George Fodor

2009 Canadian Cardiovascular Society/Canadian guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease in the adult – 2009 recommendations

The present article represents the 2009 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease in the adult.

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.

Canadian Cardiovascular Society position statement – Recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease

Since the last publication of the recommendations for the management and treatment of dyslipidemia, new clinical trial data have emerged that support a more vigorous approach to lipid lowering in specific patient groups. The decision was made to update the lipid guidelines in collaboration with the Canadian Cardiovascular Society. A systematic electronic search of medical literature for original research consisting of blinded, randomized controlled trials was performed. Meta-analyses of studies of the efficacy and safety of lipid-lowering therapies, and of the predictive value of established and emerging risk factors were also reviewed. All recommendations are evidence-based, and have been reviewed in detail by primary and secondary review panels. Major changes include a lower low-density lipoprotein cholesterol (LDL-C) treatment target (lower than 2.0 mmol/L) for high-risk patients, a slightly higher intervention point for the initiation of drug therapy in most low-risk individuals (LDL-C of 5.0 mmol/L or a total cholesterol to high-density lipoprotein cholesterol ratio of 6.0) and recommendations regarding additional investigations of potential use in the further evaluation of coronary artery disease risk in subjects in the moderate-risk category.

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.

Results of the Ontario Survey on the Prevalence and Control of Hypertension

Background: Available information on the prevalence and management of hypertension in the Canadian population dates back to 1986–1992 and probably does not reflect the current status of this major risk factor for cardiovascular disease. We sought to evaluate the current prevalence and management of hypertension among adults in the province of Ontario. Methods: Potential respondents from randomly selected dwellings within target neighbourhoods in 16 municipalities were contacted at their homes to request participation in the study. For potential respondents who agreed to participate, blood pressure was measured with an automated device. Estimation weights were used to obtain representative estimates of population parameters. Responses were weighted to the total adult population in Ontario of 7 996 653. Results: From 6436 eligible dwellings, contact was made with 4559 potential participants, of whom 2992 agreed to participate. Blood pressure measurements were obtained for 2551 of these respondents (age 20–79 years). Hypertension, defined as systolic blood pressure of 140 mm Hg or more, diastolic blood pressure of 90 mm Hg or more, or treatment with an antihypertensive medication, was identified in 21.3% of the population overall (23.8% of men and 19.0% of women). Prevalence increased with age, from 3.4% among participants 20–39 years of age to 51.6% among those 60–79 years of age. Hypertension was more common among black people and people of South Asian background than among white people; hypertension was also associated with higher body mass index. Among participants with hypertension, 65.7% were undergoing treatment with control of hypertension, 14.7% were undergoing treatment but the hypertension was not controlled, and 19.5% were not receiving any treatment (including 13.7% who were unaware of their hypertension). The extent of control of hypertension did not differ significantly by age, sex, ethnic background or comorbidities. Interpretation: In Ontario, the overall prevalence of hypertension is high in the older population but appears not to have increased in recent decades. Hypertension management has improved markedly among all age groups and for both sexes.

Distribution of blood pressure and hypertension in Canada and the United States.

BACKGROUND Two North American population based surveys, the Third National Health and Nutrition Examination Survey (NHANES III) and the Canadian Heart Health Surveys (CHHS) have similar time frames and methods that allow comparisons between these countries in terms of the distribution of systolic (SBP) and diastolic (DBP) blood pressure and the levels of hypertension awareness, treatment, and control. METHODS Cross-sectional population surveys using similar methods conducted home interviews and clinic visits (CHHS), and medical examinations (NHANES III). The CHHS included the ten Canadian provinces (1986-1992) and NHANES III, a representative sample of the United States population (1988-1994). Blood pressure measurements were available for 23,111 Canadians (age 18-74 years), and restricted to the 15,326 US participants in the same age range (age 18-74 years) with both systolic and diastolic mean values. Standardized techniques were used for BP measurements. Mean of all available measurements was used from four measurements for the CHHS and six measurements for NHANES III. A mean SBP/DBP of 140/90 mm Hg or treated with medication defined hypertension. All measures were weighted to represent population values. RESULTS Both surveys showed similar trends in mean BP by age, with slightly higher levels in the CHHS. Hypertension prevalence using the same definitions and the same age range (18-74 years) was NHANES III: 20.1%, CHHS: 21.1%. Although the prevalence of isolated systolic hypertension (ISH) was similar in both studies, around 8% to 9%, the CHHS had higher ISH prevalence than NHANES III in the younger age groups and lower prevalence in the older age groups. Elevated SBP dominated the prevalence figures after the 1950s in both studies. Compared to NHANES III, the CHHS showed a lower proportion (43% v 50%) of individuals with optimal BP (< 120/80 mm Hg) and a very low proportion of hypertensives under control (13% v 25%). About half of diabetic participants were hypertensive (using 140/90 mm Hg) in both countries with a very low level of control in Canada (9%) v the US (36%) for ages 18 to 74 years. CONCLUSIONS The results of these two surveys highlight the importance of SBP, in the later decades of life, an overall low control of hypertension in both countries, and a better overall awareness, treatment, and control of hypertension in the US than in Canada for that period. Dissemination of hypertension guidelines and a more aggressive focus on SBP are urgently needed in Canada, with special attention to diabetics.

