What are the new primary care guidelines for Hypertension (HTN) in Canada?

From the Guidelines

The new primary care guidelines for hypertension in Canada recommend a blood pressure target of less than 140/90 mmHg for most adults, with a lower target of less than 130/80 mmHg for those with diabetes or high cardiovascular risk, as supported by the most recent guidelines from the World Health Organization 1.

Key Recommendations

• Diagnosis requires multiple readings over several visits or through 24-hour ambulatory or home monitoring.
• First-line medications include ACE inhibitors (like ramipril 5-10 mg daily), ARBs (such as candesartan 8-32 mg daily), thiazide diuretics (hydrochlorothiazide 12.5-25 mg daily), or long-acting calcium channel blockers (amlodipine 5-10 mg daily) 1.
• For most patients, treatment should begin with a single agent, titrating to maximum dose before adding a second medication from a different class.
• Combination therapy is often necessary, with certain combinations like ACE inhibitors with calcium channel blockers being particularly effective.
• Lifestyle modifications remain essential, including reducing sodium intake to less than 2000 mg daily, regular physical activity (150 minutes weekly), limiting alcohol consumption, maintaining healthy weight, and following a DASH-style diet rich in fruits, vegetables, and low-fat dairy.

Rationale

The guidelines emphasize a comprehensive approach because hypertension is a leading risk factor for cardiovascular disease, with proper management significantly reducing the risk of stroke, heart attack, and heart failure 1. The World Health Organization guidelines provide the most current and relevant evidence-based guidance for the pharmacological treatment of hypertension in non-pregnant adults, with a particular focus on practice in middle- and low-income countries 1.

Implementation

To fully implement current guidelines appropriately, physicians and/or health care personnel need more time with patients to educate them on approaches to lifestyle modifications and the importance of how and when to assess their BP 1. This will require appropriate and additional funding from payers (insurance companies, governments, and others) to achieve this quality improvement.

Evidence Base

The guidelines are based on the latest evidence, including systematic reviews of randomized controlled trials and meta-analyses, as well as expert consensus and patient values 1. The World Health Organization guidelines are developed in accordance with the World Health Organization Handbook for Guideline Development and use the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to evaluate the quality of the evidence and strength of the recommendations 1.

From the Research

New Primary Care Guidelines for HTN in Canada

The new primary care guidelines for hypertension (HTN) in Canada aim to improve hypertension management in adults at the population level 2, 3. The guidelines provide pragmatic primary care-focused recommendations, developed using the Grading of Recommendations Assessment, Development and Evaluation and ADAPTE frameworks.

Diagnostic Recommendations

• A standardized approach to measuring blood pressure (BP) and confirming hypertension 2, 3
• A uniform definition for hypertension of BP ≥ 130/80 mm Hg 2, 3

Treatment Recommendations

• Targeting a systolic BP < 130 mm Hg 2, 3
• Implementing healthy lifestyle changes 4, 5
• Providing stepwise guidance on optimal medication choices for patients requiring pharmacotherapy 2, 3
• Considering a combination of two first-line agents as the initial treatment of hypertension if the systolic blood pressure is 20 mmHg above the target or if the diastolic blood pressure is 10 mmHg above the target 4, 5

Lifestyle Modifications

• Restricting dietary sodium to less than 2300 mg (100 mmol)/day 4
• Performing 30 min to 60 min of aerobic exercise four to seven days per week 4
• Maintaining a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference 4
• Limiting alcohol consumption to no more than 14 units per week in men or nine units per week in women 4

Pharmacological Management

• Treatment thresholds and targets should be predicated on the patient's global atherosclerotic risk, target organ damage, and comorbid conditions 4, 5
• Blood pressure should be decreased to lower than 140/90 mmHg in all patients, and to lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease 4, 5
• Most patients will require more than one agent to achieve these target blood pressures 4, 5
• Antihypertensive therapy should be considered in all adult patients regardless of age 4, 5