Chep Recommendations

THE 2009
CANADIAN HYPERTENSION
EDUCATION PROGRAM
RECOMMENDATIONS

AN ANNUAL UPDATE

Hypertension recommendations designed for patient
and public education have been developed in 2008.
Bulk orders of 25 or more copies can be obtained by
contacting hyperten@ucalgary.ca.
Hypertension recommendations for patients with
diabetes, developed in 2009, are also available.
These summaries are available electronically at
www.hypertension.ca/bpc.
A free, confidential tool is available at
www.heartandstroke.ca/bp. Developed by the
Heart and Stroke Foundation, the Blood Pressure
Action Plan enables people to get a personalized
action plan tailored to their risk profile, promote
self-management and help people to make lifestyle
changes, monitor their blood pressure and print
reports to take to their healthcare provider.

TAblE Of CONTENTS

Scientific Summary ......................................................................................................... 1

The 2009 Canadian Recommendations for the
Management of Hypertension:
Diagnosis & Assessment ....................................................................... 21

Therapy ............................................................................................................................. 39

Therapy Tables ..................................................................................................... 49

Evidence-Based Recommendations Task Force
2008 for the 2009 Recommendations........................................... 59

On behalf of the Canadian
Hypertension Education Program
Acknowledgement:
This manuscript was written by
Dr. N. Campbell with the assistance
of the CHEP Executive,
Dr. M. Hill,
Dr. N. Khan and
Dr. G. Tremblay.

2

Summary
The 2009 Canadian Hypertension Education Program (CHEP)
recommendations are the 10th annual update. Recent surveil-
lance data indicates that two-thirds of diabetic people with
hypertension have uncontrolled blood pressure. The focus
of this year’s update is on improving the blood pressure
management in these people. Other management gaps
include suboptimal use of pharmacotherapy in younger
hypertensive people with multiple cardiovascular risk factors
and a low uptake of lifestyle changes after a hypertension
diagnosis. In 2009, CHEP specifically recommends not to
combine an ACE inhibitor with an angiotensin receptor
blocker (ARB) in people with uncomplicated hypertension,
diabetes (without micro or overt albuminuria), chronic
kidney disease (without proteinuria) and ischemic heart
disease (without heart failure).

Abstract
This report highlights the key messages of the 2009 Canadian
Hypertension Education Program recommendations for
management of hypertension and the supporting clinical
science. In 2009, CHEP emphasizes the need to improve
control of hypertension in people with diabetes. Intensive
reduction in blood pressure (<130/80 mm Hg) in people with
diabetes leads to significant reductions in mortality rates,
disability rates, and overall health care system costs and may
lead to improved quality of life. The CHEP recommendations
continue to emphasize the important role played by patient
self-efficacy by promoting lifestyle change to prevent and
control hypertension and by encouraging home measure-
ment of blood pressure. Unfortunately, most Canadians
make only minor changes in lifestyle after a diagnosis of
hypertension. Routine blood pressure measurement at all
appropriate visits and screening for and management of
all cardiovascular risks are key to blood pressure manage-
ment. Many young hypertensive Canadians with multiple
cardiovascular risks are not treated with antihypertensive
drugs. This is despite the evidence that those with multiple
cardiovascular risks and hypertension should be strongly
considered for antihypertensive drug therapy regardless
of age. In 2009, CHEP now specifically recommends not
to combine an ACE inhibitor with an ARB in people with
uncomplicated hypertension, diabetes (without micro
or macro albuminuria), chronic kidney disease (without
nephropathy (micro or overt proteinuria)) or ischemic heart
disease (without heart failure).

3

Key Words
Hypertension, High Blood Pressure, Clinical Practice
Guidelines, Knowledge Translation.

2009 marks the tenth consecutive year that the Canadian
Hypertension Education Program (CHEP) has had updated
recommendations for the management of hypertension.
CHEP is a program of the Canadian Hypertension Society,
Blood Pressure Canada, the Public Health Agency of Canada,
the Heart and Stroke Foundation of Canada, the Canadian
Council of Cardiovascular Nurses, the Canadian Pharmacists
Association and the College of Family Physicians of Canada.
CHEP makes substantive efforts to harmonize recommen-
dations for the management of hypertension with other
organizations that also produce guidelines that include
blood pressure lowering therapy. In particular the 2009
CHEP recommendations are harmonized with those of the
Canadian Diabetes Association, the Canadian Society of
Nephrology and the Canadian Stroke Network.

CHEP’s leadership in guidelines processes is characterized
by the routine cycles of surveillance, evaluation of care gaps,
and development of programs and educational resources to
address the care gaps. In 2008, CHEP was aided by data that
allowed identification not only of successes that could be
attributed to the program but also of important clinical care
gaps that continue to exist. A survey (ONBP) conducted by
the Heart and Stroke Foundation found that while Ontario
had a low prevalence of hypertension (21%) relative to other
developed countries it had the world’s highest published
rates of awareness, treatment and control of hypertension.1, 2
Nevertheless, the survey found that two-thirds of Ontarians
with hypertension and diabetes have uncontrolled blood
pressure (½ the control rate of those without diabetes). A
national survey also demonstrated a care gap in that only
½ of younger people with hypertension were treated with
medications and the rate of treatment did not increase
with increasing number of concomitant cardiovascular
risk factors. 3 In fact hypertensive people who smoked
were less likely to be treated and those with five additional
cardiovascular risk factors were no more likely to be treated
than those with hypertension alone. The CHEP recommenda-
tions continue to emphasize the importance of patient
self-efficacy by promoting lifestyle change to prevent and
control hypertension and by home measurement of blood
pressure. In a prospective national cohort survey there was
little indication that a diagnosis of hypertension triggered

4

overall healthy lifestyle change for most people.4 After
being diagnosed with hypertension, there was a slight
increase in smoking cessation and an increase in physical
activity; however, body mass index (BMI) increased and
there was no change in excess alcohol consumption. Those
who were not prescribed medications were not more likely
to make lifestyle changes. CHEP will make efforts to develop
resources and tools to improve care in these areas.

There were several major hypertension clinical trials in 2008
as well as new information from trials published in 2007. The
major changes in the evidence have resulted in new CHEP
recommendations to specifically not combine an ACE inhibi-
tor with an ARB in people with uncomplicated hypertension,
ischemic heart disease in the absence of heart failure, past
stroke, non-proteinuric chronic kidney disease or diabetes
without nephropathy (albuminuria, see Table 1). The HYVET
trial supported a previous CHEP recommendation to treat
hypertension in those over age 80. The same cautions as
indicated in the past need to be exercised when prescribing
antihypertensive therapy in those who are at risk for adverse
effects of blood pressure lowering (e.g. the frail elderly).
The recent publication of the ADVANCE trial has resulted in
CHEP recommending consideration of initial therapy with 2
antihypertensive drugs for people with diabetes and blood
pressures >150/90 mm Hg.5, 6

This is a short scientific summary of the new clinical hyper-
tension evidence and the 2009 CHEP recommendations
as well as the opinions of the CHEP Executive regarding
important issues in hypertension management in Canada.
The full CHEP recommendations are available at www.
hypertension.ca and will be published in the May 2009
issue of the Canadian Journal of Cardiology. Tables 2 and
3 contain the target values for treating hypertension and
recommended lifestyle respectively.

New evidence has allowed CHEP to address additional
clinical questions in the management of hypertension
for the 2009 recommendations.
Why should I treat people with diabetes and hyperten-
sion to a target of less than 130/80 mm Hg?
In 2008, the ONBP survey found two-thirds of people with
diabetes and hypertension had blood pressure that was
130/80 mm Hg or above. Up to 80% of people with diabetes
die of cardiovascular complications and up to three-quarters
of specific diabetic complications can be attributed to high

5

blood pressure.7 In people with diabetes and hypertension
reducing blood pressure results in a large reduction in death
and disability.6, 8-12 In the Syst Eur trial of isolated systolic
hypertension, hypertensive therapy in people with diabetes
reduced total mortality by 55%, cardiovascular mortality by
76%, and all cardiovascular events by 67%.13 In the HOT trial,
people with diabetes who had more intensive treatment
of diastolic blood pressure had a 66% reduction in death
from heart disease and stroke even though the difference
in diastolic blood pressure was only 4 mm Hg at the end of
the trial.14 In a meta analysis of randomized controlled trials,
more vs. less intensive lowering of blood pressure reduced
total mortality by 24% and major cardiovascular events by
25%.15 The use of an ACE inhibitor or ARB based therapeutic
regime to lower blood pressure has additional advantages
in people with proteinuric chronic kidney disease.15 CHEP
recommends treating systolic blood pressure to <130 mm Hg
and diastolic to <80 mm Hg. Economic analysis indicates that
more intensive reduction in blood pressure in people with
diabetes is one of the few medical interventions that may
reduce overall health costs.16

