Lyne Cloutier

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 2008 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 1 - blood pressure measurement, diagnosis and assessment of risk.

OBJECTIVE To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension. OPTIONS AND OUTCOMES The diagnosis of hypertension is dependent on appropriate blood pressure measurement, the timely assessment of serially elevated readings, degree of blood pressure elevation, method of measurement (office, ambulatory, home) and associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk and determine the urgency, intensity and type of treatment required. EVIDENCE MEDLINE searches were conducted from November 2006 to October 2007 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed, full-text articles only. RECOMMENDATIONS Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Key messages in 2008 include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of global risk assessment and the need for ongoing monitoring of hypertensive patients to identify incident type 2 diabetes. 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 received at least 70% consensus. These guidelines will continue to be updated annually.

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.

A New Algorithm for the Diagnosis of Hypertension in Canada

Accurate blood pressure measurement is critical to properly identify and treat individuals with hypertension. In 2005, the Canadian Hypertension Education Program produced a revised algorithm to be used for the diagnosis of hypertension. Subsequent annual reviews of the literature have identified 2 major deficiencies in the current diagnostic process. First, auscultatory measurements performed in routine clinical settings have serious accuracy limitations that have not been overcome despite great efforts to educate health care professionals over several years. Thus, alternatives to auscultatory measurements should be used. Second, recent data indicate that patients with white coat hypertension must be identified earlier in the process and in a systematic manner rather than on an ad hoc or voluntary basis so they are not unnecessarily treated with antihypertensive medications. The economic and health consequences of white coat hypertension are reviewed. In this article evidence for a revised algorithm to diagnose hypertension is presented. Protocols for home blood pressure measurement and ambulatory blood pressure monitoring are reviewed. The role of automated office blood pressure measurement is updated. The revised algorithm strongly encourages the use of validated electronic digital oscillometric devices and recommends that out-of-office blood pressure measurements, ambulatory blood pressure monitoring (preferred), or home blood pressure measurement, should be performed to confirm the diagnosis of hypertension.

Blood pressure measurement: arm circumference and cuff size availability.

To avoid inaccurate blood pressure (BP) readings, the American Heart Association (AHA) recommends cuff width (CW) encircling 40% of the arm circumference (AC) and cuff length at least 80-100%. This study aimed to identify inpatients AC, the corresponding cuff size and the cuff size availability. In total, 81 AC were measured in the right arm. The cuff sizes to fit them were calculated according to AHA AC/CW width 0.40 ratio. The AC varied from 17.5 to 40.5 cm and the corresponding cuff width from 6 to 16 cm. The standard cuff 12 by 23 cm, the only size available in the clinics, was appropriate for only 17.3% of the subjects, whose AC varied between 32.5 and 34.3 cm. The lack of availability of different cuff sizes continues being a challenging problem to be faced. The standard cuff available, 12 cm large, did not fit 82.7% of the identified AC, resulting in over or underestimated BP registers.To avoid inaccurate blood pressure (BP) readings, the American Heart Association (AHA) recommends cuff width (CW) encircling 40% of the arm circumference (AC) and cuff length at least 80-100%. Objective: To identify inpatientsAC, the corresponding cuff size and the cuff size availability. Methods: 81 AC were measured in the right arm. The cuff sizes to fit them were calculated according to AHA AC/CW width 0.40 ratio. Results: The AC varied from 17.5 to 40.5 cm and the corresponding cuff width from 6 to 16cm. The standard cuff 12 by 23 cm, the only size available in the clinics, was appropriate for only 17.3% of the subjects, whose AC varied between 32.5 and 34.3 cm. Discussion: The lack of availability of different cuff sizes continues being a challenge problem to be faced. Conclusion: The standard cuff available, 12cm large, did not fit 82.7 of the identified AC, resulting in over or underestimated BP registers.

Blood pressure assessment in severe obesity: validation of a forearm approach.

Obesity is frequently associated with systemic hypertension. Blood pressure measure is inaccurate in severely obese patients because of poor cuff size fitting. The aim of the study is to assess the degree of agreement between the intra‐arterial method as the gold standard vs. noninvasive methods, i.e., forearm blood pressure and upper‐arm blood pressure measures.

Knowledge and practice outcomes after home blood pressure measurement education programs.

ObjectivesWe investigated the outcomes of three home blood pressure measurement (HBPM) education programs on adult knowledge and practice. MethodsWe chose a pretest/post-test design and randomly divided 95 adults into three groups: individual training (group A), group training (group B), and self-learning (group C), for education regarding HBPM in accordance with the Canadian Hypertension Education Program. Participants involved in groups A and B received interactive education led by a nurse. Participants in group C learned by themselves using an instruction booklet and a HBPM device lent to them for 7 days. Knowledge was assessed pretest and post-test by questionnaire. Skills were evaluated postintervention by direct observation. ResultsAnalysis of the 60 participants indicated significant knowledge improvement. Pretest scores of 38 (group A), 54 (group B), and 45% (group C) rose significantly to 97, 99, and 90%, respectively (pretest vs. post-test; P<0.0001). Individual and group training sessions were significantly more effective compared with the self-learning program, which was confirmed by differences between groups in post-test practice. Assessment scores: 74 (group A), 79 (group B), and 53% (group C; group A vs. group C; P=0.001, group B vs. group C; P=0.001). ConclusionOur findings indicate that adults attending an individual or group training program for HBPM retained its theoretical and practical principles better than those engaged in self-learning. Their success may be attributed to interaction with the nurse.

