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

8 Nov

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


Initial Therapy

Second-Line Therapy

Notes and Cautions

Hypertension without
compelling indications for other medications

Thiazide diuretics,
6- blockers
(for patients under
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
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

Diabetes mellitus with

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


6-Blockers (strongly
consider adding ACE inhibitors)

Long-acting CCBs

Avoid short-acting

Prior myocardial

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

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

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

Avoid hydralazine and

Peripheral arterial

Does not affect
treatment recommendations

Avoid 6-blockers with
severe disease.


Does not affect
treatment recommendations

enzyme, ARB


antiogensin II receptor
blocker, ASA TIA


transient ischemic accident.

, =
acetylsalicylic acid,


calcium-channel blocker,


Treatment of Patients with Hypertension
Cialis Jelly

• 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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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.


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.