Hypertension Evidence and

CHS Guidelines
2005

Continuing Medical Implementation

Evidence Evolution
Hard end-points

Mortality
CVD events
Cerebrovascular events
PVD events
CHF
Progression to ESRD

Surrogate end-points
Rising CR
Progression to proteinuria
Progression/regression of micro-albuminuria

Continuing Medical Implementation

 Continuing Medical Implementation

Evidence Evolution

MRC-1985
HAPPHY-1987
EWPHE-1991
STOP-1991
SHEP-1991-4
STONE-1996
SYS-EUR-1997
SYS-CHINA-1996-98
HOT-1998
UKPDS -1998
CAPPP-1999
STOP 2 -1999

HOPE -2000
MICRO-HOPE -2000
INSIGHT -2000
NORDIL -2000
CALM -2000
INDT -2001
IRMA -2001
RENAAL -2001
PROGRESS -2001
LIFE-2002
SCOPE 2002
ALLHAT 2002

Continuing Medical Implementation

CHS Guideline Evolution 2002

Impact of the ALLHAT - 2002
Consideration of

PROGRESS - 2001
IDNT - 2001
RENAAL - 2001
ANBP2 - 2003

Continuing Medical Implementation

Treat Hypertension in the Context of Overall

2003
Cardiovascular Risk
Grade 1
Other Risk Factors &
Disease History

I.No other risk

factors
II.1-2 risk factors
III.3 risk factors or
TOD or De novo
diabetes
IV. ACC or Diabetes

SBP 140
-159 or
DBP 90
-99
(mild hypertension)

Grade 2

Grade 3

SBP 160
-179 or
SBP ? 180
DBP 100
-109
or DBP ? 110
(moderate hypertension) (severe hypertension)

Low risk

Medium risk

High risk

Medium risk

Medium risk

V high risk

High risk

High risk

V high risk

V high risk

V high risk

V high risk

Risk strata (typical % 10 year risk of stroke, myocardial

tion or
infarc
death)
<15%

15-20%

20-30%

30%

Adapted from WHO/ISH Recommendations on Hypertension.

ChalmersJ et al.J Hyper 1999;17:151
-85.

Continuing Medical Implementation

Canadian Hypertension Education Program Recommendations

37

Guideline Evolution 2004

Hypertension

Post stroke

PROGRESS - 2001

ALLHAT - 2002
LIFE - 2002
ANBP2 - 2003
OPTIMAAL - 2002
EPHESUS - 2003
CHARM - 2003

Psaty-Network meta-analysis
Law Meta-analysis
Staessen
Meta-regression analysis

ASA and Statins

HOT - 1998
ASCOT-LLA - 2003
PROSPER - 2002
HPS - 2002
ALLHAT-LLT - 2002

Continuing Medical Implementation

CHS January 2004

Indications for drug therapy in adults with hypertension
without compelling indications for specific agents:
1.

Strongly consider antihypertensive therapy if DBP 90

with TOD or CV risk factors

2.
3.
4.

Elevated SBP, smoking, dyslipidemia, strong FH CAD, truncal

obesity, sedentary lifestyle

Rx antihypertensive therapy for DBP 100 or SBP

160 without TOD or CV risk factors
Rx statin therapy in HTN patients > 40 yr of age with 3
or more CV risk factors or established atherosclerotic
disease
Strongly consider low dose ASA in HTN patients > 50
yr of age. (Caution if BP not controlled)

Continuing Medical Implementation

Cardiovascular risk factors for consideration of statin

therapy in non-hyperlipidemic patients with hypertension
(derived from ASCOT-LLA)

Male
Age 55 years or older
Left ventricular
hypertrophy
Other electrocardiogram
abnormalities:
left bundle branch block,
left ventricular strain
pattern, abnormal Q waves
or ST-T changes compatible
with ischemic heart disease

