For the Canadian Hypertension Education Program, 2008 marks the ninth consecutive year that recommendations for the management of hypertension, with the goal of preventing cardiovascular disease, have been updated. The program follows a rigorous, systematic, evidenced-based approach to annually updating therapeutic recommendations. This year’s update focused on the health care professional’s role in encouraging appropriate patients to properly measure their blood pressure at home.
Blood pressure measurement at home
Blood pressure measurements taken at home have a stronger association with cardiovascular prognosis than office-based readings. Home measurement can confirm the diagnosis of hypertension, improve blood pressure control, reduce the need for medications in some patients, help identify white-coat and masked hypertension, and improve medication adherence in non-adherent patients. Health care professionals should encourage appropriate patients to assess their blood pressures properly at home. Brief patient instructions can be found on CFPlus.*
Instructions for purchasing and using home blood pressure measurement devices can be found at www.hypertension.ca and www.heartandstroke.ca/BP. The latter site’s e-health tool, the Blood Pressure Action Plan, has an interactive self-management portal (“My Health on Track”) for patients that provides a mechanism for recording and monitoring blood pressure measurements, medications, and lifestyle changes and encourages positive steps toward better blood pressure management. General sources for patient information on hypertension can be found in Table 1.
Internet resources for patient information: Many of these resources can be downloaded and printed or hard copies ordered for patients who do not use the Internet.
Other key recommendations
All Canadian adults require blood pressure assessment at all appropriate clinical visits
Blood pressure increases with age, such that 50% of Canadians older than age 65 have hypertension. For those with normal blood pressure at age 55, more than 90% will develop hypertension within an average lifespan. To identify hypertension, all adults require ongoing assessment of blood pressure throughout their lives and those with high-normal blood pressures require annual assessment.
Optimum management requires assessment of other cardiovascular risk factors (smoking, dyslipidemia, diabetes, sedentary behaviour, and unhealthy eating)
More than 90% of Canadians with hypertension have other cardiovascular risk factors. Identifying and managing risk factors beyond hypertension can reduce the overall risk of cardiovascular disease by more than 60% and can alter the blood pressure target (Table 2) and specific classes of antihypertensive medications recommended (Table 3).
Target values for blood pressure: Office measurement values vary depending on certain conditions.
Considerations in the individualization of antihypertensive therapy
Lifestyle modifications are effective in reducing blood pressure and cardiovascular risks
Hypertension can be prevented, blood pressure can be reduced, and other cardiovascular risks can be improved by a healthy diet, regular physical activity, moderation in alcohol consumption, reductions in dietary sodium, and, in some, stress reduction (Table 4). Simple and brief health care professional interventions markedly increase the probability of patient adherence to lifestyle changes. A section of the Heart and Stroke Foundation website (www.heartandstroke.ca/BP) has been designed to assess hypertensive patients’ lifestyles and provides individualized approaches and monitoring to assist lifestyle changes.
Lifestyle therapies to reduce the possibility of becoming hypertensive, reduce blood pressure, and reduce the risk of blood pressure–related cardiovascular complications
Treat patients to the recommended targets to achieve optimum cardiovascular risk reduction
Greater reduction in cardiovascular disease is achieved by lowering blood pressure to the appropriate targets (Table 2).
Combination therapy (both drugs and lifestyle changes) is generally necessary to achieve target blood pressures
Most patients require more than 1 anti-hypertensive drug combined with lifestyle changes to achieve recommended blood pressure targets. When using 2 drugs to lower blood pressure, combinations of β–blockers, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers produce a less-than-additive hypotensive effect. If blood pressure is > 20/10 mm Hg above target, therapy can be initiated with a combination of 2 first-line antihypertensive drugs.
Monitor patients whose blood pressure is above target at least every 2 months
To achieve blood pressure control, follow-up at short intervals is required to improve patient adherence to therapy and to increase the intensity of treatment.
Focus on adherence
Nonadherence to therapy is one of the biggest challenges to improving blood pressure control. Adherence to therapy should be assessed at each visit and specific interventions (visit CFPlus*) can help improve patient adherence to therapy.
Resources
A version of the hypertension recommendations designed for patient and public education has been developed to assist health care practitioners in managing hypertension. The summary is available electronically at www.hypertension.ca and www.heartandstroke.ca. Bulk orders of 25 or more copies can be obtained by contacting hyperten{at}ucalgary.ca. A free, confidential, Web-based tool for patients is available at www.heartandstroke.ca/BP. Developed by the Heart and Stroke Foundation, the Blood Pressure Action Plan enables patients to build a personalized action plan tailored to their risk profiles, promotes self-management, and helps patients make lifestyle changes, monitor their blood pressure, and print reports for their health care providers.
Acknowledgment
This manuscript was written by Dr N. Campbell, with the assistance of the Canadian Hypertension Education Program Executive, Dr D.W. McKay, and Dr G. Tremblay.
Footnotes
↵* Additional tools for blood pressure and hypertension management are available at www.cfp.ca. Go to the full text of this article on-line, then click on CFPlus in the menu at the top right-hand side of the page.
Competing interests
None declared
The Canadian Hypertension Education Program is overseen by a steering committee that includes the Canadian Council of Cardiovascular Nurses, the Canadian Pharmacy Association, the College of Family Physicians of Canada, the Public Health Agency of Canada, the Canadian Hypertension Society, Blood Pressure Canada, and the Heart and Stroke Foundation of Canada. The program is unique in having a specific implementation task force with subgroups of family physicians, nurses, pharmacists, and medical specialists to oversee translation of the recommendations into education material suited to their disciplines; the program also has a task force to evaluate whether the process is improving hypertension management in Canada.
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