What are the implications of new clinical trials for
treating people with hypertension?
Should I prescribe the combination of an ACE inhibitor
with an ARB in my patients?
The ONgoing Telmisartan Alone and in combination with
Ramipril Global Endpoint Trial (ONTARGET) was a large,
randomized double-blinded trial to determine if telmisartan
was non-inferior to ramipril at full doses and whether the
combination of telmisartan and ramipril was superior to
ramipril alone.17, 18 People were enrolled into the study if they
were aged 55 years and older and had evidence of vascular
disease or diabetes with target organ damage. 25,620 people
were randomized to either telmisartan 80 mg/day, ramipril
10 mg/day, or a combination of telmisartan 80 mg/day and
ramipril 10 mg/day. After a median follow-up of 56 months,
the telmisartan (-0.9/-0.6 mm Hg) and the combination
therapy (-2.4/-1.4 mm Hg) groups had significantly lower
blood pressures compared to the ramipril monotherapy
group. There was no significant difference in the primary
outcome (cardiovascular death, myocardial infarction, stroke
or hospitalization for congestive heart failure) between the
ramipril and telmisartan monotherapy groups as well as
the combination therapy group compared with the ramipril
monotherapy group. However, combination therapy was
associated with significantly higher rates of discontinuation

6

due to syncope and renal impairment compared with rami-
pril. Specifically, combination therapy was associated with a
significantly increased rate of dialysis and doubling of serum
creatinine compared to ramipril monotherapy (HR: 1.09; 95%
CI: 1.01-1.18, p=0.037). The findings of this study provide
evidence that telmisartan is equally as effective as ramipril
for people with cardiovascular disease or diabetes with
target organ damage. The findings also demonstrate that
the combination of telmisartan and ramipril do not provide
additional cardiovascular benefits above and beyond either
therapy alone but does increase the adverse event rate in
the ONTARGET population. The COOPERATE trial has been
used as evidence in favour of prescribing the combination
of an ACE inhibitor with an ARB.19 In 2008, serious concerns
have been raised regarding several data inconsistencies
in the study.20 To date, the only data supporting improved
patient-related outcomes from prescribing the combination
of an ACE inhibitor with an ARB have been from secondary
outcome analysis of heart failure trials.21,22 There are ongoing
trials in proteinuric people with substantive chronic kidney
disease. In the absence of evidence there is no recommenda-
tion to use the combination aside from in people with heart
failure. CHEP recommends specifically to not prescribe the
combination of an ACE inhibitor with an ARB in people with
uncomplicated hypertension, ischemic heart disease in the
absence of heart failure, past stroke, non-proteinuric chronic
kidney disease or diabetes without albuminuria.

Should I prescribe an ARB in people who have had a
stroke?
The PRoFESS study was a large randomized 2x2 factorial
trial of an ARB based blood pressure lowering therapy and
antiplatelet therapy to prevent recurrent strokes.23 Over
twenty thousand patients aged 50 or older with a prior
ischemic stroke were randomized to telmisartan vs. placebo
regardless of their pre-treatment blood pressure. No statisti-
cally significant interaction effect between antiplatelet
and telmisartan arms was observed. In the latter arm, the
blood pressure was 3.8/2.0 mm Hg lower than placebo,
with a mean follow-up of 2.5 years. The ARB therapy did
not reduce the primary endpoint of recurrent stroke (HR:
0.95 (0.86-1.04, p=0.23)) nor the secondary outcome of
major cardiovascular events (stroke, MI, vascular death,
worsening CHF), (HR: 0.94 (0.87-1.01, p=0.11)). Exploratory
analyses suggested that a difference in outcome in favour
of telmisartan began to emerge after the first 6 months
of therapy. Although the absolute risk increase was small

7

(~3%), adverse events, principally hypotensive symptoms,
syncope and atrial fibrillation were more common in the
telmisartan group compared to placebo. It is possible
that the modest reduction in blood pressure in a PRoFESS
study population and the relatively low entry blood pres-
sure (144/84 mm Hg) may be the reason for the negative
results. CHEP recommendations currently support a target
blood pressure of <140/90 mm Hg in post-stroke patients;
hence, many of the PRoFESS trial patients would have been
within CHEP targets at the start of the trial. Taken within
the context of a previous large randomized controlled trial
(PROGRESS with a combination of a diuretic (indapamide)
and ACE inhibitor (perindopril)) and meta analyses of blood
pressure lowering trials showing a reduction in recurrent
stroke24, 25, the PRoFESS trial has not impacted the CHEP
recommendations. The PROGRESS trial entered people
with an average blood pressure of 147/86 mm Hg. In the
PROGRESS trial people who received ACE inhibitor therapy
only, the reduction in stroke was not significant (post hoc
analysis) but a large reduction in stroke was seen in the
trial overall and in particular in those who received the ACE
inhibitor with the diuretic indapamide. CHEP recommends
that strong consideration should be given to the initiation
of antihypertensive therapy and preferably an ACE inhibitor
plus diuretic combination after the acute phase of a stroke
or transient ischemic attack.

In people who are intolerant to an ACE inhibitor and
who have cardiovascular disease or diabetes, should
I prescribe an ARB?
The TRANSCEND study randomized 5,926 people with
coronary disease, prior stroke or diabetes mellitus with end-
organ damage and who were intolerant of ACE inhibitors
to telmisartan or placebo with an average blood pressure
at baseline of 141/69 mm Hg.26 The mean blood pressure
difference was 3.2/1.3 mm Hg lower at study end in the telm-
isartan group. Over a median follow-up of just over 2.5 years,
the telmisartan therapy did not reduce the primary outcome
(composite of cardiovascular death, myocardial infarction,
stroke or hospitalization for heart failure (HR: 0.92 (0.81-1.05,
p=0.216)). The study does not exclude a small therapeutic
benefit and a secondary endpoint of cardiovascular death,
myocardial infarction or stroke was close to conventional
significance level (HR: 0.87 (0.76-1.00, p=0.068)). Syncopal
spells were more common in the telmisartan group but
the absolute risk difference was small (0.44%) and overall
adverse events were not different between the two groups.

8

The TRANSCEND trial has not changed the CHEP recom-
mendation to prescribe an ACE inhibitor for most people
with hypertension and documented coronary artery disease
based on the HOPE, EUROPA and PEACE studies.27-29

Should I start people with diabetes and hypertension
on a combination of two antihypertensive drugs?
The ADVANCE trial was a randomized controlled trial that
included 11,140 people with type 2 diabetes and at least
another cardiovascular risk factor.6 The ADVANCE trial used
a factorial design to assess both the effects of an intensive
glucose lowering regimen and antihypertensive treatment.
In the hypertension aspect of the trial people were random-
ized to a fixed combination tablet consisting of perindopril
(an ACE inhibitor) and indapamide (a diuretic) or placebo.
The treatment reduced both cardiovascular death (HR: 0.82;
95% CI: 0.68 – 0.98) and total mortality (HR: 0.86; 95% CI:
0.75 – 0.98). In 2008, it was established that there was no in-
teraction between the glucose lowering and blood pressure
lowering therapies; hence, CHEP recommends consideration
of initial therapy with a combination of first-line drugs in
people with diabetes if blood pressure is 150/90 mm Hg or
higher.5, 6 Caution is required in people where a substantial
fall in blood pressure is more likely or would be poorly
tolerated (e.g. those with postural hypotension).

How do I optimally reduce cardiovascular risk in my
patients?
Although it remains important to stay up to date with new
evidence and recommendations, much of what is important
to improve patient outcomes remains unchanged.

Because most Canadians will develop hypertension during
their lives, routine assessment of blood pressure is recom-
mended in all people at all appropriate visits. Most people
with high normal blood pressure (130-139 mm Hg systolic or
85-89 mm Hg diastolic) will develop hypertension in the next
2-4 years and require annual assessment of blood pressure.
To encourage self-efficacy, people with hypertension are
recommended to measure their blood pressure at home.

Nine in ten Canadians with hypertension will have other risks
for cardiovascular disease. Hence, optimum management of
hypertension requires assessment of overall cardiovascular
risk. This includes identifying and managing these other
risks (e.g. smoking, dyslipidemia, dysglycemia (e.g. impaired
fasting glucose, diabetes)), abdominal obesity, unhealthy
diet, physical inactivity. A comprehensive approach to

9

cardiovascular risk reduction can more than double car-
diovascular risk reduction compared to blood pressure
management alone.

To optimally reduce cardiovascular risk, blood pressure
should be lowered to less than 140/90 mm Hg in most people
and in those with diabetes or chronic kidney disease, to less
than 130/80 mm Hg. Although it is usually more difficult to
lower systolic than diastolic blood pressure, the risk reduc-
tion from lowering the systolic blood pressure is as large if
not larger than the diastolic blood pressure. Combinations
of both lifestyle and drug therapies are generally necessary
to achieve target blood pressures. Most people require more
than one antihypertensive drug and many with diabetes or
chronic kidney disease may require three or more drugs.
People whose blood pressure is above target should be
monitored at least every 2 months and the intensity of
treatment increased until the targets are achieved.

Lack of adherence to therapy is an important cause of
poor blood pressure control and poor outcomes. Patient
adherence to therapy should be assessed at each visit and
interventions to improve adherence should be a part of
clinical routine.

