2014 CHEP高血压指南

Guidelines

The2014CanadianHypertensionEducationProgramRecommendationsforBloodPressureMeasurement,Diagnosis,AssessmentofRisk,Prevention,and

TreatmentofHypertension

KaberiDasgupta,MD,MSc,aRobertR.Quinn,MD,PhD,bKellyB.Zarnke,MD,MSc,cDoreenM.Rabi,MD,MSc,dPietroRavani,MD,PhD,bStellaS.Daskalopoulou,MD,PhD,aSimonW.Rabkin,MD,eLucTrudeau,MD,fRossD.Feldman,MD,gLyneCloutier,RN,PhD,hAllyPrebtani,MD,iRobertJ.Herman,MD,jSimonL.Bacon,PhD,kRichardE.Gilbert,MD,PhD,lMarcelRuzicka,MD,PhD,mDonaldW.McKay,PhD,nTavisS.Campbell,PhD,oStevenGrover,MD,MPA,pGeorgeHonos,MD,qErnestoL.Schiffrin,MD,PhD,rPeterBolli,MD,sThomasW.Wilson,MD,tPatriceLindsay,RN,PhD,uMichaelD.Hill,MD,MSc,vShelaghB.Coutts,MD,wGordGubitz,MD,xMarkGelfer,MD,yMichelVall󰀁ee,MD,PhD,zG.V.RameshPrasad,MBBS,MSc,aaMarcelLebel,MD,bbDonnaMcLean,RN,NP,PhD,ccJ.MalcolmO.Arnold,MD,ddGordonW.Moe,MD,MSc,eeJonathanG.Howlett,MD,ffJean-MartinBoulanger,MD,ggPierreLarochelle,MD,hhLawrenceA.Leiter,MD,iiCharlotteJones,MD,PhD,jjRichardI.Ogilvie,MD,kkVincentWoo,MD,llJanuszKaczorowski,PhD,mmKevinD.Burns,MD,nnRobertJ.Petrella,MD,PhD,ooSwapnilHiremath,MD,MPH,ppAlainMilot,MD,MSc,qqJamesA.Stone,MD,PhD,rrDenisDrouin,MD,ssKimL.Lavoie,PhD,ttMaximeLamarre-Cliche,MD,uuGuyTremblay,MD,vvPavelHamet,MD,PhD,wwGeorgeFodor,MD,PhD,xxS.GeorgeCarruthers,MD,yyGeorgeB.Pylypchuk,MD,zzEllenBurgess,MD,aaaRichardLewanczuk,MD,PhD,bbbGeorgeK.Dresser,MD,PhD,cccS.BrianPenner,MD,dddRobertA.Hegele,MD,eeePhilipA.McFarlane,MD,PhD,fffMilanKhara,MBChB,gggAndrewPipe,CM,MD,hhhPaulOh,MD,MSc,iiiPeterSelby,MBBS,MHSc,jjjMukulSharma,MD,MSc,kkkDebraJ.Reid,PhD,RD,lllReceivedforpublicationJanuary23,2014.AcceptedFebruary3,2014.

Correspondingauthor:DrKaberiDasgupta,DivisionofClinicalEpidemiology,DepartmentofMedicine,McGillUniversityHealthCentre,687PineAveWest,V-Building(V1.08),Montreal,Qu󰀁ebecH3A1A1,Canada.Tel.:þ1-514-934-1934Â44715;fax:þ1-514-934-8293.

E-mail:kaberi.dasgupta@mcgill.ca

Seepage500fordisclosureinformation.

Aversionofthehypertensionrecommendationsdesignedforpatientandpubliceducationhasbeendevelopedtoassisthealthcarepractitionersmanaginghypertension.Thesummaryisavailableelectronically(gotohttp://www.hypertension.caorhttp://www.heartandstroke.ca).

0828-282X/$-seefrontmatterÓ2014CanadianCardiovascularSociety.PublishedbyElsevierInc.Allrightsreserved.http://dx.doi.org/10.1016/j.cjca.2014.02.002

486

CanadianJournalofCardiology

Volume302014

SheldonW.Tobe,MD,MSc(HPTE),mmmRajS.Padwal,MD,MSc,nnnandLucPoirier,BPharm,MSc;ooofortheCanadianHypertensionEducationProgram

DivisionsofGeneralInternalMedicine,ClinicalEpidemiologyandEndocrinology,DepartmentofMedicine,McGillUniversity,McGillUniversityHealthCentre,Montreal,Qu󰀁ebec,Canada;bDivisionofNephrology,DepartmentofMedicine,andDepartmentofCommunityHealthSciences,FoothillsMedicalCentre,UniversityofCalgary,Calgary,Alberta,Canada;cDivisionofGeneralInternalMedicine,UniversityofCalgary,Calgary,Alberta,Canada;dDepartmentsofMedicine,CommunityHealth,andCardiacSciences,UniversityofCalgary,Calgary,Alberta,Canada;eVancouverHospital,UniversityofBritishColumbia,Vancouver,BritishColumbia,

eal,Qu󰀁ebec,Canada;gWesternUniversity,London,Ontario,Canada;hUniversit󰀁eduQu󰀁ebecàTrois-Canada;fDivisionofInternalMedicine,McGillUniversity,Montr󰀁

ijkRivières,Trois-Rivières,Qu󰀁ebec,Canada;McMasterUniversity,Hamilton,Ontario,Canada;UniversityofCalgary,Calgary,Alberta,Canada;MontrealBehaviouralMedicineCentre,ConcordiaUniversityandHôpitalduSacr󰀁e-CoeurdeMontr󰀁eal,Montr󰀁eal,Qu󰀁ebec,Canada;lUniversityofToronto,DivisionofEndocrinology,St