Changes in the rates of awareness, treatment and control of hypertension in Canada over the past two decades.

Background Analyses of medication databases indicate marked increases in prescribing of antihypertensive drugs in Canada over the past decade. This study was done to examine the trends in the prevalence of hypertension and in control rates in Canada between 1992 and 2009. Methods Three population-based surveys, the 1986–1992 Canadian Heart Health Surveys, the 2006 Ontario Survey on the Prevalence and Control of Hypertension and the 2007–2009 Canadian Health Measures Survey, collected self-reported health information from, and measured blood pressure among, community-dwelling adults. Results The population prevalence of hypertension was stable between 1992 and 2009 at 19.7%–21.6%. Hypertension control improved from 13.2% (95% confidence interval [CI] 10.7%–15.7%) in 1992 to 64.6% (95% CI 60.0%–69.2%) in 2009, reflecting improvements in awareness (from 56.9% [95% CI 53.1%–60.5%] in 1992 to 82.5% [95% CI 78.5%–86.0%] in 2009) and treatment (from 34.6% [95% CI 29.2%–40.0%] in 1992 to 79.0% [95% CI 71.3%–86.7%] in 2009) among people with hypertension. The size of improvements in awareness, treatment and control were similar among people who had or did not have cardiovascular comorbidities Although systolic blood pressures among patients with untreated hypertension were similar between 1992 and 2009 (ranging from 146 [95% CI 145–147] mm Hg to 148 [95% CI 144–151] mm Hg), people who did not have hypertension and patients with hypertension that was being treated showed substantially lower systolic pressures in 2009 than in 1992 (113 [95% CI 112–114] v. 117 [95% CI 117–117] mm Hg and 128 [95% CI 126–130] v. 145 [95% CI 143–147] mm Hg). Interpretation The prevalence of hypertension has remained stable among community-dwelling adults in Canada over the past two decades, but the rates for treatment and control of hypertension have improved markedly during this time.

Effect of telmisartan on renal outcomes: a randomized trial.

