HYPERTENSION HIGHLIGHTS - A Practical Guide informed by the Hypertension Canada Guidelines for the Prevention, Diagnosis, Risk Assessment, and ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
2020 - 2022
HYPERTENSION
HIGHLIGHTS
A Practical Guide informed
by the Hypertension Canada
Guidelines for the Prevention,
Diagnosis, Risk Assessment,
and Treatment of Hypertension
a
BLOOD PRESSURE HYPERTENSION 2020-22: HIGHLIGHTS
MEASUREMENT
TECHNIQUE 2020 - 2022
HYPERTENSION
The Hypertension Canada Guidelines
are the nation’s clinical practice
HIGHLIGHTS
guidelines for the management
Accurate diagnosis begins of hypertension. Developed by
an expert volunteer network, the
with accurate measurement: A Practical Guide informed
by the Hypertension Canada Guidelines are evidence-based,
Guidelines for the Diagnosis,
Risk Assessment, Prevention,
rigorously reviewed, and updated
ü Sitting position and Treatment of Hypertension regularly to keep Canada’s health
care professionals informed of
ü Back supported best-practices in hypertension
management.
ü Arm bare and supported
This booklet highlights the most critical and widely relevant
ü Use a cuff size appropriate aspects of the Hypertension Canada Guidelines. Beginning
for your arm
with proper measurement techniques for diagnosis and
ü Middle of the cuff at heart advancing through treatment and follow up, this booklet
level
serves as a practical guide for health care professionals.
ü Lower edge of cuff 3 cm
above elbow crease The full Guidelines with supporting evidence, which also
address complex specialty issues, can be accessed at
guidelines.hypertension.ca, and have been published at:
ü Do not talk or move before Rabi, Doreen M. et al. Hypertension Canada’s 2020
or during the measurement
Comprehensive Guidelines for the Prevention, Diagnosis,
ü Legs uncrossed Risk Assessment, and Treatment of Hypertension in Adults
ü Feet flat on the floor and Children. Can J Cardiol. 2020;36(5):596-624.
1WHAT’S STILL REALLY
WHAT’S NEW? IMPORTANT?
• The use of a low-dose acetylsalicylic acid (ASA) for primary • Out-of-office measurements
prevention of cardiovascular disease is no longer recommended are essential to rule out white
in people with hypertension in the absence of manifest vascular coat hypertension in patients
disease. with or without diabetes, and
to diagnose masked hypertension,
• The possibility of pregnancy should be considered in all women when suspected.
of reproductive age with a new diagnosis of hypertension,
and during follow-up visits. Determination of pregnancy is • A risk-based approach should be
important in treatment of women of reproductive age as some followed to identify appropriate
medications (e.g., ACE inhibitors/angiotensin receptor blockers) treatment thresholds and targets.
are contraindicated in pregnancy. Practitioners should offer • When possible, the use of a single-pill
preconception counselling and check for possible pregnancy at combination (SPC) should be considered to
regular intervals for women of reproductive age being managed improve treatment efficacy, adherence and
for hypertension. tolerability.
• The recommended measurement frequency for ambulatory • Follow-up visits are an essential part of
blood pressure monitoring (ABPM) is 20- to 30-minute intervals management and frequency should
throughout the day and night. It is no longer recommended to reflect individual clinical situations
have different intervals for nocturnal and daytime measurements. (see p. 24).
• Resistant hypertension is defined as blood pressure above
target despite three or more blood pressure lowering drugs at
optimal doses, preferably including a diuretic (and usually a
renin-angiotensin-aldosterone system blocker and a
calcium channel blocker).
2 3RECOMMENDED TECHNIQUE FOR AUTOMATED OFFICE
PATIENT EVALUATION BLOOD PRESSURE (AOBP)
I. MEASUREMENT • Measurements should be taken in a
AOBP Threshold
The use of standardized measurement techniques and validated sitting position with the back supported
for diagnosis:
equipment is recommended for all blood pressure (BP) methods. using a validated device known to be
A mean SBP ≥135 mmHg
accurate.
or DBP ≥85 mmHg.
Acronym Definition
• BP should be taken in both arms on at
AOBP Automated Office Blood Pressure is performed using an Preferred method least one visit and if one arm has a consistently higher pressure, that
automated device that can take a series of oscillometric of in-office arm should be used for BP measurement and interpretation.
measurements without the provider or others present. measurement.