mMichael’sHospital,Toronto,Ontario,Canada;DivisionofNephrology,DepartmentofMedicine,OttawaHospitalResearchInstitute,UniversityofOttawa,Ottawa,Ontario,Canada;nFacultyofMedicine,MemorialUniversityofNewfoundland,StJohn’s,NewfoundlandandLabrador,Canada;oDepartmentofPsychology,University

ebec,Canada;qUniversityofMontreal,Montreal,ofCalgary,Calgary,Alberta,Canada;pDivisionofClinicalEpidemiology,MontrealGeneralHospital,Montreal,Qu󰀁

rebec,Canada;Qu󰀁ebec,Canada;DepartmentofMedicineandLadyDavisInstituteforMedicalResearch,JewishGeneralHospital,McGillUniversity,Montreal,Qu󰀁

sAmbulatoryInternalMedicineTeachingClinic,StCatharines,Ontario,Canada;tDepartmentofMedicine,UniversityofSaskatchewan,Saskatoon,Saskatchewan,Canada;uBestPracticesandPerformance,HeartandStrokeFoundation,Toronto,Ontario,Canada;vDepartmentofClinicalNeurosciences,HotchkissBrainInstitute,UniversityofCalgary,Calgary,Alberta,Canada;wDepartmentsofClinicalNeurosciencesandRadiology,HotchkissBrainInstitute,UniversityofCalgary,Calgary,Alberta,Canada;xDivisionofNeurology,HalifaxInfirmary,DalhousieUniversity,Halifax,NovaScotia,Canada;yDepartmentofFamilyMedicine,UniversityofBritish

edeMontr󰀁eal,Montr󰀁eal,Qu󰀁ebec,Canada;Columbia,CopemanHealthcareCentre,Vancouver,BritishColumbia,Canada;zHôpitalMaisonneuve-Rosemont,Universit󰀁

aabbccUniversityofToronto,Toronto,Ontario,Canada;DepartmentofMedicine,l’Universit󰀁eLaval,Qu󰀁ebec,Qu󰀁ebec,Canada;UniversityofAlberta,Edmonton,Alberta,Canada;ddWesternUniversity,London,Ontario,Canada;eeStMichael’sHospital,UniversityofToronto,Toronto,Ontario,Canada;ffDepartmentofMedicine,

ebec,Canada;hhInstitutdeUniversityofCalgary,Calgary,Ontario,Canada;ggCharlesLeMoyneHospitalResearchCentre,SherbrookeUniversity,Sherbrooke,Qu󰀁

iirecherchescliniquesdeMontr󰀁eal,Universit󰀁edeMontr󰀁eal,Montr󰀁eal,Qu󰀁ebec,Canada;KeenanResearchCentreintheLiKaShingKnowledgeInstituteofStMichael’sHospital,andUniversityofToronto,Toronto,Ontario,Canada;jjSouthernMedicalProgram,UniversityofBritishColumbia,OkanaganCampus,Kelowna,BritishColumbia,Canada;kkUniversityHealthNetwork,DepartmentsofMedicineandPharmacology,UniversityofToronto,Toronto,Ontario,Canada;llUniversityof

edeMontr󰀁ealandCHUM,Montr󰀁eal,Qu󰀁ebec,Canada;nnOttawaHospitalResearchInstitute,Ottawa,Ontario,Manitoba,Winnipeg,Manitoba,Canada;mmUniversit󰀁

ooppCanada;DepartmentofFamilyMedicine,WesternUniversity,London,Ontario,Canada;DivisionofNephrology,UniversityofOttawa,Ottawa,Ontario,Canada;qqDepartmentofMedicine,Universit󰀁eLaval,Qu󰀁ebec,Qu󰀁ebec,Canada;rrDivisionofCardiology,DepartmentofMedicine,UniversityofCalgary,Calgary,Alberta,

eLaval,Qu󰀁ebec,Qu󰀁ebec,Canada;ttDepartmentofPsychology,UniversityofQu󰀁ebecatMontreal(UQAM),Montr󰀁eal,Qu󰀁ebec,Canada;ssFacultyofMedicine,Universit󰀁

uueal,Universit󰀁edeMontr󰀁eal,Qu󰀁ebec,Canada;vvCHU-Qu󰀁ebec-HopitalStSacrement,Qu󰀁ebec,Qu󰀁ebec,Canada;Canada;InstitutdeRecherchesCliniquesdeMontr󰀁

wwFacult󰀁edeM󰀁edicine,Universit󰀁edeMontr󰀁ealandCentrehospitalierdel’Universit󰀁edeMontr󰀁eal(CHUM),Montr󰀁eal,Qu󰀁ebec,Canada;xxUniversityofOttawaHeartInstitute,Ottawa,Ontario,Canada;yyLisburn,NorthernIreland,UK;zzDepartmentofMedicine,UniversityofSaskatchewan,Saskatoon,Saskatchewan,Canada;aaaFacultyofMedicine,UniversityofCalgary,Calgary,Alberta,Canada;bbbUniversityofAlberta,Edmonton,Alberta,Canada;cccSchulichSchoolofMedicineandDentistry,WesternUniversity,London,Ontario,Canada;dddDepartmentofInternalMedicine,UniversityofManitoba,Winnipeg,Manitoba,Canada;eeeDepartmentsofMedicine(DivisionofEndocrinology)andBiochemistry,WesternUniversity,London,Ontario,Canada;fffDivisionofNephrology,StMichael’sHospital,UniversityofToronto,Toronto,Ontario,Canada;gggVancouverCoastalHealthAddictionServices,FacultyofMedicine,UniversityofBritishColumbia,Vancouver,BritishColumbia,Canada;hhhDivisionofPreventionandRehabilitation,UniversityofOttawaHeartInstituteandUniversityofOttawa,Ottawa,Ontario,Canada;iiiUniversityHealthNetwork,UniversityofToronto,Toronto,Ontario,Canada;jjjCentreforAddictionandMentalHealth,UniversityofToronto,Toronto,Ontario,Canada;kkkTheCanadianStrokeNetwork,Ottawa,Ontario,Canada;lllCanadianForcesHealthServices,DepartmentofNationalDefenceandDietitiansofCanada,Ottawa,Ontario,Canada;mmmNorthernOntarioSchoolofMedicine,GreaterSudbury,Ontario,andUniversityofToronto,Toronto,Ontario,Canada;nnnDepartmentofMedicine,

