What are the Canadian Hypertension Education Program (CHEP) guidelines for diagnosing and managing hypertension in adults?

Canadian Hypertension Guidelines for Diagnosis, Management, and Follow-Up

Blood Pressure Measurement and Diagnosis

The Canadian Hypertension Education Program (CHEP) requires blood pressure measurements on 4-5 separate office visits before diagnosing hypertension when systolic BP is 140-160 mmHg or diastolic BP is 90-100 mmHg, or alternatively, diagnosis can be confirmed using ambulatory or home blood pressure monitoring. 1

Diagnostic Criteria

• Office BP threshold: Hypertension is defined as seated BP ≥140/90 mmHg based on multiple measurements 1
• Stage 1 hypertension: 140-159/90-99 mmHg 1
• Stage 2 hypertension: ≥160/100 mmHg 1

Measurement Technique

• Obtain BP readings with the patient seated quietly for >5 minutes, feet flat on floor, back supported, arm at heart level 2
• Use validated devices with appropriate cuff size that encircles 80% of the arm 2
• Base diagnosis on average of ≥2 readings obtained on ≥2 separate occasions 1

Out-of-Office BP Monitoring

CHEP uniquely recommends that hypertension diagnosis can be made using either ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM), not just office measurements. 1

• Use ABPM or HBPM to detect white coat hypertension (high office BP but normal out-of-office BP) and masked hypertension (normal office BP but high out-of-office BP) 1
• ABPM/HBPM thresholds for hypertension are lower than office measurements 1
• White coat hypertension carries cardiovascular risk similar to normal BP, while masked hypertension carries risk equivalent to sustained hypertension 1

Critical pitfall: The CHEP requirement for 4-5 office visits is more stringent than American guidelines (which require only 2 visits), reflecting a more conservative diagnostic approach to avoid overdiagnosis 1

Initial Assessment and Risk Stratification

Laboratory Testing

All newly diagnosed hypertensive patients require: 2

• Fasting glucose
• Complete blood count
• Lipid profile
• Serum creatinine with estimated glomerular filtration rate (eGFR)
• Electrolytes
• Thyroid-stimulating hormone (TSH)
• Urinalysis
• Electrocardiogram

Screening for Secondary Hypertension

Screen for secondary causes when patients present with: 1

• Early onset hypertension (<30 years) without risk factors (obesity, metabolic syndrome, family history)
• Resistant hypertension (uncontrolled on 3+ medications including a diuretic)
• Sudden deterioration in BP control
• BP lability with episodic symptoms, snoring/hypersomnolence, muscle cramps/weakness 2

Basic screening includes: thorough history, physical examination, serum sodium, potassium, eGFR, TSH, and dipstick urinalysis 1

Global Cardiovascular Risk Assessment

• Assess for target organ damage and established atherosclerotic disease to determine treatment urgency and intensity 3, 4
• Evaluate all cardiovascular risk factors including dyslipidemia, diabetes, smoking, and family history 3
• Consider echocardiography in selected patients to detect left ventricular hypertrophy 3, 4

Treatment Thresholds and Blood Pressure Targets

When to Initiate Pharmacological Therapy

For most patients: Initiate drug therapy when BP ≥140/90 mmHg 5

For high-risk patients (diabetes mellitus or chronic kidney disease): Initiate therapy at BP ≥130/80 mmHg 5

For Stage 1 hypertension with low cardiovascular risk: Consider lifestyle modifications alone for 3-6 months before starting medications 2

Blood Pressure Targets

Target BP <140/90 mmHg for all hypertensive patients 5

Target BP <130/80 mmHg for patients with: 5

• Diabetes mellitus
• Chronic kidney disease

Critical distinction: Canadian guidelines maintain the 140/90 mmHg threshold for most patients, which differs from the 2017 ACC/AHA guidelines that lowered the threshold to 130/80 mmHg for the general population 1

Lifestyle Modifications

All patients with hypertension should implement: 5

• Dietary sodium restriction: <2300 mg (100 mmol)/day; ideally 1500-2300 mg (65-100 mmol)/day for hypertensive patients
• Physical activity: 30-60 minutes of aerobic exercise 4-7 days per week
• Weight management: Maintain BMI 18.5-24.9 kg/m² and waist circumference <102 cm (men) or <88 cm (women)
• Alcohol limitation: ≤14 units/week (men) or ≤9 units/week (women)
• DASH diet: Emphasize fruits, vegetables, low-fat dairy, whole grains, dietary fiber, and plant-based protein while reducing saturated fat and cholesterol
• Stress management: Consider in selected individuals