The patient is left unattended in a private area while • A cuff with an appropriate bladder size for the arm should be
3-6 oscillometric, consecutive readings are taken.
chosen: bladder width should be close to 40% of the arm
OBPM Office Blood Pressure Measurement is performed using an circumference and length should cover 80-100% of the arm
upper arm device with the provider in the room. Oscillometric circumference.
or electronic devices are preferred when using this method.
• The arm should be bare, supported, and kept at heart level.
Auscultatory – mercury or aneroid – devices are an alternative
if an electronic device is not available. • The lower edge of the cuff should sit 3 cm above the elbow crease
ABPM Ambulatory Blood Pressure Monitoring requires the use of Preferred out-of- with the bladder centred over the brachial artery.
a validated oscillometric device which must be worn by the office method for
patient for a 24-hour period, with measurements taken at 20- diagnosis • The patient’s legs should be uncrossed with feet flat on the floor.
to 30-minute intervals.
• There should be no talking and the room should be quiet.
HBPM Home Blood Pressure Monitoring is a self-monitoring method
which requires the patient to measure their blood pressure • The device should be set to take measures at 1-to 2-minute
twice in the morning and evening for 7 days. intervals.
Are you measuring correctly? • The first measurement should be taken to verify the cuff position and
Accurate diagnosis begins with accurate validity of the measurement.
Is arm size an issue?
measurement.
In patients with very • The patient should be left alone after the first measurement while the
Evidence demonstrates that routine manual BP large arm circumference, device automatically takes subsequent readings.
readings obtained in clinical practice are, on when standard upper arm
average, higher than when validated automated measurement methods • The mean BP as displayed on the electronic device should be
measurement devices are used. Inaccuracies in cannot be used, validated recorded, as well as the arm used and whether the patient was
BP measurement can have clinical consequences wrist devices (utilized with supine, sitting or standing.
such as incorrect diagnosis, misclassification arm and wrist supported at
heart level) may be used for
of cardiovascular risk, or improper dosage of
blood pressure estimation.
antihypertensive medication.
It is important to note
Measurement using electronic upper arm devices
that wrist devices are
is preferred over auscultation. If electronic for estimation and not
devices are unavailable, be sure to implement the recommended for exact
recommended standardized technique for OBPM. measurement.
4 5RECOMMENDED TECHNIQUE FOR OFFICE BLOOD What About Auscultation?
PRESSURE MEASUREMENT (OBPM)
• Increase pressure rapidly to 30 mmHg
Tips:
• Measurement using validated electronic above the level at which the radial
(oscillometric) upper arm devices is OBPM threshold for pulse is extinguished. If Korotkoff sounds continue as
preferred over auscultation. diagnosis in the absence of the level approaches 0 mmHg,
compelling indications: • Place the bell or diaphragm of the
listen for when the sound
• Measurements should be taken in a A mean SBP ≥140 mmHg stethoscope gently and steadily over
becomes muffled to indicate the
sitting position with a device known to be and/or DBP ≥90 mmHg. the brachial artery.
diastolic pressure.
accurate.
Threshold for diagnosis • Open the control valve so that the rate
Leaving the cuff partially inflated
• BP should be taken in both arms on in Diabetes: of deflation of the cuff is approximately
for too long will make sounds
at least one visit and if one arm has a A mean SBP ≥130 mmHg 2 mmHg per heart beat.
difficult to hear. Leave 1 minute
consistently higher pressure, that arm and/or DBP ≥80 mmHg. between readings for optimal
• The systolic level is the first
should be used for BP measurement and results.
appearance of a clear tapping sound
interpretation.
(phase I Korotkoff).
• If an electronic device is not available,
Take note: • The diastolic level is the point at which the sounds disappear
a recently calibrated aneroid device or
(phase V Korotkoff).
sphygmomanometer can be used and Record BP to the closest
ensure the device is clearly visible at eye 2 mmHg on the • In the case of arrhythmia, additional readings with auscultation may be
level. sphygmomanometer, as well required to estimate the mean systolic and diastolic pressure. Isolated
as the arm used and whether extra beats should be ignored. Note the rhythm and pulse rate.