What lifestyle changes are effective in preventing
hypertension, in treating people with hypertension
and in reducing blood pressure?
High blood pressure as well as other cardiovascular risk fac-
tors can be prevented or reduced through simple sustained
lifestyle changes. Lifestyle interventions can bring about a
similar reduction in blood pressure to single antihypertensive
drugs. A healthy diet, regular physical activity, moderation
in alcohol consumption, reductions in dietary sodium, and a
smoke-free environment are the cornerstone of prevention
and management of hypertension. In selected people, stress
reduction, including behaviour modification, is helpful.

A recent meta analysis found decreasing dietary sodium intake
by 1,860 mg/day reduced blood pressure 5.1/2.7 mm Hg.30 In
Canada it has been estimated that a 1,860 mg/day decrease
in dietary sodium would cause a substantive reduction in
prevalence of hypertension, health costs and cardiovascular
complications.31,32 In the DASH trial, a diet rich in fruits, veg-
etables and low-fat dairy products with reduced saturated and
total fat decreased blood pressure by 5.5/3.0 mm Hg overall
and by 11.4/5.5 mm Hg in those with hypertension.33 A meta

10

analysis on the effects of regular aerobic exercise showed
physical activity reduced blood pressure by 3.8/2.6 mm Hg
in people who were previously inactive.34 The TOHP study
found a decrease in weight of 4.4 kg led to a blood pressure
reduction of 4.0/2.8 mm Hg.35

Brief clinical interventions increase the probability of a
patient adhering to lifestyle changes even for addictive
behaviours such as smoking and problem alcohol consump-
tion36,37 and more comprehensive interdisciplinary care
approaches are more effective.33,38-41 Because few Canadians
change their lifestyle after a diagnosis of hypertension
it is important that health professionals assist people in
implementing lifestyle interventions.4 For this reason, Blood
Pressure Canada, the Heart and Stroke Foundation and CHEP
have developed a variety of patient resources including
paper copies, videos and web-based interactive monitor-
ing systems to assist people making lifestyle changes.4
These resources can be found at www.hypertension.ca and
www.heartandstroke.ca/bp.

Comments from the CHEP Executive
CHEP believes that, reliable up-to-date, evidence-based
recommendations that are broadly disseminated in easy-
to-use formats are important to the care of Canadians with
hypertension. The CHEP program has taken a number of
steps to reduce personal and commercial bias (Table 4).
CHEP also supports regular evaluation of the impact of its
program to identify ongoing clinical issues where care needs
to improve. Further, CHEP monitors ongoing changes in the
health care system that will change the way hypertension
will be managed in the future and is actively developing
new partnerships, educational resources and dissemina-
tion strategies. Important to the prevention and control of
hypertension is active involvement of people in their care.
CHEP partners with Blood Pressure Canada, the Heart and
Stroke Foundation of Canada, the Public Health Agency of
Canada and other organizations to develop resources to assist
people to become more informed about hypertension and
more engaged in their care (Table 5). Recently the increase
in treatment of hypertension has been found to be strongly
associated with reductions in death and hospitalization of
major cardiovascular events in Canada.42

In 2010, the results of a national survey on hypertension
prevalence, treatment and control will be released by
Statistics Canada. The survey results will allow CHEP to more
carefully assess the hypertension care gaps that remain.

11

Further, in 2010, the results of another survey that assesses
patient knowledge, attitudes and barriers to care will be
released, enabling much more focused patient education
programs to be developed. The development of a com-
prehensive hypertension evaluation program in Canada
with ongoing assessment of care gaps and subsequent
development of tailored intervention programs is expected
to result in further reductions in cardiovascular disease.

TABlE 1:
Considerations in the Individualization of Antihypertensive Therapy†*
ACE: angiotensin converting enzyme; TIA: transient ischemic attack; ARB: angiotensin receptor blocker

Initial Therapy Second-line Therapy Notes and/or Cautions
HYPERTENSION WITHOUT OTHER COMPELLING INDICATIONS - TARGET < 140/90 mm Hg
Diastolic +/- systolic hypertension Thiazide diuretics, beta-blockers, ACE inhibitors, Combinations of first-line drugs Beta-blockers are not recommended as initial therapy in those over 60 years
ARBs or long-acting calcium channel blockers of age. Hypokalemia should be avoided by using potassium-sparing agents in
(consider ASA and statins in selected patients). those who are prescribed diuretics as monotherapy. ACE inhibitors are not recom-
Consider initiating therapy with a combination mended as monotherapy in blacks.
12

of two first-line drugs if the blood pressure ACE inhibitors, ARBs and direct renin inhibitors are potential teratogens and cau-
is ≥20 mm Hg systolic or ≥10 mm Hg diastolic tion is required if prescribing to women of child bearing potential. Combinations
above target. of an ACE inhibitor with an ARB is specifically not recommended.
Isolated systolic hypertension without Thiazide diuretics, ARBs or long-acting Combinations of first-line drugs Same as diastolic +/- systolic hypertension
other compelling indications dihydropyridine calcium channel blockers
DIABETES MELLITUS - TARGET < 130/80 mm Hg
Diabetes mellitus with nephropathy ACE inhibitors or ARBs Addition of thiazide diuretics, cardioselective beta- If the serum creatinine level is >150 μmol/L, a loop diuretic should be used as
blockers, long-acting calcium channel blockers a replacement for low-dose thiazide diuretics if volume control
is required

Diabetes mellitus without nephropathy ACE inhibitors, ARBs, dihydropyridine calcium Combination of first-line drugs, or if first-line Normal albumin to creatinine ratio [ACR] < 2.0 mg/mmol in men and
channel blockers or thiazide diuretics agents are not tolerated, addition of < 2.8 mg/mmol in women.
cardioselective beta-blockers and/or long-acting Combinations of an ACE inhibitor with an ARB is specifically not recommended.
nondihydropyridine calcium channel blockers
CARDIOVASCULAR AND CEREBROVASCULAR DISEASE - TARGET < 140/90 mm Hg
Angina Beta-blockers; ACE inhibitors except in low risk Long-acting calcium channel blockers Avoid short-acting nifedipine. Combinations of an ACE inhibitor with an ARB is
patients specifically not recommended.
Prior myocardial infarction Beta-blockers and ACE inhibitors Long-acting calcium channel blockers Combinations of an ACE inhibitor with an ARB is specifically not recommended
(ARBs if ACEI-intolerant)
13

Heart failure ACE inhibitors (ARBs if ACEI-intolerant) and ARBs or hydralazine/isosorbide dinitrate Titrate doses of ACE inhibitor and ARB to those used in clinical trials. Avoid
beta-blockers. Spironolactone in patients (thiazide or loop diuretics, as additive therapy) nondihydropyridine calcium channel blockers (diltiazem, verapamil).
with NYHA Class III or IV symptoms. Monitor potassium and renal function if combining an ACE inhibitor
with an ARB
Left ventricular hypertrophy Does not affect initial treatment recommendations Combinations of additional agents Hydralazine and minoxidil can increase left ventricular hypertrophy

Past cerebrovascular accident or TIA ACE inhibitor/diuretic combinations Combinations of additional agents This does not apply to acute stroke. Blood pressure reduction reduces recurrent
cerebrovascular events in stable patients. Combinations of an ACE inhibitor with
ARB is specifically not recommended.

NON-DIABETIC CHRONIC KIDNEY DISEASE - TARGET < 130/80 mm Hg
Non-diabetic chronic kidney disease ACE inhibitors (ARBs if ACEI-intolerant), Combinations of additional agents Avoid ACE inhibitors or ARBs if bilateral renal artery stenosis or unilateral
with proteinuria diuretics as additive therapy disease with solitary kidney. Patients placed on an ACE inhibitor or an ARB
should have their serum creatinine and potassium carefully monitored.
Combinations of an ACE inhibitor and ARB is specifically not recommended in
patients with chronic kidney disease without proteinuria.
Renovascular disease Does not affect initial treatment recommendations Combinations of additional agents Avoid ACE inhibitors or ARBs if bilateral renal artery stenosis or unilateral
disease with solitary kidney
OTHER CONDITIONS - TARGET < 140/90 mm Hg
14

Peripheral arterial disease Does not affect initial treatment recommendations Combinations of additional agents Avoid beta-blockers in patients with severe disease
Dyslipidemia Does not affect initial treatment recommendations Combinations of additional agents
Overall vascular protection Statin therapy for patients with three or more Caution should be exercised with the ASA recommendation if blood
cardiovascular risk factors or with atherosclerotic pressure is not controlled
disease. Low-dose ASA in patients with controlled
blood pressure.

