Skip to main content

Main menu

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums

User menu

  • My alerts

Search

  • Advanced search
The College of Family Physicians of Canada
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums
  • My alerts
The College of Family Physicians of Canada

Advanced Search

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • RSS feeds
  • Follow cfp Template on Twitter
  • LinkedIn
  • Instagram
OtherPractice

Managing hypertension in primary care

Khrystine Waked, Jeff Nagge and Kelly Grindrod
Canadian Family Physician October 2019; 65 (10) 725-729;
Khrystine Waked
Pharmacy resident at the Centre for Family Medicine Family Health Team in Kitchener, Ont.
PharmD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Jeff Nagge
Clinical Associate Professor in the School of Pharmacy at the University of Waterloo in Ontario, and a clinical pharmacist at the Centre for Family Medicine.
PharmD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Kelly Grindrod
Associate Professor in the School of Pharmacy at the University of Waterloo, and a clinical pharmacist at the Kitchener Downtown Community Health Centre.
PharmD MSc
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • CFPlus
  • eLetters
  • Info & Metrics
  • PDF
Loading

In Canada, hypertension is one of the most common reasons for patients to visit their family physicians.1 Further, most patients with hypertension are managed in a primary care setting by family physicians rather than other specialists.2 With cardiovascular disease being one of the leading causes of death in Canada, improved management of hypertension is key in reducing risk.3

To support primary care providers with the management of hypertension, as well as patients with self-measurement of blood pressure at home, we created 2 infographics (Figures 1 and 2), also available at CFPlus.* To do this, we considered evidence from landmark trials and recommendations from Canadian and American guidelines. The 2-page infographic (Figure 1) on hypertension management is described in the following sections.

Figure 1
  • Download figure
  • Open in new tab
Figure 1
  • Download figure
  • Open in new tab
Figure 1
Figure 2
  • Download figure
  • Open in new tab
Figure 2

When to start a drug?

Evidence for when to start a drug is mixed, and primary care providers should choose a threshold based on patient preference (drug or nondrug options), comorbidities, and frailty. Additionally, it is important to rule out short-term factors that could be temporarily increasing blood pressure (eg, sickness, pain, stress, trauma).

For primary prevention (no history of coronary artery disease, heart attack, stroke, heart failure, or other cardiovascular risk factors†), strong evidence supports the use of an antihypertensive drug once the blood pressure level exceeds 160/100 mm Hg.4,5 For secondary prevention (history of heart attack or stroke) or patients with a 10-year Framingham cardiovascular risk score of 15% or higher, evidence to support the use of an antihypertensive drug once the blood pressure level exceeds 140/90 mm Hg is generally positive.4 For patients with diabetes (type 1 or type 2), lower-quality evidence‡ suggests that a drug should be started once the blood pressure level exceeds 130/80 mm Hg.4

What drug to start first?

To start, prescribe the lowest available dose of a first-line antihypertensive drug and schedule a follow-up blood pressure check 4 weeks later.6 This is the approach used in several landmark antihypertensive trials such as ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) and SPRINT (Systolic Blood Pressure Intervention Trial). Recommended first-line monotherapy drugs are listed in Figure 1.* Of note, long-acting thiazide-like diuretics such as chlorthalidone and calcium channel blockers (CCBs) such as amlodipine are more effective and safer than angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in black patients.7

When choosing a drug, consider the landmark ALLHAT study, which demonstrated that chlorthalidone lowers cardiovascular risk more than amlodipine and lisinopril do.8 Chlorthalidone is longer acting and has more consistent evidence supporting its blood pressure–lowering and cardiovascular risk–lowering effects than hydrochlorothiazide does.9

What blood pressure goal to aim for?