ebecetFacult󰀁edePharmacie,Universit󰀁eLaval,Qu󰀁ebec,Qu󰀁ebec,CanadaUniversityofAlberta,Edmonton,Alberta,Canada;oooCentreHospitalierUniversitairedeQu󰀁

aABSTRACT

Herein,updatedevidence-basedrecommendationsforthediagnosis,

assessment,prevention,andtreatmentofhypertensioninCanadianadultsaredetailed.For2014,3existingrecommendationsweremodifiedand2newrecommendationswereadded.Thefollowingrecommendationsweremodified:(1)therecommendedsodiumintakethresholdwaschangedfrom 1500mg(3.75gofsalt)toapproximately2000mg(5gofsalt)perday;(2)apharmacotherapytreatmentinitiationsystolicbloodpressurethresholdof!160mmHgwasaddedinveryelderly(age!80years)patientswhodonothavediabetesortargetorgandamage(systolicbloodpressuretargetinthispopulationremainsat<150mmHg);and(3)thetargetpopulationrecommendedtoreceivelow-doseacetylsalicylicacidtherapyforpri-marypreventionwasnarrowedfromallpatientswithcontrolledhy-pertensiontoonlythose!50yearsofage.The2new

󰀁󰀁RESUME

󰀁sentonsende󰀁taillesmisesàjourdesrecommandationsIcinouspre

󰀁essurdespreuvesconcernantlediagnostic,l’e󰀁valuation,lafonde

󰀁ventionetletraitementdel’hypertensionarte󰀁rielledesadultespre

󰀁e2014,3recommandationsonte󰀁te󰀁modifie󰀁escanadiens.Pourl’anne

󰀁te󰀁ajoute󰀁es.Lesrecommanda-et2nouvellesrecommandationsonte

󰀁󰀁󰀁tionssuivantesontetemodifiees:1)lesseuilsdel’apport

󰀁ensodiumsontpasse󰀁sde 1500mg(3,75gdesel)àrecommande

approximativement2000mg(5gdesel)parjour;2)unseuilde

󰀁riellesystoliqueaude󰀁butdela!160mmHgpourlapressionarte

󰀁rapieae󰀁te󰀁ajoute󰀁pourlespatientstrèsâge󰀁s(!80ans)pharmacothe

n’ayantpasdediabèteoud’atteinteàunorganecible(lesvaleurs

󰀁riellesystoliquechezcettepopulationonte󰀁te󰀁ciblesdepressionarte

maintenuesà<150mmHg);3)lapopulationcibledevantrecevoirle

󰀁tylsalicyliqueàfaibledosepourlapre󰀁ventiontraitementd’acideace

ExecutiveSummary

Objective:Toprovideupdated2014evidence-basedrec-ommendationsfortheprevention,diagnosis,assessment,andtreatmentofhypertensioninadults.

Methods:AmedicallibrarianindependentlyconductedaMEDLINEsearchcurrenttoAugust2013.Referencelistswerereviewedandexpertswerecontactedtoidentifyaddi-tionalstudies.Contentandmethodologyexpertsreviewedandappraisedrelevantarticlesusingstandardizedgradingalgo-rithms.Forpharmacologicinterventions,evidencefromran-domizedtrialsandsystematicreviewsoftrialswerepreferredandchangesincardiovascularmorbidityandmortality,andtotalmortality,weretheprimaryoutcomesofinterest.Forhealthbehaviourmanagement,bloodpressure(BP)-loweringwasacceptedasaprimaryoutcome.Inpatientswithchronickidneydisease(CKD),progressiverenalimpairmentwas

Dasguptaetal.

2014CHEPRecommendations

recommendationsare:(1)advicetobecautiouswhenloweringsystolicbloodpressuretotargetlevelsinpatientswithestablishedcoronaryarterydiseaseifdiastolicbloodpressureis 60mmHgbecauseofconcernsthatmyocardialischemiamightbeexacerbated;and(2)theadditionofglycatedhemoglobin(A1c)inthediagnosticwork-upofpatientswithnewlydiagnosedhypertension.Therationalefortheserecommendationchangesisdiscussed.Inaddition,emergingdataonbloodpressuretargetsinstrokepatientsarediscussed;thesedatadidnotleadtorecommendationchangesatthistime.TheCanadianHy-pertensionEducationProgramrecommendationswillcontinuetobeupdatedannually.

acceptedasaclinicallyrelevantprimaryoutcome.Allrec-ommendationsweregradedaccordingtothestrengthofthesupportingevidence,andnewlyproposedrecommendationsorchangestoexistingrecommendationswerediscussedataconsensusconferenceheldOctober15-16,2013,inMontreal,Canada.Proposedchangestotherecommendationsacceptedattheconsensusconferenceweresubsequentlyvotedonbythe69membersoftheCanadianHypertensionEducationProgram(CHEP)RecommendationsTaskForce(RTF).Recommendationsthatreceivedatleast70%taskforceapprovalwereacceptedasfinal.