Peripheral arterial disease

Previous stroke or
transient ischemic attack
Microalbuminuria or
proteinuria
Diabetes mellitus
Smoking
Family history of
premature cardiovascular
disease
TC/HDL 6

Continuing Medical Implementation

CHS January 2004

Recommendations for individuals with diastolic hypertension
with or without systolic hypertension. Initial therapy:

Grade A:
thiazide diuretics
Grade B:
-blockers (in those
younger than 60 years)
ACE inhibitors (in
non-Blacks)
long-acting
dihydropyridine CCBs
angiotensin receptor
antagonists (ARBs)

If adverse effects substitute

another drug from this group
Avoid hypokalemia: Use K
sparing diuretic with thiazides
Use combination therapy if
partial response
Add other classes if poor
control
- blocker, centrally acting
agents or non-DHP CCB

- blocker not recommended as

first line agents

Continuing Medical Implementation

CHS January 2004

Recommendations for individuals with
Isolated Systolic Hypertension Initial therapy:

Grade A:
thiazide diuretics
long-acting dihydropyridine
CCBs

Grade B:
angiotensin receptor
antagonists (ARBs)

If adverse effects substitute

another drug from this group
Avoid hypokalemia: Use K
sparing diuretic with
thiazides

Use combination therapy

if partial response
Add other classes if poor
control or adverse effects
- blocker, ACE inhibitors,
centrally acting agents or
non-DHP CCB

-blockers and -blockers

are not recommended as
first line agents

Continuing Medical Implementation

CHS January 2004

Considerations for individualization of anti-hypertensive therapy

Indication

Initial Therapy

Second line Rx

Notes/Cautions

DM with nephropathy

ACE-i or ARB

addition thiazide, *
-blockers , LA-CCB,
ACE/ARB combo

DM without
nephropathy

ACE-i or ARB
or thiazide

Combo1st line Rx or *blockers, LA-CCB

*Cardioselective
-blockers
If CR >150 mmol/l use
loop diuretic for volume
control

Angina

-blockers + strongly
consider ACE-i

LA-CCB

Prior MI

-blockers + ACE-i

Combine additional Rx

CHF

-blockers + ACE-i +
spironolactone (ARB if
ACE-i intolerant )

Hydralazine /ISDN:
thiazide or loop diuretics
as additive therapy

Prior CVA or TIA

ACE-i/diuretic
combination

Renal Disease

ACE-i/diuretic as
additive Rx

LVH

ACE-I, ARBs, DHPCCB, thiazide,

-blockers < 55 yr

Avoid short acting

nifedipine

Avoid non DHP-CCB

(diltiazem, verapamil)
BP reduction recurrent
events

ARB if ACE-i intolerant

Combo other agents

Avoid ACE-i if bilateral

Renal artery stenosis
Avoid hydralazine and
minoxidil

Guideline Evolution 2005

SHEAF Study
Ohasama Cohort
OvA Study
Staessen et al
Thijs et al
VALUE
ACTION
INVEST
VALIANT
BP Lowering Treatment Trialists Collaboration

Continuing Medical Implementation

Guideline Evolution 2005

Key Messages
Expedited diagnosis of hypertension (HTN)
Use any validated technology to diagnose HTN
Office BP
Ambulatory BP
Self/Home BP

Focus on BP control rather than preferred

first line agent
Continuing Medical Implementation

Guideline Evolution 2005

Integrate global CVD management into
HTN management plan
Lifestyle modifications are key
Combination therapies (lifestyle and Rx) to
achieve target
Focus on adherence

Continuing Medical Implementation

Choice of Pharmacological Treatment

Associated risk factors?
or
Target organ damage/complications?
or
Concomitant diseases/conditions?
NO

Treatment in the
absence of compelling
indication

YES

Individualized
Treatment
(with compelling indications)

16

Choice of pharmacological treatment

for hypertensive patients without other
compelling indications:
Treatment of Systolic Diastolic
hypertension
Treatment of Isolated Systolic
hypertension