• A cuff with an appropriate bladder size
the patient was supine, sitting
for the arm should be chosen: bladder
or standing.
width should be close to 40% of the arm
circumference and length should cover Record the heart rate.
80-100% of the arm circumference.
Seated vs. Standing
• The arm should be bare, supported and
kept at heart level. The seated BP is used to
determine and monitor
• The lower edge of the cuff should sit 3 cm
treatment decisions.
above the elbow crease with the bladder
centred over the brachial artery. The standing BP is used
to examine for postural
• The patient should rest comfortably for
hypotension, which may
5 minutes prior to the measurement in the
modify treatment.
seated position with their back supported.
• The patient’s legs should be uncrossed with feet flat on the floor.
• There should be no talking and the room should be quiet.
• The first reading should be discarded and the latter two averaged.
6 7HOME BLOOD PRESSURE MONITORING (HBPM) Hypertension Canada’s Recommended BPM Devices Listing
Home blood pressure monitoring (HBPM) Refer patients to Hypertension Canada’s list of devices that are validated
Home BP threshold
can be used in the diagnosis of hypertension, as accurate at hypertension.ca/BPdevices.
for diagnosis:
and monitoring on a regular basis should be Have your patients look for the following logos to ensure their home BP
considered for all hypertensive patients and SBP >135 mmHg or monitor is valid and has been verified by Hypertension Canada’s experts.
particularly those with: DBP >85 mmHg should be
considered elevated and
• Inadequately controlled hypertension
associated with increased
• Diabetes mellitus
overall mortality risk.
• Chronic kidney disease
• Suspected non-adherence
• Demonstrated or suspected white coat effect
Gold-rated devices meet the Silver-rated devices meet
• BP controlled in the office but not at home (masked hypertension)
highest and most current the highest international
If white coat or masked hypertension is suggested by HBPM, it should international standard for standards available prior to
be confirmed by repeat HBPM or ABPM before treatment decisions blood pressure measurement the most recent updates.
are made. devices.
BP Home Series
Both Gold and Silver ratings are accepted by Hypertension Canada as
White coat or sustained hypertension values should be based on accurate.
duplicate measures, morning and evening for seven days. First day
values should be discarded. AMBULATORY BLOOD PRESSURE MONITORING (ABPM)
Log the Results Ambulatory blood pressure monitoring (ABPM)
can be used in the diagnosis of hypertension ABPM threshold
Blood pressure logs are available for health care professionals to use for diagnosis:
with their patients at hypertension.ca. and should be considered when an office-
induced increase in BP (white coat effect) is A mean 24-hour
suspected in treated patients with: SBP >130 mmHg
Every year, with your health care professional, review the technique for measuring your
• BP that is not below target, despite receiving and/or DBP >80 mmHg.
My target blood pressure at home is less than:
appropriate chronic antihypertensive therapy OR
Home Blood
/ mmHG
systolic diastolic
Pressure Log I use my: Left Arm • Symptoms suggestive of hypotension A mean daytime
Heart Rate
BP Reading #1 BP Reading #2
• Fluctuating office BP readings SBP >135 mmHg
What
Date type of blood pressure
Time monitor should I
Comments buy?
(beats/min)
The blood pressure monitor you purchase should be proven accurate, and the monitor’s
Systolic Diastolic Systolic Diastolic
and/or DBP >85 mmHg.
The magnitude of changes in nocturnal
Sample
Morning 8:00 a.m. Meds at 9 a.m. 138 82 135 80
June 15
Sample
Evening 8:00 p.m. Upset
To help you in your purchasing decisions, Hypertension Canada provides a list of
157 92 154 90 BP should be taken into consideration when determining whether
recommended monitors which have been proven accurate in research studies at
hypertension.ca
to prescribe or withhold drug therapy based upon ambulatory BP
Day 1 Evening
monitoring. A decrease in nocturnal BP ofDIAGNOSIS HYPERTENSION DIAGNOSTIC ALGORITHM FOR ADULTS
Elevated BP Suspected
(office, home or pharmacy)
Office Visit Assessment of BP1
Mean Office BP ≥ 180/110 YES HTN
NO
OBPM≥ 130/80 Probable HTN
Diabetes? YES for ≥ 3 measurements YES
on different days *Consider out-of-office
NO
measures to rule out WCH
AOBP ≥ 135/85
OR
OBPM≥140/90
YES Out-of-office measurement to rule out WCH2
(If AOBP unavailable)
ABPM (preferred)
Daytime mean ≥ 135/85
24hr mean ≥ 130/80
OR YES HTN
HBPM Series3 Mean ≥135/85
NO
*Diagnostic thresholds for AOBP, ABPM, and HBPM in patients with diabetes
have yet to be established (and may be lower than those listed above)
NO
No HTN WCH
Algorithm Notes:
1) If AOBP is used, use the mean calculated and displayed by the AOBP: A
utomated Office Blood Pressure. This is performed with the
device. If OBPM is used, take at least three readings, discard the patient unattended in a private room.
