This session will help pharmacists enhance their expertise in managing patients with hypertension through updates on the latest hypertension guidelines, discussion on the role that pharmacists can and should play in the detection and ongoing management of hypertension and hands-on experience with blood pressure measurement devices.

1. May 12, 2018
Phil Emberley, PharmD, MBA
Director, Practice Advancement and Research
Pharmacist Management of
Hypertension

2. Disclosures
 Participation on short term advisory boards for:
• Merck Consumer Health
• Pfizer
• None of these have influence over today’s presentation

3. Learning Objectives
1. To be familiar with the 2017 and 2018 Updates to the Guidelines for the
Management of Hypertension
2. To be aware of how hypertension is best assessed in the primary care
setting.
3. To be familiar with the current pharmacologic and non-pharmacologic
options for the treatment of hypertension.
4. To gain an understanding of how pharmacists play an integral role in the
management of hypertension.

4. Hypertension Pathophysiology
http://www.mydr.com.au/heart-
stroke/high-blood-pressure-overview

5. What Causes Hypertension?

6. Hypertension- the Silent Killer
 Hypertension affects a large proportion of the Canadian population:
• 2% of children and adolescents
• 7% of pregnant women
• 25% of the adult population
 The associated harms from hypertension are well documented and include
chronic kidney disease, stroke, cardiovascular disease and death
 18% of Canadians with measured hypertension are not aware of their
condition, while 14% who are being treated have not met their blood
pressure targets

7. Hypertension: Increasing Prevalence

8. Canadian Hypertension Guidelines
 Since 1999, Hypertension Canada (formerly the Canadian
Hypertension Education Program) has been providing guidelines
for hypertension
 These are clinical practice guidelines which are rigorously
reviewed and updated annually, providing health care
professionals with the most up-to-date recommendations and
guidelines for the detection, treatment and control of
hypertension.

9. Key Messages: 2017 Hypertension Guidelines
 All Canadian adults should have their blood pressure assessed at all
appropriate clinical visits.
 Automated measurement is preferred to manual measurement.
 In the office, multiple unattended automatic measurements are
recommended.
 Out-of-office measurement should be performed to confirm the initial
diagnosis of hypertension.
 Optimum management of the hypertensive patient requires assessment
and communication of overall cardiovascular risk using an analogy like
“vascular age”.

10. Key Messages: 2017 Hypertension Guidelines
 Identify the threshold for initiating therapy; treat to target.
 Health behavior modification is effective in preventing hypertension,
treating hypertension and reducing cardiovascular risk.
 Combinations of both health behavior changes and drugs are generally
necessary to achieve target blood pressures.
 Home BP monitoring is an important tool in self-monitoring and self-
management.
 Focus on adherence

11. What Was New in the 2017 Guidelines?
 Treatment thresholds no longer based on age
 First line therapy recommendations in adults with uncomplicated
hypertension included long acting diuretics and single pill combinations
 Guidelines for the screening and treatment of fibromuscular dyslplasis
(FMD)
 Caution regarding excessive DBP lowering in patients with CAD and LVH
 Patients who experience hyperacute intracerebral hermorrhage should
not have their SBP lowered to below 140 mmHg.

12. Hypertension Canada 2018 Guidelines
 The 2018 version of the Hypertension Canada guidelines included the following new
guidelines:
• In patients with large arm circumference, when standard upper arm methods cannot be
used, validated wrist devices may be used for BP estimation
• Standardized office BP measurement should be used for follow-up. Measurement using
electronic oscillometric upper arm devices is preferred over auscultation
• Ambulatory BP monitoring or home BP is recommended for follow-up of patients with
demonstrated white coat effect
• Global cardiovascular risk should be assessed. Multifactorial risk assessment models can
be used to help engage individuals in conversations about health behavior change to
lower BP
• An Angiotensin Receptor-Neprilysin Inhibitor combination should be used in place of an
ACE-I or ARB for patients with HFrEF (EF,40%) who remain symptomatic despite
treatment with appropriate dose of guideline directed HF therapy

13. Canadian Hypertension Guidelines
 Guidelines provide recommendations in the following
areas:
• Diagnosis
• Assessment
• Prevention
• treatment

14. Diagnosis and Assessment of Hypertension

15. BP Measurement in
Practice
For every 10 patients who request a renewal
of a stable antihypertensive, how many do
you measure BP on?
A. 0
B. 1-2
C. 3-5
D. 6-9
E. 10