RecommendationsDiagnosisandassessment

Onenewrecommendationrelatedtotheadditionofgly-catedhemoglobin(A1C)asadiagnosticscreeningtestinnewlydiagnosedhypertensivepatientswasadded.Preventionandtreatment

For2014,3existingrecommendationsweremodifiedand1newrecommendationwasadded.Modificationstoexistingrecommendationsinclude:(1)achangeintherecommendedsodiumintakethresholdtoapproximately2000mg(5gofsalt)perdayfrom 1500mg(3.75gofsalt);(2)theadditionofasystolicBP(SBP)!160mmHgpharmacotherapytreatmentinitiationthresholdinveryelderly(age!80years)patientswhodonothavediabetesortargetorgandamage(withtheSBPtargetinthispopulationremainingat<150mmHg);and(3)amodificationtothetargetpopulationrecommendedtoreceivelow-doseacetylsalicylicacid(ASA)therapyforprimarypreventionfromallcontrolledhyperten-sivepatientstothose!50years.ThenewrecommendationsincludeadvicetobecautiouswhenloweringSBPtotargetlevelsinpatientswithestablishedcoronaryarterydisease(CAD)ifdiastolicBP(DBP)is 60mmHgbecauseofconcernsthatmyocardialischemiamightbeexacerbated.Updates

CHEPwillcontinuetoupdaterecommendationsannually.

487

primaireestpass󰀁e

edetouslespatientsayantunehypertensionquiestcontrôl󰀁e

eàseulementceuxayant!50ans.Les2nouvellesrecommandationssont:1)lesconseilsdeprudencelorsdeladimi-nutiondelapressionart󰀁e

riellesystoliqueauxvaleurscibleschezlespatientsayantunecoronaropathie󰀁e

tabliesilapressionarte󰀁riellediastoliqueest 60mmHgpuisquelesrisquesli󰀁e

sàl’ische󰀁miemyocardiquepourraientêtreexacerb󰀁e

s;2)l’ajoutdel’he󰀁moglobineglyqu󰀁ee(A1c)aubilandiagnostiquedespatientsayantnouvellementreçuundiagnosticd’hypertension.Nousdiscutonsdesraisonsdeces

modificationsdesrecommandations.Nousdiscutons󰀁e

galementdesnouvellesdonn󰀁e

essurlesvaleursciblesdepressionarte󰀁riellechezlespatientsayantsubiunaccidentvasculairec󰀁e

re󰀁bral;cesdonne󰀁esn’ontactuellementpasentraîn󰀁e

demodificationsdesrecommandations.LesrecommandationsduProgramme󰀁e

ducatifcanadiensurl’hy-pertensioncontinuerontd’êtremisesàjourannuellement.

Introduction

Hypertensionaffectsapproximately20%oftheCanadianadultpopulation1,2andisamajorriskfactorforcardiovasculardisease,CKD,anddeath,remaininglargelysilentuntilthedevelopmentofcomplications.3,4Worldwide,highBPaffectsmorethan40%ofadults5andistheleadingglobalriskfactorfordeathordisability.6BPcontrolratesarenearly65%inCanadaand13.2%globally.1,5Withthegoalofimprovinghypertensionprevention,detection,assessment,andmanagementinCanadianadults,theCHEP,withfundingfromHypertensionCanada,pro-ducesannuallyupdated,evidence-basedrecommendationsforprimarycareandotherhealthcareproviders.ThisdocumentoutlinesallrecommendationsendorsedbytheCHEPRTFandcontainsdetaileddiscussionoftheevidencebaseandrationaleforrecommendationsthathavebeenupdatedornewlyaddedfor2014.Discussionoftherationaleforrec-ommendationsthatremainunchangedisavailableinpreviouspublications.7-28Afullsetofsupplementarytablesareavail-ableasanonlinesupplementtothisarticle.

Therecommendationsdetailedhereinareintendedtoguidehealthcareprovidersandshouldnotreplacesoundclinicaljudgement.Practitionersareadvisedtoconsiderpatientpref-erenceswhenapplyingtheserecommendationsinthecareoftheirpatientsandshouldnotethatCHEPdoesnotcurrentlytakeintoaccounteconomicconsiderationswhenformulatingrecommendations.Althoughindividualantihypertensiveagentsmaybementionedwhendiscussingevidence,thereadershouldassumeaclasseffect,unlessotherwisestated.Methods

TheCHEPRTFisamultidisciplinarypanelofcontentandmethodologicalexpertscomprisedof2Co-Chairs,aCentralReviewCommittee(CRC),and23subgroups.Eachsubgroupaddressesadistinctcontentareainhypertension(seeSupplementalAppendixS1forthecurrentCHEPmember-shiplist).MembersoftheCanadianTaskForceonPreventiveHealthCare,CanadianDiabetesAssociationGuidelinesCommittee,CanadianSocietyofNephrology,CanadianStrokeNetwork,CanadianCardiovascularSociety,andtheCanadianCardiovascularHarmonizedNationalGuidelineEndeavourInitiativeregularlycollaboratewithCHEPmem-berstofacilitateharmonizationofhypertension-related

488

recommendationsacrossorganizations.Inmanycases,theCHEPRTFmembersserveasvolunteersformultipleorganizations.