first and calculate the mean of the remaining measurements. A
OBPM: Office Blood Pressure Measurement. These are measurements
history and physical exam should be performed and diagnostic
performed in the office using an electronic upper arm device
tests ordered.
with a provider in the room.
2) Serial office measurements over 3-5 visits can be used if ABPM ABPM: Ambulatory Blood Pressure Monitoring
or HBPM are not available.
HBPM: Home Blood Pressure Monitoring
3) Home BP Series: Two readings taken each morning and evening
for 7 days (28 total). Discard first day readings and average the WCH: White Coat Hypertension
last 6 days. HTN: Hypertension
4) In patient with suspected masked hypertension, ABPM or HBPM All measurement values in algorithm are reported as mmHg.
10 could be considered to rule out masked hypertension. 11PATIENT EVALUATION Target Organ Damage
Target Organ Damage (TOD) should be assessed in patients with
II. ASSESSMENT hypertension. Presence of any of the following would put a patient into
BP should be assessed in all adult patients at all appropriate visits to the moderate-to-high or high-risk categories for therapy.
determine cardiovascular risk and monitor antihypertensive treatment. Cardiovascular Disease
When to check?
Routine Lab Testing • Coronary artery disease
• Acute coronary syndromes If the mean AOBP or OBPM is
Preliminary investigations of patients with hypertension • Angina pectoris high during visit 1, a history and
1. Urinalysis • Heart failure or left ventricular physical examination should
dysfunction be performed and, if clinically
2. Blood chemistry (potassium, sodium and creatinine) • Left ventricular hypertrophy indicated, diagnostic tests
Cerebrovascular Disease to search for TOD should be
3. Fasting blood glucose and/or glycated hemoglobin (A1c)
• Aneurysmal sub-arachnoid hemorrhage arranged within 2 visits.
4. Serum total cholesterol, low-density lipoprotein (LDL), high-density • Carotid artery disease
lipoprotein (HDL), non-HDL cholesterol, and triglycerides; lipids may • Intracerebral hemorrhage
be drawn fasting or non-fasting • Ischemic stroke or transient ischemic attack
5. Standard 12-lead ECG • Vascular dementia
• Mixed vascular dementia and dementia of the Alzheimer’s type
Routine testing of microalbuminuria in patients with hypertension without
diabetes or renal disease is not supported by current evidence. Hypertensive Retinopathy
Follow-up investigations of patients with hypertension Peripheral Arterial Disease
• Intermittent claudication
During the maintenance phase of hypertension management, tests • Lower extremity trophic changes
(including electrolytes, creatinine, fasting lipids, and pregnancy) should
be repeated with a frequency reflecting the clinical situation. Renal Disease
• Albuminuria
Pregnancy testing should be considered prior to initiation of health
• Chronic Kidney Disease (GFR < 60 ml/min/1.73 m²)
behaviour changes or drug therapy.
Diabetes develops in 1-3% per year of those with drug-treated Global Cardiovascular Risk Assessment
Improve Risk Factor
hypertension. The risk is higher in those with one or more of the following: Global cardiovascular risk should be assessed. Modification
treated with a diuretic or β-Blockers, impaired fasting glucose or Multifactorial risk assessment models can
impaired glucose tolerance, obesity (especially abdominal), dyslipidemia, be used to more accurately predict global Inform patients of
sedentary lifestyle and poor dietary habits. cardiovascular risk and antihypertensive therapy. their global risk
and consider using
Screen adults with hypertension with annual fasting plasma glucose Assessments can be done through risk
analogies that describe
testing and follow the screening recommendations. calculators like:
comparative risks like
For diabetes management visit: guidelines.diabetes.ca/fullguidelines • www.ccs.ca/en/resources/calculators-forms
“cardiovascular age”,
• www.myhealthcheckup.com
“vascular age”, or
• www.epicore.ualberta.ca/epirxisk/
“heart age”.
