What are the Canadian goals of therapy for hypertension?

Canadian Goals of Therapy for Hypertension

The Canadian Hypertension Education Program (CHEP) recommends a blood pressure target of <140/90 mmHg for most adults with hypertension, and <130/80 mmHg for patients with diabetes mellitus or chronic kidney disease. 1, 2, 3, 4, 5

Blood Pressure Targets by Patient Population

General Adult Population

• Target BP: <140/90 mmHg for all adults without specific comorbidities 1, 2, 3, 4, 5
• This applies regardless of age, though caution should be exercised in frail elderly patients 2, 4

High-Risk Populations

Diabetes Mellitus:

• Target BP: <130/80 mmHg 1, 2, 3, 4, 5
• This lower target applies to all diabetic patients regardless of age 2, 3, 4

Chronic Kidney Disease:

• Target BP: <130/80 mmHg 1, 2, 3, 4, 5
• This applies to both diabetic and non-diabetic CKD patients 2, 3, 4
• Particularly important in patients with proteinuria 1, 2, 3

Elderly Patients (Age >80 years)

• Target BP: <150/90 mmHg for those over 80 years 1
• For fit elderly patients under 80 years: target SBP <140 mmHg 1
• Clinical discretion should be used for frail elderly patients 1, 2, 4

Treatment Initiation Thresholds

When to Start Pharmacological Therapy:

• All patients with confirmed hypertension (BP ≥140/90 mmHg) should receive treatment 2, 3, 4, 5
• Treatment decisions should be based on global atherosclerotic risk, target organ damage, and comorbid conditions 2, 3, 4, 5
• Most patients will require more than one agent to achieve target blood pressures 2, 3, 4, 5

First-Line Pharmacological Therapy

For Adults Without Compelling Indications:

• Thiazide diuretics are recommended as initial therapy 2, 3, 4, 5
• Alternative first-line agents include: ACE inhibitors (except in Black patients), long-acting calcium channel blockers, ARBs, or beta-blockers (in patients <60 years) 1, 2, 3, 4, 5

Combination Therapy Initiation:

• Consider starting with two first-line agents if SBP is 20 mmHg above target or DBP is 10 mmHg above target 2, 4, 5
• Do not combine ACE inhibitors with ARBs unless compelling indications exist 2, 4

Specific Comorbidity-Based Recommendations

Coronary Artery Disease:

• First-line: Beta-blockers and ACE inhibitors 2, 3, 4, 5

Cerebrovascular Disease:

• First-line: ACE inhibitor/diuretic combination 1, 2, 3, 4, 5

Proteinuric Non-Diabetic CKD:

• First-line: ACE inhibitors (or ARBs if ACE inhibitor intolerant) 2, 3, 4, 5

Diabetes Mellitus:

• First-line: ACE inhibitors or ARBs 1, 2, 3, 4, 5
• In patients without albuminuria: thiazides or dihydropyridine CCBs are also appropriate 2, 3, 4, 5

Lifestyle Modifications

Dietary Sodium Restriction:

• <2300 mg (100 mmol) per day for prevention 3, 4
• 1500-2300 mg (65-100 mmol) per day for hypertensive patients 2, 3, 4
• More recent recommendations specify age-based targets: 1500 mg/day for adults ≤50 years, 1300 mg/day for 51-70 years, and 1200 mg/day for >70 years 2

Physical Activity:

• 30-60 minutes of moderate aerobic exercise 4-7 days per week 2, 3, 4, 5

Weight Management:

• Maintain BMI 18.5-24.9 kg/m² 2, 3, 4, 5
• Waist circumference: <102 cm for men, <88 cm for women 2, 3, 4, 5

Alcohol Limitation:

• ≤14 standard drinks per week for men, ≤9 for women 2, 3, 4, 5

Dietary Pattern:

• Emphasize fruits, vegetables, low-fat dairy products, dietary and soluble fiber, whole grains, and plant-based protein 2, 3, 4, 5
• Reduce saturated fat and cholesterol 2, 3, 4, 5

Important Clinical Caveats

Accurate BP Measurement:

• Patient should avoid exercise, caffeine, alcohol, and smoking within 30 minutes before measurement 1
• Rest for at least 5 minutes before readings 1
• Use appropriate cuff size covering at least 80% of arm circumference 1
• Position patient with feet on floor and arm at heart level 1

Adjunctive Therapy:

• Once BP is controlled, consider low-dose acetylsalicylic acid therapy 2, 3, 4, 5
• Treat dyslipidemia according to Canadian lipid treatment guidelines 2, 3, 4, 5
• Selected high-risk hypertensive patients should receive statin therapy even if they don't meet traditional lipid thresholds 2, 3, 4, 5