2014 chepwhatsnew en jan7

8/12/2019 2014 Chepwhatsnew en Jan7

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The 2014 CHEP

RecommendationsWhats new in the treatment of

hypertension?

Whats still really important?

2014


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Evidence-based

Annual Recommendations

The Canadian Hypertension Education Program

is central to Hypertension Canada

CHEP is known as the most credible source for evidence-basedchronic disease management recommendations with annual

updates, a well-validated review process and effectivedissemination techniques across Canada

Canada has the worlds highest reported

national blood pressure control rates

2014


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Hypertension Canada Knowledge Translation

Organizational Chart

Outcomes

Research

Committee

Central ReviewCommittee

CPD, eLearning

Public/Patient KT

Committees

Topic subgroups

Topic subgroups

Topic subgroups

Topic subgroups

Canadian Hypertension Education Program Committee

2014


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Canadian Hypertension

Education Program

(Knowledge Creation)

Annual systematic

review and critical appraisal

of studies

Synthesis into

recommendations

Scientific

Manuscripts

and

Summaries

Identify New Knowledge, Select

What is Still Important

Adapt KnowledgeTo Local/Regional Context

Address Barriers to

Knowledge Use

Tailor Tools for

Interprofessional

Team Members

Monitor Knowledge Use

Evaluate

Outcomes

By Combining National

and Provincial

Administrative Data

Knowledge Gaps, Best

Practice Goals

Professiona

lEducationCommittee

OutcomesR

esearchComm

ittee

Hypertension Canadas Annual KTCycle for

developing management recommendations

Adapted from Graham ID, Logan, J., Harrison MB, Straus, S., Tetroe, JM, Caswell, W. et al.

(2006). Lost in knowledge translation: Time for a map?Journal of Continuing Education inHealth Professions, 26, 13-24.

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The Canadian Hypertension Education Program:

2014 Recommendations

Whats still important?

Out-of-office blood pressure measurements areimportant in both the diagnosis and management ofhypertension

The management of hypertension is all about globalcardiovascular risk management and vascularprotection

Single pill combinations help achieve blood pressure

control The most important step in prescription of

antihypertensive therapy is achieving patient buy-in

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CHEP 2014 Recommendations

Whats new?

More guidance for treating to target: revisions in some

BP targets, thresholds AND limits

New targets for health behaviour management-especially in regards to dietary sodium intake

2014

II I di ti f Ph th


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Population SBP DBP

Diabetes 130 80

High risk (TOD or CV risk factors) 140 90

Low risk (no TOD or CV risk

factors)

160 100

Very elderly 160 NA

II. Indications for Pharmacotherapy

Usual blood pressure threshold values for

initiation of pharmacological treatment

TOD=target organ damage

*This higher treatment target for the very elderly reflects current evidence and

heightened concerns of precipitating adverse effects, particularly in frail patients.

Decisions regarding initiating and intensifying pharmacotherapy in the very elderly

should be based upon an individualized risk-benefit analysis.

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Population SBP DBP

Diabetes


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HYVET protocol

Threshold BP >160 mmHg sitting

Target BP


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N Engl J Med. 2008 May 1;358(18):1887-98.

HYVET (threshold for initiation of >160 mmHg):

the basis for the new 80+ recommendation

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Considerations in the management of

octogenarian hypertension

The elderly in HYVET were rather healthy HYVET examined the efficacy of a treatment target

among patients that HAD hypertension (65% of patients

had previously treated hypertension, not a de novo

diagnosis) Several issues around early stopping of HYVET

Stopped for benefit of a secondary endpoint

Between interim analysis and actual stopping- the

apparent benefit on primary benefit had gone

Caution around early stopping

There is no diastolic threshold or target

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III. Choice of Therapy for Adults withHypertension without Compelling

Indications for Specific Agents

Propos ed New Recommendat ion

For 2014

B) Recommendations for Individuals

with Isolated Systolic Hypertension

6) In the very elderly (age 80 years

and older), the target for SBP

should be 160 mmHg and

the SBP target is


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We all know its true

High BP is better than no BP

Rangno, Ogilvie,Canadian Hypotension Society

2014


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Framingham Study: patients with or without

previous CHD

D'Agostino et al. BMJ 1991;303:385-9.