Context Few trials have evaluated whether angiotensin-receptor blockers (ARBs) prevent renal disease in people without proteinuria. Contribution In this trial, patients with cardiovascular disease or diabetes, but without macroalbuminuria or heart failure, were randomly assigned to receive telmisartan or placebo. During 4 to 5 years of follow-up, telmisartan recipients had albuminuria less often but had doubling of serum creatinine and slight decreases in estimated glomerular filtration rate more often than placebo recipients. Few patients in either group required dialysis. Implication The effects of ARBs on renal variables are complicated, but no strong evidence indicates that they prevent clinically important renal disease in patients without proteinuria. The Editors The TRANSCEND (Telmisartan Randomised Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease) study examined cardiovascular outcomes with telmisartan, an angiotensin-receptor blocker (ARB), compared with placebo in people at high vascular risk who were intolerant of angiotensin-converting enzyme (ACE) inhibitors. Telmisartan had no statistically significant effect on the primary cardiovascular outcome, but it reduced the risk for the secondary composite outcome of cardiovascular death, myocardial infarction, and stroke to a moderate extent and had no effect on cardiovascular or total mortality (1). Renal outcomes were prespecified, important secondary outcomes of the TRANSCEND study, because a growing number of patients with atherosclerotic vascular disease are starting renal replacement therapy (2). For example, in a German registry, the proportion of individuals with vascular causes of nephropathy leading to long-term dialysis increased from 12% in 1995 to 23% in 2005 (3). Drugs used to reduce vascular events may also affect the kidney, so the effects of such drugs on renal outcomes in people with vascular disease are relevant. Angiotensin-receptor blockers reduce elevated blood pressure (4) and urinary protein excretion (5), which are both considered to be surrogate variables of renal benefit. Large trials in patients with overt diabetic nephropathy have demonstrated that ARBs reduce the rate of dialysis and doubling of serum creatinine (6, 7). The impact of ARBs on renal outcomes in other patients is not reliably known. This prespecified analysis of the TRANSCEND study (1) examined the effects of telmisartan on renal function in a large sample that was intolerant of ACE inhibitors and had vascular disease but not macroalbuminuria. The composite renal outcome was dialysis or doubling of serum creatinine. We also report changes in estimated glomerular filtration rate (GFR) and albuminuria. Methods Design Overview We enrolled and randomly assigned participants age 55 years or older with documented cardiovascular disease or diabetes with end-organ damage who could not tolerate ACE inhibitors between November 2001 and May 2004 to receive telmisartan, 80 mg/d, or matching placebo along with standard treatment. Follow-up was completed by March 2008. The main trial primary outcome, reported elsewhere (1), was the composite of myocardial infarction, stroke, cardiovascular death, and hospitalization for heart failure. We report the prespecified renal outcomes in this article. The ethics committees at all participating institutions and the regulatory authorities in each country approved the study protocol, and each participant provided written informed consent. Setting and Participants In 630 centers in 40 countries, we enrolled 5926 patients age 55 years or older who were intolerant of ACE inhibitors if they had coronary, peripheral, or cerebrovascular disease or diabetes with end-organ damage (1, 8). We defined ACE inhibitor intolerance as discontinuation of an ACE inhibitor for a documented reasonmost commonly cough (88.2%), symptomatic hypotension (4.1%), angioedema (1.3%), and renal dysfunction (1%) (1, 8). We excluded patients who, according to the clinical investigators, needed an ARB; were known to be hypersensitive or intolerant to ARBs; or had heart failure, significant valvular or cardiac outflow tract obstruction, constrictive pericarditis, complex congenital heart disease, unexplained syncope, planned cardiac surgery, cardiac revascularization in the previous 3 months, systolic blood pressure of 160 mm Hg or greater, heart transplantation, subarachnoid hemorrhage, known significant renal artery stenosis (formal exclusion not required), serum creatinine levels greater than 265 mol/L (>3.0 mg/dL), or hepatic dysfunction. The Appendix Table lists all exclusion criteria. Macroalbuminuria (urinary albumincreatinine ratio [UACR] >33.9 mg/mmol) was an exclusion criterion, but it was detected at baseline in 78 participants (1.44%) when the urine was analyzed centrally. Before entering the study, 1773 participants (29.9%) were receiving or had received ARBs. Appendix Table. Exclusion Criteria The study was coordinated by the Population Health Research Institute at McMaster University, Hamilton, Ontario, Canada. The steering committee designed and oversaw the trial and implemented an operations committee, an independent data safety and monitoring board, and an end point adjudication committee. Clinical sites in 40 countries, selected by the national coordinators, used a wide variety of recruitment strategies, including chart review, referral from other physicians, and mass mailing. Randomization and Interventions After a 3- to 4-week run-in phase, participants were randomly assigned to telmisartan, 80 mg/d, or placebo. During the run-in phase, all participants received single-blind placebo for 1 week followed by telmisartan, 80 mg/d, for 2 to 3 weeks. Of 6666 participants entering the run-in phase, 11 (0.2%) withdrew because of elevated serum creatinine levels and 26 (0.4%) withdrew because of elevated serum potassium levels. Figure 1 shows the study flow diagram and reasons for exclusion; baseline characteristics of the participants are published elsewhere (1). Participants were randomly assigned by telephone through a central automated system. Randomization was stratified by hospital or clinic. All participants and trial investigators were blinded to randomized treatment. Tablets identical in color, shape, and taste were provided in blister packs. Unblinded data were made available exclusively to the independent data safety and monitoring board by a statistician who was independent of the trial. Figure 1. Study flow diagram. All participants received randomized therapy and were followed, except for 18 (0.3%) who were followed until the end of the study or until a primary event occurred. The number of patients considered for the trial who did not enter the run-in phase is unknown. A figure showing trial follow-up and cardiovascular outcomes is published elsewhere (1). Progression of proteinuria was defined as new microalbuminuria, macroalbuminuria, or both. eGFR= estimated glomerular filtration rate; UACR= urinary albumincreatinine ratio. Outcomes and Measurements In August 2007, before completion of the TRANSCEND study, we developed a statistical analysis plan for the renal outcomes. As in other large renal trials, the primary composite outcome was defined as the first occurrence of dialysis, renal transplantation, doubling of serum creatinine, or death (6, 7, 9). No cases of renal transplantation were reported in this trial. The secondary renal outcome was the composite of dialysis or doubling of serum creatinine. After completion of the analysis, deatha nonspecific outcomeoutnumbered the other components of the primary outcome by 4-fold. Therefore, we determined the secondary outcome as the composite outcome measure of this analysis. Further outcomes were components of the composite outcome, changes in estimated GFR and UACR, and progression of proteinuria (defined as development of new micro- or macroalbuminuria), as well as the original primary composite outcome and the composite of dialysis; doubling of serum creatinine; or development of new microalbuminuria, macroalbuminuria, or both. Dialysis was categorized as short-term (2 months) or long-term (>2 months). Such information was missing in 1 patient. Urinary albumin and creatinine were measured centrally (10), and serum creatinine was measured locally at study sites. The estimated GFR was calculated from serum creatinine by using the 4-variable Modification of Diet in Renal Disease Study formula (11). Serum creatinine values below 35 mol/L (<0.4 mg/dL) were considered implausible, and we excluded participants with such values from the analysis (10 patients at baseline and 15 patients at follow-up). Information about dialysis was recorded at each visit. Follow-up Procedures and Monitoring We followed participants after 6 weeks, 6 months, and every 6 months thereafter for a mean of 56 months. At each visit, we collected information about adverse events, including dialysis; adherence to trial medication; and outcomes. We began data management as soon as data had been submitted, usually within 1 week of the patient visit. The data were sent through the datafax system and examined for ranges, plausibility, and missing data. Queries were sent to the investigator until responses were obtained. We measured serum creatinine before the run-in phase, 6 weeks after randomization, after 2 years, and at the end of the study, and we measured UACR before the run-in phase, at 2 years, and at the penultimate visit in a first morning urine sample. A UACR between 3.4 and 33.9 mg/mmol was defined as microalbuminuria and a value greater than 33.9 mg/mmol (approximately 300 mg/g creatinine) as macroalbuminuria. A blinded central committee, using standardized criteria, adjudicated all deaths and primary outcomes. After trial conclusion, a questionnaire was sent to all sites that reported dialysis to obtain information about duration of dialysis. Statistical Analysis The original sample size esti

