Guidelines
Hypertension Canada’s 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children

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Abstract

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children. This year, the adult and pediatric guidelines are combined in one document. The new 2018 pregnancy-specific hypertension guidelines are published separately. For 2018, 5 new guidelines are introduced, and 1 existing guideline on the blood pressure thresholds and targets in the setting of thrombolysis for acute ischemic stroke is revised. The use of validated wrist devices for the estimation of blood pressure in individuals with large arm circumference is now included. Guidance is provided for the follow-up measurements of blood pressure, with the use of standardized methods and electronic (oscillometric) upper arm devices in individuals with hypertension, and either ambulatory blood pressure monitoring or home blood pressure monitoring in individuals with white coat effect. We specify that all individuals with hypertension should have an assessment of global cardiovascular risk to promote health behaviours that lower blood pressure. Finally, an angiotensin receptor-neprilysin inhibitor combination should be used in place of either an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in individuals with heart failure (with ejection fraction < 40%) who are symptomatic despite appropriate doses of guideline-directed heart failure therapies. The specific evidence and rationale underlying each of these guidelines are discussed.

Résumé

Chaque année Hypertension Canada publie une mise à jour de ses lignes directrices fondées sur des données probantes relatives au diagnostic, à l'évaluation, à la prévention et au traitement de l'hypertension chez l'adulte et l'enfant. Cette année, les lignes directrices applicables aux adultes et aux enfants sont combinées en un seul document. Les nouvelles lignes directrices 2018 portant précisément sur l'hypertension pendant la grossesse sont publiées séparément. Pour 2018, cinq nouvelles lignes directrices sont présentées, et une ligne directrice existante portant sur les seuils et les cibles de pression artérielle dans le contexte de la thrombolyse dans un cas d'accident vasculaire cérébral ischémique aigu est révisée. L'utilisation de tensiomètres-bracelets validés pour l'estimation de la pression artérielle chez les personnes dont le bras a une circonférence élevée est à présent incluse. Des indications sont données pour les mesures de la pression artérielle dans le cadre d'un suivi à l'aide de méthodes normalisées et de dispositifs électroniques (oscillométriques) positionnés au niveau du bras chez les personnes hypertendues, ainsi que de la surveillance de la pression artérielle ambulatoire ou à domicile chez les personnes sujettes au « syndrome de la blouse blanche ». Nous recommandons notamment de procéder à une évaluation du risque cardiovasculaire global de toutes les personnes atteintes d'hypertension afin de les inciter à adopter de saines habitudes de vie permettant d’abaisser leur pression artérielle. Enfin, chez les personnes atteintes d'insuffisance cardiaque (présentant une fraction d'éjection < 40 %) qui sont symptomatiques malgré un traitement de cette affection à des doses appropriées et conforme aux lignes directrices, il est recommandé d'utiliser une association de médicaments inhibiteurs des récepteurs de l'angiotensine et de la néprilysine au lieu d’un inhibiteur de l’enzyme de conversion de l'angiotensine ou d'un antagoniste des récepteurs de l'angiotensine en monothérapie. Les données probantes et la justification qui sous-tendent chacune de ces lignes directrices sont analysées.

Section snippets

Methods

Hypertension Canada’s guidelines are developed annually through a highly structured and systematic process designed to minimize bias. Hypertension Canada’s guideline process has been externally reviewed and is in concordance with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument for guideline development (guidelines.hypertension.ca/about/overview-process).38 The Hypertension Canada Guidelines Committee (HCGC) is comprised of a multidisciplinary panel of content as

I. Accurate measurement of blood pressure

Background. Blood pressure (BP) is traditionally measured using an upper arm cuff, however, recent studies suggest that accurate measurement of BP can be challenging in patients with increased upper arm size, particularly in obese patients with a body mass index > 35.2, 39, 40 In these patients, there is a concern of hidden undercuffing (ie, the cuff bladder is too small or narrow for the arm size) leading to falsely elevated BP values.39 A 2016 systematic review and meta-analysis examined the

Hypertension Canada’s 2018 Guidelines: Prevention and Treatment of Hypertension in Adults

Hereafter, all BP treatment thresholds and targets refer to non-AOBP measurements performed in office (see Supplemental Table S2, section on Recommended Technique for Automated Office Blood Pressure [AOBP]), because most of the supporting evidence is derived from studies using this BP measurement method. A summary of the potential factors that should be considered when selecting specific drug therapy for individualized treatment is presented in Table 1. BP thresholds for initiation of treatment

Hypertension Canada’s 2018 Guidelines: Diagnosis and Assessment of Hypertension in Children

Background. There are no changes to these guidelines35 for 2018.

Hypertension Canada’s 2018 Guidelines: Prevention and Treatment of Hypertension in Children

There are no changes to these guidelines36 for 2018.

Summary/Future Directions

These guidelines are a summary of the best available evidence to guide clinicians in the measurement, diagnosis, and treatment of hypertension in adults and children (key similarities and differences are summarized in Table 10). The next update for Hypertension Canada’s guideline is planned for 2020 to allow for optimal dissemination of the 2018 guidelines although literature searches will be continued on an annual basis. New evidence identified as being “practice-changing” for clinicians (ie,

Implementation

Implementation and dissemination of the guidelines is a priority for Hypertension Canada. Many strategies are used to reach a variety of providers who care for patients with hypertension. Efforts include knowledge exchange forums, targeted educational materials for primary care providers and patients, “Train the Trainer” teaching sessions, as well as slide kits and summary documents, which are freely available online in French and English (www.hypertension.ca). Hypertension Canada receives

Acknowledgements

Hypertension Canada thanks Ms Angela Eady for assistance with the literature searches. We sincerely thank Ms Susan Carter for providing technical assistance with the manuscript and administrative support of the process and committee.

Funding Sources

Activities of the HCGC are supported by Hypertension Canada. The members of the HCGC are unpaid volunteers who contribute their time and expertise to the annual development and dissemination of the Hypertension Canada guidelines. To maintain professional credibility of the content, the process for the development of the guidelines is fully independent and free from external influence. External partners assist with the dissemination of the approved guidelines.

Disclosures

Please see Supplemental Appendix S2 for a complete list of disclosures.

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