What are the Canadian guidelines for managing hypertension?

Canadian Guidelines for Managing Hypertension

The Canadian Hypertension Education Program (CHEP) recommends treating hypertensive patients to achieve a blood pressure target of ≤130/80 mmHg, particularly for those with diabetes, based on evidence showing this reduces the risk of stroke without increasing myocardial infarction risk. 1

Diagnosis and Assessment

• Blood pressure should be measured routinely at least once annually, with more frequent measurements based on individual clinical circumstances 1
• Proper standardized techniques should be followed for blood pressure measurement in office, home, and community settings 1
• Patients with elevated blood pressure (systolic >130 mmHg and/or diastolic >85 mmHg) should undergo thorough assessment for hypertension diagnosis 1
• A specific follow-up visit should be scheduled for hypertension assessment following an initial elevated reading 1
• During assessment visits, three blood pressure measurements should be conducted according to Hypertension Canada Guidelines 1
• Patients with refractory hypertension should undergo comprehensive investigations for secondary causes 1

Blood Pressure Targets

• For patients who have had a stroke or transient ischemic attack, blood pressure should be consistently lower than 140/90 mmHg 1
• For patients with diabetes, systolic blood pressure targets should be consistently lower than 130 mmHg and diastolic blood pressure targets consistently lower than 80 mmHg 1
• For patients with nondiabetic chronic kidney disease, blood pressure should be consistently lower than 140/90 mmHg 1

Lifestyle Modifications

• All patients with hypertension or at risk for hypertension should receive aggressive risk factor modification and lifestyle counseling 1
• Weight management: Maintain a healthy body mass index (20-25 kg/m²) and waist circumference (<94 cm in men and <80 cm in women) 1
• Physical activity: Engage in moderate-intensity aerobic exercise of ≥150 minutes/week (30+ minutes, 5-7 days/week) or 75 minutes of vigorous exercise weekly, complemented with resistance training 2-3 times/week 1
• Dietary approaches:
  • Follow Mediterranean or DASH diets to help reduce blood pressure 1
  • Restrict sodium to approximately 2 g per day (equivalent to about 5 g of salt) 1
  • Increase dietary potassium intake through consumption of fruits and vegetables 1
  • Limit free sugar consumption, particularly sugar-sweetened beverages, to a maximum of 10% of energy intake 1
• Alcohol consumption: Limit to less than 100 g/week of pure alcohol (approximately 14 drinks/week for men and 9/week for women) 1, 2
• Smoking cessation: Stop tobacco use completely with appropriate supportive care 1

Pharmacological Treatment

• First-line therapy includes:

  • ACE inhibitors
  • ARBs (Angiotensin Receptor Blockers)
  • Dihydropyridine calcium channel blockers
  • Thiazide/thiazide-like diuretics 1

• Combination therapy approach:

  • For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination BP-lowering treatment is recommended as initial therapy 1
  • Preferred combinations are a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or diuretic 1
  • Fixed-dose single-pill combinations are recommended to improve adherence 1
  • If BP is not controlled with a two-drug combination, a three-drug combination is recommended (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic) 1
  • Combining two RAS blockers (ACE inhibitor and ARB) is not recommended 1

• Special considerations:

  • Beta-blockers should be combined with other major BP-lowering drug classes when there are specific indications (angina, post-MI, heart failure, or heart rate control) 1
  • For patients aged ≥85 years, those with symptomatic orthostatic hypotension, or moderate-to-severe frailty, monotherapy may be considered instead of combination therapy 1

Implementation and Follow-up

• Medications should be taken at the most convenient time of day to establish a habitual pattern and improve adherence 1
• BP-lowering drug treatment should be maintained lifelong, even beyond age 85, if well tolerated 1
• Regular follow-up (monthly) is recommended until target BP is achieved 1
• Strategies to improve medication compliance include:
  • Informing patients about hypertension risks and treatment benefits
  • Providing clear written and oral instructions
  • Tailoring treatment regimens to patient's lifestyle
  • Simplifying treatment by reducing the number of daily medications
  • Involving family members in treatment plans
  • Encouraging home BP monitoring
  • Addressing side effects promptly 1

Common Pitfalls and Caveats

• Many patients believe not adding salt to food equals a low-salt diet, but education about checking food labels and hidden sodium sources is essential 1
• Failure to adhere to low-sodium diets (<2,300 mg/day) is a significant cause of resistant hypertension 1
• Potassium supplementation should be avoided in patients with chronic renal failure or those taking potassium-sparing diuretics 1
• Despite the benefits of BP control, many adults with hypertension still do not achieve target blood pressure levels 3
• A team approach involving physicians, nurses, dietitians, and other healthcare providers improves time efficiency and patient education 1