† It is recommended that normotensive adults with established cardiovascular disease be treated with an ACE inhibitor. Normotensive adults who have had a stroke or TIA should be treated with an ACE inhibitor and a diuretic.
*With permission of the Canadian Hypertension Education Program

15

TABlE 2:
Target Values for Blood Pressure*

Setting Target
(SBP/DBP mm Hg)
Home:
Home blood pressure <135/85
and daytime ABPM†‡
Office:
Diastolic ± systolic hypertension <140/90
Isolated systolic hypertension <140
Diabetes <130/80
Chronic kidney disease <130/80
† The target value readings taken by home measurement and ABPM in those with diabetes or chronic
kidney disease have not been established.
‡ ABPM – Ambulatory blood pressure monitoring

TABlE 3:
lifestyle Therapy to Reduce the Possibility of
Becoming Hypertensive, to Reduce Blood Pressure
and to Reduce the Risk of Blood Pressure-related
Cardiovascular Complications in Hypertensive
Patients**
1. Healthy diet: high in fresh fruits and vegetables, low-fat
dairy products, dietary and soluble fibre, whole grains
and protein from plant sources, low in saturated fat,
cholesterol and salt, in accordance with Canada’s Guide
to Healthy Eating
2. Regular physical activity: accumulation of 30-60 minutes
of moderate intensity dynamic exercise 4-7 days per
week in addition to daily activities
3. Low-risk alcohol consumption (≤2 standard drinks/day
and less than 14/week for men and less than 9/week for
women)
4. Attaining and maintaining ideal body weight (BMI
18.5-24.9 kg/m2)
5. A waist circumference:
Europid < 94 cm for men
< 80 cm for women
South Asian, Japanese, Chinese < 90 cm for men
< 80 cm for women
6. Reduction in sodium intake to less than 2, 300 mg/day
7. A smoke-free environment


16

TABlE 4:
CHEP Reduces the Impact of Bias
by the Following Methods*

1 A history of requiring a high level of evidence with patient rel-
evant outcomes for pharmacotherapy recommendations
2 A centralized systematic literature review by a Cochrane
Group librarian
3 Multiple clinical experts in subgroups to represent different
perspectives
4 A Central Review Committee (CRC) that is “free of com-
mercial conflicts of interest” to oversee the evaluation
of evidence, the development of recommendations and
to present the evidence/recommendations
5 A consensus conference chaired by the CRC and with the
evidence primarily presented by the CRC
6 Overt written disclosure of potential conflicts of interest
at the time of the consensus conference when the recom-
mendations are discussed
7 Voting on recommendations with the removal of
recommendations voted against by 30% or more
of members
8 Annual hypertension management themes, key messages
and major implementation tools are developed through a
consensus of the full CHEP Executive. Other internal imple-
mentation tools require the consensus of two members of
the Executive.

* With permission of the Canadian Hypertension Education Program

17

TABlE 5:
Internet Resources for Patient Information†*

Resource Description Source
2008 Patient General www.hypertension.ca/bpc
Hypertension information on
Recommendations prevention and
treatment of
hypertension
2009 Patient Specific www.hypertension.ca/bpc
Hypertension information on
Recommendations the management
of hypertension
in the diabetic
patient
Diabetes & Information on www.diabetes.ca
Hypertension hypertension
for people with
diabetes
On-line, Create a www.heartandstroke.ca/bp
personalized blood personalized
pressure plan action plan for
healthy living
DASH diet The DASH diet and www.nhlbi.nih.gov/hbp/
healthy eating to prevent/h_eating/h_eating.
improve blood html
pressure control
Canada’s Food Canada’s official www.hc-sc.gc.ca/fn-an/
Guide guide to healthy food-guide-aliment/
eating and index_e.html
lifestyle choices.
Personalize your
own food guide!
Dietitians of Tips for eating well www.dietitians.ca
Canada and living well
On-line health and Learn about your www.healthtoolsonline.
fitness calculators risk factors using com/health-fit.html
different tools
to calculate your
personal factors
† Many of the resources can be downloaded and printed or hard copies ordered for patients who
do not use the internet.

* With permission of Blood Pressure Canada

18

Reference list
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events. N Engl J Med 2008;358:1547-1559.
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routine screening for target organ damage? J Hypertens 2002;20:1255-1257.
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The Cochrane Database of Systematic Reviews 2004;1-64.
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of randomized, controlled trials. Ann Intern Med 2002;136:493-503.
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reductions in cardiovascular events in Canada. Hypertension 2008;In Press.

PART 1

DiAgNosis & AssEssmENT

22

I ACCURATE MEASUREMENT OF BlOOD PRESSURE
1) The blood pressure (BP) of all adult patients
should be assessed at all appropriate visits for de-
termination of cardiovascular risk and monitoring of
antihypertensive treatment by health care profession-
als who have been specifically trained to measure BP
accurately (Grade D).

2) Use of standardized measurement techniques
(Table 1) is recommended when assessing blood
pressure (Grade D).

II CRITERIA FOR DIAGNOSIS OF HYPERTENSION AND
RECOMMENDATIONS FOR FOllOW-UP (Figure 1)
1) At visit 1, patients demonstrating features of a
hypertensive urgency or emergency ( Table 2)
should be diagnosed as hypertensive and require im-
mediate management (Grade D).

2) If systolic BP (SBP) is 140 mm Hg or greater and/or
diastolic BP (DBP) is 90 mm Hg or greater a specific visit
should be scheduled for the assessment of hypertension
(Grade D). If BP is high-normal (SBP 130-139 mm Hg and/
or DBP 85-89 mm Hg) annual follow-up is recommended
(Grade C).

3) At the initial visit for the assessment of hypertension, if
systolic BP (SBP) is 140 mm Hg or greater and/or diastolic
BP (DBP) is 90 mm Hg or greater, at least two more read-
ings should be taken during the same visit using a vali-
dated device and according to the recommended pro-
cedure for accurate BP determination (Table 1). The first
reading should be discarded and the latter two averaged.
A history and physical examination should be per-
formed and, if clinically indicated, diagnostic tests to
search for target organ damage (Table 3) and associated
cardiovascular risk factors (Table 4) should be arranged
within two visits. Exogenous factors that can induce
or aggravate hypertension should be assessed and
removed if possible (Table 5). Schedule visit 2 within
one month (Grade D).

Bold typeface in the body text indicates a new or revised recommendation

23

4) At visit 2 for the assessment of hypertension, patients with
macrovascular target organ damage, diabetes mellitus,
or chronic kidney disease (CKD; GFR <60 mL/min/1.73m2)
can be diagnosed as hypertensive if SBP is 140 mm Hg or
greater and/or DBP is 90 mm Hg or greater (Grade D).

5) At visit 2 for the assessment of hypertension, patients
without macrovascular target organ damage, diabetes
mellitus, and/or chronic kidney disease can be diag-
nosed as hypertensive if SBP is 180 mm Hg or greater
and/or DBP is 110 mm Hg or greater (Grade D). Patients
without macrovascular target organ damage, diabetes
mellitus, or CKD but with lower blood pressure levels
should undergo further evaluation using any of the
three approaches outlined below:

i) Office BPs:
Using office BP measurements, patients can be
diagnosed as hypertensive if the SBP is 160 mm Hg
or higher or the DBP is 100 mm Hg or higher
averaged across the first 3 visits, OR if the SBP
averages 140 mm Hg or higher or the DBP aver-
ages 90 mm Hg or higher averaged across 5 visits
(Grade D).

ii) Ambulatory BP Monitoring (ABPM):
Using ABPM (see Section VIII), patients can be
diagnosed as hypertensive if the mean awake SBP
is 135 mm Hg or higher or the DBP is 85 mm Hg or
higher, OR if the mean 24 hour SBP is 130 mm Hg or
higher or the DBP is 80 mm Hg or higher (Grade C).

iii) Home BP Measurement:
Using home BP measurements (see Section VII), pa-
tients can be diagnosed as hypertensive if the average
SBP is 135 mm Hg or higher or the DBP is 85 mm Hg
or higher (Grade C). If the average home BP is lower
than 135/85 mm Hg, it is advisable to perform 24 h
ABPM to confirm the mean 24 h ABPM is lower than
130/80 mm Hg and the mean awake ABPM is lower
than 135/85 mm Hg before diagnosing white coat
hypertension (Grade D).

6) Investigations for secondary causes of hypertension
should be initiated in patients with suggestive clinical
and/or laboratory features (outlined below) (Grade D).

24

7) If at the last diagnostic visit the patient is not diagnosed
to be hypertensive and has no evidence of macrovascular
target organ damage, the patient’s BP should be assessed
at yearly intervals (Grade D).

8) Hypertensive patients receiving lifestyle modification
advice alone (non-pharmacological treatment) should
be followed up at three-to-six month intervals. Shorter
intervals (one or two monthly) are needed for patients
with higher BPs (Grade D).

9) Patients on antihypertensive drug treatment should be
seen monthly or every two months, depending on BP,
until readings on two consecutive visits are below their
target (Grade D). Shorter intervals between visits will be
needed for symptomatic patients and those with severe
hypertension, intolerance to antihypertensive drugs or
those with target organ damage (Grade D). Once the
target BP has been reached, patients should be seen at
three-to-six month intervals (Grade D).