SystematicliteraturesearchescurrenttoAugust2013wereperformedbyaCochraneCollaborationlibrarianinMED-LINE/PubMedusingtextwordsandMeSHheadings.Searchtermsincludedhypertension[MeSH],hypertens*[ti,ab],andbloodpressure;thesewerecombinedwithtopic-specificterms.Bibliographiesofidentifiedarticleswerealsomanuallysearched.Detailsofsearchstrategiesandretrievedarticlesareavailableonrequest.Randomizedcontrolledtrialsandsys-tematicreviewsofrandomizedtrialswerereviewedfortreat-mentrecommendationsandcross-sectionalandcohortstudieswerereviewedforassessmentofdiagnosisandprognosis.Eachsubgroupexaminedthesearchresultspertinenttoitscontentarea.Studiesthatassessedrelevantoutcomeswereselectedforfurtherreview.Cardiovascularmorbidityandmortalityandtotalmortalityoutcomeswereprioritizedforpharmacotherapystudies.Forhealthbehaviourrecommenda-tions,BPwasconsideredanacceptablesurrogateand,inpa-tientswithCKD,progressiverenalimpairmentwasconsideredtobeaclinicallyimportantoutcome.Studycharacteristicsandstudyqualitywereassessedusingprespecified,standardizedalgorithmsdevelopedbytheCHEP29forthecriticalappraisalofrandomizedcontrolledtrialsandcohortstudies.Recom-mendationsweregradedaccordingtothestrengthoftheirunderlyingevidence(fordetails,seeSupplementalTableS1),rangingfromGradeA(strongestevidence,basedonhigh-qualitystudies)toGradeD(weakestevidence,basedonlowpower,imprecisestudies,orexpertopinionalone).AlthoughtheCHEPdoesnotusetheGradingofRecommendationsAssessment,DevelopmentandEvaluation(GRADE)recom-mendationscheme(www.gradeworkinggroup.org),itshouldbe“notedthatallCHEPrecommendationsareconsideredtoberecommendations).strong”innature(ie,Thus,theCHEPtheCHEPrefrainsgradingfrommakingscheme“weakrefers”onlytothequalityofevidenceandnottotherelativestrengthoftherecommendation.Forpharmacotherapyrecommenda-tions,asageneralrule,theCHEPconsidersevidenceevalu-atingspecificagentstobegeneralizabletoa“classeffect.”Fordiuretictherapy,theterm“thiazides”referstohydro-chlorthiazide(orsimilaragents)andtheterm“thiazide-like”referstochlorthalidoneandindapamide.

fiand,elds,Subgroupifweremembers,consideredcontentexpertsintheirindicated,responsibledraftingfornewreviewingrecommendationsannualsearchorproposingresultschangestooldrecommendations.AnindependentCRCconsistingofmethodologicalexpertswithnoindustryaffilia-tionsindependentlyreviewed,graded,andrefinedproposedrecommendations,whichwerethenpresentedataconsensusconferenceoftheRTFinMontreal,CanadaonOctober16and17,2013.ThismeetingincludedtheCo-Chairs,CRC,andmembersofallsubgroups.Furtherrevisionstothepro-posedrecommendationswerebasedonthesediscussions.fibersnalizedAftertheoftheandconsensusCHEPsubmittedmeeting,RTFforelectronicallytherecommendationsapproval.Memberstoall69werewithvotingpotentialmem-conflictsofinterestrecusedthemselvesfromvotingonspecificrecommendations(alistofconflictsisinSupplementalAppendixS2).Recommendationsreceiving>70%approvalpassed.TheCHEPrecommendationsprocessisinaccordance

CanadianJournalofCardiology

Volume302014

withtheAGREEIIguidelines30andhasbeenexternallyreviewed.AsummaryofhowtheCHEPprocessalignswithAppraisalofGuidelines,ResearchandEvaluation(AGREE)IImaybefoundonlineat:http://www.hypertension.ca/en/chep/overview-a-processagree.Materialstoassistwithpatientandpubliceducationbasedontheserecommendationsarefreelyavailableat:http://www.hypertension.ca.

The2014CHEPDiagnosisandAssessmentRecommendations

I.AccuratemeasurementofBPRecommendations1.HealthcareprofessionalswhohavebeenspecificallytrainedtomeasureBPaccuratelyshouldassessBPinalladultpatientsatallappropriatevisitstodeterminecardiovascularriskandmonitorantihypertensivetreatment(GradeD).2.Useofstandardizedmeasurementtechniques(SupplementalTableS2)isrecommendedwhenassessingBP(GradeD).3.AutomatedofficeBPmeasurement(OBPM)canbeusedintheassessmentofofficeBP(GradeD).

4.When!considered135usedmminproperconditions,automatedofficeSBPof!(Grade135mmanalogousHgorDBPD).HgandDBPtomeanof!85mmHgshouldbeof!awake85mmambulatoryHg,respectivelySBPofBackground.Therearenochangestotheserecommenda-tionsfor2014.

II.Criteriafordiagnosisofhypertensionandrecommendationsforfollow-up(Fig.1)Recommendations1.Atinitialpresentation,patientsdemonstratingfeaturesofahypertensiveurgencyoremergency(SupplementalTableS3)shouldbediagnosedashypertensiveandrequireimmediatemanagement(GradeD).

2.IfSBPis!140mmHgand/orDBPis!90mmHg,aspecificvisitshouldbescheduledfortheassessmentofhypertension(GradeD).IfBPishigh-normal(SBP130-139mmHgand/orDBP85-89mmHg),annualfollow-upisrecommended(GradeC).

3.Attheinitialvisitfortheassessmentofhypertension,ifSBPis!140and/orDBPis!90mmHg,atleast2morereadingsshouldbetakenduringthesamevisitusingavalidateddeviceandaccordingtotherecommendedpro-cedureforaccurateBPdetermination(SupplementalTableS2).Thefirstreadingshouldbediscardedandthelatter2ormorereadingsaveraged.Ahistoryandphysicalexaminationshouldbeperformedand,ifclinicallyindi-cated,diagnosticteststosearchfortargetorgandamage(SupplementalTableS4)andassociatedcardiovascularriskfactors(SupplementalTableS5)shouldbearrangedwithin2visits.Exogenousfactorsthatcaninduceoraggravatehypertensionshouldbeidentifiedandaddressedifpossible(SupplementalTableS6).Visit2shouldbescheduledwithin1month(GradeD).

Dasguptaetal.