12 13THRESHOLDS AND TARGETS THERAPY
Populations and Stratification I. TREATMENT
Hypertension Canada stratifies patients by cardiovascular risk and, based Health Behaviour Recommendations
on that risk, there are different thresholds and targets for treatment.
Objective Recommendation Application
Hypertension Canada * Hypertension Canada High-Risk Patient
High-Risk Patient* Being More An accumulation of 30-60 minutes of dynamic Prescribe to both
Individuals ≥50y AND with SBP 130-180 mmHg AND
Physically exercise of moderate intensity (such as walking, normotensive and
with one or more of the following CV risk factors should
Diabetes Mellitus be considered for intensive BP management:
Active cycling, swimming) 4-7 days per week in addition hypertensive individuals
to the routine activities of daily living. Higher for prevention and
3 Clinical or sub-clinical cardiovascular disease intensities of exercise are no more effective at management of
OR BP lowering. For non-hypertensive or hypertensive hypertension, respectively.
individuals with SBP/DBP of 140-159/90-99 mmHg,
Moderate-to-high Risk 3 Chronic kidney disease
the use of resistance or weight training exercise
(multiple cardiovascular risk (non-diabetic nephropathy, proteinuriaHealth Behaviours Combination Therapy
For both the prevention and management of hypertension, health
To achieve optimal Suspected Resistant
behaviour strategies have been proven to effectively lower BP. Health
blood pressure targets: Hypertension
behaviours can be beneficial to individualized therapy. Individuals
should be engaged in conversation about health behaviour changes • Multiple drugs are often • Consider white coat
and informed on how life style adjustments can help to lower their BP. required to reach target levels, hypertension and
Encourage them to start today. especially in patients with non-adherence.
Hypertension Canada has resources available to use with your patients at Type 2 diabetes.
• Diuretic therapy should be
hypertension.ca. • Replace multiple considered if not already
antihypertensive agents with prescribed or contraindicated.
First Line Treatment of Adults with Systolic/Diastolic single pill combination therapy.
Hypertension Without Other Compelling Indications • β-Blockers, when used in
• Single pill combinations addition to ACE inhibitors or
or monotherapy should ARBs, have not been shown
Health Behaviour Management be considered for initial to have a clinically important
antihypertensive therapy. effect on BP.
• Low doses of multiple drugs • Monitor creatinine and
Thiazide/ may be more effective and potassium when combining
Long-acting Single pill better tolerated than higher potassium sparing diuretics,
thiazide-like† ACE-I ARB β-blocker*
CCB combination**
diuretic doses of fewer drugs. ACE inhibitors and/or ARBs.
†
Long-acting diuretics like indapamide and chlorthalidone are
• Reassess patients with • Consider referral to a
preferred over shorter acting diuretics like hydrochlorothiazide. uncontrolled BP at least every hypertension specialist if
two months. BP is still not controlled
* β-blockers are not indicated as first-line therapy for age 60 and above.
after treatment with three
• The combination of ACE antihypertensive medications.
Short-acting nifedipine should not be used for management of hypertension.
inhibitors and ARBs should not
** Recommended SPC choices are those in which an ACE-I be used.
is combined with a CCB, an ARB with a CCB, or
an ACE-I or ARB with a diuretic • In patients in whom
combination therapy is
being considered, an ACE
Renin angiotensin system (RAS) inhibitors are contraindicated in
pregnancy and caution is required in prescribing to women of
inhibitor plus a long-acting
child bearing potential dihydropyridine CCB is
preferable to an ACE inhibitor
plus a thiazide or thiazide-like
diuretic.
