long-acting CCBs,
or a combination of ARB and ACE inhibitor


Diabetes mellitus
without nephropathy


ACE inhibitors, ARBs,
thiazides diuretics, or dihydropyridine CCBs


Combination of
first-line drugs or addition of cardioselective 6-blockers


Angina


6-Blockers (strongly
consider adding ACE inhibitors)


Long-acting CCBs


Avoid short-acting
nifedipine.


Prior myocardial
infarction


6-Blockers and ACE
inhibitors (ARBs for patients with intolerance to ACE inhibitors)


Heart failure


ACE inhibitors (ARBs
for patients with intolerance to ACE inhibitors), 6-blockers, and
spironolactone in selected patients


ARBs or
hydralazine/isosorbide dinitrate (thiazide or loop diuretics as additive
therapy)


Avoid
non-dihydropyridine CCBs.


Past cerebrovascular
accident or TIA


Combinations of ACE
inhibitor and diuretic


Caution is indicated in
deciding whether to lower blood pressure in patients with acute stroke.
Pharmacological agents and routes of administration should be chosen to
avoid precipitous drops in blood pressure.


Chronic kidney disease


ACE inhibitors
(diuretics as additive therapy)


Combinations of
additional agents (ARBs for patients with intolerance to ACE inhibitors)


Avoid ACE inhibitors
and ARBs if bilateral renal artery stenosis is present


Left ventricular
hypertrophy



ACE inhibitors, ARBs, CCBs, thiazide
diuretics, or 6-blockers for patients under
60
years of age


Avoid hydralazine and
minoxidil.


Peripheral arterial
disease


Does not affect
treatment recommendations


Avoid 6-blockers with
severe disease.


Dyslipidemia


Does not affect
treatment recommendations



ACE
=
angiotensin-converting
enzyme, ARB

=

antiogensin II receptor
blocker, ASA TIA

=

transient ischemic accident.



, =
acetylsalicylic acid,
CCB

=

calcium-channel blocker,

NEW RECOMMENDATIONS FOR 2006

Treatment of Patients with Hypertension
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• 6-Blocker therapy remains strongly recommended for hypertensive patients of all ages who have specific indications, such as prior myocardial infarction, angina, or congestive heart failure. New evidence supports the use of ^-blockers as first-line therapy in uncomplicated hypertension only for patients younger than 60 years of age.

• Angiotensin II receptor blockers (ARBs) are recom­mended after myocardial infarction for patients in whom angiotensin-converting enzyme (ACE) inhibitors are not well tolerated.

• Patients with hypertension who are taking ACE inhibitors and ARBs must undergo monitoring for hypotension, hyperkalemia, and worsening renal failure.

• For patients with diabetes, normal urinary albumin excretion, and hypertension, any of an ACE inhibitor, ARB, dihydropyridine calcium channel blocker, or thiazide diuretic is recommended, with special con­sideration to the ACE inhibitors and ARBs (given their potential renal benefits).

Diagnosis of Hypertension

It is becoming increasingly evident that blood pres­sure measured in the office may overestimate or under­estimate risk. Accordingly, emphasis is now being placed on home or self-administered blood pressure readings. In the 2006 recommendations, CHEP identified that treated hypertensive patients with masked hypertension (blood pressure controlled in the officebut not at home) should monitor home/self blood pressure regularly because the cardiovascular prognosis for patients with confirmed masked hypertension is similar to that of patients with uncontrolled hypertension.
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DELETED 2005 RECOMMENDATION

For patients with proteinuria greater than 1 g/day, the recommendation for a target blood pressure of 125/75 mm Hg has been deleted in 2006. This revision is based on new evidence demonstrating that in patients with proteinuria greater than 1 g/day, a target blood pressure of less than 125/75 mm Hg was not superior to a target of less than 130/80 mm Hg.

CONCLUSIONS

As in previous years, it needs to be reiterated that the CHEP hypertension management recommendations are based solely on efficacy data. Considerations relating to individual patient or physician preferences and the cost-effectiveness of different drug classes have notbeen a component of this process and need to be considered by the physician and patient when individu­alizing therapy.

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