2014CHEPRecommendations

489

Figure1.Theexpeditedassessmentanddiagnosisofpatientswithhypertension:FocusonvalidatedtechnologiesforBPassessment.**ThresholdsrefertoBPvaluesaveragedacrossthecorrespondingnumberofvisitsandnotjustthemostrecentofficevisit.ABPM,ambulatoryBPmonitoring;BP,bloodpressure(mmHg);DBP,diastolicBP(mmHg);HBPM,homeBPmeasurement;HTN,hypertension;OBPM,officeBPmeasurement;SBP,systolicBP(mmHg).ReproducedwithpermissionfromtheCanadianHypertensionEducationProgram.

4.Atvisit2fortheassessmentofhypertension,patientswithmacrovasculartargetorgandamage,diabetesmellitus,orCKD(glomerularfiltrationrate<60mL/min/1.73m2)canbediagnosedashypertensiveifSBPis!140mmHgand/orDBPis!90mmHg(GradeD).

5.Atvisit2fortheassessmentofhypertension,patientswithoutmacrovasculartargetorgandamage,diabetesmellitus,orCKDcanbediagnosedashypertensiveiftheSBPis!180mmHgand/ortheDBPis!110mmHg(GradeD).Patientswithoutmacrovasculartargetorgandamage,diabetesmellitus,orCKDbutwithlowerBPlevelsshouldundergofurtherevaluationusinganyofthe3approachesoutlinednext:

i.OBPM:UsingmanualOBPM,patientscanbediag-nosedashypertensiveiftheSBPis!160mmHgortheDBPis!100mmHgaveragedacrossthefirst3visits,oriftheSBPaverages!140mmHgortheDBPav-erages!90mmHgaveragedacross5visits(GradeD).ii.AmbulatoryBPmonitoring(ABPM):UsingABPM(seeRecommendationsinsectionVIII.ABPM),patientscanbediagnosedashypertensiveifthemeanawakeSBPis!135mmHgortheDBPis

490

!mm85HgmmorHgtheorDBPiftheis!mean80mm24-hourHg(GradeSBPisC).!130iii.HomeBPmonitoring(HBPM):UsingHBPM(seeRecommendationsinsectionVII.HBPM),patientscanbe!If135diagnosedthemmaverageHgashomeorhypertensivetheDBPBPisisiftheaverageSBPisbeforediagnosingwhitecoathy-6.

Investigationsforsecondarycausesofhypertensionshouldbeinitiatedinpatientswithsuggestiveclinicaland/orlaboratoryfeatures(outlinedinsectionsV.AssessmentforRenovascularHypertensionandVI.EndocrineHypertension)(GradeD).7.

If,atthelastdiagnosticvisit,thepatientisnotdiagnosedashypertensiveandhasnoevidenceofmacrovasculartargetorgandamage,thepatient’sBPshouldbeassessedatyearlyintervals(GradeD).

8.

Hypertensivepatientsactivelymodifyingtheirhealthbe-havioursshouldbefollowedupat3-to6-monthintervals.Shorterintervals(every1or2months)areneededforpatientswithhigherBPmeasurements(GradeD).

9.

Patientsusingantihypertensivedrugsshouldbeseenmonthlyorevery2months,dependingonthelevelofBP,untilreadingson2consecutivevisitsarebelowtheirtarget(GradeD).Shorterintervalsbetweenvisitswillbeneededforsymptomaticpatientsandthosewithseverehypertension,intolerancetoantihypertensivedrugs,ortargetorgandam-age(GradeD).WhenthetargetBPhasbeenreached,pa-tientsshouldbeseenat3-to6-monthintervals(GradeD).

Background.Therearenochangestotheserecommenda-tionsfor2014.

III.AssessmentofoverallcardiovascularriskinhypertensivepatientsRecommendations1.Globalcardiovascularriskshouldbeassessed.Multifac-torialriskassessmentmodelscanbeusedtopredictmoreaccuratelyanindividual’sglobalcardiovascularrisk(GradeA)andtouseantihypertensivetherapymoreefficiently(GradeD).IntheabsenceofCanadiandatatodeterminetheaccuracyofriskcalculations,avoidusingab-solutelevelsofrisktosupporttreatmentdecisions(GradeC).2.Considerinformingpatientsoftheirglobalrisktoimprovetheeffectivenessofriskfactormodification(GradeB).Consideralsousinganalogiesthatdescribecomparativerisksuchas“cardiovascularage,”“vascularage,”or“heartage”toinformpatientsoftheirriskstatus(GradeB).Background.Therearenochangestotheserecommenda-tionsfor2014.Riskcalculatorsarefreelyavailableat:www.myhealthcheckup.com(www.monbilansante.com)andwww.score-canada.ca.ThelatterWebsiteistheSystematicCere-brovascularandCoronaryRiskEvaluation[SCORE])riskcalculator.AlthoughnoriskenginedevelopedfromCanadian

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dataexists,CanadiancardiovasculardiseaseprevalenceandmortalityriskhavebeenintegratedintotheoriginalSCOREriskenginetoproducespecificestimatesfortheCanadianpopulation(SCORECanada).

IV.RoutineandoptionallaboratorytestsfortheinvestigationofpatientswithhypertensionRecommendations1.Routinelaboratoryteststhatshouldbeperformedfortheinvestigationofallpatientswithhypertensionincludethefollowing:

i.Urinalysis(GradeD);

ii.Bloodchemistry(potassium,sodium,andcreatinine)(GradeD);

iii.Fastingbloodglucoseand/orglycatedhemoglobin(A1C)(GradeD)(newrecommendation);

iv.Fastingserumtotalcholesterol,high-densitylipopro-teincholesterol,low-densitylipoproteincholesterol,andtriglycerides(GradeD);and

v.Standard12-leadelectrocardiography(GradeC).

2.Assessurinaryalbuminexcretioninpatientswithdiabetes(GradeD).