16. BP Measurement in
Practice
For those patients you do measure BP on, how do
you take the measurement?
A. Manual sphygmomanometer
B. BP monitor for home use
C. Professional/office BP monitor
D. In-pharmacy BP kiosk
E. Not applicable / unsure

17. Measurement Technique
 Patient's arm is unsupported
 Patient's back is unsupported
 Patient is talking
 Patient is engaged in active listening
 Wrong size cuff
 Cuff is positioned too low on the upper
arm; appears to be over the elbow
 Patient’s legs are crossed
 HCP in room
Perm J 2009;13(3):51-54.

18. BP Measurement
 Factors influencing BP results:2-5
Factor Impact on SBP
(mm Hg)
Impact on DBP
(mm Hg)
Talking or active listening 10-17 10-13
Back unsupported 6-10 --
Arm unsupported 1-7 5-11
Legs crossed 8-10 4-5
Physician/HCP in room 7 6
Full bladder 15 10
Smoking within 30 minutes 6-20 --

19. BP Measurement
 “Automated Office BP (AOBP) is the
preferred method of performing in-office BP
measurement” (2017 CHEP Guidelines)5
Avoids terminal digit preference
Avoids overly fast cuff deflation
Can take multiple measurements
Can be performed unattended, and can
calculate average for you

20. Measurement / Assessment
Tips
 Hypertension Canada recommends you leave the
room:
oIncreased risk of white coat effect
oIncreased risk of conversation during readings
oIncreased chance that time pressure or lack of
patience will lead the health care provider to
forego performing multiple measurements

21. Out-Of-Office Measurements
Preferred for Diagnosis Because:
 Office visits rarely accurately performed
 ABPM and HBPM have better prognostic ability
for CV events than conventional office BP
readings6-7
 ABPM preferred over HBPM due to:
• Greater number of measurements per day
• Improved adherence to measurement regimen
• Daytime and nighttime values considered

22. Automated BP Monitors

23. Hypertension Canada Recommends BP Monitors
 Hypertension Canada has endorsed certain monitors with the symbol
below.
 Monitors recommended by Hypertension Canada can be found at the
following link: https://hypertension.ca/hypertension-and-you/managing-
hypertension/measuring-blood-pressure/devices/

24. What is ‘High’?
Setting / Method SBP DBP
Automated Office BP ≥135 ≥85
Non-Automated Office BP ≥140 ≥90
Ambulatory BP (mean awake) ≥135 ≥85
Ambulatory BP (mean 24-hour) ≥130 ≥80
Home BP (BID x 1 week) ≥135 ≥85
What if office BP is high, but home BP is OK?
Hypertension Canada 2017

25. Treatment Options
 Non-drug therapy for all:
• Weight reduction
• Exercise
• Alcohol consumption
• Diet, includes ↓ sodium and ↑ potassium (if
not at risk of hyperkalemia)
• Stress reduction
Hypertension Canada 2017

26. Case Study- Joan Williams
 38 y/o female
 Past medical history:
• Non-smoker, occasional EtOH
• Recently went back to work after
the birth of her child
• Total cholesterol: 4.1 mmol/L
• HDL: 1.7 mmol/L
• LDL: 3.1 mmol/L
• Family history of diabetes

27. Joan Williams- Tests and Vitals
 Tests ordered:
• ECG- proved normal
 Labs:
• Cr: 0.9mg/dL, Na 135mmol/L, fasting glucose: 5.4 mmol/L, HCT: 35; TSH
2.1; K: 4.2mmol/L
 Vital signs:
• HR 83 bpm, BP: 138/89mm/Hg, BMI 23

28. Joan Williams- Treatment Alternatives
 What would you recommend for her:
1. Diet and lifestyle management
2. Start drug therapy
3. Ask her to return for another blood pressure check in one
week
4. All of the above
5. 1 & 3 only

29. Joan Williams- Treatment Alternatives
 What would you recommend for her:
1. Diet and lifestyle management
2. Start drug therapy
3. Ask her to return for another blood pressure check in one
week
4. All of the above
5. 1 & 3 only

30. One Week Follow-Up
 Joan returns in one week. She has made changes to her diet
and begun a running program. The blood pressure reading
today is 138/88. She would be classified as having:
1. Normal BP
2. High normal BP
3. Stage 1 hypertension
4. Not sure

