Guidelines
The 2013 Canadian Hypertension Education Program Recommendations for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension

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Abstract

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2013. This year's 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.

Résumé

Nous avons mis à jour les recommandations fondées sur des données probantes de 2013 en matière de diagnostic, d’évaluation, de prévention et de traitement de l’hypertension chez les adultes. Cette mise à jour annuelle inclut 2 nouvelles recommandations. Premièrement, chez les individus non hypertendus ou les individus hypertendus de stade 1, la pratique de l’entraînement musculaire et de l’entraînement poids et haltères n’influencent pas défavorablement la pression artérielle (PA; cote D). Par conséquent, ces patients ne doivent pas éviter ce type d’exercice par crainte d’une élévation de la PA. Deuxièmement, et de manière distincte, chez les patients très âgés ayant une hypertension systolique isolée (80 ans et plus), la valeur cible de PA systolique recommandée devrait être < 150 mm Hg (cote C) plutôt que < 140 mm Hg comme chez les patients plus jeunes. Nous avons également discuté en détail de 2 autres sujets (du traitement pharmacologique de l’hypertension légère et de la possibilité d’une courbe J de la pression diastolique chez les patients hypertendus ayant une maladie coronarienne). Après avoir considéré plusieurs limites méthodologiques, une revue systématique récente de 4 essais chez des patients ayant une hypertension non compliquée de stade 1 n’a pas mené à des changements dans les recommandations de prise en charge. De plus, en raison d’un manque de données aléatoires prospectives évaluant les seuils de PA diastolique chez les patients ayant une maladie coronarienne et une hypertension, aucune recommandation pour établir une limite supérieure de la pression diastolique pour ces patients ne pourrait être affirmée. Cependant, ces deux problèmes seront examinés de façon continue, en particulier à mesure que de nouvelles données scientifiques verront le jour.

Section snippets

Executive Summary

Objective: To provide annually updated evidence-based recommendations for the prevention, diagnosis, assessment, and treatment of hypertension in adults for 2013.

Methods: A Cochrane Collaboration librarian conducted an independent MedLine search up to August 2012. To identify additional studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by content and methodology experts using standardized grading algorithms. For

Diagnosis and assessment

Recommendations for BP measurement, criteria for hypertension diagnosis and follow-up, diagnosis of white coat hypertension, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, ambulatory monitoring, and the use of echocardiography in hypertensive individuals are unchanged.

Prevention and treatment

New recommendations include: (1) for nonhypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise (such as

Methods

The CHEP Recommendations Task Force is a multidisciplinary panel comprised of 2 co-chairs and 23 subgroups. Subgroup members, considered content experts in their fields, were responsible for reviewing annual search results and, if indicated, drafting new recommendations or proposing changes to old recommendations (see Supplemental Appendix S1 for the current CHEP membership list). An independent central review committee of methodology experts who had no industry affiliations separately

I. Accurate measurement of BP

Recommendations

  1. 1.

    Health care professionals who have been specifically trained to measure BP accurately should assess BP in all adult patients at all appropriate visits to determine cardiovascular risk and monitor antihypertensive treatment (Grade D).

  2. 2.

    Use of standardized measurement techniques (Supplemental Table S2) is recommended when assessing BP (Grade D).

  3. 3.

    Automated office BP measurement (OBPM) can be used in the assessment of office BP (Grade D).

  4. 4.

    When used in proper conditions, automated office SBP of ≥ 135 mm

I. Health behaviour management

Recommendations

  1. A.

    Physical exercise

    • 1.

      For nonhypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise (such as free weight lifting, fixed-weight lifting, or handgrip exercise) does not adversely influence BP (Grade D) (new recommendation). For nonhypertensive individuals (to reduce the possibility of becoming hypertensive) or for hypertensive patients (to reduce their BP), prescribe the accumulation of 30-60 minutes of moderate intensity dynamic exercise (eg, walking,

Implementation

The implementation task force conducts an extensive knowledge translation effort to enhance uptake and applicability of these recommendations. These efforts include knowledge exchange forums, targeted educational materials for primary care providers and patients, and freely available slide kits and summary documents of all recommendations on the Canadian Hypertension Society Web site (www.hypertension.ca). Documents are available in French and English, and some documents are translated into

Future Directions

Table 1 contains a summary of pharmacological management recommendations for hypertension. The present report represents the 14th iteration of the annually updated CHEP recommendations for the management of hypertension. The Recommendations Task Force will continue to conduct systematic reviews of the clinical trial evidence and update these recommendations annually.

Acknowledgements

The authors thank Drs Lee Green, Sonia Singh, and Karen Tu for external appraisal of the manuscript, and Ms Susan Carter for expert technical assistance with the manuscript.

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    The patients were compliant to the regular home-based blood pressure monitoring and the results noted by the patients were corroborated by a mercury sphygmomanometer five minutes after resting in the sitting position. The diagnostic threshold of ≥ 135/85 mmHg was considered abnormal which was based on the guidelines of HBPM [8–11]. The study was approved by the institutional ethics committee and the study was conducted in accordance with the Helsinki declaration.

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See page 541 for disclosure information.

A version of the hypertension recommendations designed for patient and public education has been developed to assist health care practitioners managing hypertension. The summary is available electronically (go to http://www.hypertension.ca or http://www.heartandstroke.ca).

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