III ASSESSMENT OF OVERAll CARDIOVASCUlAR RISK IN
HYPERTENSIVE PATIENTS
1) Global cardiovascular risk should be assessed. Multifactorial
risk assessment models can be used to predict more
accurately an individual’s global cardiovascular risk
(Grade A) and to use antihypertensive therapy more
efficiently (Grade D). In the absence of Canadian data to
determine the accuracy of risk calculations, avoid using
absolute levels of risk to support treatment decisions
(Grade C).

2) Consider informing patients of their global risk to improve
the effectiveness of risk factor modification (Grade C).

IV ROUTINE AND OPTIONAl lABORATORY TESTS
FOR THE INVESTIGATION OF
PATIENTS WITH HYPERTENSION
1) Routine laboratory tests should be performed for
the investigation of all patients with hypertension,
including:

i) urinalysis (Grade D)

ii) blood chemistry (potassium, sodium, and creatinine)
(Grade D)

25

iii) fasting blood glucose (Grade D)

iv) fasting total cholesterol and high density lipoprotein
cholesterol, low density lipoprotein cholesterol and
triglycerides (Grade D)

v) standard 12-lead electrocardiography (Grade C)

2) Assess urinary albumin excretion in patients with
diabetes (Grade D).

3) i) All treated hypertensive patients should be moni-
tored according to the current Canadian Diabetes
Association guidelines for a new appearance of
diabetes (Grade B)

ii) During the maintenance phase of hypertension
management, tests (including those for electrolytes,
creatinine, glucose and fasting lipids) should be
repeated with a frequency reflecting the clinical
situation (Grade D).

V ASSESSMENT FOR RENOVASCUlAR
HYPERTENSION
1) Patients presenting with two or more of the clinical
clues listed below, suggesting renovascular hyperten-
sion, should be investigated (Grade D):

i) sudden onset or worsening of hypertension and age
older than 55 years or younger than 30 years

ii) the presence of an abdominal bruit

iii) hypertension resistant to three or more drugs

iv) a rise in serum creatinine level of 30% or more as-
sociated with use of an ACE inhibitor or ARB

v) other atherosclerotic vascular disease, particularly in
patients who smoke or have dyslipidemia

vi) recurrent pulmonary edema associated with hyper-
tensive surges

2) When available, the following tests are recommended
to aid in the usual screening for renal vascular disease:
captopril-enhanced radioisotope renal scan, Doppler
sonography, magnetic resonance angiography,
computed tomographic angiography (for those with

26

normal renal function) (Grade B). Captopril-enhanced
radioisotope renal scan is not recommended for those
with CKD (GFR < 60 mL/min/1.73 m2) (Grade D).

VI ENDOCRINE HYPERTENSION
A) Hyperaldosteronism: Screening and Diagnosis
1) Screening for hyperaldosteronism should be considered
for the following patients (Grade D):

i) hypertensive patients with spontaneous hypo-
kalemia (potassium level lower than 3.5 mmol/L)

ii) hypertensive patients with marked diuretic-
induced hypokalemia (potassium level lower than
3.0 mmol/L)

iii) patients with hypertension refractory to treatment
with three or more drugs

iv) hypertensive patients found to have an incidental
adrenal adenoma

2) Screening for hyperaldosteronism should include
assessment of plasma aldosterone and plasma renin
activity (Table 6).

3) For patients with suspected hyperaldosteronism (on
the basis of the screening test, Table 6 [Section iii]), a
diagnosis of primary aldosteronism should be estab-
lished by demonstrating inappropriate autonomous
hypersecretion of aldosterone using at least one of
the maneuvers listed in Table 6 [Section iv]. When the
diagnosis is established, the abnormality should be
localized using any of the tests described in Table 6
[Section v].

B) Pheochromocytoma Screening and Diagnosis
1) If pheochromocytoma is strongly suspected, the patient
should be referred to a specialized hypertension center,
particularly if biochemistry screening tests (Table 7)
have already been found to be positive (Grade D).

2) The following patients should be considered for screen-
ing for pheochromocytoma (Grade D):
i) patients with parox ysmal and/or severe
(BP ≥180/110 mm Hg) sustained hypertension
refractory to usual antihypertensive therapy

27

ii) patients with hypertension and multiple symptoms
suggestive of catecholamine excess (e.g., headaches,
palpitations, sweating, panic attacks and pallor)

iii) patients with hypertension triggered by beta-blockers,
monoamine oxidase inhibitors, micturition or changes
in abdominal pressure

iv) patients with incidentally discovered adrenal mass,
patients with hypertension and multiple endocrine
neoplasia (MEN) 2A or 2B, von Recklinghausen
disease (neurofibromatosis) or von Hippel-Lindau
disease

3) For patients with positive biochemical screening tests,
localization of pheochromocytomas should employ
magnetic resonance imaging (preferable), computed
tomography (if magnetic resonance imaging is unavail-
able), and/or iodine I-131 meta-iodobenzylguanidine
(MIBG) scintigraphy (Grade C for each modality).

VII HOME MEASUREMENT OF BlOOD
PRESSURE
1) Home BP readings can be used in the diagnosis of
hypertension (Grade C).

2) The use of home BP monitoring on a regular basis should
be considered for patients with hypertension, particularly
those with:
i) diabetes mellitus (Grade D)

ii) chronic kidney disease (Grade C)

iii) suspected non-adherence (Grade D)

iv) demonstrated white coat effect (Grade C)

v) BP controlled in the office but not at home (masked
hypertension) (Grade C)

3) When white coat hypertension is suggested by home
monitoring, its presence should be confirmed with ABPM
before making treatment decisions (Grade D).

4) Patients should be advised to purchase and use only home
BP monitoring devices that are appropriate for the indi-
vidual and have met the standards of the Association for
the Advancement of Medical Instrumentation, the most

28

recent requirements of the British Hypertension Society
protocol or the International Protocol for validation
of automated BP measuring devices. Patients should
be encouraged to use devices with data recording
capabilities or automatic data transmission to increase
the reliability of reported home BP values (Grade D).
5) Home SBP values of 135 mm Hg or higher or DBP
values of 85 mm Hg or higher should be considered to
be elevated and associated with an increased overall
mortality risk analogous to office SBP readings of
140 mm Hg or higher or DBP readings of 90 mm Hg or
higher (Grade C).
6) Health care professionals should ensure that patients
who measure their BP at home have adequate train-
ing and, if necessary, repeat training in measuring
their BP. Patients should be observed to determine
that they measure BP correctly and should be given
adequate information about interpreting these read-
ings (Grade D).
7) The accuracy of all individual patients’ validated devices
(including electronic devices) must be regularly checked
against a device of known calibration (Grade D).
8) Home BP values for assessing white coat hypertension
or sustained hypertension should be based on duplicate
measures, morning and evening, for an initial seven-
day period. First-day home BP values should not be
considered (Grade D).

VIII AMBUlATORY BlOOD PRESSURE
MEASUREMENT
1) Ambulatory BP readings can be used in the diagnosis
of hypertension (Grade C).
2) ABPM should be considered when an office-induced
increase in BP is suspected in treated patients with:
i) BP that is not below target despite receiving appropri-
ate chronic antihypertensive therapy (Grade C)
ii) symptoms suggestive of hypotension (Grade C)
iii) fluctuating office BP readings (Grade D)
3) Physicians should use only ABPM devices that have
been validated independently using established
protocols (Grade D).

4) Therapy adjustment should be considered in patients with

29

24 h ambulatory SBP of 130 mm Hg or higher and/or DBP
of 80 mm Hg or higher and/or awake SBP of 135 mm Hg
or higher and/or DBP of 85 mm Hg or higher (Grade D).

5) The magnitude of changes in nocturnal BP should be
taken into account in any decision to prescribe or with-
hold drug therapy based upon ambulatory BP (Grade C)
because a decrease in nocturnal BP of less than 10% is
associated with increased risk of cardiovascular events.

IX ROlE OF ECHOCARDIOGRAPHY
1) Routine echocardiographic evaluation of all hyperten-
sive patients is not recommended (Grade D).

2) An echocardiogram for assessment of left ventricular
hypertrophy is useful in selected cases to help define
the future risk of cardiovascular events (Grade C).

3) Echocardiographic assessment of left ventricular mass,
as well as systolic and diastolic left ventricular function,
is recommended for hypertensive patients suspected
to have left ventricular dysfunction or coronary artery
disease (Grade D).

4) Patients with hypertension and evidence of heart
failure should have an objective assessment of
left ventricular ejection fraction, either by echo-
cardiogram or nuclear imaging (Grade D).

DIAGNOSIS & ASSESSMENT TABlES

TABlE 1:
Recommended Technique for Measuring Blood
Pressure†*

i) Measurements should be taken with a sphyg-
momanometer known to be accurate. A recently
calibrated aneroid or a validated and recently
calibrated electronic device can be used (see text below
for further discussion). Aneroid devices or mercury
columns need to be clearly visible at eye level.

† These are instructions for blood pressure measurement when using a sphygmomanom-
eter and stethoscope; many steps may not apply when using automated devices.

