hypertension canada's 2017 guidelines for diagnosis, risk ...ckdpathway.ca/content/pdfs/chep...

rdiology 33 (2017) 557e576
Canadian Journal of Ca
Guidelines

Hypertension Canada’s 2017 Guidelines for Diagnosis, RiskAssessment, Prevention, and Treatment of Hypertension in

AdultsAlexander A. Leung, MD, MPH,a Stella S. Daskalopoulou, MD, PhD,b

Kaberi Dasgupta, MD, MSc,b Kerry McBrien, MD, MPH,c Sonia Butalia, BSc, MD,d

Kelly B. Zarnke, MD, MSc,e Kara Nerenberg, MD, MSc,f Kevin C. Harris, MD, MHSc,g

Meranda Nakhla, MD, MSc,h Lyne Cloutier, RN, PhD,i Mark Gelfer, MD,j

Maxime Lamarre-Cliche, MD,k Alain Milot, MD, MSc, MD,l Peter Bolli, MD,m

Guy Tremblay, MD,n Donna McLean, RN, NP, PhD,o Sheldon W. Tobe, MD, MSc(HPTE),p

Marcel Ruzicka, MD, PhD,q Kevin D. Burns, MD,q Michel Vall�ee, MD, PhD,r

G.V. Ramesh Prasad, MBBS, MSc,p Steven E. Gryn, MD,s Ross D. Feldman, MD,t

Peter Selby, MBBS, MHSc,u Andrew Pipe, CM, MD,v Ernesto L. Schiffrin, MD, PhD,w

Philip A. McFarlane, MD, PhD,x Paul Oh, MD,y Robert A. Hegele, MD,z Milan Khara, MBChB,aa

Thomas W. Wilson, MD,bb S. Brian Penner, MD,cc Ellen Burgess, MD,dd

Praveena Sivapalan, MD,bb Robert J. Herman, MD,e Simon L. Bacon, PhD,ee

Simon W. Rabkin, MD,ff Richard E. Gilbert, MD, PhD,gg Tavis S. Campbell, PhD,hh

Steven Grover, MD, MPA,ii George Honos, MD,jj Patrice Lindsay, RN, PhD,kk

Michael D. Hill, MD, MSc,ll Shelagh B. Coutts, MD,mm Gord Gubitz, MD,nn

Norman R.C. Campbell, MD,oo Gordon W. Moe, MD, MSc,pp Jonathan G. Howlett, MD,qq

Jean-Martin Boulanger, MD,rr Ally Prebtani, MD,ss Gregory Kline, MD,dd

Lawrence A. Leiter, MD,tt Charlotte Jones, MD, PhD,uu Anne-Marie Côt�e, MD, MHSc,vv

Vincent Woo, MD,ww Janusz Kaczorowski, PhD,xx Luc Trudeau, MD,yy

Ross T. Tsuyuki, BSc (Pharm), PharmD, MSc,zz Swapnil Hiremath, MD, MPH,aaa

Denis Drouin, MD,bbb Kim L. Lavoie, PhD,ccc Pavel Hamet, MD, PhD,ddd

Jean C. Gr�egoire, MD,eee Richard Lewanczuk, MD, PhD,o George K. Dresser, MD, PhD,fff

Mukul Sharma, MD, MSc,ggg Debra Reid, PhD, DtP,hhh Scott A. Lear, PhD,iii

Gregory Moullec, PhD,jjj Milan Gupta, MD,kkk Laura A. Magee, MD, MSc,lll

Alexander G. Logan, MD,p Janis Dionne, MD,g Anne Fournier, MD,mmm

Received for publication February 21, 2017. Accepted March 5, 2017.

Corresponding author: Dr Alexander A. Leung, Division of Endocri-nology and Metabolism, Departments of Medicine and Community Health

Sciences, University of Calgary, 1820 Richmond Rd SW, Calgary, AlbertaT2T 5C7, Canada. Tel.: þ1-403-955-8358; fax: þ1-403-955-8249.

E-mail: [email protected] page 573 for disclosure information.

http://dx.doi.org/10.1016/j.cjca.2017.03.0050828-282X/� 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.cjca.2017.03.005


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558 Canadian Journal of CardiologyVolume 33 2017

Geneviève Benoit, MD,nnn Janusz Feber, MD,ooo Luc Poirier, BPharm, MSc,ppp

Raj S. Padwal, MD, MSc,qqq and Doreen M. Rabi, MD, MSc;rrr for Hypertension CanadaaDivision of Endocrinology and Metabolism, Department of Medicine, University of Calgary, Calgary, Alberta, Canada; bDivisions of General Internal Medicine, ClinicalEpidemiology and Endocrinology, Department of Medicine, McGill University, McGill University Health Centre, Montreal, Quebec, Canada; cDepartments of FamilyMedicine and Community Health Sciences, Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; dDepartments ofMedicine and Community Health Sciences, Libin Cardiovascular Institute of Alberta, O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada;eDivision of General Internal Medicine, University of Calgary, Calgary, Alberta, Canada; fDepartment of Medicine and Department of Obstetrics and Gynecology,University of Calgary, Calgary, Alberta, Canada; gDepartment of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; hMontreal Children’sHospital, McGill University, Montreal, Quebec, Canada; iUniversit�e du Qu�ebec à Trois-Rivières, Trois-Rivières, Quebec, Canada; jDepartment of Family Medicine,University of British Columbia, Copeman Healthcare Centre, Vancouver, British Columbia, Canada; k Institut de Recherches Cliniques de Montr�eal, Universit�e deMontr�eal, Montr�eal, Quebec, Canada; lDepartment of Medicine, Universit�e Laval, Qu�ebec, Quebec, Canada; mMcMaster University, Hamilton, Ontario, Canada;nCHU-Qu�ebec-Hopital St Sacrement, Qu�ebec, Quebec, Canada; oUniversity of Alberta, Edmonton, Alberta, Canada; pUniversity of Toronto, Toronto, Ontario, Canada;qDivision of Nephrology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; rHôpital Maisonneuve-Rosemont,Universit�e de Montr�eal, Montr�eal, Quebec, Canada; sDepartment of Medicine, Division of Clinical Pharmacology, Western University, London, Ontario, Canada;tDiscipline of Medicine, Memorial University of Newfoundland, St John’s, Newfoundland and Labrador; uCentre for Addiction and Mental Health, University of Toronto,Toronto, Ontario, Canada; vUniversity of Ottawa Heart Institute, Ottawa, Ontario, Canada; wDepartment of Medicine and Lady Davis Institute for Medical Research,Jewish General Hospital, McGill University, Montreal, Quebec, Canada; xDivision of Nephrology, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada;yUniversity Health Network, University of Toronto, Toronto, Ontario, Canada; zDepartments of Medicine (Division of Endocrinology) and Biochemistry, WesternUniversity, London, Ontario, Canada; aaVancouver Coastal Health Addiction Services, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia,Canada; bbDepartment of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; ccDepartment of Internal Medicine, University of Manitoba,Winnipeg, Manitoba, Canada; ddDepartment of Medicine, University of Calgary, Calgary, Alberta, Canada; eeDepartment of Exercise Science, Concordia University, andMontreal Behavioural Medicine Centre, Centre int�egr�e universitaire de sant�e et de services sociaux du Nord-de-l’Île-de-Montr�eal (CIUSSS-NIM), Hôpital du Sacr�e-Coeurde Montr�eal, Montr�eal, Quebec, Canada; ff Vancouver Hospital, University of British Columbia, Vancouver, British Columbia, Canada; ggUniversity of Toronto, Divisionof Endocrinology, St Michael’s Hospital, Toronto, Ontario, Canada; hhDepartment of Psychology, University of Calgary, Calgary, Alberta, Canada; iiDivision of ClinicalEpidemiology, Montreal General Hospital, Montreal, Quebec, Canada; jjUniversity of Montreal, Montreal, Quebec, Canada; kkStroke, Heart and Stroke Foundation ofCanada, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; llDepartment of Clinical Neurosciences, HotchkissBrain Institute, University of Calgary, Calgary, Alberta, Canada; mmDepartments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary,Calgary, Alberta, Canada; nnDivision of Neurology, Halifax Infirmary, Dalhousie University, Halifax, Nova Scotia, Canada; ooMedicine, Community Health Sciences,Physiology and Pharmacology, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; pp St Michael’s Hospital, University of Toronto,Toronto, Ontario, Canada; qqDepartments of Medicine and Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada; rrCharles LeMoyne Hospital ResearchCentre, Sherbrooke University, Sherbrooke, Quebec, Canada; ssMcMaster University, Hamilton, Ontario, Canada; ttKeenan Research Centre in the Li Ka Shing KnowledgeInstitute of St Michael’s Hospital, and University of Toronto, Toronto, Ontario, Canada; uuUniversity of British Columbia, Southern Medical Program, Kelowna, BritishColumbia, Canada; vvUniversit�e de Sherbrooke, Sherbrooke, Quebec, Canada; wwUniversity of Manitoba, Winnipeg, Manitoba, Canada; xxUniversit�e de Montr�eal andCentre hospitalier de l’Universit�e de Montr�eal (CHUM), Montr�eal, Quebec, Canada; yyDivision of Internal Medicine, McGill University, Montr�eal, Quebec, Canada;zzDepartment of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; aaaFaculty of Medicine, University of Ottawa, OttawaHospital Research Institute, Ottawa, Ontario, Canada; bbbFaculty of Medicine, Universit�e Laval, Qu�ebec, Quebec, Canada; cccDepartment of Psychology, University ofQuebec at Montreal, Montr�eal, Quebec, Canada; dddFacult�e de M�edicine, Universit�e de Montr�eal, Montr�eal, Quebec, Canada; eeeUniversit�e de Montr�eal, Institut decardiologie de Montr�eal, Montr�eal, Quebec, Canada; fff Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; gggMcMaster University,Hamilton Health Sciences Population Health Research Institute, Hamilton, Ontario, Canada; hhhCentre int�egr�e de sant�e et de services sociaux (CISSS) de l’Outaouais,Groupes de m�edecine de famille (GMF) de Wakefield, Wakefield, Quebec, Canada; iii Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia,Canada; jjj Research Center, Hôpital du Sacr�e-Coeur de Montr�eal, Public Health School, University of Montr�eal, Montr�eal, Quebec, Canada; kkkMcMaster University,Hamilton, Ontario, and Canadian Collaborative Research Network, Brampton, Ontario, Canada; lll St George’s, University of London and the St George’s HospitalNational Health Service (NHS) Foundation Trust, London, United Kingdom; mmmService de cardiologie, Centre Hospitalier Universitaire Sainte-Justine, Universit�e deMontr�eal, Montr�eal, Quebec, Canada; nnnCentre Hospitalier Universitaire Sainte-Justine, Department of Pediatrics, Universit�e de Montr�eal, Montr�eal, Quebec, Canada;oooDivision of Neurology, Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada; pppCentre HospitalierUniversitaire de Qu�ebec et Facult�e de Pharmacie, Universit�e Laval, Qu�ebec, Quebec, Canada; qqqDepartment of Medicine, University of Alberta, Edmonton, Alberta,Canada; rrrDepartments of Medicine, Community Health and Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada

ABSTRACTHypertension Canada provides annually updated, evidence-basedguidelines for the diagnosis, assessment, prevention, and treatmentof hypertension. This year, we introduce 10 new guidelines. Threeprevious guidelines have been revised and 5 have been removed.Previous age and frailty distinctions have been removed as consider-ations for when to initiate antihypertensive therapy. In the presence ofmacrovascular target organ damage, or in those with independentcardiovascular risk factors, antihypertensive therapy should be

R�ESUM�EHypertension Canada pr�esente annuellement une mise à jour de seslignes directrices fond�ees sur des donn�ees probantes en vue dudiagnostic, de l’�evaluation, de la pr�evention et du traitement de l’hy-pertension. Cette ann�ee, nous pr�esentons 10 nouvelles lignes di-rectrices. Trois de nos lignes directrices ont �et�e revues et cinq autresont �et�e �elimin�ees. Nous avons notamment retir�e les distinctions rela-tives à l’âge et à la fragilit�e du patient dans le cadre de l’�evaluationpr�ealable à l’instauration d’un traitement antihypertenseur. En

Hypertension affects nearly a quarter of Canadian adults and With the goal of improving the prevention, detection,
represents a major risk factor for cardiovascular morbidity,chronic kidney disease, and death; however, it often remainsclinically silent until complications arise.1-3 Worldwide, highblood pressure (BP) affects > 40% of adults older than the ageof 25 years, and is the leading global risk factor for death ordisability.4,5
assessment, and management of hypertension, HypertensionCanada (formerly the Canadian Hypertension EducationProgram) has been producing annually-updated, evidence-based guidelines for health care providers since 1999. (Therebranding of Hypertension Canada was in response tofeedback and marketing research from primary care

considered for all individuals with elevated average systolic nonauto-mated office blood pressure (non-AOBP) readings � 140 mm Hg. Forindividuals with diastolic hypertension (with or without systolic hyper-tension), fixed-dose single-pill combinations are now recommended asan initial treatment option. Preference is given to pills containing anangiotensin-converting enzyme inhibitor or angiotensin receptorblocker in combination with either a calcium channel blocker ordiuretic. Whenever a diuretic is selected as monotherapy, longer-actingagents are preferred. In patients with established ischemic heart dis-ease, caution should be exercised in lowering diastolic non-AOBP to� 60 mm Hg, especially in the presence of left ventricular hypertrophy.After a hemorrhagic stroke, in the first 24 hours, systolic non-AOBPlowering to < 140 mm Hg is not recommended. Finally, guidance isnow provided for screening, initial diagnosis, assessment, and treat-ment of renovascular hypertension arising from fibromusculardysplasia. The specific evidence and rationale underlying each of theseguidelines are discussed.

pr�esence de l�esions macrovasculaires aux organes cibles ou de fac-teurs ind�ependants de risque cardiovasculaire, un traitement anti-hypertenseur doit être envisag�e chez tous les patients dont la pressionsystolique moyenne s’elève à � 140 mm Hg (mesure de la pressionart�erielle en clinique [MPAC]). En ce qui a trait aux patients quipr�esentent une hypertension diastolique (avec ou sans hypertensionsystolique), on recommande d�esormais un traitement par une asso-ciation m�edicamenteuse à dose fixe pr�esent�ee en un seul comprim�e àtitre d’option th�erapeutique initiale. Nous privil�egions notamment lesm�edicaments associant un inhibiteur de l’enzyme de conversion del’angiotensine ou un inhibiteur des r�ecepteurs de l’angiotensine à unbloqueur des canaux calciques ou à un diur�etique. En cas d’adminis-tration d’un diur�etique en monoth�erapie, il convient de privil�egier lesagents à action prolong�ee. Chez les patients atteints d’une car-diopathie isch�emique av�er�ee, il faut faire preuve de prudence lorsd’une baisse de la pression diastolique (MPAC) à � 60 mm Hg, surtouten pr�esence d’une hypertrophie ventriculaire gauche. Au cours des 24premières heures suivant un accident vasculaire c�er�ebralh�emorragique, il n’est pas recommand�e d’abaisser a pression systo-lique (MPAC) à moins de 140 mm Hg. Enfin, nous avons inclus deslignes directrices en vue du d�epistage, du diagnostic initial, del’�evaluation et du traitement de l’hypertension r�enovasculaire associ�eeà la dysplasie fibromusculaire. La justification et les donn�ees pro-bantes pour chacune de nos lignes directrices sont �egalementpr�esent�ees.

Leung et al. 5592017 Hypertension Canada Guidelines for Adults

stakeholders.) We present herein updated guidelines for 2017,along with discussion of the supporting evidence. Furtherdetails along with supporting references pertaining to estab-lished guidelines are available in previous publications,6-32 andonline (guidelines.hypertension.ca). Pediatric-specific guide-lines are published separately.

Our guidelines are intended to provide a framework butshould not replace clinical judgement. Practitioners areadvised to consider patient preferences, values, and clinicalfactors when determining how to best apply these guidelinesat the bedside.

MethodsThe Hypertension Canada Guidelines Committee

(HCGC) is a multidisciplinary panel of content as well asmethodological experts comprised of a Chair, a Central Re-view Committee with a designated Chair, and 15 subgroups.Each subgroup addresses a distinct content area in hyperten-sion (see Supplemental Appendix S1 for the current mem-bership list). All HCGC members are volunteers.

Systematic literature searches to August 2016 were per-formed by a librarian from the Cochrane Collaboration inMedLine/PubMed using text words and Medical SubjectHeadings. Details of search strategies and retrieved articles areavailable upon request. Randomized controlled trials andsystematic reviews of randomized controlled trials werereviewed for treatment guidelines, whereas cross-sectional andcohort studies were reviewed for evidence related to diagnosisand prognosis.

Each subgroup examined the search results pertinent toits content area. Studies that assessed relevant outcomeswere selected for further review. Cardiovascular morbidity

and mortality as well as total mortality outcomes wereprioritized for pharmacotherapy studies. For healthbehaviour guidelines, BP was considered an acceptablesurrogate. Similarly, progressive renal impairment was anacceptable surrogate for guidelines relevant to chronickidney disease. Study characteristics and study qualitywere assessed using prespecified, standardized algorithmsdeveloped by Hypertension Canada for the criticalappraisal of randomized controlled trials and observationalstudies.33

Guidelines were individually graded according to thesupporting evidence. All guidelines, regardless of grading, arebelieved to have benefits that strongly outweigh risks. In thissense, all of Hypertension Canada’s guidelines are ‘strong’ innature (ie, the HCGC refrains from making ‘weak’ guide-lines). For pharmacotherapy guidelines, as a general rule,Hypertension Canada considers evidence evaluating specificagents to be generalizable to a ‘class effect’ unless otherwisestated.

Expert subgroup members were responsible for reviewingannual search results and, if indicated, drafting new guidelinesor revising existing guidelines. An independent CentralReview Committee consisting of methodological experts withno industry affiliations independently reviewed, graded, andrefined proposed guidelines, which were then presented at aconsensus conference of the HCGC in Montreal on October19, 2016.

All guidelines were finalized and submitted electronicallyto all 81 voting members of the HCGC for approval.Members with potential conflicts of interest recused them-selves from voting on specific guidelines (a list of conflicts isavailable as Supplemental Appendix S2). Guidelines receiving> 70% approval were passed. The Hypertension Canada

http://guidelines.hypertension.ca


Guidelines process is in accordance with the Appraisal ofGuidelines for Research and Evaluation II (AGREE II)guidelines (guidelines.hypertension.ca/about/overview-process),34 and has been externally reviewed (SupplementalTable S1).

Hypertension Canada’s 2017 Guidelines:Diagnosis and Assessment of Hypertension

I. Accurate measurement of BP

Background. There are no changes to these guidelines for2017.

Guidelines

1. Health care professionals who have been specificallytrained to measure BP accurately should assess BP in alladult patients at all appropriate visits to determine car-diovascular risk and monitor antihypertensive treatment(Grade D).

2. Use of standardized measurement techniques and vali-dated equipment for all methods (automated office BP[AOBP], non-AOBP, home BP monitoring, and ambu-latory BP monitoring) is recommended (Grade D; seeSupplemental Table S2; and sections III. Home BPMeasurement; and IV. Ambulatory BP Measurement).Measurement using electronic (oscillometric) upper armdevices is preferred over auscultation (Grade C). (Unlessspecified otherwise, electronic [oscillometric] measure-ment should be used.)