17

Treatment of Adults with Systolic-Diastolic

Hypertension without Other Compelling
Indications
TARGET <140 mm Hg systolic and < 90 mmHg diastolic
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy

Thiazide

ACE-I

ARB

Longacting
CCB

Betablocker*

* Not indicated as first line therapy over 60

18

Combination Therapy for Systolic-Diastolic

Hypertension without Other Compelling Indications
If partial response to monotherapy

1. Dual Combination Therapy

CONSIDER

2. Triple or Quadruple Therapy

Nonadherence?
Secondary HTN?
Interfering drugs or lifestyle?
White coat effect?
Resistant Hypertension?

If blood pressure is still not controlled, or there are adverse

effects, other classes of antihypertensive drugs may be combined
(such as alpha blockers, centrally acting agents, or
nondihydropyridine calcium channel blocker).
19

Summary: Treatment of Systolic-Diastolic Hypertension

without Other Compelling Indications
TARGET <140 mm Hg systolic and < 90 mmHg diastolic
Lifestyle modification
therapy

Thiazide
diuretic

CONSIDER
Nonadherence?
Secondary HTN?
Interfering drugs or
lifestyle?
White coat effect?

ACE-I

ARB

Long-acting
CCB

Betablocker*

Dual Combination

Triple or Quadruple
Therapy

* Not indicated as first line therapy over 60

20

Choice of pharmacological treatment

for hypertensive patients with other
compelling indications
Treatment of diastolic-systolic
hypertension
Treatment of isolated systolic
hypertension

21

Treatment Algorithm for Isolated Systolic Hypertension

without Other Compelling Indications
TARGET <140 mmHg Systolic BP
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy

Thiazide
diuretic

ARB

Long-acting
DHP CCB

22

Summary: Treatment of Isolated Systolic Hypertension

without Other Compelling Indications
TARGET <140 mmHg Systolic BP
Lifestyle modification
therapy

Thiazide
diuretic

CONSIDER
Nonadherence?
Secondary HTN?
Interfering drugs or
lifestyle?
White coat effect?

ARB

Dual combination

Triple or Quadruple*
combination

Long-acting
DHP CCB

*If blood pressure is still not

controlled, or there are
adverse effects, other
classes of antihypertensive
drugs may be combined
(such as alpha blockers,
centrally acting agents, or
nondihydropyridine calcium
channel blocker).
23

Anti-Hypertensive
Therapeutic Classification
(K sparing)

DIURETIC

-blocker*

(Thiazide)

Long Acting
CCB*

ACE inhibitor
ARB

*Caution combining non-DHP-CCB (especially verapamil) with a -blocker

Continuing Medical Implementation

First Line Therapy

(K sparing)

DIURETIC
(Thiazide)

Long Acting
CCB*

-blocker*
ACE inhibitor
ARB

*Caution combining non-DHP-CCB (especially verapamil) with a -blocker

Continuing Medical Implementation

Systolic/Diastolic HTN
(K sparing)

DIURETIC

-blocker*

(Thiazide)

Long Acting
CCB*

ACE inhibitor
ARB

*Caution combining non-DHP-CCB (especially verapamil) with a -blocker

Continuing Medical Implementation

Post-CVA or TIA
(K sparing)

DIURETIC

-blocker*

(Thiazide)

Long Acting
CCB*

ACE inhibitor
ARB

*Caution combining non-DHP-CCB (especially verapamil) with a -blocker

Continuing Medical Implementation

Isolated Systolic HTN-Elderly

(K sparing)

DIURETIC

-blocker

(Thiazide)
Long Acting

DHP-CCB

ACE inhibitor
ARB

Continuing Medical Implementation

Isolated Systolic HTN-Elderly

(K sparing)

DIURETIC

-blocker

(Thiazide)
Long Acting

DHP-CCB

ACE inhibitor/
ARB

Continuing Medical Implementation

CAD - Chronic Angina

(K sparing)