Once drug therapy is started, consider the patient’s overall health and preferences when setting a blood pressure goal. Strong evidence suggests that most patients taking an antihypertensive medication should aim for a blood pressure level below 140/90 mm Hg.4 Grade C evidence suggests that patients who have diabetes should aim for a level below 130/80 mm Hg.4 High-risk patients with specific cardiovascular risk factors might consent to aim for a systolic goal of 120 mm Hg.4

For patients whose blood pressure levels are consistently above their goals despite taking the usual dose of a first-line antihypertensive drug, expert opinion suggests adding a drug with a complementary mechanism of action.4,10 For example, a patient taking chlorthalidone should usually have an ACEI or ARB added instead of a CCB.4,10

Follow-up with the patient

Measuring blood pressure in the clinic and at home.

Prescribers might find it helpful to ask patients to monitor their blood pressure at home if they suspect a white-coat effect.4,11 To ensure accurate results are obtained, patients should be taught proper technique (Figure 2).*

Laboratory monitoring.

Before initiating or adjusting the doses of ACEIs, ARBs, or diuretics, electrolyte and serum creatinine levels should be measured at baseline. Once the drug or new dose has been started, the same laboratory parameters should be measured within 1 to 2 weeks. Patients at higher risk of hyperkalemia or acute kidney injury should get bloodwork within 7 days.12

If serum creatinine levels rise higher than 30% over baseline after starting an ACEI or ARB, the drug should be stopped and serum creatinine levels rechecked in 3 days.13 If the level increase is from a temporary cause such as dehydration, the drug can be restarted once the event is resolved.13 If no cause is identified, consider the possibility of renal artery stenosis or a drug-induced kidney injury. With both options, the drug should be discontinued, and the primary care provider should request the appropriate laboratory workup for the patient and the patient might require referral to nephrology.13 Angiotensin-converting enzyme inhibitors and ARBs can also increase serum potassium concentrations. A serum potassium level higher than 5.6 mmol/L generally requires a dose reduction or discontinuation of the medication.14

Special situations

Resistant hypertension.

Patients who do not reach their blood pressure goals despite having used at least 3 different antihypertensive drugs—a diuretic, an ACEI or ARB, and a CCB—might have resistant hypertension.15 If the patient is adherent to therapy and the drugs are at the patient’s maximally tolerated doses, it is more effective to add spironolactone than a β-blocker or an α-blocker.16 If spironolactone is added, monitor for elevated potassium levels.16

When to refer.

If you suspect your patient is experiencing a hypertensive emergency, refer him or her to the hospital. Hypertensive emergencies are characterized by acute target organ damage (kidneys, heart, or brain) in the setting of a notably elevated blood pressure level. There is no specific blood pressure measurement that defines a hypertensive emergency, as it is dependent on the signs or symptoms of organ damage (see Figure 1 for a list of symptoms).17

Conclusion

Our 2-page infographic on managing hypertension (Figure 1) is a great tool for primary care providers to use as an easy reference to our discussion in this article. Figure 2 provides a stepwise approach to taking blood pressure at home and can be a resource for your patients. Each figure can be easily accessed from CFPlus.*

Acknowledgments

We thank Adrian Poon for designing the infographics, and Rosemary Killeen for editing the infographics. This work was supported in part by the Ontario College of Pharmacists through funding in support of the Pharmacy5in5 program.

Notes

We encourage readers to share some of their practice experience: the neat little tricks that solve difficult clinical situations. Praxis articles can be submitted online at http://mc.manuscriptcentral.com/cfp or through the CFP website (www.cfp.ca) under “Authors and Reviewers.”

Footnotes

  • ↵* The infographics on managing hypertension (Figure 1) and on how to take blood pressure at home (Figure 2) are available at www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.