31. One Week Follow-Up
 Joan returns in one week. She has made changes to her diet
and begun a running program. The blood pressure reading
today is 138/88. She would be classified as having:
1. Normal BP
2. High normal BP
3. Stage 1 hypertension
4. Not sure

32. Joan Williams- Next Steps
 What is the best recommendation for Joan at this stage?
1. Continue diet and lifestyle modification, have her
check her BP regularly and suggest a home bp monitor
2. Drug therapy
3. Both 1 and 2

33. Joan Williams- Next Steps
 What is the best recommendation for Joan at this stage?
1. Continue diet and lifestyle modification, have her
check her BP regularly and suggest a home bp monitor
2. Drug therapy
3. Both 1 and 2

34. Epilogue- Joan Williams
 One year after her first appointment, Joan is
dedicated to her running program
 Twelve years after, she is running 10Ks
 BP is 118/70

35. Blood Pressure Progression
 According to evidence reviewed by Hypertension Canada:
• In a trial of subjects with high normal BP, 40% of subjects in the placebo
arm developed hypertension within two years and 63% within four
years (5). This is consistent with observational data, indicating that these
individuals exhibit higher four-year rates of progression to overt
hypertension (6). In addition, the 10-year risk of incident cardiovascular
disease was greater in both men (hazard ratio 1.6; 95% CI 1.1 to 2.3) and
women (hazard ratio 1.8; 95% CI 1.0 to 3.1) with high normal BP than in
subjects with BP levels lower than 120/80 mm Hg (7).

36. Initiating Drug Therapy
Population SBP DBP
High risk (SPRINT population)*** ≥ 130 n/a
Moderate to high risk
(Target organ damage or CV risk factors)
≥ 140 ≥ 90
Low risk
(no target organ damage or CV risk factors)
≥ 160 ≥ 100
Diabetes ≥ 130 ≥ 80

37. Goals of Therapy
Population SBP DBP
High risk (SPRINT population) ≤ 120 N/A
Diabetes < 130 < 80
All others (including CKD, elderly) < 140 < 90
Wasn’t there a separate goal for elderly?
Wasn’t there a separate goal for CKD?

38. Frequency of Follow-Up
Outcome Frequency
BP within target Annual
Office BP ‘high-normal’ (130-139 / 85-89 mm Hg) Annual
High initial office BP Visit 2 within 1
month
Hypertensive, non-drug therapy only 3-6 months*
Hypertensive, on drug therapy, not at target 1-2 months*
Hypertensive, on drug therapy, at target for 2
consecutive visits
3-6 months
Hypertension Canada 2017

39. Choice of Pharmacological Treatment
Uncomplicated
Associated risk factors?
or
Target organ damage/complications?
or
Concomitant diseases/conditions?
Individualized
Treatment
(and compelling indications)
YES
Treatment in the
absence of compelling
indications for specific
therapies
NO

40. Treatment of Adults with Systolic/Diastolic
Hypertension without Other Compelling
Indications
TARGET <140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
*BBs are not indicated as first line therapy for age 60 and above
Beta-
blocker*
Long-acting
CCB
Thiazide ACEI ARB
Health Behaviour
Management
ACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and caution is required in
prescribing to women of child bearing potential
A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20
mmHg systolic or >10 mmHg diastolic above target

41. Considerations Regarding the Choice of
First-Line Therapy
 Use caution in initiating therapy with 2 drugs in whom adverse events are more likely (e.g. frail elderly,
those with postural hypotension or who are dehydrated).
 ACE inhibitors, renin inhibitors and ARBs are contraindicated in pregnancy and caution is required in
prescribing to women of child bearing potential.
 Beta blockers are not recommended as first line therapy for patients age 60 and over without another
compelling indication.
 Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agents if
required.
 The use of dual therapy with an ACE inhibitor and an ARB should only be considered in selected and
closely monitored people with advanced heart failure or proteinuric nephropathy.
 ACE-inhibitors are not recommended (as monotherapy) for black patients without another compelling
indication.