DIURETIC

-blocker*

(Thiazide)

Long Acting
CCB*

ACE inhibitor
ARB

Consider adding ACE-I for all patients with

documented CAD (Grade A) based on
HOPE and EUROPA
Continuing
Medical
Implementation
*Caution
combining
non-DHP-CCB
(especially verapamil) with a -blocker

CAD-Recent MI or LV
Dysfunction
(K sparing)

DIURETIC

-blocker*

(Thiazide)

Long Acting
CCB*

ACE inhibitor

Continuing
Medical
Implementation
*Caution
combining
non-DHP-CCB
(especially verapamil) with a -blocker

CHF + HTN

DIURETIC

-blocker

(loop/spironolactone)
Long Acting

DHP-CCB

ACE inhibitor
ARB if ACE
intolerant

Continuing Medical Implementation

DM without Nephropathy
BP Target < 130/80
(K sparing)
DIURETIC or

-blocker*

(Thiazide)

Long Acting
CCB*

ACE inhibitor
or ARB

Continuing
Medical
Implementation
*Caution
combining
non-DHP-CCB
(especially verapamil) with a -blocker

DM with Nephropathy
First line therapy:
(K sparing)
DIURETIC

-blocker*

(Thiazide)

Long Acting
CCB*

ACE inhibitor
or ARB

Continuing
Medical
Implementation
*Caution
combining
non-DHP-CCB
(especially verapamil) with a -blocker

DM with Nephropathy
Second line therapy:
(K sparing)
DIURETIC

-blocker*

(Thiazide)

Long Acting
CCB*

ACE inhibitor
or ARB

Continuing
Medical
Implementation
*Caution
combining
non-DHP-CCB
(especially verapamil) with a -blocker

DM with Nephropathy
Second line therapy:
(K sparing)
DIURETIC
(Thiazide)

Long Acting
CCB*

Cardioselective
-blocker*
ACE inhibitor
or ARB

Continuing
Medical
Implementation
*Caution
combining
non-DHP-CCB
(especially verapamil) with a -blocker

DM with Nephropathy
Second line therapy:
(K sparing)
DIURETIC

-blocker*

(Thiazide)

Long Acting
CCB*

ACE inhibitor
or ARB

Continuing
Medical
Implementation
*Caution
combining
non-DHP-CCB
(especially verapamil) with a -blocker

DM with Nephropathy
Second line therapy:
(K sparing)
DIURETIC

-blocker*

(Thiazide)

Long Acting
CCB*

ACE inhibitor
and ARB

Continuing
Medical
Implementation
*Caution
combining
non-DHP-CCB
(especially verapamil) with a -blocker

Non-diabetic Nephropathy
BP Target < 125/75
DIURETIC
(Thiazide or loop)

-blocker*

As additive
therapy

Long Acting
CCB*

ACE inhibitor
ARB if ACE
intolerant

Continuing
Medical
Implementation
*Caution
combining
non-DHP-CCB
(especially verapamil) with a -blocker

See www.hypertension.ca for

Complete Recommendations

Continuing Medical Implementation

Global Vascular Protection for

Patients with Hypertension

Diet (DASH)
Weight loss (waist < 102 cm M and 88 cm F)
Exercise- 30 to 60 min 4-7 days/week
Smoking Cessation
Moderate Alcohol intake
Low dose ASA if BP controlled
Statin
ACE inhibitors for established vascular disease
ACE inhibitors or ARBs for diabetics or patients with
kidney disease

Continuing Medical Implementation

Important Messages for the

Management of Hypertension
Expedite the diagnosis of hypertension
Assess the risk
Treat to target
Lifestyle
Combination therapy

Promote adherence

42

Summary
Hypertension is a major factor responsible
for progression of atherosclerotic disease.
Therefore, a comprehensive treatment of
hypertension should aim at CV risk reduction
strategies, including management of all
associated risk factors.

43