30

ii) Choose a cuff with an appropriate bladder size matched
to the size of the arm. For measurements taken by aus-
cultation, bladder width should be close to 40% of arm
circumference and bladder length should cover 80–100%
of arm circumference. When using an automated device,
select the cuff size recommended by its manufacturer.

iii) Place the cuff so that the lower edge is 3 cm above the
elbow crease and the bladder is centered over the bra-
chial artery. The patient should be resting comfortably for
5 minutes in the seated position with back support. The
arm should be bare and supported with the antecubital
fossa at heart level, as a lower position will result in an
erroneously higher SBP and DBP. There should be no
talking, and the patients’ legs should not be crossed. At
least three measurements should be taken in the same
arm with the patient in the same position. The first reading
should be discarded and the latter two averaged. Blood
pressure also should be assessed after 2 minutes standing
(with arm supported) and at times when patients report
symptoms suggestive of postural hypotension. Supine
BP measurements may also be helpful in the assessment
of elderly and diabetic patients.

iv) Increase the pressure rapidly to 30 mm Hg above the level
at which the radial pulse is extinguished (to exclude the
possibility of a systolic auscultatory gap).

v) Place the bell or diaphragm of the stethoscope gently
and steadily over the brachial artery.

vi) Open the control valve so that the rate of deflation of
the cuff is approximately 2 mm Hg per heart beat. A
cuff deflation rate of 2 mm Hg per beat is necessary for
accurate systolic and diastolic estimation.

vii) Read the systolic level — the first appearance of a clear
tapping sound (phase I Korotkoff ) — and the diastolic
level (the point at which the sounds disappear (phase V
Korotkoff )). Continue to auscultate at least 10 mm Hg
below phase V to exclude a diastolic auscultatory gap.
Record the blood pressure to the closest 2 mm Hg on
the manometer (or 1 mm Hg on electronic devices)
as well as the arm used and whether the patient was
supine, sitting or standing. Avoid digit preference by
not rounding up or down. Record the heart rate. The
seated blood pressure is used to determine and monitor
treatment decisions. The standing blood pressure is used

31

to examine for postural hypotension, if present, which
may modify the treatment.

viii) If Korotkoff sounds persist as the level approaches
0 mm Hg, then the point of muffling of the sound is used
(phase IV) to indicate the diastolic pressure.

ix) In the case of arrhythmia, additional readings may be
required to estimate the average systolic and diastolic
pressure. Isolated extra beats should be ignored. Note
the rhythm and pulse rate.

x) Leaving the cuff partially inflated for too long will fill the
venous system and make the sounds difficult to hear. To
avoid venous congestion, it is recommended that at least
one minute should elapse between readings.

xi) Blood pressure should be taken in both arms on at
least one visit and if one arm has a consistently higher
pressure, that arm should be subsequently used for
blood pressure measurement and interpretation.

TABlE 2:
Examples of Hypertensive Urgencies and
Emergencies*
Asymptomatic diastolic BP ≥ 130 mm Hg
Hypertensive encephalopathy
Acute aortic dissection
Acute left ventricular failure
Acute myocardial ischemia

TABlE 3:
Examples of Target Organ Damage*
Cerebrovascular Disease
Stroke
Ischemic stroke and transient ischemic attack
Intracerebral hemorrhage
Aneurysmal sub-arachnoid hemorrhage
Dementia
Vascular dementia
Mixed Vascular Dementia and Dementia of the Alzheimer’s
Type


32

Hypertensive Retinopathy
Left Ventricular Dysfunction
Coronary Artery Disease
Myocardial infarction
Angina pectoris
Congestive heart failure
Chronic Kidney Disease
Hypertensive nephropathy (GFR < 60 mL/min/1.73 m2)
Albuminuria
Peripheral Artery Disease
Intermittent claudication

TABlE 4:
Examples of Key Cardiovascular Risk Factors for
Atherosclerosis*
A history of clinically overt atherosclerotic disease
indicates a very high risk for a recurrent atherosclerotic event
(e.g., peripheral arterial disease, previous stroke or TIA)
Non-Modifiable
Age ≥ 55 years
Male sex
Family history of premature cardiovascular disease
(age < 55 years in men and < 65 years in women)
Modifiable
Sedentary lifestyle
Poor dietary habits
Abdominal obesity
Impaired glucose tolerance or diabetes mellitus
Smoking
Dyslipidemia
Stress
Target Organ Damage
Left ventricular hypertrophy
Microalbuminuria or proteinuria
Chronic kidney disease (glomerular filtration rate
< 60 mL/min/1.73 m2)


33

TABlE 5:
E x a m p l e s o f E xo g e n o u s Fa c t o r s t h a t c a n
Induce/Aggravate Hypertension*
Prescription Drugs
NSAIDs, including coxibs
Corticosteroids and anabolic steroids
Oral contraceptives and sex hormones
Vasoconstricting or sympathomimetic decongestants
Calcineurin inhibitors (cyclosporin, tacrolimus)
Erythropoietin and analogues
Monoamine oxidase inhibitors (MAOIs)
Midodrine
Other Substances and Conditions
Licorice root
Stimulants, including cocaine
Salt
Excessive alcohol use
Sleep apnea

TABlE 6:
Hyperaldosteronism: Screening and Diagnosis**
i) Plasma aldosterone and plasma renin activity (see
Section ii below for conversion factors) should be
measured under standardized conditions, including
the collection of morning samples taken from patients
in a sitting position after resting at least 15 minutes.
Antihypertensive drugs may be continued, with the
exception of aldosterone antagonists, angiotensin recep-
tor blockers, beta-blockers and clonidine.

ii) Renin, Aldosterone and Ratio Conversion Factors:

A. To estimate: B. From: Multiply (B) by:
Plasma renin Plasma renin activity 0.206
concentration (ng/mL/hr)
(ng/mL)
Plasma renin Plasma renin activity 0.278
activity (ng/mL/hr)
(g/L/s)
Plasma Plasma aldosterone 28
aldosterone concentration
concentration (ng/dL)
(pmol/L)


34

iii) Definition of a positive screening test: plasma aldosterone/
renin activity ratio greater than 550 pmol/L/ng/mL/hr (or
140 pmol/L/ng/L when renin is measured as renin mass or
concentration).

iv) Maneuvers to demonstrate autonomous hypersecretion
of aldosterone:

a) saline loading tests (2L of normal saline over 4 h with
primary aldosteronism defined as failure to suppress
plasma aldosterone to less than 280 pmol/L; or oral
sodium 300 mmol/day for three days with primary
aldosteronism defined as failure to suppress plasma
aldosterone to less than 240 pmol/L)

b) fludrocortisone suppression test (oral sodium loading
plus oral fludrocortisone 0.25 mg per day for 2 days)
positive for primary aldosteronism: plasma aldosterone
of 140 pmol/L or greater in upright and/or supine
positions

c) a plasma aldosterone/PRA ratio greater than
1,400 pmol/L/ng/mL/hr with a plasma aldosterone
greater than 440 pmol/L

d) captopril suppression test (primary aldosteronism
defined as failure to suppress plasma aldosterone to
less than 240 pmol/L two hours after 25 mg of oral
captopril)

v) Differentiating potential causes of primary aldosteronism:

a) for patients with established primary aldosteronism,
attempts to differentiate potential causes should be
made and may include localization with adrenal CT-
scan (standard: 3 mm contiguous cuts) or magnetic
resonance imaging (where available), or assessment
of plasma aldosterone before (supine) and after 2 h to
4 h of upright posture.

b) for patients with established primary aldosteronism
and negative imaging studies, selective adrenal venous
sampling should be considered because it may be the
only way to reliably differentiate unilateral from bilateral
overproduction of aldosterone. Adrenal venous sam-
pling should be conducted in centres with experience
in performing this diagnostic technique.

35

TABlE 7:
Pheochromocytoma: Screening and Diagnosis*
1) Biochemical screening tests for
pheochromocytomas:
a) to screen for pheochromocytomas, 24 h urinary
total metanephrines (sensitivity 95%) and urinary
metanephrine-to-creatinine ratio (sensitivity 100%)
should be assessed. Plasma catecholamines and,
where available, plasma metanephrines may also be
considered if clinical suspicion is high, particularly dur-
ing a hypertensive episode or for those with familial
forms. Urinary or plasma VMA measurements should
not be used as screening tests. In a low risk setting,
plasma fractionated free metanephrine measure-
ments can be used to rule out pheochromocytoma.

b) in the presence of borderline biochemical test results
(e.g., plasma noradrenaline and adrenaline levels of
approximately 500 ng/L to 2,000 ng/L) or potentially
false positive results, repeated testing and/or the
clonidine suppression test may be used.