3. Four approaches can be used to assess BP:i. AOBP is the preferred method of performing in-officeBP measurement (Grade D). When using AOBP (seeSupplemental Table S2, section on RecommendedTechnique for Automated Office Blood Pressure[AOBP]), a displayed mean systolic BP (SBP) � 135mm Hg or diastolic BP (DBP) � 85 mm Hg DBP ishigh (Grade D).

ii. When using non-AOBP, a mean SBP � 140 mm Hgor DBP � 90 mm Hg is high, and an SBP between130 and 139 mm Hg and/or a DBP between 85 and89 mm Hg is high-normal (Grade C).

iii. Using ambulatory BP monitoring (see Guidelines insection IV, Ambulatory BP Measurement), patients canbe diagnosed as hypertensive if the mean awake SBP is� 135 mm Hg or the DBP is � 85 mm Hg or if themean 24-hour SBP is � 130 mm Hg or the DBP is �80 mm Hg (Grade C).

iv. Using home BP monitoring (see Guidelines in sectionIII, Home BP Measurement), patients can be diag-nosed as hypertensive if the mean SBP is � 135 mmHg or the DBP is � 85 mm Hg (Grade C). If theoffice BP measurement is high and the mean homeBP is < 135/85 mm Hg, it is advisable to eitherrepeat home monitoring to confirm the home BP is< 135/85 mm Hg or perform 24-hour ambulatoryBP monitoring to confirm that the mean 24-hourambulatory BP monitoring is < 130/80 mm Hg

and the mean awake ambulatory BP monitoring is< 135/85 mm Hg before diagnosing white coathypertension (Grade D).

II. Criteria for diagnosis of hypertension and guidelinesfor follow-up

Background. There are no changes to these guidelines for2017. A hypertension diagnostic algorithm is shown inFigure 1.

Guidelines

1. At the time of initial presentation, patients demonstratingfeatures of a hypertensive urgency or emergency(Supplemental Table S3) should be diagnosed as hyper-tensive and require immediate management (Grade D).In all other patients, at least 2 more readings should betaken during the same visit. If using AOBP, the BPcalculated and displayed by the device should be used. Ifusing non-AOBP measurement, the first reading shouldbe discarded and the latter readings averaged.

2. If the visit 1 office BP measurement is high-normal(thresholds outlined in section I, Guideline 3) annualfollow-up is recommended (Grade C).

3. If the visit 1 mean AOBP or non-AOBP measurement ishigh (thresholds outlined in section I, Guideline 3), ahistory and physical examination should be performedand, if clinically indicated, diagnostic tests to search fortarget organ damage (Supplemental Table S4) andassociated cardiovascular risk factors (SupplementalTable S5) should be arranged within 2 visits. Exoge-nous factors that can induce or aggravate hypertensionshould be assessed and removed if possible(Supplemental Table S6). Visit 2 should be scheduledwithin 1 month (Grade D).

4. If the visit 1 mean AOBP or non-AOBP SBP is � 180mm Hg and/or DBP is � 110 mm Hg then hypertensionis diagnosed (Grade D).

5. If the visit 1 mean AOBP SBP is 135-179 mm Hg and/orDBP is 85-109 mm Hg or the mean non-AOBP SBP is140-179 mm Hg and/or DBP is 90-109 mm Hg, out-of-office BP measurements should be performed before visit2 (Grade C).
i. Ambulatory BP monitoring is the recommended out-of-office measurement method (Grade D). Patientscan be diagnosed with hypertension according to thethresholds outlined in section I, Guideline 3.
ii. Home BP monitoring is recommended if ambula-tory BP monitoring is not tolerated, not readilyavailable, or because of patient preference (GradeD). Patients can be diagnosed with hypertensionaccording to the thresholds outlined in section I,Guideline 3.

iii. If the out-of-office BP average is not elevated, whitecoat hypertension should be diagnosed and pharma-cologic treatment should not be instituted (Grade C).

6. If the out-of-office measurement, although preferred, is notperformed after visit 1, then patients can be diagnosed as

http://guidelines.hypertension.ca/about/overview-process

http://guidelines.hypertension.ca/about/overview-process


hypertensive using serial office BP measurement visits if anyof the following conditions are met:
i. At visit 2, mean non-AOBP measurement(averaged across all visits) is � 140 mm Hg SBP and/or � 90 mm Hg DBP in patients with macrovasculartarget organ damage, diabetes mellitus, or chronickidney disease (glomerular filtration rate < 60 mL/min/1.73 m2) (Grade D);
ii. At visit 3, mean non-AOBP measurement (averagedacross all visits) is � 160 mm Hg systolic or � 100mm Hg diastolic;

iii. At visit 4 or 5, mean non-AOBP measurement(averaged across all visits) is � 140 mm Hg SBP or �90 mm Hg DBP.

7. Investigations for secondary causes of hypertensionshould be initiated in patients with suggestive clinicaland/or laboratory features (outlined in sections V, VII,and VIII; Grade D).

8. If at the last diagnostic visit the patient is not diagnosed ashypertensive and has no evidence of macrovascular targetorgan damage, the patient’s BP should be assessed atyearly intervals (Grade D).

9. Hypertensive patients actively modifying their healthbehaviours should be followed up at 3- to 6-month in-tervals. Shorter intervals (every 1 or 2 months) are neededfor patients with higher BP (Grade D).

10. Patients receiving antihypertensive drug treatmentshould be seen monthly or every 2 months, dependingon the level of BP, until readings on 2 consecutivevisits are below their target (Grade D). Shorter in-tervals between visits will be needed for symptomaticpatients and for those with severe hypertension, intol-erance to antihypertensive drugs, or target organdamage (Grade D). When the target BP has beenreached, patients should be seen at 3- to 6-monthintervals (Grade D).

III. Home BP measurement

Background. There are no changes to these guidelines for2017. A suggested protocol for home BP monitoring is pre-sented in Supplemental Table S2.

Guidelines

1. Home BP monitoring can be used in the diagnosis ofhypertension (Grade C).

2. The use of home BP monitoring on a regular basis shouldbe considered for patients with hypertension, particularlythose with:i. Diabetes mellitus (Grade D);ii. Chronic kidney disease (Grade C);iii. Suspected nonadherence (Grade D);iv. Demonstrated white coat effect (Grade C);v. BP controlled in the office but not at home (masked

hypertension; Grade C).3. When white coat hypertension is suggested according to

home BP monitoring, its presence should be confirmed byrepeat home BP monitoring (Guideline 7, in this section) or

ambulatory BP monitoring before treatment decisions aremade (Grade D).

4. Patients should be advised to purchase and use onlyhome BP monitoring devices that are appropriate forthe individual and have met standards of the Associa-tion for the Advancement of Medical Instrumentation,the most recent requirements of the British Hyperten-sion Society protocol, or the International Protocol forvalidation of automated BP measuring devices. Patientsshould be encouraged to use devices with datarecording capabilities or automatic data transmission toincrease the reliability of reported home BP monitoring(Grade D).

5. Home SBP values � 135 mm Hg or DBP values � 85 mmHg should be considered to be elevated and associated withan increased overall mortality risk (Grade C).

6. Health care professionals should ensure that patientswho measure their BP at home have adequate trainingand, if necessary, repeat training in measuring theirBP. Patients should be observed to determine thatthey measure BP correctly and should be givenadequate information about interpreting these readings(Grade D).

7. Home BP monitoring for assessing white coat hypertensionor sustained hypertension should be on the basis ofduplicate measures, morning and evening, for an initial 7-day period. First-day home BP values should not beconsidered (Grade D).

IV. Ambulatory BP measurement

Background. There are no changes to these guidelines for2017. A suggested protocol for ambulatory BP monitoring ispresented in Supplemental Table S2.

Guidelines

1. Ambulatory BP monitoring can be used in the diagnosis ofhypertension (Grade C). Ambulatory BP monitoringshould be considered when an office-induced increase in BPis suspected in treated patients with:i. BP that is not below target despite receiving appro-priate chronic antihypertensive therapy (Grade C);

ii. Symptoms suggestive of hypotension (Grade C);iii. Fluctuating office BP readings (Grade D).

2. Ambulatory BP monitoring upper arm devices thathave been validated independently using establishedprotocols must be used (see www.dableducational.org)(Grade D).

3. Therapy adjustment should be considered in patients witha mean 24-hour ambulatory BP monitoring SBP of � 130mm Hg and/or DBP of � 80 mm Hg, or a mean awakeSBP of � 135 mm Hg and/or DBP of � 85 mm Hg(Grade D).

4. The magnitude of changes in nocturnal BP should betaken into account in any decision to prescribe or with-hold drug therapy on the basis of ambulatory BP moni-toring (Grade C) because a decrease in nocturnal BP of

http://www.dableducational.org


< 10% is associated with increased risk of cardiovascularevents.

V. Routine and optional laboratory tests for theinvestigation of patients with hypertension

Background. There are no changes to these guidelinesfor 2017.

Guidelines

1. Routine laboratory tests that should be performed for theinvestigation of all patients with hypertension include thefollowing:i. Urinalysis (Grade D);ii. Blood chemistry (potassium, sodium, and creatinine;

Grade D);iii. Fasting blood glucose and/or glycated hemoglobin

(A1c; Grade D);iv. Serum total cholesterol, low-density lipoprotein, high-

density lipoprotein, non-high-density lipoproteincholesterol, and triglycerides (Grade D); lipids may bedrawn fasting or nonfasting (Grade C);

v. Standard 12-lead electrocardiography (Grade C).2. Assess urinary albumin excretion in patients with diabetes

(Grade D).3. All treated hypertensive patients should be monitored ac-

cording to the current Diabetes Canada guidelines for thenew appearance of diabetes (Grade B).

4. During the maintenance phase of hypertension manage-ment, tests (including those for electrolytes, creatinine, andfasting lipids) should be repeated with a frequencyreflecting the clinical situation (Grade D).