2014


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The rationale for caution in lowering

BP < 60 mmHg in CAD

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Epidemiological caveat:

sources of confounding not fully accounted for

co-morbid diseases, increased baseline risk

increased non-CV mortality at low BPs (e.g., HOT)

observed J/U curves in placebo groups (e.g., INDANA) observed J-curves despite little change in BP Rx (e.g., TNT)

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BP targets for treatment of hypertension in

association with CAD

A. Recommendations for hypertensive patients with CAD:

1. An ACE inhibitor or ARB is recommended for most patients with HT and CAD (Grade A).

2. For patients with stable angina, BBs are preferred as initial therapy (Grade B). CCBs may also be used (Grade B).

3. Short-acting nifedipine should not be used (Grade D).

4. For patients with CAD, but without coexisting systolic HF, the combination of an ACE inhibitor and ARB is not recommended

(Grade B).

5. In high-risk patients, when combination therapy is being used, choices should be individualized. The combination of an ACE

inhibitor and a dihydropyridine CCB is preferable to an ACE inhibitor and a diuretic in selected patients (Grade A).

6. When low er ing SBP to target levels in pat ients with establ ished CAD

(especially i f ISH is present), be caut ious when the diastol ic bloo d

pressure is


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Whats new?

Revisions in some BP targets, thresholds AND limits

More guidance in health behaviour management-

especially in regards to dietary sodium intake

2014


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Impact of health behaviours on

blood pressure

InterventionSystolic BP

(mmHg)

Diastolic BP

(mmHg)

Diet and weight control -6.0 -4.8

Reduced salt/sodium intake - 5.4 - 2.8

Reduced alcohol intake (heavy

drinkers)-3.4 -3.4

DASH diet -11.4 -5.5

Physical activity -3.1 -1.8

Relaxation therapies -3.7 -3.5

Multiple interventions -5.5 -4.5

Clinical Guideline : Methods, evidence and recommendations National Institute for

Health and Clinical Excellence (NICE) May 2011

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Health Behaviours in Adults with Hypertension:

Summary

Intervention Target

Reduce foods withadded sodium 2000 mg /day

Weight loss BMI


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Cochrane review of cross-over and parallel

RCTs for BP effects of salt reduction

Studies examining the impact of modest reduction in salt intake vs.

usual intake (reduction in 24 hour urinary sodium 40-120 mmol)

In hypertensive individuals (22 trials; N=999)

24 hr urine Na: median 162 mmol (9.5 g/day salt)

Baseline blood pressure: 148/93 mm Hg

Urine Na change: 75 mmol (-4.4 g/day salt)

SBP change 5.39 mm Hg (95% CI 6.62 to 4.15)

DBP change 2.82 mm Hg (95% CI 3.54 to 2.11)

He, BMJ 2013

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Implications of Cochrane Review

24 hr urine Na: median 162 mmol (9.5 g/day salt)

Urine Na change: 75 mmol (-4.4 g/day salt)

Achieved reduction in Na: 87 mmol per day

87 mmol = 2,000 mg of sodium = 5 g of salt

2014


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WHO meta-analysis

Prospective cohort studies

RCTs

decreased Na intake vs control 40 mmol/day 4 weeks in duration

Measured 24 hour urinary sodium excretion

No co-intervention

Aburto et al, BMJ 2013

2014


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Estimates of the effect of sodium

restriction on BP

Aburto et al, BMJ 2013

2014

Th C di H t i Ed ti P


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What

s still important? Out-of-office blood pressure measurements are

important in both the diagnosis and management ofhypertension


Single pill combinations help achieve blood pressurecontrol

The most important step in prescription ofantihypertensive therapy is achieving patient buy-in

2014

O l l i l ffi i


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Only relying on manual office pressures misses

out on white coat and masked hypertension

Manual Office BP mmHg

AmbulatoryBP

mmHg

Hypertension

Normotension

White Coat

Hypertension

Masked

Hypertension

200

180

160

140

120

100100 120 140 160 180 200

135

From Pickering et al. Hypertension2002;40:795-796

2014


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The prognosis of masked hypertension

Prevalence is approximately 10% in hypertensive patients.

0

5

10

15

20

25

30

35

Normal23/685

Whitecoat24/656

Uncontrolled41/462

Masked236/3125

CV

eventsper1000pa

tient-year CV Events

Okhubo et al. J. Am. Coll. Cardiol. 2005;46;508-515

2014


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BP: 140-179 / 90-109

ABPM

(If available)

Office

BPM

Home BPM

(If available)

Yes

Hypertension Visit 2Target Organ Damage

or Diabetesor BP 180/110?