3.Alltreatedhypertensivepatientsshouldbemonitoredac-cordingtothecurrentCanadianDiabetesAssociationguidelinesforthenewappearanceofdiabetes(GradeB).4.Duringthemaintenancephaseofhypertensionmanage-ment,tests(includingthoseforelectrolyte,creatinine,andfastinglipidlevels)shouldberepeatedwithafrequencyreflectingtheclinicalsituation(GradeD).Background.Whencomparedwithoralglucosetolerancetesting,asystematicreviewsuggeststhatA1Candfastingglucoselevelsdemonstratecomparablesensitivityandspecificityfordiabetesdetection.31Inamorerecentanalysisofmorethan2000adultsathighriskfordiabetes,HuandcolleaguesdeterminedthesensitivityandspecificityfordiabetesofA1Candfastingglucosetobevirtuallyidenticalatthethresholdsevaluated.Inaddition,whenbothtestswerecombined,sensi-tivity(96.5%)andspecificity(96.3%)increased.32Theaddi-tionofA1CharmonizestheCHEPrecommendationswiththoseoftheCanadianDiabetesAssociation.33V.AssessmentforrenovascularhypertensionRecommendations1.Patientspresentingwith!2oftheclinicalclueslistedbelow,suggestingrenovascularhypertension,shouldbeinvestigated(GradeD):

i.Suddenonsetorworseningofhypertensionandage>55or<30years;

ii.Presenceofanabdominalbruit;iii.Hypertensionresistantto!3drugs;

iv.Increaseinserumcreatininelevel!30%associatedwithuseofanangiotensin-convertingenzyme(ACE)inhibitororangiotensinreceptorblocker(ARB);

v.Otheratheroscleroticvasculardisease,particularlyinpatientswhosmokeorhavedyslipidemia;

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vi.Recurrentpulmonaryedemaassociatedwithhyper-tensivesurges.

2.Whenavailable,thefollowingtestsarerecommendedtoaidintheusualscreeningforrenalvasculardisease:captopril-enhancedradioisotoperenalscan,Dopplersonography,magneticresonanceangiography,andcomputedtomogra-phyangiography(forthosewithnormalrenalfunction)(GradeB).Captopril-enhancedradioisotoperenalscanisnotrecommendedforthosewithCKD(glomerularfiltra-tionrate<60mL/min/1.73m2)(GradeD).Background.Therearenochangestotheserecommenda-tionsfor2014.

VI.EndocrinehypertensionRecommendationsA.Hyperaldosteronism:screeninganddiagnosis

1.Screeningforhyperaldosteronismshouldbeconsideredforthefollowingpatients(GradeD):

i.Hypertensiveþpatientswithspontaneoushypokale-mia(Kii.Hypertensive<3.5patientsmmol/L);

withmarkeddiuretic-inducedhypokalemia(Kþiii.Patientswithhypertensiontotreatmentwith!3drugs;

iv.Hypertensivepatientsfoundtohaveanincidentaladrenaladenoma.

2.Screeningforhyperaldosteronismshouldincludeassessmentofplasmaaldosteroneandplasmareninactivityorplasmarenin(SupplementalTableS7).3.Forpatientswithsuspectedhyperaldosteronism(onthebasisofthescreeningtest;SupplementalTableS7,itemiii.DefinitionofaPositiveScreeningTest),adiagnosisofprimaryaldosteronismshouldbeestablishedbydemonstratinginappropriateautonomoushypersecretionofaldosteroneusingatleast1ofthemanoeuvreslistedinSupplementalTableS7,itemiv.ManoeuvrestodemonstrateAutonomousHypersecretionofAldosterone.Whenthediagnosisisestab-lished,theabnormalityshouldbelocalizedusinganyofthetestsdescribedinSupplementalTableS7,itemv.Differ-entiatingPotentialCausesofPrimaryAldosteronism.B.Pheochromocytoma:screeninganddiagnosis

1.Ifpheochromocytomaisstronglysuspected,thepatientshouldbereferredtoaspecializedhyperten-sioncentre,particularlyifbiochemicalscreeningtests(SupplementalTableS8)havealreadybeenfoundtobepositive(GradeD).

2.Thefollowingpatientsshouldbeconsideredforscreeningforpheochromocytoma(GradeD):

i.Patientswithparoxysmaland/orsevere(BP!180/110mmHg)sustainedhypertensionrefractorytousualantihypertensivetherapy;

ii.Patientswithhypertensionandmultiplesymptomssuggestiveofcatecholamineexcess(eg,headaches,palpitations,sweating,panicattacks,andpallor);iii.Patientswithhypertensiontriggeredbyinhibitors,micturition,b-blockers,monoamineoxidaseorchangesinabdominalpressure;

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iv.Patientswithincidentallydiscoveredadrenalmassandpatientswithhypertensionandmultipleendocrineneoplasia2Aor2B,vonRecklinghausenneurofibromatosis,orvonHippel-Lindaudisease;v.Forpatientswithpositivebiochemicalscreeningtests,localizationofpheochromocytomasshouldinvolvetheuseofmagneticresonanceimaging(preferable),computedtomography(ifmagneticresonanceimagingisunavailable),and/oriodineI-131meta-iodobenzylguanidinescintigraphy(GradeCforeachmodality).Background.Therearenochangestotheserecommenda-tionsfor2014.VII.HBPMRecommendations1.HBPMcanbeusedinthediagnosisofhypertension(GradeC).

2.TheuseofHBPMonaregularbasisshouldbeconsideredforpatientswithhypertension,particularlythosewith:i.Diabetesmellitus(GradeD);ii.CKD(GradeC);

iii.Suspectednonadherence(GradeD);

iv.Demonstratedwhitecoateffect(GradeC);or

v.BPcontrolledintheofficebutnotathome(maskedhypertension)(GradeC).