VI. Assessment of overall cardiovascular risk inhypertensive patients

Background. There are no changes to these guidelines for2017. Examples of risk calculators include www.myhealthcheckup.com and www.score-canada.ca.

Guidelines

1. Global cardiovascular risk should be assessed. Multifac-torial risk assessment models can be used to predictmore accurately an individual’s global cardiovascular risk(Grade A) and to use antihypertensive therapy moreefficiently (Grade D). In the absence of Canadian datato determine the accuracy of risk calculations, avoidusing absolute levels of risk to support treatment de-cisions (Grade C).

2. Consider informing patients of their global risk toimprove the effectiveness of risk factor modification(Grade B). Consider also using analogies that describecomparative risk such as “cardiovascular age,” “vascularage,” or “heart age” to inform patients of their risk status(Grade B).

VII. Assessment for renovascular hypertension

Background. Despite the lack of high-quality evidence, theHCGC deemed it important to provide guidance for thediagnosis of renal FMD. Affecting up to 4% of adults,35-40

FMD is an idiopathic condition, characterized by segmental,nonatherosclerotic narrowing of small- and medium-sizedarteries, which commonly affects renal blood flow.41 Thereis a marked female-to-male preponderance of 9:1, moreoften affecting younger women.41,42 It is estimated thatmore than half of individuals with FMD have renal arterystenosis, one-third have cervicocranial involvement, whereasfew are affected at other sites.39,43,44 Hypertension is themost common manifestation, often requiring multipledrugs.42 Headache, tinnitus, dizziness, neck pain, and cer-vical/abdominal bruits might also be present.42 The diag-nosis of FMD is on the basis of diagnostic imaging withcatheter-based angiography being the ‘gold standard.’Noninvasive imaging modalities include captopril renal scan,duplex ultrasound, computed tomographic angiography, andmagnetic resonance angiography. Estimates of sensitivityand specificity vary widely and are generally derived fromsmall studies.38,40,44-48 On the basis of a consensus of expertopinion, we recommend either computed tomographicangiography or magnetic resonance angiography as theinitial diagnostic test. If renal FMD is confirmed, patientsshould be screened for cervicocephalic and intracranialinvolvement, because these sites are also commonlyaffected.42 Screening of other vascular sites should be guidedby symptoms.

Guidelines

1. Patients who present with � 2 of the following clinicalclues, suggestive of renovascular hypertension, should beinvestigated (Grade D):i. Sudden onset or worsening of hypertension and age >55 or < 30 years;

ii. Presence of an abdominal bruit;iii. Hypertension resistant to � 3 drugs;iv. Increase in serum creatinine level� 30% associated with

use of an angiotensin-converting enzyme (ACE) inhib-itor or angiotensin receptor blocker (ARB);

v. Other atherosclerotic vascular disease, particularly inpatients who smoke or have dyslipidemia;

vi. Recurrent pulmonary edema associated with hyper-tensive surges.

2. When available, the following tests are recommended toaid in the usual screening for renal vascular disease:captopril-enhanced radioisotope renal scan, Doppler so-nography, magnetic resonance angiography, and computedtomography angiography (for those with normal renalfunction; Grade B). Captopril-enhanced radioisotope renalscan is not recommended for those with chronic kidneydisease (glomerular filtration rate < 60 mL/min/1.73 m2;Grade D).

3. Patients with hypertension who present with at least 1 ofthe following clinical clues should be investigated for

http://www.myhealthcheckup.com

http://www.myhealthcheckup.com

http://www.score-canada.ca

Figure 1. Hypertension diagnostic algorithm. ABPM, ambulatory blood pressure measurement; AOBP, automated office blood pressure; BP, bloodpressure. *If AOBP is used, use the mean calculated and displayed by the device. If non-AOBP (see y) is used, take at least 3 readings, discard thefirst, and calculate the mean of the remaining measurements. A history and physical exam should be performed and diagnostic tests ordered.yAOBP is performed with the patient unattended in a private area. Non-AOBP is performed using an electronic upper arm device with the provider inthe room. zDiagnostic thresholds for AOBP, ABPM, and home BP in patients with diabetes have yet to be established (and might be lower than13080 mm Hg). xSerial office measurements over 3-5 visits can be used if ABPM or home measurement is not available. kFor a home BP series, 2readings are taken each morning and evening for 7 days (28 total). Discard the first day readings and average the last 6 days. {Annual BPmeasurement is recommended to detect progression to hypertension.


fibromuscular dysplasia (FMD)-related renal artery stenosis(Grade D; new guideline):i. Age < 30 years, especially in nonobese women;ii. Hypertension resistant to � 3 drugs;iii. Significant (> 1.5 cm), unexplained asymmetry in

kidney sizes;iv. Abdominal bruit without apparent atherosclerosis;v. FMD in another vascular territory;

viii. Positive family history for FMD.4. In patients with confirmed renal FMD (Grade D; new

guideline):i. Screening for cervicocephalic lesions and intracranialaneurysm is recommended;

ii. Screening for FMD in other vascular beds in the pres-ence of suggestive symptoms is recommended.

5. The following tests are recommended to screen for renalFMD (both with similar sensitivity and specificity; GradeD; new guideline): magnetic resonance angiography andcomputed tomography angiography.

VIII. Assessment for endocrine hypertension

A. Hyperaldosteronism: screening and diagnosis


Guidelines

1. Screening for hyperaldosteronism should be consid-ered in hypertensive patients with the following(Grade D):
i. Unexplained spontaneous hypokalemia (Kþ < 3.5Mmol/L) or marked diuretic-induced hypokalemia(Kþ < 3.0 Mmol/L);
ii. Resistance to treatment with � 3 drugs;iii. An incidental adrenal adenoma.

2. Screening for hyperaldosteronism should includeassessment of plasma aldosterone and plasma renin ac-tivity or plasma renin (Supplemental Table S7).

3. For patients with suspected hyperaldosteronism (onthe basis of the screening test, SupplementalTable S7, item iii), a diagnosis of primary aldoste-ronism should be established by showing inappro-priate autonomous hypersecretion of aldosteroneusing at least 1 of the manoeuvres listed inSupplemental Table S7, item iv. When the diagnosisis established, the abnormality should be localizedusing any of the tests described in SupplementalTable S7, item v.

4. In patients with primary aldosteronism and a definiteadrenal mass who are eligible for surgery, adrenal


venous sampling is recommended to assess forlateralization of aldosterone hypersecretion. Adrenalvein sampling should be performed exclusively byexperienced teams working in specialized centres(Grade C).

B. Pheochromocytoma and paraganglioma: screening anddiagnosis

Background. There are no changes to these guidelines for2017.

1. If pheochromocytoma or paraganglioma is stronglysuspected, the patient should be referred to a specializedhypertension centre, particularly if biochemicalscreening tests (Supplemental Table S8) have alreadybeen found to be positive (Grade D).

2. The following patients should be considered forscreening for pheochromocytoma or paraganglioma(Grade D):i. Patients with paroxysmal, unexplained, labile, and/or severe (BP � 180/110 mm Hg) sustainedhypertension refractory to usual antihypertensivetherapy;

ii. Patients with hypertension and multiple symp-toms suggestive of catecholamine excess (eg,headaches, palpitations, sweating, panic attacks,and pallor);

iii. Patients with hypertension triggered by b-blockers,monoamine oxidase inhibitors, micturition, changesin abdominal pressure, surgery, or anaesthesia;

iv. Patients with an incidentally discovered adrenalmass;

v. Patients with a predisposition to hereditary causes(eg, multiple endocrine neoplasia 2A or 2B, vonRecklinghausen neurofibromatosis type 1, or VonHippel-Lindau disease);

vi. For patients with positive biochemical screeningtests, localization of pheochromocytomas or para-gangliomas should use magnetic resonance imaging(preferable), computed tomography (if magneticresonance imaging unavailable), and/or iodineI-131 meta-iodobenzylguanidine scintigraphy(Grade C for each modality).

IX. Role of echocardiography


Guidelines

1. Routine echocardiographic evaluation of all hypertensivepatients is not recommended (Grade D).

2. An echocardiogram for assessment of left ventricular hy-pertrophy (LVH) is useful in selected cases to help definethe future risk of cardiovascular events (Grade C).

3. Echocardiographic assessment of left ventricular mass, aswell as of systolic and diastolic left ventricular function isrecommended for hypertensive patients suspected to have

left ventricular dysfunction or coronary artery disease(CAD; Grade D).

4. Patients with hypertension and evidence of heart failureshould have an objective assessment of left ventricularejection fraction, either using echocardiogram or nuclearimaging (Grade D).

Hypertension Canada’s 2017 Guidelines:Prevention and Treatment of Hypertension

Please note, hereafter, all treatment thresholds and targetsrefer to non-AOBP measurements performed in-office (seeSupplemental Table S2, section on Recommended Techniquefor Automated Office Blood Pressure [AOBP]), because most ofthe supporting evidence is derived from studies using thismethod of BP measurement. Please refer to the section onHypertension Canada’s 2017 Guidelines: Diagnosis and Assess-ment of Hypertension, section II, Criteria for Diagnosis ofHypertension and Guidelines for Follow-up, for correspondingvalues using other measurement methods. A summary of thepotential factors that should be considered when selectingspecific drug therapy for individualized treatment is presentedin Table 1.

I. Health behaviour management


Guidelines

A. Physical exercise
1. For nonhypertensive individuals (to reduce the pos-
sibility of becoming hypertensive) or for hypertensivepatients (to reduce their BP), prescribe the accumu-lation of 30-60 minutes of moderate intensity dy-namic exercise (eg, walking, jogging, cycling, orswimming) 4-7 days per week in addition to theroutine activities of daily living (Grade D). Higherintensities of exercise are not more effective (GradeD). For nonhypertensive or stage 1 hypertensive in-dividuals, the use of resistance or weight trainingexercise (such as free weight-lifting, fixed weight-lifting, or handgrip exercise) does not adversely in-fluence BP (Grade D).