  • ↵† Risk factors include increasing age, tobacco smoking, poor eating habits, excess weight in the abdominal area, uncontrolled diabetes, high cholesterol, male sex, and family history of cardiovascular disease.4

  • ↵ǂ Grade C evidence involves the following: “Recommendations are based on trials that have lower levels of internal validity and/or precision, or trials reporting unvalidated surrogate outcomes, or results from non-randomized observational studies.”4

  • Competing interests

    None declared

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Kaczorowski J,
    2. Myers MG,
    3. Gelfer M,
    4. Dawes M,
    5. Mang EJ,
    6. Berg A,
    7. et al
    . How do family physicians measure blood pressure in routine clinical practice? National survey of Canadian family physicians. Can Fam Physician 2017;63:e193-9. Available from: www.cfp.ca/content/cfp/63/3/e193.full.pdf. Accessed 2019 Aug 28.
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    1. Godwin M,
    2. Williamson T,
    3. Khan S,
    4. Kaczorowski J,
    5. Asghari S,
    6. Morkem R,
    7. et al
    . Prevalence and management of hypertension in primary care practices with electronic medical records: a report from the Canadian Primary Care Sentinel Surveillance Network. CMAJ Open 2015;3(1):E76-82.
    OpenUrl
  3. 3.↵
    1. Government of Canada [website].
    Heart disease in Canada. Ottawa, ON: Government of Canada; 2017. Available from: www.canada.ca/en/public-health/services/publications/diseases-conditions/heart-disease-canada.html. Accessed 2019 Mar 29.
  4. 4.↵
    1. Nerenberg KA,
    2. Zarnke KB,
    3. Leung AA,
    4. Dasgupta K,
    5. Butalia S,
    6. McBrien K,
    7. et al
    . Hypertension Canada’s 2018 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children. Can J Cardiol 2018;34(5):506-25. Epub 2018 Mar 1.
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Benjamin EJ,
    2. Muntner P,
    3. Alonso A,
    4. Bittencourt MS,
    5. Callaway CW,
    6. Carson AP,
    7. et al
    . Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation 2019;139(10):e56-528.
    OpenUrlCrossRef
  6. 6.↵
    1. SPRINT Research Group,
    2. Wright JT Jr,
    3. Williamson JD,
    4. Whelton PK,
    5. Snyder JK,
    6. Sink KM,
    7. et al
    . A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015;373(22):2103-16. Epub 2015 Nov 9. Erratum in: N Engl J Med 2017;377(25):2506.
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Whelton PK,
    2. Carey RM,
    3. Aronow WS,
    4. Casey DE Jr,
    5. Collins KJ,
    6. Dennison Himmelfarb C,
    7. et al
    . 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018;71(6):e13-115. Epub 2017 Nov 13. Erratum in: Hypertension 2018;71(6):e140–4.
    OpenUrlCrossRef
  8. 8.↵
    1. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group.
    The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002;288(23):2981-97. Errata in: JAMA 2003;289(2):178, JAMA 2004;291(18):2196.
    OpenUrlCrossRefPubMed
  9. 9.↵
    1. Roush GC,
    2. Holford TR,
    3. Guddati AK
    . Chlorthalidone compared with hydrochlorothiazide in reducing cardiovascular events; systematic review and network meta-analyses. Hypertension 2012;59(6):1110-7. Epub 2012 Apr 23.
    OpenUrlCrossRef
  10. 10.↵
    1. Canadian Hypertension Recommendations Working Group.
    The 2001 Canadian hypertension recommendations. Perspect Cardiol 2002;18(2):38-46.
    OpenUrl
  11. 11.↵
    1. Muntner P,
    2. Shimbo D,
    3. Carey RM,
    4. Charleston JB,
    5. Gaillard T,
    6. Misra S,
    7. et al
    . Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension 2019;71(5):e35-66.
    OpenUrl
  12. 12.↵
    1. Cohen DL,
    2. Townsend RR
    . What should the physician do when creatinine increases after starting an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker? J Clin Hypertens (Greenwich) 2008;10(10):803-4.
    OpenUrlPubMed
  13. 13.↵
    1. Schmidt M,
    2. Mansfield KE,
    3. Bhaskaran K,
    4. Nitsch D,
    5. Sørensen HT,
    6. Smeeth L,
    7. et al
    . Serum creatinine elevation after renin-angiotensin system blockade and long term cardiorenal risks: cohort study. BMJ 2017;356:j791.
    OpenUrlAbstract/FREE Full Text
  14. 14.↵
    1. Schmidt M,
    2. Mansfield KE,
    3. Bhaskaran K,
    4. Nitsch D,
    5. Sørensen HT,
    6. Smeeth L,
    7. et al
    . Adherence to guidelines for creatinine and potassium monitoring and discontinuation following renin-angiotensin system blockade: a UK general practice-based cohort study. BMJ Open 2017;7(1):e012818. Erratum in: BMJ Open 2017;7(9):e012818corr1.
    OpenUrlAbstract/FREE Full Text
  15. 15.↵
    1. Carey RM,
    2. Calhoun DA,
    3. Bakris GL,
    4. Brook RD,
    5. Daugherty SL,
    6. Dennison-Himmelfarb CR,
    7. et al
    . Resistant hypertension: detection, evaluation, and management: a scientific statement from the American Heart Association. Hypertension 2018;72(5):e53-90.
    OpenUrl
  16. 16.↵
    1. Williams B,
    2. MacDonald TM,
    3. Morant S,
    4. Webb DJ,
    5. Sever P,
    6. McInnes G,
    7. et al
    . Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet 2015;386(10008):2059-68. Epub 2015 Sep 20.
    OpenUrlCrossRefPubMed
  17. 17.↵
    1. Thomas L
    . Managing hypertensive emergencies in the ED. Can Fam Physician 2011;57:1137-41. (Eng), e363–6 (Fr).
    OpenUrlFREE Full Text
PreviousNext
Back to top