16 17Considerations in the Individualization of Pharmacological Therapy in Adults
Condition Initial therapy Second-line therapy Notes and/or cautions
Hypertension without other compelling indications
Diastolic hypertension with or without systolic Monotherapy or SPC. Recommended monotherapy Combination of first-line drugs. Not recommended for monotherapy: α-blockers,
hypertension choices include thiazide/thiazide-like diuretics β-blockers in those ≥60 years of age, ACE inhibitors
(longer-acting diuretics preferred), β-blockers, ACE in persons of African descent except if diabetes.
inhibitors, ARBs, or long-acting CCB. Recommended Hypokalemia should be avoided in those prescribed
SPC choices include combinations of an ACE diuretics. Combination of an ACE inhibitor with an
inhibitor with CCB, ARB with CCB, or ACE inhibitor/ ARB is not recommended.
ARB with a diuretic. (Consider statins in selected
patients).
Isolated systolic hypertension without other Thiazide/thiazide-like diuretics, ARBs or long-acting Combinations of first-line drugs. Same as above for diastolic hypertension with or
compelling indications dihydropyridine CCBs. without systolic hypertension.
Diabetes mellitus
Diabetes mellitus with microalbuminuria*, renal ACE inhibitors or ARBs. Addition of a dihydropyridine CCB is preferred over a A loop diuretic could be considered in hypertensive
disease, CVD or additional CV risk factors thiazide/thiazide-like diuretic. chronic kidney disease patients with extracellular
fluid volume overload.
Diabetes mellitus without factors listed above ACE inhibitors, ARBs, dihydropyridine CCBs or Combination of first-line drugs. If combination with Normal urine microalbumin to creatinine ratioCondition Initial therapy Second-line therapy Notes and/or cautions
Cardiovascular disease (continued)
Left ventricular hypertrophy ACE inhibitor, ARB, long-acting CCB or thiazide/ Combination of first-line agents. Hydralazine and minoxidil should not be used.
thiazide-like diuretics.
Past stroke or TIA ACE inhibitor and a thiazide/thiazide-like diuretic Combination of first-line agents. Treatment of hypertension should not be routinely
combination. undertaken in patients with acute stroke unless
extreme BP elevation. Combination of an ACE
inhibitor with an ARB is not recommended.
Non-diabetic chronic kidney disease
Non-diabetic chronic kidney disease with ACE inhibitors (ARBs if ACE inhibitor-intolerant) if Combinations of first-line agents. Carefully monitor renal function and potassium for
proteinuria† there is proteinuria. those on an ACE inhibitor or ARB. Combinations of
Diuretics as additive therapy. an ACE inhibitor and ARB are not recommended.
Other conditions
Peripheral arterial disease Does not affect initial treatment recommendations. Combinations of additional agents. Avoid ß-blockers with severe disease.
Reproductive considerations
Preconception As per above indications. – Consider discontinuing ACE inhibitors and ARBs
unless there is a compelling indication for their use
(i.e., proteinuric kidney disease).
Pregnancy Labetalol, methyldopa and long-acting oral Clonidine, hydralazine and thiazide diuretics. ACE inhibitors and ARBs should not be used.
nifedipine. Other β-blockers (acebutolol, metoprolol, Additional antihypertensive drugs should be used if
pindolol and propranolol) can also be used. target BP levels are not achieved with standard-
dose monotherapy. Add-on drugs should be of a
different drug class than those chosen from first-line
or second-line options. Carefully monitor maternal
and fetal response to BP medications.
Lactation Labetalol, methyldopa, long-acting oral nifedipine, Combinations of first-line agents. Monitor infant for adverse effects.
enalapril or captopril.
* Microalbuminuria is defined as persistent albumin to creatinine ratio >2.0 mg/mmol.
†P roteinuria is defined as urinary protein >150 mg/24hr or albumin to creatinine ratio
[ACR] >30 mg/mmol in two of three specimens.
ACE: Angiotensin converting enzyme NT-proBNP: N-terminal pro B-type natriuretic peptide
ARB: Angiotensin receptor blocker NYHA: New York Heart Association
BNP: B-type natriuretic peptide TIA: Transient ischemic attack
CCB: Calcium channel blocker LVH: Left ventricular hypertrophy
CVD: Cardiovascular Disease SPC: Single pill combination.
HFrEF: Heart failure with reduced ejection fraction < 40%
20 21THERAPY
II. ADHERENCE • Associated conditions
• Obesity
Improve patient adherence using a multi-pronged approach.
