Denis Drouin

The 2009 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 2 – therapy

OBJECTIVE To update the evidence-based recommendations for the prevention and management of hypertension in adults for 2009. OPTIONS AND OUTCOMES For lifestyle and pharmacological interventions, evidence from randomized controlled trials and systematic reviews of trials was preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field. Progression of kidney dysfunction was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease. EVIDENCE A Cochrane collaboration librarian conducted an independent MEDLINE search from 2007 to August 2008 to update the 2008 recommendations. To identify additional published studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence. RECOMMENDATIONS For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to less than 2300 mg (100 mmol)/day (and 1500 mg to 2300 mg [65 mmol to 100 mmol]/day in hypertensive patients); perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (smaller than 102 cm for men and smaller than 88 cm for women); limit alcohol consumption to no more than 14 units per week in men or nine units per week in women; follow a diet that is reduced in saturated fat and cholesterol, and that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on by the patients global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to lower than 140/90 mmHg in all patients, and to lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor antagonists (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as the initial treatment of hypertension if the systolic blood pressure is 20 mmHg above the target or if the diastolic blood pressure is 10 mmHg above the target. The combination of ACE inhibitors and ARBs should not be used. Other agents appropriate for first-line therapy for isolated systolic hypertension include long- acting dihydropyridine CCBs or ARBs. In patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered. VALIDATION All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

The 2013 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2013. This years update includes 2 new recommendations. First, among nonhypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise does not adversely influence blood pressure (BP) (Grade D). Thus, such patients need not avoid this type of exercise for fear of increasing BP. Second, and separately, for very elderly patients with isolated systolic hypertension (age 80 years or older), the target for systolic BP should be < 150 mm Hg (Grade C) rather than < 140 mm Hg as recommended for younger patients. We also discuss 2 additional topics at length (the pharmacological treatment of mild hypertension and the possibility of a diastolic J curve in hypertensive patients with coronary artery disease). In light of several methodological limitations, a recent systematic review of 4 trials in patients with stage 1 uncomplicated hypertension did not lead to changes in management recommendations. In addition, because of a lack of prospective randomized data assessing diastolic BP thresholds in patients with coronary artery disease and hypertension, no recommendation to set a selective diastolic cut point for such patients could be affirmed. However, both of these issues will be examined on an ongoing basis, in particular as new evidence emerges.

The 2011 Canadian Hypertension Education Program Recommendations for the Management of Hypertension: Blood Pressure Measurement, Diagnosis, Assessment of Risk, and Therapy

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2011. The major guideline changes this year are: (1) a recommendation was made for using comparative risk analogies when communicating a patients cardiovascular risk; (2) diagnostic testing issues for renal artery stenosis were discussed; (3) recommendations were added for the management of hypertension during the acute phase of stroke; (4) people with hypertension and diabetes are now considered high risk for cardiovascular events if they have elevated urinary albumin excretion, overt kidney disease, cardiovascular disease, or the presence of other cardiovascular risk factors; (5) the combination of an angiotensin-converting enzyme (ACE) inhibitor and a dihydropyridine calcium channel blocker (CCB) is preferred over the combination of an ACE inhibitor and a thiazide diuretic in persons with diabetes and hypertension; and (6) a recommendation was made to coordinate with pharmacists to improve antihypertensive medication adherence. We also discussed the recent analyses that examined the association between angiotensin II receptor blockers (ARBs) and cancer.

Implementation of recommendations on hypertension: The Canadian Hypertension Education Program

The diffusion of research evidence or practice guidelines does not, by itself, lead to changes in practice behaviour or patient outcomes. The Canadian Hypertension Education Program (CHEP) was specifically structured to have an explicit process to improve the ability of primary care professionals to use CHEP recommendations. The key features of this process are reviewed in the present report. The responsibility for implementation of recommendations is divided between the executive committee of CHEP and the Implementation Task Force (ITF). The executive develops an extensive array of summaries and implementation tools for the recommendations, and encourages and facilitates other organizations to develop educational materials and programs. The ITF creates further implementation tools, tailors the tools to specific health care disciplines and creates discipline-specific dissemination strategies. Currently, CHEP recommendations are disseminated through updated full scientific manuscripts, short scientific and clinical summaries, one-page handouts, wall posters, pocket cards, advertisements, extensive slide kits, textbooks, didactic lectures and workshops. A Web site with the recommendations in different formats is maintained to allow easy access. More recently, media releases have been used to alert the public and health care professionals to important recommendations. The transparent and interactive annual process of developing the recommendations by most of Canadas clinical hypertension experts is also viewed as critical to providing uniform educational messages to health care professionals from national and local opinion leaders. The CHEP ITF includes primary care disciplines and specialties important to blood pressure control. The CHEP process for the implementation of recommendations is very extensive and continues to evolve. There is early evidence for improvement in the management of hypertension in Canada that coincides with the initiation of CHEP, suggesting that CHEP could serve as a model for disease management recommendations.

