What are the Canadian guidelines for hypertension management, including blood pressure (BP) targets and treatment options?

Canadian Hypertension Guidelines: BP Targets and Treatment Options

According to the Canadian Hypertension Education Program (CHEP), the general blood pressure target for most hypertensive patients is <140/90 mmHg, with a lower target of <130/80 mmHg for patients with diabetes or chronic kidney disease (particularly those with proteinuria). 1

Blood Pressure Targets by Patient Population

General Population

• Target: <140/90 mmHg 1
• Diagnosis threshold: Repeated office BP ≥140/90 mmHg (confirmed with home BP ≥135/85 mmHg or 24h ambulatory BP ≥130/80 mmHg) 1

Special Populations

1. Diabetes:

   • Target: <130/80 mmHg 1, 2

2. Chronic Kidney Disease:

   • Without proteinuria: <140/90 mmHg
   • With proteinuria: <130/80 mmHg 1

3. Elderly Patients:

   • Age >80 years: <150/90 mmHg
   • Frail elderly: Treatment at clinician's discretion 1
   • Hypertension Canada (2020) recommends a more aggressive target of <120 mmHg systolic for high-risk older adults 1

Pharmacological Treatment Algorithm

First-Line Therapy Options

• General population: Thiazide diuretics, ACE inhibitors (in non-black patients), ARBs, or calcium channel blockers (CCBs) 1, 2
• Isolated systolic hypertension: Long-acting dihydropyridine CCBs or ARBs 2, 3

Population-Specific First-Line Recommendations

1. Black patients: Thiazide diuretics or CCBs 1

2. Diabetes:

   • With CKD: ACE inhibitors or ARBs
   • Without CKD: Thiazide diuretics, CCBs, ACE inhibitors, or ARBs 1, 2

3. Chronic Kidney Disease:

   • With proteinuria: ACE inhibitors or ARBs (if ACE inhibitor intolerant) 1, 3

4. Cardiovascular Disease:

   • Angina, recent MI, or heart failure: Beta-blockers and ACE inhibitors
   • Cerebrovascular disease: ACE inhibitor/diuretic combination 1, 3

Treatment Initiation and Intensification

When to Start Medication

• Grade 1 Hypertension (140-159/90-99 mmHg):

  • High-risk patients (CVD, CKD, diabetes, target organ damage, or age 50-80): Start drug treatment immediately
  • Others: After 3-6 months of lifestyle intervention if BP remains elevated 3

• Grade 2 Hypertension (≥160/100 mmHg): Start drug treatment immediately 1

Combination Therapy

• Most patients will require more than one agent to achieve target BP 2, 3
• Consider initial combination therapy if systolic BP is ≥20 mmHg above target or diastolic BP is ≥10 mmHg above target 3
• Avoid combining ACE inhibitors with ARBs 3

Lifestyle Modifications

Essential components of hypertension management include:

• Sodium restriction: <2300 mg/day (100 mmol/day) for prevention; 1500-2300 mg/day (65-100 mmol/day) for treatment 3
• Regular aerobic exercise: 30-60 minutes, 4-7 days/week 2, 3
• Healthy weight maintenance: BMI 18.5-24.9 kg/m² and waist circumference <102 cm (men) or <88 cm (women) 3
• Alcohol limitation: ≤14 units/week (men) or ≤9 units/week (women) 3
• DASH-style diet: Rich in fruits, vegetables, low-fat dairy, whole grains, reduced in saturated fat and cholesterol 3

Monitoring and Follow-up

• Target BP should be achieved within 3 months 1
• Use validated BP measuring devices with appropriate cuff size 1
• Consider home BP monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg) to confirm diagnosis and monitor treatment 1

Common Pitfalls to Avoid

1. Inaccurate BP measurement: Ensure proper technique, validated equipment, and appropriate cuff size
2. Clinical inertia: Don't delay treatment intensification when targets aren't met
3. Ignoring home BP readings: These often provide better prognostic information than office readings
4. Overlooking adherence issues: Always assess medication adherence before adding new agents
5. Neglecting lifestyle modifications: These remain foundational to hypertension management and enhance medication efficacy

The Canadian guidelines emphasize a systematic approach to hypertension management with clear BP targets based on patient characteristics and comorbidities, along with specific recommendations for pharmacological therapy tailored to different patient populations.