B. Weight reduction
1. Height, weight, and waist circumference should be
measured and body mass index calculated for all adults(Grade D).

2. Maintenance of a healthy body weight (body massindex 18.5-24.9, and waist circumference < 102cm for men and < 88 cm for women) is recom-mended for nonhypertensive individuals to preventhypertension (Grade C) and for hypertensive pa-tients to reduce BP (Grade B). All overweight hy-pertensive individuals should be advised to loseweight (Grade B).

3. Weight loss strategies should use a multidisciplinaryapproach that includes dietary education, increasedphysical activity, and behavioural intervention (Grade B).

Table 1. Considerations in the individualization of pharmacological therapy

Initial Therapy Second-Line Therapy Notes and/or Cautions

Hypertension without other compelling indicationsDiastolic hypertension with or

without systolic hypertensionMonotherapy or SPC. Recommended

monotherapy choices includethiazide/thiazide-like diuretics (withlonger-acting diuretics preferred),b-blockers, ACE inhibitors, ARBs,or long-acting CCB. RecommendedSPC choices include combinationsof an ACE inhibitor with CCB,ARB with CCB, or ACE inhibitor/ARB with a diuretic (consider ASAand statins in selected patients)

Further combination of first-line drugs Not recommended for monotherapy: ablockers, b-blockers in those 60years of age or older, ACE inhibitorsin black people. Hypokalemiashould be avoided in thoseprescribed diuretics. ACE inhibitors,ARBs and direct renin inhibitors arepotential teratogens, and caution isrequired if prescribing to womenwith child-bearing potential.Combination of an ACE-inhibitorwith an ARB is not recommended

Isolated systolic hypertensionwithout other compellingindications

Thiazide/thiazide-like diuretics, ARBs,or long-acting dihydropyridineCCBs

Combinations of first-line drugs Same as diastolic hypertension with orwithout systolic hypertension

Diabetes mellitusDiabetes mellitus with

microalbuminuria,* renal disease,cardiovascular disease oradditional cardiovascular riskfactors

ACE inhibitors or ARBs Combination of a dihydropyridineCCB is preferred over a thiazide/thiazide-like diuretic

A loop diuretic could be considered inhypertensive chronic kidney diseasepatients with extracellular fluidvolume overload

Diabetes mellitus not included inthe above category

ACE inhibitors, ARBs,dihydropyridine CCBs, or thiazide/thiazide-like diuretics

Combination of first-line drugs. Ifcombination with ACE inhibitor isbeing considered, a dihydropyridineCCB is preferable to a thiazide/thiazide-like diuretic

Normal urine micro-ACR < 2.0mg/Mmol

Cardiovascular diseaseCoronary artery disease ACE inhibitors or ARBs; b-blockers or

CCBs for patients with stable anginaWhen combination therapy is being

used for high-risk patients, an ACEinhibitor/dihydropyridine CCB ispreferred

Avoid short-acting nifedipine.Combination of an ACE-inhibitorwith an ARB is specifically notrecommended. Exercise cautionwhen lowering systolic BP to targetif diastolic BP is � 60 mm Hg,especially in patients with LVH

Recent myocardial infarction B-Blockers and ACE inhibitors (ARBsif ACE inhibitor-intolerant)

Long-acting CCBs if b-blockercontraindicated or not effective

Nondihydropyridine CCBs should notbe used with concomitant heartfailure

Heart failure ACE inhibitors (ARBs if ACEinhibitor-intolerant) and b-blockers.Aldosterone antagonists(mineralocorticoid receptorantagonists) may be added forpatients with a recent cardiovascularhospitalization, acute myocardialinfarction, elevated BNP or NT-proBNP level, or NYHA class II-IVsymptoms

ACE inhibitor and ARB combined.Hydralazine/isosorbide dinitratecombination if ACE inhibitor andARB contraindicated or nottolerated.

Thiazide/thiazide-like or loop diureticsare recommended as additivetherapy. Dihydropyridine CCB canalso be used

Titrate doses of ACE inhibitors andARBs to those used in clinical trials.Carefully monitor potassium andrenal function if combining any ofACE inhibitor, ARB, and/oraldosterone antagonist

LVH ACE inhibitor, ARB, long-actingCCB, or thiazide/thiazide-likediuretics

Combination of additional agents Hydralazine and minoxidil should notbe used

Past stroke or TIA ACE inhibitor and a thiazide/thiazide-like diuretic combination

Combination of additional agents Treatment of hypertension shouldnot be routinely undertaken inacute stroke unless extreme BPelevation. Combination of an ACEinhibitor with an ARB is notrecommended

Nondiabetic chronic kidney diseaseNondiabetic chronic kidney disease

with proteinuriayACE inhibitors (ARBs if ACE

inhibitor-intolerant) if there isproteinuria. Diuretics as additivetherapy

Combinations of additional agents Carefully monitor renal function andpotassium for those receiving anACE inhibitor or ARB.Combinations of an ACE inhibitorand ARB are not recommended inpatients without proteinuria

Continued


Table 1. Continued.

Initial Therapy Second-Line Therapy Notes and/or Cautions

Renovascular disease Does not affect initial treatmentrecommendations. Atheroscleroticrenal artery stenosis should beprimarily managed medically,whereas revascularization should beconsidered for renal fibromusculardysplasia

Combinations of additional agents Caution with ACE inhibitors or ARB ifbilateral renal artery stenosis orunilateral disease with solitarykidney. Renal artery angioplasty andstenting could be considered forpatients with renal artery stenosisand complicated, uncontrolledhypertension

Other conditionsPeripheral arterial disease Does not affect initial treatment

recommendationsCombinations of additional agents Avoid b-blockers with severe disease

Dyslipidemia Does not affect initial treatmentrecommendations

Combinations of additional agents e

Overall vascular protection Statin therapy for patients with � 3cardiovascular risk factors oratherosclerotic disease. Low-doseASA in patients aged 50 years orolder. Advise on smoking cessationand use pharmacotherapy forsmoking cessation if indicated

e Caution should be exercised with theASA recommendation if BP is notcontrolled

ACE, angiotensin-converting enzyme; ACR, albumin to creatinine ratio; ARB, angiotensin receptor blocker; ASA, acetylsalicylic acid; BNP, B-type natriureticpeptide; BP, blood pressure; CCB, calcium channel blocker; LVH, left ventricular hypertrophy; NT-proBNP, N-terminal pro-BNP; NYHA, New York HeartAssociation; SPC, single pill combination; TIA, transient ischemic attack.

*Microalbuminuria is defined as persistent albumin to creatinine ratio > 2.0 mg/Mmol.y Proteinuria is defined as urinary protein > 500 mg per 24 hours or ACR > 30 mg/Mmol in 2 of 3 specimens.


C. Alcohol consumption
1. To prevent hypertension and reduce BP in hyper-
tensive adults, individuals should limit alcohol con-sumption to � 2 drinks per day, and consumptionshould not exceed 14 standard drinks per week formen and 9 standard drinks per week for women(Grade B). (Note: One standard drink is considered tobe the equivalent of 13.6 g or 17.2 mL of ethanol orapproximately 44 mL [1.5 oz] of 80 proof [40%]spirits, 355 mL [12 oz] of 5% beer, or 148 mL [5 oz]of 12% wine.)

D. Diet
1. It is recommended that hypertensive patients and
normotensive individuals at increased risk of devel-oping hypertension consume a diet that emphasizesfruits, vegetables, low-fat dairy products, wholegrain foods rich in dietary fibre, and protein fromplant sources that is reduced in saturated fat andcholesterol (Dietary Approaches to Stop Hyperten-sion [DASH] diet;49-52 Supplemental Table S9)(Grade B).

E. Sodium intake
1. To prevent hypertension and reduce BP in hyperten-
sive adults, consider reducing sodium intake toward2000 mg (5 g of salt or 87 mmol of sodium) per day(Grade A).

F. Calcium and magnesium intake
1. Supplementation of calcium and magnesium is not
recommended for the prevention or treatment ofhypertension (Grade B).

G. Potassium intake
1. For patients not at risk of hyperkalemia (see Table 2),
increase dietary potassium intake to reduce BP (Grade A).

H. Stress management
1. In hypertensive patients in whom stress might be
contributing to high BP, stress management should beconsidered as an intervention (Grade D). Individual-ized cognitive-behavioural interventions are morelikely to be effective when relaxation techniques areused (Grade B).

II. Indications for drug therapy for adults withhypertension without compelling indications for specificagents

Background. Age and frailty distinctions have been removedfrom our guidelines for the treatment of uncomplicated hy-pertension. This revision is on the basis of evidence thatsuggests that older individuals with hypertension benefit fromBP reduction irrespective of baseline frailty.53,54 In those witha baseline SBP of 140-160 mm Hg, treatment reduces the rateof major adverse cardiovascular events, myocardial infarction,stroke, and mortality, but might also increase the risk of renaldysfunction.53-56 Caution should be exercised in elderly pa-tients with orthostasis.