FigURE 1: The Expedited Assessment and Diagnosis of Patients with Hypertension:
Focus on Validated Technologies for Blood Pressure Assessment*

Elevated Out-of-the-Office BP Measurement Elevated Random Office BP Measurement

Hypertension Visit 1
BP Measurement, Hypertensive
History and Physical Urgency / Emergency
36

Diagnostic tests ordering
at visit 1 or 2

within 1 month BP ≥ 180/110 mm Hg OR
Yes Diagnosis
BP 140-179/90-109 mm Hg Yes
of HTN
with Target Organ Damage, Diabetes
or Chronic Kidney Disease

No

BP: 140 -179/90 -109 mm Hg

Clinic BPM ABPM (if available) Home BPM (if available)
Awake BP ≥135 mm Hg
≥160 mm Hg SBP or Diagnosis
≥100 mm Hg DBP Awake BP ≥135 mm Hg SBP or <135/85 mm Hg SBP
of HTN
<135/85 mm Hg ≥85 mm Hg DBP or
and or ≥85 mm Hg
37

ABPM or 24-hour 24-hour
<160/100 mm Hg DBP
or Home BPM <130/80 mm Hg ≥130 mm Hg SBP or or
if available ≥80 mm Hg DBP
Hypertension Visit 4-5
≥140 mm Hg SBP or Diagnosis
≥90 mm Hg DBP of HTN Continue to Diagnosis Continue to Diagnosis
follow-up of HTN follow-up of HTN
Continue to
<140/90 mm Hg
follow-up


40

I lIFESTYlE MANAGEMENT
A) Physical Exercise
1) For non-hypertensive individuals (to reduce the pos-
sibility of becoming hypertensive) or for hypertensive
patients (to reduce their blood pressure) prescribe
the accumulation of 30 to 60 minutes of moderate
intensity dynamic exercise (such as walking, jogging,
cycling or swimming) 4 -7 days per week, in addition
to the routine activities of daily living (Grade D). Higher
intensities of exercise are no more effective (Grade D).

B) Weight Reduction
1) Height, weight, and waist circumference (WC) should
be measured and body mass index (BMI) calculated
for all adults (Grade D).

2) Maintenance of a healthy body weight (BMI 18.5
to 24.9 kg/m² and WC of less than 102 cm for men
and less than 88 cm for women) is recommended
for non-hypertensive individuals to prevent hyper-
tension (Grade C) and for hypertensive patients to
reduce blood pressure (Grade B). All overweight
hypertensive individuals should be advised to lose
weight (Grade B).

3) Weight loss strategies should use a multidisciplinary
approach that includes dietary education, increased
physical activity and behavioral intervention
(Grade B).

C) Alcohol Consumption
1) To reduce blood pressure, alcohol consumption
should be in accordance with Canadian low-risk
drinking guidelines in both normotensive and
hypertensive individuals. Healthy adults should limit
alcohol consumption to 2 drinks or less per day, and
consumption should not exceed 14 standard drinks
per week for men and 9 standard drinks per week for
women (Grade B).

(Note: one standard drink is considered 13.6 g or 17.2 mL of
ethanol, or approximately 44 mL of 80 proof (40%) spirits,
355 mL of 5% beer or 148 mL of 12% wine.)

D) Dietary Recommendations
1) It is recommended that hypertensive patients and nor-
motensive individuals at increased risk of developing

41

hypertension consume a diet that emphasizes fruits,
vegetables, low-fat dairy products, dietary and soluble
fiber, whole grains and protein from plant sources that
is reduced in saturated fat and cholesterol (Dietary
Approaches to Stop Hypertension [DASH] diet; see
Table 1) (Grade B).

E) Salt Intake
1) For prevention of hypertension, in addition to a
well-balanced diet, a dietary sodium intake of less
than 100 mmol (2,300 mg) per day is recommended
(Grade B).

2) In hypertensive patients, dietary sodium intake should be
limited to 65 mmol to 100 mmol (1,495 mg to 2,300 mg)
per day (Grade B).

F) Potassium, Calcium and Magnesium Intake
1) Supplementation of potassium, calcium and mag-
nesium is not recommended for the prevention or
treatment of hypertension (Grade B).

G) Stress Management
1) In hypertensive patients in whom stress may be
contributing to blood pressure elevation, stress
management should be considered as an interven-
tion (Grade D). Individualized cognitive behavioral
interventions are more likely to be effective when
relaxation techniques are used (Grade B).

II INDICATIONS FOR DRUG THERAPY FOR ADUlTS
WITH HYPERTENSION WITHOUT COMPEllING
INDICATIONS FOR SPECIFIC AGENTS
1) Antihypertensive therapy should be prescribed for
average diastolic blood pressures of 100 mm Hg or
higher (Grade A) or average systolic blood pressures
of 160 mm Hg or higher (Grade A) in patients without
macrovascular target organ damage or other cardiovas-
cular risk factors (see Tables 3 and 4 from accompanying
CHEP Diagnosis paper).

2) Antihypertensive therapy should be strongly consid-
ered if diastolic blood pressure readings average 90 mm
Hg or higher in the presence of macrovascular target
organ damage or other independent cardiovascular
risk factors (Grade A).

42

3) Antihypertensive therapy should be strongly con-
sidered if systolic blood pressure readings average
140 mm Hg or higher in the presence of macrovascular
target organ damage (Grade C for 140 mm Hg to
160 mm Hg; Grade A for higher than 160 mm Hg).

4) Antihypertensive therapy should be considered
in all patients meeting the above indications
regardless of age (Grade B). Caution should be
exercised in elderly patients who are frail.

III CHOICE OF THERAPY FOR ADUlTS WITH HYPER-
TENSION WITHOUT COMPEllING INDICATIONS
FOR SPECIFIC AGENTS
A) Recommendations for Individuals with Diastolic
± Systolic Hypertension
1) Initial therapy should be monotherapy with
a thiazide diuretic (Grade A); a beta-blocker (in
patients younger than 60 years of age, Grade B);
an ACE inhibitor (in non-black patients, Grade B);
a long-acting CCB (Grade B) or an ARB (Grade B). If
there are adverse effects, another drug from this
group should be substituted. Hypokalemia should
be avoided in patients treated with thiazide diuretic
monotherapy (Grade C).

2) Additional antihypertensive drugs should be used
if target blood pressure levels are not achieved
with standard dose monotherapy (Grade B). Add-
on drugs should be chosen from first-line choices.
Useful choices include a thiazide diuretic or CCB
with an ACE inhibitor, ARB or beta-blocker (Grade B
for the combination of thiazide diuretic with a di-
hydropyridine CCB; Grade C for the combination of
dihydropyridine CCB and ACE inhibitor and Grade
D for all other combinations). Caution should be
exercised in combining a nondihydropyridine CCB
and a beta-blocker (Grade D). The combination of
an ACE inhibitor and ARB is not recommended
(Grade A).

3) Combination therapy using two first-line agents may
also be considered as initial treatment of hypertension
if systolic blood pressure is 20 mm Hg above target or
if diastolic blood pressure is 10 mm Hg above target
(Grade C). However, caution should be exercised in
patients in whom a substantial fall in blood pressure

43

is more likely or more poorly tolerated (e.g., elderly
patients) from initial combination therapy.

4) If blood pressure is still not controlled with
a combination of two or more first-line agents, or
there are adverse effects, other antihypertensive
drugs may be added (Grade D).

5) Possible reasons for poor response to therapy
(Table 2) should be considered (Grade D).

6) Alpha-blockers are not recommended as first-line
agents for uncomplicated hypertension (Grade A);
beta-blockers are not recommended as first-line
therapy for uncomplicated hypertension in patients
aged 60 years of age or older (Grade A) and ACE
inhibitors are not recommended as first-line therapy
for uncomplicated hypertension in black patients
(Grade A). However, these agents may be used in
patients with certain comorbid conditions or in
combination therapy.

B) Recommendations for Individuals with Isolated
Systolic Hypertension
1) Initial therapy should be monotherapy with a thiazide
diuretic (Grade A); a long-acting dihydropyridine
CCB (Grade A) or an ARB (Grade B). If there are ad-
verse effects, another drug from this group should
be substituted. Hypokalemia should be avoided in
patients treated with thiazide diuretic monotherapy
(Grade C).

2) Additional antihypertensive drugs should be used
if target blood pressure levels are not achieved with
standard-dose monotherapy (Grade B). Add-on drugs
should be chosen from first-line choices (Grade D).

3) If blood pressure is still not controlled with a com-
bination of two or more first-line agents, or there
are adverse effects, other classes of drugs (such as
alpha-blockers, ACE inhibitors, centrally acting agents
or nondihydropyridine CCBs) may be added or substi-
tuted (Grade D).

4) Possible reasons for poor response to therapy
(Table 2) should be considered (Grade D).

agents for uncomplicated isolated systolic hypertension

44

(Grade A), and beta-blockers are not recommended as
first-line therapy for isolated systolic hypertension in
patients aged 60 years or older (Grade A). However, both
agents may be used in patients with certain comorbid
conditions or in combination therapy.

IV GlOBAl VASCUlAR PROTECTION THERAPY FOR
ADUlTS WITH HYPERTENSION WITHOUT
COMPEllING INDICATIONS FOR SPECIFIC AGENTS
1) Statin therapy is recommended in hypertensive pa-
tients with three or more cardiovascular risk factors
as defined in Table 3 (Grade A in patients older than
40 years) or with established atherosclerotic disease
(Grade A, regardless of age).