In this issue

Canadian Family Physician: 65 (10)
Canadian Family Physician
Vol. 65, Issue 10
1 Oct 2019
  • Table of Contents
  • About the Cover
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on The College of Family Physicians of Canada.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Managing hypertension in primary care
(Your Name) has sent you a message from The College of Family Physicians of Canada
(Your Name) thought you would like to see the The College of Family Physicians of Canada web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Managing hypertension in primary care
Khrystine Waked, Jeff Nagge, Kelly Grindrod
Canadian Family Physician Oct 2019, 65 (10) 725-729;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Respond to this article
Share
Managing hypertension in primary care
Khrystine Waked, Jeff Nagge, Kelly Grindrod
Canadian Family Physician Oct 2019, 65 (10) 725-729;
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • When to start a drug?
    • What drug to start first?
    • What blood pressure goal to aim for?
    • Follow-up with the patient
    • Special situations
    • Conclusion
    • Acknowledgments
    • Notes
    • Footnotes
    • References
  • Figures & Data
  • CFPlus
  • eLetters
  • Info & Metrics
  • PDF

Related Articles

  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

Practice

  • Effectiveness of dermoscopy in skin cancer diagnosis
  • Spontaneous pneumothorax in children
  • Is 45 the new 50 in colorectal cancer screening?
Show more Practice

Praxis

  • Éponge à haut rebond comme outil de simulation d’une suture périnéale
  • High-rebound sponge as a simulation tool for perineal suture
  • Assessment and management of disability due to mental disorders
Show more Praxis

Similar Articles

Navigate

  • Home
  • Current Issue
  • Archive
  • Collections - English
  • Collections - Française

For Authors

  • Authors and Reviewers
  • Submit a Manuscript
  • Permissions
  • Terms of Use

General Information

  • About CFP
  • About the CFPC
  • Advertisers
  • Careers & Locums
  • Editorial Advisory Board
  • Subscribers

Journal Services

  • Email Alerts
  • Twitter
  • LinkedIn
  • Instagram
  • RSS Feeds

Copyright © 2025 by The College of Family Physicians of Canada

Powered by HighWire