In a post hoc analysis of the Hypertension in the VeryElderly Trial (HYVET), investigators examined the associ-ation between frailty and treatment outcomes in 2656individuals, aged 80 years and older, and with a baseline SBP� 160 mm Hg.53 The benefits of BP reduction were similarirrespective of frailty for the outcomes of stroke, cardiovas-cular events, and mortality (P for interaction ¼ 0.52, 0.73,and 0.61, respectively). Similarly, a prespecified subgroupanalysis of 2636 adults 75 years of age and older withouthistory of diabetes, stroke, or baseline orthostasis from the

Table 2. Risk factors for hyperkalemia

Before advising an increase in potassium intake, the following types ofpatients, who are at high risk of developing hyperkalemia, should beassessed for suitability, and monitored closely:

� Patients receiving renin-angiotensin-aldosterone inhibitors� Patients receiving other drugs that can cause hyperkalemia (eg, trimetho-

prim and sulfamethoxazole, amiloride, triamterene)� Chronic kidney disease (glomerular filtration rate < 60 mL/min/1.73m2)� Baseline serum potassium > 4.5 Mmol/L


Systolic Blood Pressure Intervention Trial (SPRINT)showed that intensive treatment (SBP target < 120 mm Hg)compared with standard treatment (< 140 mm Hg) resultedin a significant reduction in major adverse cardiovascularevents (hazard ratio [HR], 0.66; 95% confidence interval[CI], 0.51-0.85) and mortality (HR, 0.67; 95% CI, 0.49-0.91) over 3.14 years with no detectable difference inoutcome benefit with intensive treatment when examinedaccording to baseline frailty.54,55 Rates of serious adverseevents were not statistically different when examined ac-cording to frailty. However, there was a significant increasein renal dysfunction with intensive treatment for thosewithout preexisting kidney disease (HR, 3.14; 95% CI,1.66-6.37). Individuals with limited life expectancy (ie, < 1year or < 3 years, respectively), dementia, or those needinginstitutionalized care were ineligible for HYVET orSPRINT.53,54 Altogether, these findings are consistent withthose from a large meta-analysis of 19 randomized controlledtrials (n ¼ 44,989) showing that intensive BP reduction isjust as beneficial for the reduction of major cardiovascularevents in older adults (62 years of age and older) as it is inthose who are younger.56

Guidelines

1. Antihypertensive therapy should be prescribed for averageDBP measurements of � 100 mm Hg (Grade A) oraverage SBP measurements of � 160 mm Hg (Grade A) inpatients without macrovascular target organ damage orother cardiovascular risk factors.

2. Antihypertensive therapy should be strongly consideredfor average DPB readings � 90 mm Hg (Grade A) orfor average SBP readings � 140 mm Hg (Grade B for140-160 mm Hg; Grade A for > 160 mm Hg; revisedguideline) in the presence of macrovascular target or-gan damage or other independent cardiovascular riskfactors.

III. Choice of therapy for adults with hypertensionwithout compelling indications for specific agents

A. Indications for drug therapy for adults with diastolicand with or without systolic hypertension

Background. This year, we introduce a number of new andrevised guidelines for the initial treatment of hypertension.Although thiazide as well as thiazide-like diuretics remaininitial treatment options, preference is now given to thelonger-acting, thiazide-like diuretics (eg, chlorthalidone andindapamide). A meta-analysis of 21 randomized controlled

trials showed that the use of thiazide-like diuretics resulted inan additional 12% risk reduction for cardiovascular events(P ¼ 0.049) and 21% risk reduction in heart failure (P ¼0.023) compared with thiazide diuretics, after adjusting fordifferences in BP reduction.57 Compared with placebo, onlythiazide-like diuretics reduced the risk of coronary events andall-cause mortality. In another meta-analysis of 14 random-ized controlled trials, the use of indapamide or chlorthali-done resulted in greater SBP reduction compared withhydrochlorothiazide (�5.1 mm Hg; 95% CI, �8.7 to �1.6mm Hg; and �3.6 mm Hg; 95% CI, �7.3 to 0.0 mm Hg,respectively) without any detectable difference in adverseeffects.58 Consistent with these findings, a 12-week double-blind randomized controlled trial of 54 patients showed agreater reduction in mean 24-hour BP compared withbaseline with chlorthalidone and extended-release hydro-chlorothiazide, but not with conventional, short-acting hy-drochlorothiazide.59 Collectively, evidence supports the useof longer-acting diuretics for reducing cardiovascular eventsand BP.

We recommend SPCs as an initial treatment option, onthe basis of a global body of evidence, showing their effec-tiveness in reducing cardiovascular events,60,61 improvingBP control,60-64 promoting adherence,65,66 and reducingmedication side effects.67 The therapeutic efficacy of com-bination therapy is well established. A meta-analysis of 42randomized trials testing the combined use of 2 drugs ofdifferent classes compared with doubling the dose of 1 drugshowed a 5-fold greater reduction in BP with combinationtreatment compared with increasing the dose of 1 drugalone.68 Further supporting evidence is derived from theSimplified Treatment Intervention to Control Hypertension(STITCH) study, a cluster randomized trial of 45 familypractices in Ontario.62 A total of 2111 patients with un-controlled hypertension were assigned to initial fixed-dosecombination therapy with an ACE inhibitor or ARB anddiuretic vs monotherapy with uptitration as appropriate.After 6 months, there was a larger reduction in BP (�5.2/�2.2 mm Hg) and greater proportion of target BP control(64.7% vs 52.7%; P ¼ 0.03) in those who received initialfixed-dose combination therapy compared with a singleagent. Consistent with these findings, observational data alsosuggest that initial combination treatment compared withmonotherapy is associated with a lower likelihood ofdeveloping a cardiovascular event, shorter median time toachieve target BP control, and less health care utiliza-tion.60,61 Moreover, fixed-dose antihypertensive combina-tions (ie, SPCs) are reasonable as first-line treatment becausemost patients require 2 or even 3 antihypertensive agents toreach target BP control in practice.55,69-73

When an SPC is selected, the combination of an ACEinhibitor with a CCB, ARB with a CCB, or ACE inhibitor orARB with a diuretic is recommended. The most compellingevidence comes from the Avoiding Cardiovascular Eventsthrough Combination Therapy in Patients Living with Sys-tolic Hypertension (ACCOMPLISH) trial, which randomized11,506 adults at high risk for cardiovascular disease to either acombination of benazepril with amlodipine or benazepril withhydrochlorothiazide.63 A reduction in the composite of car-diovascular death and major adverse cardiovascular events wasnoted with benazepril with amlodipine vs benazepril with


hydrochlorothiazide (HR, 0.80; 95% CI, 0.72-0.90). Morerecently, the Heart Outcomes Prevention Evaluation(HOPE)-3 trial evaluated 12,705 individuals at intermediaterisk of cardiovascular disease and randomized them to receivea fixed-dose combination of candesartan and hydrochloro-thiazide or placebo.64 Although there were no significantdifferences in outcomes overall, there appeared to be benefitfavouring fixed-dose combination therapy in the subgroup ofpatients with hypertension. For individuals with a baselineSBP > 143.5 mm Hg, treatment with candesartan and hy-drochlorothiazide vs placebo reduced the risk of the firstcoprimary outcome (a composite of cardiovascular death,nonfatal myocardial infarction, or nonfatal stroke; HR, 0.73;95% CI, 0.56-0.94) and second coprimary outcome(a composite of the first coprimary outcome, plus resuscitatedcardiac arrest, heart failure, or revascularization; HR, 0.76;95% CI, 0.60-0.96). Finally, as discussed previously,STITCH provided additional supporting evidence for the useof an ACE inhibitor with a diuretic or an ARB with a diureticas initial therapy.62

Guidelines

1. Initial therapy should be with either monotherapy orsingle pill combination (SPC).
i. Recommended monotherapy choices are:
a. A thiazide/thiazide-like diuretic (Grade A), withlonger-acting diuretics preferred (Grade B; newguideline);

b. A b-blocker (in patients younger than 60 years;Grade B);

c. An ACE inhibitor (in nonblack patients;Grade B);

d. An ARB (Grade B); ore. A long-acting calcium channel blocker (CCB;

Grade B).
ii. Recommended SPC choices are those in which an
ACE inhibitor is combined with a CCB (Grade A;new guideline), ARB with a CCB (Grade B; newguideline), or ACE inhibitor or ARB with a diuretic(Grade B; new guideline).

iii. Hypokalemia should be avoided in patients treatedwith thiazide/thiazide-like diuretic monotherapy(Grade C).

2. Additional antihypertensive drugs should be used iftarget BP levels are not achieved with standard-dosemonotherapy (Grade B). Add-on drugs should bechosen from first-line choices. Useful choices include athiazide/thiazide-like diuretic or CCB with either:ACE inhibitor, ARB, or b-blocker (Grade B for thecombination of thiazide/thiazide-like diuretic and adihydropyridine CCB; Grade C for the combination ofdihydropyridine CCB and ACE inhibitor; and GradeD for all other combinations). Caution should beexercised in combining a nondihydropyridine CCBand a b-blocker (Grade D). The combination of anACE inhibitor and an ARB is not recommended(Grade A).

3. If BP is still not controlled with a combination of 2 ormore first-line agents, or there are adverse effects, otherantihypertensive drugs may be added (Grade D).

4. Possible reasons for poor response to therapy(Supplemental Table S10) should be considered(Grade D).

5. a-Blockers are not recommended as first-line agents foruncomplicated hypertension (Grade A); b-blockers arenot recommended as first-line therapy for uncompli-cated hypertension in patients 60 years of age or older(Grade A); and ACE inhibitors are not recommended asfirst-line therapy for uncomplicated hypertension inblack patients (Grade A). However, these agents may beused in patients with certain comorbid conditions or incombination therapy.

B. Guidelines for individuals with isolated systolichypertension


Guidelines

1. Initial therapy should be single-agent therapy with athiazide/thiazide-like diuretic (Grade A), a long-actingdihydropyridine CCB (Grade A), or an ARB (GradeB). If there are adverse effects, another drug from thisgroup should be substituted. Hypokalemia should beavoided in patients treated with thiazide/thiazide-likediuretic monotherapy (Grade C).

2. Additional antihypertensive drugs should be used iftarget BP levels are not achieved with standard-dosemonotherapy (Grade B). Add-on drugs should bechosen from first-line options (Grade D).

3. If BP is still not controlled with a combination of � 2first-line agents, or there are adverse effects, other classesof drugs (such as a-blockers, ACE inhibitors, centrallyacting agents, or nondihydropyridine CCBs) may becombined or substituted (Grade D).