2) Strong consideration should be given to the addition of
low-dose ASA therapy in hypertensive patients (Grade A
in patients older than 50 years). Caution should be
exercised if blood pressure is not controlled (Grade C).

V GOAl OF THERAPY FOR ADUlTS WITH
HYPERTENSION WITHOUT COMPEllING
INDICATIONS FOR SPECIFIC AGENTS
1) The systolic blood pressure treatment goal is lower
than 140 mm Hg (Grade C). The diastolic blood
pressure treatment goal is lower than 90 mm Hg
(Grade A).

VI TREATMENT OF HYPERTENSION IN ASSOCIATION
WITH ISCHEMIC HEART DISEASE
A) Recommendations for Hypertensive Patients
with Coronary Artery Disease
1) An ACE inhibitor is recommended for most patients
with hypertension and documented coronary
artery disease (Grade A).
2) For patients with stable angina, beta-blockers are
preferred as initial therapy (Grade B). Long-acting
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 heart failure, the combination of an
ACE inhibitor and ARB is not recommended
(Grade B).

45

B) Recommendations for Patients with
Hypertension who have had a Recent ST-
elevation Myocardial Infarction or Non-ST
Segment Elevation Myocardial Infarction
1) Initial therapy should include both a beta-blocker and
an ACE inhibitor (Grade A). An ARB may be used if the
patient is intolerant of an ACE inhibitor (Grade A in patients
with left ventricular systolic dysfunction).
2) Long-acting CCBs may be used in post-myocardial
infarction patients when beta-blockers are contraindi-
cated or not effective. Nondihydropyridine CCBs should
not be used when there is heart failure as evidenced by
pulmonary congestion on examination or radiograph
(Grade D).

VII TREATMENT OF HYPERTENSION IN ASSOCIATION
WITH HEART FAIlURE
1) In patients with systolic dysfunction, ACE inhibitors
(Grade A) and beta-blockers (Grade A) are recom-
mended for initial therapy. Aldosterone antagonists
(Grade B) are also recommended for patients with
NYHA Class III or IV symptoms of heart failure or follow-
ing MI. Other diuretics are recommended as additional
therapy if needed (Grade B for thiazide diuretics for
blood pressure control, Grade D for loop diuretics for
volume control). Beyond considerations of blood pres-
sure control, doses of ACE inhibitors or ARBs should be
titrated to those found to be effective in trials unless
adverse effects are manifest (Grade B).
2) An ARB is recommended if ACE inhibitors are not toler-
ated (Grade A).
3) A combination of hydralazine and isosorbide dinitrate
is recommended if ACE inhibitors and ARBs are con-
traindicated or not tolerated (Grade B).
4) For hypertensive patients with heart failure whose
blood pressure is not controlled, an ARB may be added
to an ACE inhibitor and other antihypertensive drug
treatment (Grade A). Careful monitoring should be
used if combining an ACE inhibitor and an ARB due
to potential adverse effects such as hypotension,
hyperkalemia and worsening renal function (Grade C).
Additional therapies may also include long-acting
dihydropyridine CCBs (Grade C).

46

VIII TREATMENT OF HYPERTENSION IN ASSOCIATION
WITH CEREBROVASCUlAR DISEASE
1) Strong consideration should be given to the initiation
of antihypertensive therapy after the acute phase of a
stroke or transient ischemic attack (Grade A).
2) Caution is indicated in deciding whether to lower blood
pressure in the acute stroke situation; pharmacological
agents and routes of administration should be chosen
to avoid precipitous falls in blood pressure (Grade D).
3) Following the acute phase of a stroke, patients should
have their blood pressure chronically controlled to a
target of lower than 140/90 mm Hg (Grade C).
4) Treatment with an ACE inhibitor plus diuretic combina-
tion is preferred (Grade B).
5) For patients who have had a stroke the combination
of an ACE inhibitor and ARB is not recommended
(Grade B).

IX TREATMENT OF HYPERTENSION IN ASSOCIATION
WITH lEFT VENTRICUlAR HYPERTROPHY
1) Hypertensive patients with left ventricular hypertrophy
should be treated with antihypertensive therapy to
lower the rate of subsequent cardiovascular events
(Grade C).
2) The choice of initial therapy can be influenced by the
presence of left ventricular hypertrophy (Grade D). Initial
therapy can be drug treatment using ACE inhibitors,
ARBs, long-acting CCBs or thiazide diuretics. Direct arte-
rial vasodilators such as hydralazine or minoxidil should
not be used.

X TREATMENT OF HYPERTENSION IN ASSOCIATION
WITH NON-DIABETIC CHRONIC KIDNEY DISEASE
1) For patients with non-diabetic chronic kidney disease,
target blood pressure is lower than 130/80 mm Hg
(Grade C).

2) For patients with hypertension and proteinuric
chronic kidney disease (urinary protein greater than
500 mg/24h or albumin to creatinine ratio [ACR] greater
than 30 mg/mmol), initial therapy should be an ACE
inhibitor (Grade A) or an ARB if there is intolerance to
ACE inhibitors (Grade B).

47

3) Thiazide diuretics are recommended as additive antihy-
pertensive therapy (Grade D). For patients with chronic
kidney disease and volume overload, loop diuretics are
an alternative (Grade D).

4) The combination of an ACE inhibitor and ARB is not
recommended for patients with nonproteinuric
chronic kidney disease (Grade B).

XI TREATMENT OF HYPERTENSION IN ASSOCIATION
WITH RENOVASCUlAR DISEASE
1) Renovascular hypertension should be treated in the
same manner as hypertension without compelling
indications, except for caution in using ACE inhibi-
tors or ARBs due to the risk of acute renal failure in
bilateral disease or unilateral disease with a solitary
kidney (Grade D).
2) Close follow-up and early intervention (angioplasty and
stenting or surgery) should be considered for patients
with uncontrolled hypertension despite therapy with
three or more drugs, deteriorating kidney function,
bilateral atherosclerotic renal artery lesions (or tight
atherosclerotic stenosis in a single kidney) or recurrent
episodes of flash pulmonary edema (Grade D).

XII TREATMENT OF HYPERTENSION IN ASSOCIATION
WITH DIABETES MEllITUS
1) Persons with diabetes mellitus should be treated to
attain systolic blood pressure lower than 130 mm Hg
(Grade C) and diastolic blood pressure lower than
80 mm Hg (Grade A). (These target blood pressure
levels are the same as the blood pressure treatment
thresholds.) Combination therapy using two first-line
agents may also be considered as initial therapy
of hypertension (Grade B) if the SBP is 20 mm Hg
above target or the DBP is 10 mm Hg above target.
However, caution should be exercised in patients in
whom a substantial fall in blood pressure is more
likely or poorly tolerated (e.g., elderly patients,
patients with autonomic nephropathy).
2) For patients with diabetes and normal urinary albumin
excretion (ACR lower than 2.0 mg/mmol in men and
lower than 2.8 mg/mmol in women) and without chronic
kidney disease, with blood pressure 130/80 mm Hg or
higher despite lifestyle interventions, any one of the

48

following are recommended: an ACE inhibitor (Grade
A for patients 55 years or older, Grade B for patients
younger than 55 years); ARB (Grade A for persons
with left ventricular hypertrophy and age of 55 years
or older, Grade B for persons without left ventricular
hypertrophy irrespective of age); a dihydropyridine CCB
(Grade A for patients 55 years of age or older, Grade B for
patients younger than 55 years of age); or a thiazide or
a thiazide-like diuretic (Grade A for patients 55 years of
age or older, Grade B for patients younger than 55 years
of age) is recommended, with special consideration
to the ACE inhibitor and ARB, given their additional
renal benefits. If these drugs are contraindicated or
cannot be tolerated, a cardioselective beta-blocker
(Grade B) or nondihydropyridine CCB (Grade B) may be
substituted. Additional antihypertensive drugs should
be used if target blood pressure is not achieved with
standard-dose monotherapy (Grade B). Add-on drugs
should be chosen from first-line choices.
3) For patients with diabetes and albuminuria (persistent
ACR greater than 2.0 mg/mmol in men and greater than
2.8 mg/mmol in women), an ACE inhibitor or an ARB
is recommended as initial therapy (Grade A). If blood
pressure remains 130/80 mm Hg or higher despite
lifestyle interventions and the use of an ACE inhibitor
or ARB, additional antihypertensive drugs should be
used to obtain target blood pressure.
4) For patients with diabetes and a normal urinary albumin
excretion rate (ACR lower than 2.0 mg/mmol in men and
lower than 2.8 mg/mmol in women) with no chronic
kidney disease and with isolated systolic hyperten-
sion, a long-acting dihydropyridine CCB (Grade C) is an
alternative initial choice to an ACE inhibitor (Grade B),
ARB (Grade B), or a thiazide or a thiazide-like diuretic
(Grade C).
agents for the treatment of hypertension in patients
with diabetes (Grade A).

XIII CONCORDANCE STRATEGIES FOR PATIENTS
1) Adherence to an antihypertensive prescription can be
improved by a multi-pronged approach, as outlined in
Table 4.

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