2006 Canadian Hypertension Education Program Guidelines for the Management of Hypertension by Pharmacists

that pharmacists take responsibility for medication management and patient outcomes. Hypertension is a prevalent and deadly condition; pharmacists, alone or in collaboration with other health professionals, should play a major role in its management. To enable best practices in the management of hypertension by pharmacists, we have adapted guidelines directly from the Canadian Hypertension Education Program (CHEP) 2006 recommendations. These represent the first nationally recognized, peer-reviewed practice guidelines developed specifically for Canadian pharmacists. It is hoped that these guidelines will be used to help pharmacists further contribute to the improved care of patients with hypertension and ultimately enhance patient outcomes. For more background on any of the CHEP guidelines outlined here, please see the full recommendations, available at www.hypertension.ca.

Leisure activities and service knowledge and use among the rural elderly.

This exploratory study uses Andersens service utilization model to examine the relationship between the leisure activity patterns of older people and their knowledge and use of health and social services. Hierarchical stepwise multiple regression analyses of data from 418 people ages 65 and older in rural Québec revealed that leisure activity patterns may explain a greater amount of variation in service knowledge and use than conventional need characteristics such as physical and psychological health. Various activity patterns were significantly related to knowledge and use of services even after controlling for variables such as age and health status. Although some types of leisure activities appeared to augment knowledge and use of services, others seemed to deter it. Future explanatory models of service utilization among the elderly should be expanded to include leisure activity patterns.

COGNITIVE STYLES OF FRENCH CANADIAN ATHLETES

The purpose of this study was to assess field-dependence/independence of 192 French Canadian athletes involved in a university athletic program. Field-dependence refers to one who is strongly influenced by his immediate environment, while a field-independent is individually oriented and much less influenced by environment. Analysis of variance showed that for these athletes there were no significant differences for the embedded figures test scores on age, sex, level of competition, and sports. The highest mean score of 13.86 was obtained by athletes older than 18 yr. of age.

Patient Age, Ethnicity, Medical History, and Risk Factor Profile, but Not Drug Insurance Coverage, Predict Successful Attainment of Glycemic Targets: Time 2 Do More Quality Enhancement Research Initiative (T2DM QUERI)

OBJECTIVE To identify factors in patients with type 2 diabetes and A1C >7.0% associated with attainment of A1C ≤7.0%. RESEARCH DESIGN AND METHODS We used a prospective registry of 5,280 Canadian patients in primary care settings enrolled in a 12-month glycemic pharmacotherapy optimization strategy based on national guidelines. RESULTS At close out, median A1C was 7.1% (vs. 7.8% at baseline) with 48% of subjects achieving A1C ≤7.0% (P < 0.0001). Older patients of Asian or black origin, those with longer diabetes duration, those with lower baseline A1C, BMI, LDL cholesterol, and blood pressure, and those on angiotensin receptor blockers and a lower number of antihyperglycemic agents, were more likely to achieve A1C ≤7.0% at some point during the study (all P < 0.0235). Access to private versus public drug coverage did not impact glycemic target realization. CONCLUSIONS Patient demography, cardiometabolic health, and ongoing pharmacotherapy, but not access to private drug insurance coverage, contribute to the care gap in type 2 diabetes.

Time 2 Do More Quality Enhancement Research Initiative (T2DM QUERI): Patient age, ethnicity, medical history and risk factor profile, but not drug insurance coverage, predict successful attainment of glycemic targets

OBJECTIVE To identify factors in patients with type 2 diabetes and A1C >7.0% associated with attainment of A1C ≤7.0%. RESEARCH DESIGN AND METHODS We used a prospective registry of 5,280 Canadian patients in primary care settings enrolled in a 12-month glycemic pharmacotherapy optimization strategy based on national guidelines. RESULTS At close out, median A1C was 7.1% (vs. 7.8% at baseline) with 48% of subjects achieving A1C ≤7.0% (P < 0.0001). Older patients of Asian or black origin, those with longer diabetes duration, those with lower baseline A1C, BMI, LDL cholesterol, and blood pressure, and those on angiotensin receptor blockers and a lower number of antihyperglycemic agents, were more likely to achieve A1C ≤7.0% at some point during the study (all P < 0.0235). Access to private versus public drug coverage did not impact glycemic target realization. CONCLUSIONS Patient demography, cardiometabolic health, and ongoing pharmacotherapy, but not access to private drug insurance coverage, contribute to the care gap in type 2 diabetes.

COGNITIVE STYLES OF YOUNG ICE HOCKEY PLAYERS

The Childrens Embedded Figures Test was used to document field dependency among a group of 60 young French-Canadian hockey players enrolled in a structured ice hockey teaching program. The median age (8 yr., 4 mo.) was kept to form two age groups. Analysis of variance showed significant differences between age groups in total test scores and in both Tent and House series; the older children scored more field-independent.