4. Possible reasons for poor response to therapy(Supplemental Table S10) should be considered(Grade D).

5. a-Blockers are not recommended as first-line agents foruncomplicated isolated systolic hypertension (Grade A);and b-blockers are not recommended as first-line ther-apy for isolated systolic hypertension in patients aged 60years or older (Grade A). However, both agents may beused in patients with certain comorbid conditions or incombination therapy.

IV. Global vascular protection therapy for adults withhypertension without compelling indications for specificagents


Table 4. Generalizability of intensive blood pressure-lowering:cautions and contraindications

Limited or no evidenceHeart failure (ejection fraction < 35%) or recent myocardial infarction

(within past 3 months)Indication for, but not currently receiving, a b-blockerInstitutionalized elderly patient

Inconclusive evidenceDiabetes mellitusPrevious strokeeGFR < 20 mL/min/1.73 m2

ContraindicationsPatient unwilling or unable to adhere to multiple medicationsStanding SBP < 110 mm HgInability to measure SBP accuratelyKnown secondary cause(s) of hypertension

eGFR, estimated glomerular filtration rate; SBP, systolic blood pressure.


Guidelines

1. Statin therapy is recommended in hypertensive patientswith � 3 cardiovascular risk factors as defined inSupplemental Table S11 (Grade A in patients older than40 years) or with established atherosclerotic disease (GradeA regardless of age).

2. Consideration should be given to the combination of low-dose acetylsalicylic acid therapy in hypertensive patients 50years of age or older (Grade B). Caution should be exer-cised if BP is not controlled (Grade C).

3. Tobacco use status of all patients should be updated on aregular basis and health care providers should clearly advisepatients to quit smoking (Grade C).

4. Advice in combination with pharmacotherapy(eg, varenicline, bupropion, nicotine replacement therapy)should be offered to all smokers with a goal of smokingcessation (Grade C).

5. For high-risk patients (Table 3),74 aged 50 years or older,with SBP levels � 130 mm Hg, intensive management totarget a SBP of � 120 mm Hg should be considered.Intensive management should be guided by AOBP mea-surements (see Hypertension Canada’s 2017 Guidelines:Diagnosis and Assessment of Hypertension, sectionI. Accurate Measurement of BP, and SupplementalTable S2, section on Recommended Technique for Auto-mated Office Blood Pressure [AOBP]). Patient selection forintensive management is recommended and cautionshould be taken in certain high-risk groups (Table 4;Grade B).

V. Goals of therapy for adults with hypertension withoutcompelling indications for specific agents

Background. Consistent with the changes made to section II.Indications for Drug Therapy for Adults With HypertensionWithout Compelling Indications for Specific Agents, we haveremoved the previous guideline for different BP goals for theelderly. Evidence suggests that older patients with hyperten-sion similarly benefit from intensive BP reduction as youngeradults.53-56

Table 3. Clinical indications defining high-risk patients as candidatesfor intensive management

Clinical or subclinical cardiovascular diseaseor

Chronic kidney disease (nondiabetic nephropathy, proteinuria < 1 g/d,estimated glomerular filtration rate 20-59 mL/min/1.73m2*)or

yEstimated 10-year global cardiovascular risk � 15%or

Age 75 years or olderPatients with �1 clinical indication should consent to intensive

management

MDRD, Modification of Diet in Renal Disease.* Four-variable MDRD equation.y Framingham Risk Score.74

Guidelines

1. The SBP treatment goal is a pressure level of < 140 mmHg (Grade C). The DBP treatment goal is a pressure levelof < 90 mm Hg (Grade A).

VI. Treatment of hypertension in association withischemic heart disease

A. Guidelines for hypertensive patients with CAD

Background. Post hoc analyses of several large clinical trials inpatients with CAD suggest the possible existence of a J-curve,whereby reducing BP below a specific nadir might be asso-ciated with an increased risk of coronary events.30,75-77 Thismight be of greatest concern in individuals with LVH becauseof increased myocardial demand and decreased coronaryperfusion during diastole.

In a retrospective cohort of 92 patients with CAD,there was reduced coronary blood flow with increasing leftventricular mass, even after adjustment.78 This associationwas present for all levels of DBP, but was mostpronounced for those with a DBP < 70 mm Hg. Thesefindings are consistent with and extend those from asystematic review of 8 studies (n ¼ 362), which reportedan inverse association between coronary blood flow andleft ventricular mass, especially in those withhypertension.79

Nevertheless, it should be acknowledged that for mosthigh-risk individuals, BP reduction is well tolerated andbeneficial. As such, although we advise exercising cautionwhen lowering BP, antihypertensive therapy is still stronglyrecommended for individuals with hypertension whotolerate antihypertensive treatment, especially for patientswith moderate or severely increased SBP.

Guidelines

1. For most hypertensive patients with CAD, an ACEinhibitor or ARB is recommended (Grade A).


2. For hypertensive patients with CAD, but withoutcoexisting systolic heart failure, the combination of anACE inhibitor and ARB is not recommended(Grade B).

3. For high-risk hypertensive patients, when combinationtherapy is being used, choices should be individualized.The combination of an ACE inhibitor and a dihy-dropyridine CCB is preferable to an ACE inhibitor anda thiazide/thiazide-like diuretic in selected patients(Grade A).

4. For patients with stable angina pectoris but withoutprevious heart failure, myocardial infarction, orcoronary artery bypass surgery, either a b-blocker orCCB can be used as initial therapy (Grade B).

5. Short-acting nifedipine should not be used (Grade D).6. When decreasing SBP to target levels in patients

with established CAD (especially if isolated systolichypertension is present), be cautious when theDBP is � 60 mm Hg because of concerns thatmyocardial ischemia might be exacerbated, especiallyin patients with LVH (Grade D; revised guideline).

B. Guidelines for patients with hypertension who have hada recent myocardial infarction


Guidelines

1. Initial therapy should include a b-blocker as well as anACE inhibitor (Grade A).

2. An ARB can be used if the patient is intolerant of anACE inhibitor (Grade A in patients with left ventricularsystolic dysfunction).

3. CCBs may be used in patients after myocardial infarctionwhen b-blockers are contraindicated or not effective.Nondihydropyridine CCBs should not be used whenthere is heart failure, evidenced by pulmonary congestionon examination or radiography (Grade D).

VII. Treatment of hypertension in association with heartfailure


Guidelines

1. In patients with systolic dysfunction (ejection fraction< 40%), ACE inhibitors (Grade A) and b-blockers(Grade A) are recommended for initial therapy. Aldo-sterone antagonists (mineralocorticoid receptor antago-nists) may be combined in treatment for patients with arecent cardiovascular hospitalization, acute myocardialinfarction, elevated B-type natriuretic peptide or N-terminal pro-B-type natriuretic peptide level, or NewYork Heart Association Class II-IV symptoms

(Grade A). Careful monitoring for hyperkalemia isrecommended when combining an aldosterone antago-nist with ACE inhibitor or ARB treatment. Other di-uretics are recommended as additional therapy ifneeded (Grade B for thiazide/thiazide-like diuretics forBP control, Grade D for loop diuretics for volumecontrol). Beyond considerations of BP control, doses ofACE inhibitors or ARBs should be titrated to thosereported to be effective in trials unless adverse effectsbecome manifest (Grade B).

2. An ARB is recommended if ACE inhibitors are not toler-ated (Grade A).

3. A combination of hydralazine and isosorbide dinitrate isrecommended if ACE inhibitors and ARBs are contra-indicated or not tolerated (Grade B).

4. For hypertensive patients whose BP is not controlled, anARB may be combined with an ACE inhibitor and otherantihypertensive drug treatment (Grade A). Carefulmonitoring should be used if combining an ACE inhibitorand an ARB because of potential adverse effects such ashypotension, hyperkalemia, and worsening renal function(Grade C). Additional therapies may also include dihy-dropyridine CCBs (Grade C).

VIII. Treatment of hypertension in association withstroke

Background. BP is often elevated after ICH. In recentyears, several trials have studied the effect of BP-lowering inthe context of ICH. The Intensive Blood PressureReduction in Acute Cerebral Hemorrhage Trial(INTERACT)-2 enrolled 2839 patients within 6 hours ofspontaneous ICH, and compared the SBP targets of < 140mm Hg vs < 180 mm Hg.80 Targets were applied withinthe first hour of presentation and maintained for 7 days.No statistical difference was observed between the 2 stra-tegies for the primary outcome, a composite of death orstroke-related disability at 90 days (52.0% vs 55.6% forintensive compared with standard treatment, respectively;odds ratio, 0.87; 95% CI, 0.75-1.01). In the Antihyper-tensive Treatment of Acute Cerebral Hemorrhage(ATACH)-2 trial, 1000 patients who presented within 4.5hours of spontaneous ICH were randomly assigned to SBPtargets of 110-139 mm Hg vs 140-179 mm Hg for the first24 hours.81 The primary outcome was the same as inINTERACT-2. There was no difference between the 2treatment strategies for the main outcome, and the trial wasterminated early because of futility. In addition, there was atrend toward more adverse events in the lower SBP targetarm. Considered together, these 2 important trials showedno measurable benefit to lowering SBP < 140 mm Hg inthe acute period after spontaneous ICH. There is no trialevidence to delineate an appropriate SBP target, if any, >140 mm Hg. All trials to date have followed the conven-tion in limiting SBP increases beyond 180 mm Hg in theircontrol arms.


Guidelines

A. BP management in acute ischemic stroke (onset to 72hours)1. For patients with ischemic stroke not eligible for

thrombolytic therapy, treatment of hypertension inthe setting of acute ischemic stroke or transientischemic attack should not be routinely undertaken(Grade D). Extreme BP increases (eg, SBP > 220mm Hg or DBP > 120 mm Hg) may be treated toreduce the BP by approximately 15% (Grade D),and not more than 25%, over the first 24 hours withgradual reduction thereafter (Grade D). Avoidexcessive lowering of BP because this might exacer-bate existing ischemia or might induce ischemia,particularly in the setting of intracranial arterialocclusion or extracranial carotid or vertebral arteryocclusion (Grade D). Pharmacological agents androutes of administration should be chosen to avoidprecipitous decreases in BP (Grade D).