HypertensionVisit1BP Measurement,

History and Physical

examination

Hypertensive

Urgency /

Emergency

Diagnosis

of HTN

No

Diagnostic algorithm for hypertension

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Criteria for the diagnosis of hypertension

and recommendations for follow-up

BP: 140-179 / 90-109

ABPM (If available)

Diagnosis

of HTN

Awake BP

>135 SBP or

>85 DBP or24-hour

>130 SBP or

>80 DBP

Awake BP

100 DBP

>140 SBP or>90 DBP

< 140 / 90

Diagnosisof HTN

Continue to

follow-up

135/85< 135/85

Diagnosis

of HTNContinue to

follow-up

Patients with high normal blood pressure (office SBP

130-139 and/or DBP 85-89) should be followed annually.

Repeat

Home BPM

If

< 135/85

or

2014



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What

s still important? Out-of-office blood pressure measurements are

important in both the diagnosis and management ofhypertension




2014

A l b l di l i k i ll


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Assess global cardiovascular risk in all

hypertensive patients

91%

Rantala A, et al. J Intern Med1999;245;163-74. Wannamethee S, et al. J Hum Hypertens1998;12;735-41

Risk factors = Global CV risk

91% of hypertensive patients have at least 1 additional risk factor

2014


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2014 CHEP Recommendations: assessing

cardiovascular risk to improve adherence

Informing patients of their global risk to improve theeffectiveness of risk factor modification.

Using analogies that describe comparative risk such as

Cardiovascular Age, Vascular Age or Heart Age to

inform patients of their risk status.

2014

I f i ti t f th i l b l i k i


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Informing patients of their global risk improves

the effectiveness of risk factor modification

Grover SA , et al. J Gen Intern Med. 2009;24(1);3339

2014

I t bl d t t t f


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Impact on blood pressure treatment of

discussing coronary risk with patients

Grover SA, et al. J Gen Intern Med 2009;24(1);33-9

2014

The treatment of hypertension is all about


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The treatment of hypertension is all about

vascular protection

Male

55 y or older

Smoking Type 2 Diabetes

Total-C/HDL-C ratio of 6 or

higher

Premature Family History of

CV disease

Previous Stroke or TIA

LVH

ECG abnormalities Microalbuminuria or

Proteinuria

Peripheral Vascular Disease

ASCOT-LLA Lancet 2003;361:1149-58

Statins are recommended in high risk hypertensive patients based onhaving established atherosclerotic disease or at least 3 of the following:

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Vascular Protection for Hypertensive

Patients: ASA

Low dose ASA in patients >50 years

Caution should be exercised if BP is not co ntrol led.

Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and

low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal

Treatment (HOT) randomised trial. Lancet 1998; 351: 1755-1762.

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2014

M th i ft t h


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Cushman et al. J Clin Hypertens 2002;4;393-404

Monotherapy is often not enough:

medication use in ALLHAT

2014


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Single pill combination-based treatment:

Leads to improved adherence (and decreased

medical resource utilization)

Taylor AA, Shoheiber O. Congest Heart Fail. 2003;9:324-32

Leads to reduced hypertension-related CV

complication ratesCorrao G, et al. Hypertension. 2011;58:566-72

Leads to better blood pressure control rates

Feldman RD, et al. Hypertension. 2009;53;646-653

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2014

Adherence to antihypertensive management can


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be improved by a multi-pronged approach

Encourage greater patient responsibility/autonomy inregular monitoring of their blood pressure

Educate patients and patients' families about theirdisease/treatment regimens verbally and in writing

Use an interdisciplinary care approach coordinating withwork-site health care givers and pharmacists if available

Encouraging adherence to therapy by healthcarepractitioner-based telephone contact, particularly, over

the first three months of therapy

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be improved by a multi-pronged approach-II

2014

Assess adherence to pharmacological and healthbehaviour therapies at every visit

Teach patients to take their pills on a regular scheduleassociated with a routine daily activity e.g. brushingteeth.

Simplify medication regimens using long-acting once-daily dosing

Utilize single pill combinations

Utilize unit-of-use packaging e.g. blister packaging


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Whats new?

More guidance for treating to target: revised BP targets,thresholds AND limits

New targets for health behaviour management-especially in regards to dietary sodium intake

2014



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2014


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2014 chepwhatsnew en jan7

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