Pharmacological Management

First-Line Antihypertensive Agents

For adults without compelling indications, initial therapy should include thiazide diuretics. 5

Other appropriate first-line agents include: 5

• ACE inhibitors (in patients who are not Black)
• Long-acting calcium channel blockers (CCBs)
• Angiotensin receptor blockers (ARBs)
• Beta-blockers (in patients <60 years of age)

Initial Combination Therapy

Consider starting with two first-line agents if: 5

• Systolic BP is 20 mmHg above target, OR
• Diastolic BP is 10 mmHg above target

Contraindicated combination: Never combine ACE inhibitors with ARBs 5, 6

Treatment for Specific Comorbidities

Angina, recent MI, or heart failure: Beta-blockers and ACE inhibitors as first-line 5

Cerebrovascular disease: ACE inhibitor/diuretic combination preferred 5

Proteinuric non-diabetic chronic kidney disease: ACE inhibitors or ARBs (if ACE inhibitor intolerant) 5

Diabetes mellitus: 5

• ACE inhibitors or ARBs as first-line
• Alternatively, thiazides or dihydropyridine CCBs in patients without albuminuria

Resistant Hypertension

Definition: BP >140/90 mmHg despite 3+ antihypertensive medications at optimal doses including a diuretic 1

Management approach: 1

1. Exclude pseudoresistance (poor measurement technique, white coat effect, nonadherence, suboptimal drug choices)
2. Screen for substance/drug-induced hypertension
3. Evaluate for secondary causes
4. Optimize diuretic therapy (use thiazide-like rather than thiazide diuretics; switch to loop diuretics if eGFR <30 mL/min/1.73m²)
5. Add low-dose spironolactone as 4th-line agent if potassium <4.5 mmol/L and eGFR >45 mL/min/1.73m²
6. If spironolactone contraindicated: consider amiloride, doxazosin, eplerenone, clonidine, or beta-blockers

Monitoring and Follow-Up

Laboratory Monitoring

Monitor serum creatinine and potassium within 7-14 days after initiating or titrating ACE inhibitors, ARBs, or diuretics, then at least annually. 2

• Accept creatinine increases up to 30% from baseline after starting renin-angiotensin system (RAS) blockers—this reflects beneficial reduction in intraglomerular pressure 2

Follow-Up Schedule

For patients not at BP goal: Monthly follow-up until target achieved 1, 2

For patients at BP goal: Follow-up every 3-6 months 2

For high normal BP: Ongoing reassessment is required 4

Medication titration: Adjust doses every 2-4 weeks until BP target achieved, with goal of reaching target within 3 months 2

Home Blood Pressure Monitoring

HBPM is the most practical method for medication titration toward BP goal. 7

• Use validated devices 2
• Improves patient self-efficacy and engagement 6
• Helps detect white coat effect and masked uncontrolled hypertension 1

Adjunctive Cardiovascular Risk Management

Lipid Management

All hypertensive patients with dyslipidemia should receive statin therapy according to Canadian Cardiovascular Society thresholds and targets. 5

• Selected high-risk hypertensive patients who don't meet standard statin thresholds should nonetheless receive statin therapy 5

Antiplatelet Therapy

Once BP is controlled, consider acetylsalicylic acid (aspirin) therapy. 5

Critical Pitfalls to Avoid

• Do not combine ACE inhibitors with ARBs in patients with uncomplicated hypertension, diabetes without albuminuria, chronic kidney disease without proteinuria, or ischemic heart disease without heart failure 5, 6
• Do not diagnose hypertension based on single-visit measurements when BP is 140-160/90-100 mmHg—require 4-5 visits or out-of-office confirmation 1
• Do not undertreated young hypertensive patients with multiple cardiovascular risks—they require antihypertensive drug therapy regardless of age 6
• Do not neglect lifestyle modifications—most Canadians make only minor lifestyle changes after hypertension diagnosis despite their proven benefit 6

Strategies to Improve Adherence

• Use single-pill combination medications when multiple drugs are needed 2
• Implement team-based care with pharmacists and nurses 2
• Utilize home BP monitoring with telehealth follow-up 2
• Prescribe 90-day refills instead of 30-day when allowed 2
• Employ motivational interviewing and goal-setting strategies 2