The 2006 Canadian Hypertension Education Program recommendations for the management of hypertension: Part II - Therapy

OBJECTIVE To provide updated, evidence-based recommendations for the management of hypertension in adults. 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. For lifestyle interventions, blood pressure (BP) lowering was accepted as a primary outcome given the lack of long-term morbidity/mortality data in this field. For treatment of patients with kidney disease, the development of proteinuria or worsening of kidney function was also accepted as a clinically relevant primary outcome. EVIDENCE MEDLINE searches were conducted from November 2004 to October 2005 to update the 2005 recommendations. In addition, reference lists were scanned and experts were contacted to identify additional published studies. All relevant articles were reviewed and appraised independently by content and methodological experts using prespecified levels of evidence. RECOMMENDATIONS Lifestyle modifications to prevent and/or treat hypertension include the following: perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index of 18.5 kg/m2 to 24.9 kg/m2) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week in men or nine standard drinks 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; restrict salt intake; and consider stress management in selected individuals. Treatment thresholds and targets should take into account each individuals global atherosclerotic risk, target organ damage and comorbid conditions. BP should be lowered to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease (regardless of the degree of proteinuria). Most adults with hypertension require more than one agent to achieve these target BPs. For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic hypertension with or without systolic hypertension include beta-blockers (in those younger than 60 years), angiotensin-converting enzyme (ACE) inhibitors (in nonblack patients), long-acting calcium channel blockers or angiotensin receptor antagonists. Other agents for first-line therapy for isolated systolic hypertension include long-acting dihydropyridine calcium channel blockers or angiotensin receptor antagonists. Certain comorbid conditions provide compelling indications for first-line use of other agents: in patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with diabetes mellitus, ACE inhibitors or angiotensin receptor antagonists (or in patients without albuminuria, thiazides or dihydropyridine calcium channel blockers) are appropriate first-line therapies; and in patients with nondiabetic chronic kidney disease, ACE inhibitors are recommended. All hypertensive patients should have their fasting lipids screened, and those with dyslipidemia should be treated using the thresholds, targets and agents recommended by the Canadian Hypertension Education Program Working Group on the management of dyslipidemia and the prevention of cardiovascular disease. Selected patients with hypertension, but without dyslipidemia, should also receive statin therapy and/or acetylsalicylic acid therapy. VALIDATION All recommendations were graded according to strength of the evidence and voted on by the 45 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.