Medida da pressão arterial: circunferência braquial e disponibilidade de manguitos

To avoid inaccurate blood pressure (BP) readings, the American Heart Association (AHA) recommends cuff width (CW) encircling 40% of the arm circumference (AC) and cuff length at least 80-100%. This study aimed to identify inpatients AC, the corresponding cuff size and the cuff size availability. In total, 81 AC were measured in the right arm. The cuff sizes to fit them were calculated according to AHA AC/CW width 0.40 ratio. The AC varied from 17.5 to 40.5 cm and the corresponding cuff width from 6 to 16 cm. The standard cuff 12 by 23 cm, the only size available in the clinics, was appropriate for only 17.3% of the subjects, whose AC varied between 32.5 and 34.3 cm. The lack of availability of different cuff sizes continues being a challenging problem to be faced. The standard cuff available, 12 cm large, did not fit 82.7% of the identified AC, resulting in over or underestimated BP registers.To avoid inaccurate blood pressure (BP) readings, the American Heart Association (AHA) recommends cuff width (CW) encircling 40% of the arm circumference (AC) and cuff length at least 80-100%. Objective: To identify inpatientsAC, the corresponding cuff size and the cuff size availability. Methods: 81 AC were measured in the right arm. The cuff sizes to fit them were calculated according to AHA AC/CW width 0.40 ratio. Results: The AC varied from 17.5 to 40.5 cm and the corresponding cuff width from 6 to 16cm. The standard cuff 12 by 23 cm, the only size available in the clinics, was appropriate for only 17.3% of the subjects, whose AC varied between 32.5 and 34.3 cm. Discussion: The lack of availability of different cuff sizes continues being a challenge problem to be faced. Conclusion: The standard cuff available, 12cm large, did not fit 82.7 of the identified AC, resulting in over or underestimated BP registers.

Blood Pressure Measurement in the Post-SPRINT Era A Canadian Perspective

The Systolic Blood Pressure Intervention Trial (SPRINT) is in the process of changing our approach to diagnosing and treating hypertension.1 This study was stopped early because of a clear benefit in terms of reduced cardiovascular morbidity and mortality in higher-risk, older patients randomized to a target systolic blood pressure (BP) <120 mm Hg compared with the usual target of <140 mm Hg. Although it was not clearly stated when the results of SPRINT were initially published, it is now evident that office BP readings were taken using the automated office BP (AOBP) measurement technique. This method involves using a fully automated, oscillometric sphygmomanometer to record multiple BP readings with the patient resting quietly, without health professionals or research staff being present. In a subsequent commentary on the findings in SPRINT, Cushman et al2 mentioned some aspects of the BP measurement procedures followed in the study, but they did not say that the study personnel were not present during the readings. This point has now been clarified. In SPRINT, study staff were trained to program an Omron 907XL (Omron Healthcare Inc, Lake Forest, IL) to wait 5 minutes and then record 3 readings at 1-minute intervals. After the device was activated, research staff left the examining room, with the patient then being alone during the 5 minute rest period and while the 3 readings were recorded automatically (W.C. Cushman, personal communication, 2016). There is general agreement that AOBP readings are preferable to conventional BP measurement in routine clinical practice because AOBP is not subject to the white coat effect, with readings having a significantly stronger relationship to awake ambulatory and home BP. The advantages of AOBP are mostly because of minimal human involvement during the BP measurement process,3 with no opportunity for conversation, less observer bias (rounding off readings to …

Hypertension Canada's 2017 Guidelines for the Diagnosis, Assessment, Prevention, and Treatment of Pediatric Hypertension

After the 2016 guidelines for blood pressure measurement, diagnosis, and investigation of pediatric hypertension, we now present evidence-based guidelines for the prevention and treatment of hypertension in children. These guidelines were developed by Hypertension Canadas Guideline Committee pediatric subgroup after thorough evaluation of the available literature. Included are 10 guidelines specifically addressing health behaviour management, indications for drug therapy in children with hypertension, choice of therapy for children with primary hypertension, and goals of therapy for children with hypertension. Although the pediatric literature is inherently limited by small numbers of participants, fewer trials, and a prolonged latency to the development of vascular outcomes, this report reflects the current and highest level of evidence and provides guidance for primary care practitioners on the management of pediatric hypertension. Studies of therapeutic lifestyle modifications in children are available to guide current management and more antihypertensive drugs have been studied in children since the Food and Drug Administration Modernization Act. Consistent with Hypertension Canadas guideline policy, diagnostic and therapeutic algorithm tools will be developed and the guidelines will be reviewed annually and updated according to new evidence.