• Tobacco use
1. Consider tailoring or simplifying pill-taking to fit your patient’s daily • Excessive alcohol consumption
habits. • Sleep apnea
Î Use single pill combinations when possible • Chronic pain
• Mental health (i.e. depression)
2. Have your patient get involved in his/her treatment by encouraging
greater responsibility, BP goal-setting, and/or autonomy in monitoring • Drug interactions
BP and reporting the results. • Nonsteroidal anti-inflammatory drugs
• Oral contraceptives
3. Improve management in the office and beyond:
• Corticosteroids and anabolic steroids
Î In patients with hypertension who are not at target, review
• Cocaine
adherence to all health behaviours, including the use of
• Amphetamines
prescription medications, before therapy adjustments are
• Erythropoietin
considered,
• Cyclosporine, tacrolimus
Î Encourage adherence to therapy by out-of-office contact (either by
• Licorice
phone or mail) particularly during the first three months of therapy,
• Over-the-counter dietary supplements
Î Coordinate with pharmacists and worksite healthcare givers to
• Oral decongestant use (pseudoephedrine)
improve monitoring of adherence to pharmacological and lifestyle
• Monoamine oxidase inhibitors, certain selective serotonin reuptake
modification prescriptions,
inhibitors
Î Utilize electronic medication compliance aids.
Possible reasons for poor response to • Volume overload
• Excessive salt intake
antihypertensive therapy
• Renal sodium retention (pseudo-tolerance)
• Inaccurate measurement
• Secondary hypertension
Is it resistant hypertension?
• Suboptimal treatment regimens • Renal insufficiency
Causes of apparent resistant
• Dosage too low • Renovascular disease
hypertension include:
• Inappropriate combinations of antihypertensive agents • Primary hyperaldosteronism
• nonadherence,
• Thyroid disease
• Poor adherence • secondary hypertension, and
• Pheochromocytoma and other
• Dietary rare endocrine causes • white coat effect
• Physical activity • Obstructive sleep apnea These should be ruled out before true
• Medication resistant hypertension is diagnosed.
Practitioners should consider patient preferences, values, and financial
as well as clinical circumstances when determining treatment regimes for
individual patients.
22 23FOLLOW UP HYPERTENSION.CA
Measurement Professional Resources
Standardized office blood pressure measurement should be used for Hypertension Canada’s professional resources help keep you at the
follow up. Measurement using electronic (oscillometric) upper arm leading edge in hypertension prevention, diagnosis and care.
devices is preferred over auscultation. • Hypertension Canada Guidelines
• Accredited scientific meetings
White coat effect • Accredited primary care CME programs
• Hypertension Canada’s Professional Certification Program
Ambulatory or home blood pressure monitoring is recommended for • Learning and teaching resources
follow up in patients with demonstrated white coat effect. • eINFO newsletter
Modifying health behaviours Information for Patients
Hypertension Canada develops resources for you to use with your
Patient follow up every 3-6 months to monitor active modifications.
patients that reinforce these guidelines in an easy-to-understand format.
For patients with BP not at target, visits every 1-2 months are Information designed for the public can be accessed online by patients at
recommended. www.hypertension.ca. Bulk orders of patient resources can be purchased
on our website, with discounts available for members.
Antihypertensive medication
Patients on antihypertensive drug treatment should be seen every
1-2 months, depending on the level of BP, until readings on 2 consecutive
visits are below their target.
When the target BP has been reached, patients should be seen at
3- to 6-month intervals.
Follow up frequency should always reflect the individual’s Blood Pressure Action Plan
Understanding and Managing
Your Blood Pressure
clinical situation
Shorter intervals between visits will be needed for symptomatic patients Join the Hypertension Canada Community
and those with severe hypertension, intolerance to antihypertensive Hypertension Canada is a like-minded community of professionals that
drugs, or target organ damage. shapes research, education and public policy.
Visit www.hypertension.ca to join us today.
24 25Hypertension Canada www.hypertension.ca
Tel : 905-943-9400 HCP2021-EN
Email : info@hypertension.ca 2020-2022
For the complete version of the 2020 Hypertension Canada Guidelines
please refer to our website at www.hypertension.ca.
Published by Hypertension Canada.
Charitable Registration Number: 897016275RR0001You can also read