2. For patients with ischemic stroke eligible for thrombo-lytic therapy, very high BP (> 185/110 mm Hg) shouldbe treated concurrently in patients receiving thrombo-lytic therapy for acute ischemic stroke to reduce the riskof secondary intracranial hemorrhage (Grade B).

B. BP management after acute ischemic stroke1. Strong consideration should be given to the initiation of

antihypertensive therapy after the acute phase of astroke or transient ischemic attack (Grade A).

2. After the acute phase of a stroke, BP-lowering treatmentis recommended to a target of consistently < 140/90mm Hg (Grade C).

3. Treatment with an ACE inhibitor and thiazide/thiazide-like diuretic combination is preferred (Grade B).

4. For patients with stroke, the combination of anACE inhibitor and ARB is not recommended(Grade B).

C. BP management in hemorrhagic stroke (onset to 72hours)1. For patients with intracerebral hemorrhage (ICH) in the

hyperacute phase (in the first 24 hours) SBP lowering to< 140 mmHg should be avoided because of an absenceof benefit (relative to a target of < 180 mm Hg; GradeA; new guideline) and some suggestion of harm.

IX. Treatment of hypertension in association with LVH


Guidelines

1. Hypertensive patients with LVH should be treated withantihypertensive therapy to decrease the rate of subsequentcardiovascular events (Grade C).

2. The choice of initial therapy can be influenced by thepresence of LVH (Grade D). Initial therapy can be drug

treatment using ACE inhibitors, ARBs, long-actingCCBs, or thiazide/thiazide-like diuretics. Direct arterialvasodilators such as hydralazine or minoxidil should notbe used.

X. Treatment of hypertension in association withnondiabetic chronic kidney disease


Guidelines

1. For patients with nondiabetic chronic kidney disease,target BP is < 140/90 mm Hg (Grade B).

2. For patients with hypertension and proteinuric chronickidney disease (urinary protein > 500 mg per 24 hoursor albumin to creatinine ratio > 30 mg/Mmol), initialtherapy should be an ACE inhibitor (Grade A) or anARB if there is intolerance to ACE inhibitors(Grade B).

3. Thiazide/thiazide-like diuretics are recommended asadditive antihypertensive therapy (Grade D). Forpatients with chronic kidney disease and volumeoverload, loop diuretics are an alternative (Grade D).

4. In most cases, combination therapy with other antihyper-tensive agents might be needed to reach target BP levels(Grade D).

5. The combination of an ACE inhibitor and ARB is notrecommended for patients with nonproteinuric chronickidney disease (Grade B).

XI. Treatment of hypertension in association withrenovascular disease

Background. Accompanying our guidelines for the assess-ment of renal FMD (see Hypertension Canada’s 2017Guidelines: Diagnosis and Assessment of Hypertension, sectionVII. Assessment for Renovascular Hypertension), we introduce3 new guidelines for the treatment of this condition. Evi-dence guiding treatment is primarily on the basis of smallcase series and case reports. Treatment decisions should beindividualized and take into consideration the nature andlocation of the vascular lesions, severity of symptoms, pre-vious vascular events, and comorbid conditions.41 Because ofthe complexity in care, consultation with a hypertensionexpert is advised.

Hypertension arising from renal FMD is primarilymediated by the renin-angiotensin-aldosterone system.Medical therapy should be directed toward BP control andvascular risk reduction. Revascularization should beconsidered for individuals with elevated BP, particularly forthose with recent-onset or resistant hypertension. Highestcure rates are associated with younger age and shorterduration of hypertension.82,83 Although there are no datato inform the most appropriate initial revascularizationstrategy, percutaneous renal transluminal angioplasty isusually preferred over surgery because it is less costly, lessinvasive, has a lower morbidity, and can be performed on


an outpatient basis.41,44 It is associated with a combinedrate of cure or BP improvement of 86.4%.44,83 Stenting isnot routinely recommended for FMD because the risk ofrestenosis is generally believed to be low,44 but might beconsidered for lesions for which angioplasty fails or thoseassociated with flow-limiting dissection. It is reasonable toconsider surgery for complex lesions less amendable toangioplasty, stenosis associated with complex aneurysm,and restenosis despite 2 unsuccessful attempts of angio-plasty.41,44

Guidelines

1. Patients with hypertension attributable to atheroscle-rotic renal artery stenosis should be primarily medicallymanaged because renal angioplasty and stentingoffers no benefit over optimal medical therapy alone(Grade B).

2. Renal artery angioplasty and stenting for atherosclerotichemodynamically significant renal artery stenosis could beconsidered for patients with uncontrolled hypertensionresistant to maximally tolerated pharmacotherapy, pro-gressive renal function loss, and acute pulmonary edema(Grade D).

3. Patients with confirmed renal FMD should be referred to ahypertension specialist (Grade D; new guideline).

4. In patients with hypertension attributable toFMD-related renal artery stenosis, revascularizationshould be considered (Grade D; new guideline).

5. Renal artery angioplasty without stenting is recommendedfor treatment of FMD-related renal artery stenosis. Stent-ing is not recommended unless needed because of a peri-procedural dissection. Surgical revascularization should beconsidered in cases of complex lesions less amendable toangioplasty, stenosis associated with complex aneurysm,and restenosis despite 2 unsuccessful attempts of angio-plasty (Grade D; new guideline).

XII. Treatment of hypertension in association withdiabetes mellitus


Guidelines

1. Persons with diabetes mellitus should be treated to attainSBP of < 130 mm Hg (Grade C) and DBP of < 80 mmHg (Grade A; these target BP levels are the same as the BPtreatment thresholds). Combination therapy using 2 first-line agents may also be considered as initial treatment ofhypertension (Grade B) if SBP is 20 mm Hg greater thantarget or if DBP is 10 mm Hg greater than target. How-ever, caution should be exercised in patients in whom asubstantial decrease in BP is more likely or poorly tolerated(eg, elderly patients and patients with autonomicneuropathy).

2. For persons with cardiovascular or kidney disease,including microalbuminuria, or with cardiovascular risk

factors in addition to diabetes and hypertension, an ACEinhibitor or an ARB is recommended as initial therapy(Grade A).

3. For persons with diabetes and hypertension not included inother guidelines in this section, appropriate choices include(in alphabetical order): ACE inhibitors (Grade A), ARBs(Grade B), dihydropyridine CCBs (Grade A), and thiazide/thiazide-like diuretics (Grade A).

4. If target BP levels are not achieved with standard-dosemonotherapy, additional antihypertensive therapy shouldbe used. For persons in whom combination therapy withan ACE inhibitor is being considered, a dihydropyridineCCB is preferable to a thiazide/thiazide-like diuretic(Grade A).

XIII. Adherence strategies for patients

Background. There are no changes to this guideline for 2017.

Guidelines

1. Adherence to an antihypertensive prescription can beimproved by a multipronged approach (SupplementalTable S12).

XIV. Treatment of secondary hypertension due toendocrine causes

Background. There are no changes to this guideline for 2017.

Guidelines

1. Treatment of hyperaldosteronism and pheochromocytomaare outlined in Supplemental Tables S7 and S8,respectively.

XV. Treatment of resistant hypertension

Background. Resistant hypertensionddefined by uncon-trolled BP despite the use of � 3 antihypertensive agents ofdifferent classes including a diuretic, or controlled BP with� 4 agentsdis present in 10%-20% of individuals treated forhypertension.84-87 Accordingly, the HCGC has identifiedresistant hypertension as an area of importance needing to beexplicitly addressed in our guidelines. A decision was made toassemble a dedicated subgroup committee to conduct acomprehensive literature review and to develop specificguidelines in the coming years.

Preliminary discussion was held regarding the Preven-tion And Treatment of Hypertension With Algorithm-based therapy number 2 (PATHWAY-2) trial, whichenrolled 335 individuals with uncontrolled hypertensionand were receiving 3 drugs, and compared spironolactone,doxazosin, bisoprolol, or placebo as add-on therapy.88

Spironolactone was most effective in lowering SBP. After3 months, 58% of patients treated with spironolactoneachieved target BP control vs 42% treated with doxazosin


and 43% treated with bisoprolol. Although noteworthy, thecommittee decided not to generate any formal guidelineson the basis of PATHWAY-2 alone at this time, because ofthe lack of event-related outcomes. Consistent with ouroverall guidelines process, studies that assessed cardiovas-cular morbidity and mortality, as well as total mortalityare prioritized for establishing guidelines related topharmacotherapy.

ImplementationImplementation and dissemination of the guidelines is a

priority for Hypertension Canada. We use many strategies toreach out to a variety of providers who care for patients withhypertension. Our efforts include knowledge exchange fo-rums, targeted educational materials for primary care pro-viders and patients, “Train the Trainer” teaching sessions, aswell as slide kits and summary documents, which are freelyavailable online in French and English (www.hypertension.ca). Hypertension Canada receives feedback from endusers to continually improve guideline processes and con-tent. The Research and Evaluation Committee conductshypertension surveillance studies and reviews existing Ca-nadian health surveys to identify gaps between current andbest practices.

AcknowledgementsWe thank Ms Susan Carter for providing technical assis-

tance with the manuscript and administrative support.

Funding SourcesActivities of the HCGC are supported by Hypertension

Canada. The members of the HCGC are unpaid volunteerswho contribute their time and expertise to the annualdevelopment and dissemination of the Hypertension Canadaguidelines. To maintain professional credibility of the con-tent, the process for the development of the guidelines isfully independent and free from external influence. Externalpartners assist with the dissemination of the approvedguidelines.

DisclosuresPlease see Supplemental Appendix S2 for a complete list of

disclosures.

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