42. Add-on Therapy for Systolic/Diastolic
Hypertension without Other Compelling
Indications
IF BLOOD PRESSURE IS NOT
CONTROLLED CONSIDER
•Nonadherence
•Secondary HTN
•Interfering drugs or lifestyle
•White coat effect
If blood pressure is still not controlled, or there are adverse effects, other classes
of antihypertensive drugs may be combined (such as alpha blockers or centrally
acting agents).
2. Triple or Quadruple Therapy
1. Add-on Therapy
If partial response to monotherapy

43. Choice of Pharmacological Treatment
for Hypertension
Individualized treatment
 Compelling indications:
• Ischemic Heart Disease
• Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI
• Left Ventricular Systolic Dysfunction
• Cerebrovascular Disease
• Left Ventricular Hypertrophy
• Non Diabetic Chronic Kidney Disease
• Renovascular Disease
• Smoking
 Diabetes Mellitus
• With Nephropathy
• Without Nephropathy
 Global Vascular Protection for Hypertensive Patients
• Statins if 3 or more additional cardiovascular risks
• Aspirin once blood pressure is controlled

44. Opportunities for Pharmacist Intervention
 Opportunities have been identified for pharmacists according to full
scope interventions and partial scope interventions
 Full scope interventions
• Assessment of and counselling about CV risk and BP control
• Reviewing antihypertensive medications Aggregate BP ↓
• Prescribing and/or titrating drug therapy 18.3mmHg
• Lab testing
 Partial scope interventions
• Patient education, counselling, referrals, diagnostics and interventions
• (no prescribing) Aggregate BP ↓ 7.6mmHG

45. How Do We Get Started?
 Following the process of comprehensive medication
management in CDM:
• Patient Assessment
• Assessing patients' medication regimen
o Appropriateness, Effectiveness, Safety and Convenience
• Identifying any DTP’s
• Creating and implementing a care plan with patient
• Collaborating and communicating with other HCP’s
• Evaluating, documenting and following up with the patient
45

46. Link to Practice
 Community pharmacies are ideal locations to:
• Initiate early detection and screening programs for
chronic conditions
 Assist patients in monitoring and managing
their chronic condition
 CDM is a an important niche for pharmacists
• Interact with many patients without physicians
• Pharmacists accessibility make for a natural fit
oSee their patients 2-8 times more vs. physicians
46

47. Link to Practice
 Screening vs. Case Finding
• Screening: Applying tests to entire population to determine prevalence or
probability that an individual will have a disease regardless of the presence
or absence of risk factors
• Case finding: Using demographics, risk factors and/or symptoms at an
individual level to decide whether to apply or proceed with testing.
47

48. Link to Practice – Formula
 Formula for achieving objective of CDM (improving
patient outcomes):2
1. Intervention (e.g. patient assessment, education)
2. Case finding: identifying patients who could benefit
from an intervention
 “Even the best-designed patient care intervention will
NOT improve outcomes if the clinician cannot find
patients who can benefit from the intervention”
48

49. References
 myDr: High Blood Pressure Overview. http://www.mydr.com.au/heart-stroke/high-blood-pressure-overview
 Nephrosante: Causes of Hypertension. https://nephrosante.wordpress.com/2015/06/28/causes-of-hypertension/
 The Canadian Pharmacists Association. Benefits of Pharmacist Care in Hypertension in Canada. Broadstreet
Health Economics and Outcomes Research, Vancouver, BC., 2017
 Hypertension Canada. What’s New? 2017 Hypertension Canada Guidelines for the Management of Hypetension
https://hypertension.ca/wp-content/uploads/2017/11/HTN_Whats_New_2017_EN.pdf.
 Hypertension Canada’s 2018 Guidelines for Diagnosis, Risk Assessment, Prevention and Treatment of
Hypertension in Adults and Children. Cdn J Cardiology, published online February 24, 2018:
https://www.onlinecjc.ca/article/S0828-282X(18)30183-1/abstract
 The Canadian Pharmacists Association. From Guidelines to Pharmacy Practice: A Review and Case-based
Approach for the Care of Patients with Hypertension; a pre-conference workshop delivered at the 2017
Canadian Pharmacists Conference June 1, 2017.
 Georgea J, Zairinaa E. The potential role of pharmacists in chronic disease screening. Int J Pharm Pract.
2016;24(1):3-5.
 Kassamali A, Houle S, Rosenthal M, Tsuyuki RT. Case finding: The missing link in chronic disease management. Can
Pharm J. 2011;144(4):170-171.e1.

50. Questions?