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LetterCommentary

Response

Mark Gelfer, Martin Dawes, Janusz Kaczorowski, Raj Padwal and Lyne Cloutier
Canadian Family Physician April 2016, 62 (4) 306;
Mark Gelfer
Vancouver, BC
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Martin Dawes
Vancouver, BC
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Janusz Kaczorowski
Montreal, Que
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Raj Padwal
Edmonton, Alta
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Lyne Cloutier
Trois-Rivieres, Que
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We thank Dr Tsai for his thoughtful comments and questions. Our paper “Diagnosing hypertension. Evidence supporting the 2015 recommendations of the Canadian Hypertension Education Program”1 is a review article and speaks mainly of the value of improving the diagnosis of hypertension through improved blood pressure (BP) measurement in the office and in out-of-office settings. The full evidence-based discussions are published elsewhere.2,3

Dr Tsai’s initial comment on the cost to patients of out-of-office BP measurement is valid—very few jurisdictions in Canada cover ambulatory BP measurement (ABPM) through provincial health care plans, and no private insurance companies cover ABPM or home BP measurement. We agree this is a serious problem in Canada and is very short-sighted. The mandate of the Canadian Hypertension Education Program (CHEP) is to review the clinical evidence and create recommendations for practice. It is hoped that once the evidence is published, funders will see the merit of providing the necessary technologies and fee codes to improve accuracy of BP measurement. Efforts are currently under way in several provinces to bring the benefit of ABPM testing to the publicly funded system. As we wrote, other jurisdictions (United Kingdom and United States) have made similar recommendations and face the same economic issue for their patients.

The published CHEP recommendations provide a description for instructing patients in performing home BP measurement. Dr Tsai’s description is close but not quite accurate: “duplicate measures [should be taken], morning and evening, for an initial 7-day period. First-day home BP values should not be considered.”3

Although we welcome comments and questions on our recommendations, the evidence does not support Dr Tsai’s call for pharmacologic management of patients with white-coat hypertension (WCH). We addressed this concern previously4,5 and calculated the absolute risk reduction that would be obtained by treating all WCH patients with medications, representing a number needed to treat of 1000 per year. Published evidence shows that treating patients with WCH might lower their office BP readings but not their ABPM6 or cardiovascular risk.7,8

Finally, CHEP agrees fully with Dr Tsai’s final comment that as WCH might not be benign, a healthy lifestyle should be encouraged and supported at all times. We do not disagree with his addition of the term emphasized.

Footnotes

  • Competing interests

    Dr Gelfer has received consulting fees from BpTRU, Microlife, and PharmaSmart in the past. Dr Dawes has received research funds from AstraZeneca, Pfizer, Janssen, Merck, Roche, and GlaxoSmithKline.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Gelfer M,
    2. Dawes M,
    3. Kaczorowski J,
    4. Padwal R,
    5. Cloutier L
    . Diagnosing hypertension. Evidence supporting the 2015 recommendations of the Canadian Hypertension Education Program. Can Fam Physician 2015;61:957-61. (Eng), e499-503 (Fr).
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    1. Cloutier L,
    2. Daskalopoulou SS,
    3. Padwal RS,
    4. Lamarre-Cliche M,
    5. Bolli P,
    6. McLean D,
    7. et al
    . A new algorithm for the diagnosis of hypertension in Canada. Can J Cardiol 2015;31(5):620-30. Epub 2015 Feb 19.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Daskalopoulou SS,
    2. Rabi DM,
    3. Zarnke KB,
    4. Dasgupta K,
    5. Nerenberg K,
    6. Cloutier L,
    7. et al
    . The 2015 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 2015;31(5):549-68.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Gelfer M,
    2. Padwal RS,
    3. Cloutier L
    . Reply to Spence—white coat hypertension: what does it mean and what should we do until we are sure? Can J Cardiol 2015;32(2):270.e7. Epub 2015 Apr 18.
    OpenUrlPubMed
  5. 5.↵
    1. Stergiou GS,
    2. Asayama K,
    3. Thijs L,
    4. Kollias A,
    5. Niiranen TJ,
    6. Hozawa A,
    7. et al
    . Prognosis of white-coat and masked hypertension: International Database of Home Blood Pressure in Relation to Cardiovascular Outcome. Hypertension 2014;63(4):675-82. Epub 2014 Jan 13.
    OpenUrlCrossRef
  6. 6.↵
    1. Pickering TG
    . White coat hypertension. Curr Opin Nephrol Hypertens 1996;5(2):192-8.
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Fagard RH,
    2. Staessen JA,
    3. Thijs L,
    4. Gasowski J,
    5. Bulpitt CJ,
    6. Clement D,
    7. et al
    . Response to antihypertensive therapy in older patients with sustained and nonsustained systolic hypertension. Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Circulation 2000;102(10):1139-44.
    OpenUrlAbstract/FREE Full Text
  8. 8.↵
    1. Pickering TG,
    2. Levenstein M,
    3. Walmsley P
    . Differential effects of doxazosin on clinic and ambulatory pressure according to age, gender, and presence of white coat hypertension. Results of the HALT Study. Hypertension and Lipid Trial Study Group. Am J Hypertens 1994;7(9 Pt 1):848-52.
    OpenUrlAbstract/FREE Full Text
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Canadian Family Physician: 62 (4)
Canadian Family Physician
Vol. 62, Issue 4
1 Apr 2016
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