Mark Gelfer

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.

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.

A Call to Regulate Manufacture and Marketing of Blood Pressure Devices and Cuffs: A Position Statement From the World Hypertension League, International Society of Hypertension and Supporting Hypertension Organizations

From the Departments of Medicine, Physiology and Pharmacology and Community Health Sciences, O’Brien Institute for Public Health and Libin Cardiovascular Institute of Alberta, University of Calgary,Calgary, AB; Department of Family Practice, University of British Columbia, Vancouver, BC, Canada; Hypertension Center STRIDE-7, Sotiria Hospital, Third University Department of Medicine, Athens, Greece; AAMI Sphygmomanometer Committee, Pediatric Exercise Science, Memphis, TN, USA; Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Improving Health Outcomes at American Medical Association; Department of Family and Community Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Clinical Pharmacology and General Internal Medicine, University of Alberta, Edmonton, AB, Canada; MRC Research Unit on Hypertension and Cardiovascular Disease, Hypertension in Africa Research Team, North-West University, Potchefstroom, South Africa; Molecular Pharmacology, University College Dublin, Dublin, Ireland; Corvallis, Montana, USA; and University of Glasgow, Glasgow, UK

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 …

Healthy food procurement policy: an important intervention to aid the reduction in chronic noncommunicable diseases.

In 2010, unhealthy diets were estimated to be the leading risk for death and disability in Canada and globally. Although important, policies aimed at improving individuals skills in selecting and eating healthy foods has had a limited effect. Policies that create healthy eating environments are strongly recommended but have not yet been effectively and/or broadly implemented in Canada. Widespread adoption of healthy food procurement policies are strongly recommended in this policy statement from the Hypertension Advisory Committee with support from 15 major national health organizations. The policy statement calls on governments to take a leadership role, but also outlines key roles for the commercial and noncommercial sectors including health and scientific organizations and the Canadian public. The policy statement is based on a systematic review of healthy food procurement interventions that found them to be almost uniformly effective at improving sales and purchases of healthy foods. Successful food procurement policies are nearly always accompanied by supporting education programs and some by pricing policies. Ensuring access and availability to affordable healthy foods and beverages in public and private sector settings could play a substantive role in the prevention of noncommunicable diseases and health risks such as obesity, hypertension, and ultimately improve cardiovascular health.

Recommended standards for assessing blood pressure in human research where blood pressure or hypertension is a major focus

Recommended standards for assessing blood pressure in human research where blood pressure or hypertension is a major focus

Expediting the Diagnosis of Hypertension; The Canadian Hypertension Education Program 2015 Recommendations

The diagnosis of hypertension is fundamental to the practice of medicine. Increased blood pressure (BP) is the second leading global risk factor for death and disability (behind unhealthy diets), accounting for 18% of global deaths (>9 million deaths per year).1 Contemporary guidelines recommend assessing BP at every care visit; thus, BP measurement is probably the most commonly performed diagnostic maneuver in medicine.2 Importantly, evolving technology is making the diagnosis of hypertension more accurate, reliable, and rapid.