3.WhenwhitecoathypertensionissuggestedbyHBPM,itspresenceshouldbeconfirmedbyrepeatHBPM(seeRecommendation8inthissection)orABPMbeforetreatmentdecisionsaremade(GradeD).

4.PatientsshouldbeadvisedtopurchaseanduseonlyHBPMdevicesthatareappropriatefortheindividualandhavemetstandardsoftheAssociationfortheAdvancementofMedicalInstrumentation,themostrecentrequirementsoftheBritishHypertensionSocietyprotocol,ortheInterna-tionalProtocolforvalidationofautomatedBP-measuringdevices.PatientsshouldbeencouragedtousedeviceswithdatarecordingcapabilitiesorautomaticdatatransmissiontoincreasethereliabilityofreportedHBPM(GradeD).5.HomeSBPvalues!135mmHgorDBPvalues!85mmHgshouldbeconsideredincreasedandassociatedwithanincreasedoverallmortalityriskanalogoustoofficeSBPreadingsof!140mmHgorDBP!90mmHg(GradeC).6.HealthcareprofessionalsshouldensurethatpatientswhomeasuretheirBPathomehaveadequatetrainingand,ifnecessary,repeattraininginmeasuringtheirBP.PatientsshouldbeobservedtodeterminethattheymeasureBPcorrectlyandshouldbegivenadequateinformationaboutinterpretingthesereadings(GradeD).

7.Theaccuracyofallindividualpatients’validateddevices(includingelectronicdevices)mustberegularlycheckedagainstadeviceofknowncalibration(GradeD).

8.HBPMforassessingwhitecoathypertensionorsustainedhypertensionshouldbebasedonduplicatemeasures,morningandevening,foraninitial7-dayperiod.First-dayhomeBPvaluesshouldnotbeconsidered(GradeD).Background.Therearenochangestotheserecommenda-tionsfor2014.

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VIII.ABPMRecommendations1.ABPMcanbeusedinthediagnosisofhypertension(GradeC).ABPMshouldbeconsideredwhenanoffice-inducedincreaseinBPissuspectedintreatedpatientswith:

i.BPthatisnotbelowtargetdespitereceivingappro-priatechronicantihypertensivetherapy(GradeC);ii.Symptomssuggestiveofhypotension(GradeC);oriii.FluctuatingofficeBPreadings(GradeD).

2.PhysiciansshoulduseonlyABPMdevicesthathavebeenvalidatedindependentlyusingestablishedprotocols(GradeD).3.Therapyadjustmentshouldbeconsideredinpatientswithamean24-hourambulatorySBPof!130mmHgorDBPof!80mmHgorameanawakeSBPof!135mmHgorDBPof!85mmHg(GradeD).

4.ThemagnitudeofchangesinnocturnalBPshouldbetakenintoaccountinanydecisiontoprescribeorwithholddrugtherapybasedonABPM(GradeC)becauseadecreaseinnocturnalBPof<10%isassociatedwithincreasedriskofcardiovascularevents.Background.Therearenochangestotheserecommenda-tionsfor2014.

IX.RoleofechocardiographyRecommendations1.Routineechocardiographicevaluationofallhypertensivepatientsisnotrecommended(GradeD).

2.Anechocardiogramforassessmentofleftventricularhy-pertrophyisusefulinselectedcasestohelpdefinethefutureriskofcardiovascularevents(GradeC).

3.Echocardiographicassessmentofleftventricularmass,andofsystolicanddiastolicleftventricularfunctionisrecom-mendedforhypertensivepatientssuspectedtohaveleftventriculardysfunctionorCAD(GradeD).

4.Patientswithhypertensionandevidenceofheartfailureshouldhaveanobjectiveassessmentofleftventricularejectionfraction,eitherusingechocardiogramornuclearimaging(GradeD).Background.Therearenochangestotheserecommenda-tionsfor2014.

TheCHEP2014PreventionandTreatmentRecommendations

PleasenotethattreatmentthresholdsandtargetsrefertoOBPM.PleaserefertosectionII.CriteriaforDiagnosisofHypertensionandRecommendationsforFollow-up,forcorre-spondingvaluesofothermeasurementmethods.I.HealthbehaviourmanagementRecommendationsA.Physicalexercise

1.Fornonhypertensiveorstage1hypertensivein-dividuals,theuseofresistanceorweighttraining

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exercise(suchasfreeweightlifting,fixedweightlifting,orhandgripexercise)doesnotadverselyinfluenceBP(GradeD).Fornonhypertensiveindividuals(toreducethepossibilityofbecominghypertensive)orforhy-pertensivepatients(toreducetheirBP),prescribetheaccumulationof30-60minutesofmoderateintensitydynamicexercise(eg,walking,jogging,cycling,orswimming)4-7daysperweekinadditiontotheroutineactivitiesofdailyliving(GradeD).Higherintensitiesofexercisearenotmoreeffective(GradeD).B.

Weightreduction

1.Height,weight,andwaistcircumferenceshouldbemeasuredandbodymassindexcalculatedforalladults(GradeD).

2.Maintenanceofahealthybodyweight(bodymassindexof18.5to24.9,andwaistcircumference<102cmformenand<88cmforwomen)isrecommendedfornonhypertensiveindividualstopreventhypertension(GradeC)andforhypertensivepatientstoreduceBP(GradeB).Alloverweighthypertensiveindividualsshouldbeadvisedtoloseweight(GradeB).

3.Weightlossstrategiesshoulduseamultidisciplinaryapproachthatincludesdietaryeducation,increasedphysicalactivity,andbehaviouralintervention(GradeB).C.

Alcoholconsumption

1.ToreduceBP,alcoholconsumptionshouldbeinaccordancewithCanadianlow-riskdrinkingguidelinesinnormotensiveandhypertensiveindividuals.Healthyadultsshouldlimitalcoholconsumptionto 2drinksperday,andconsumptionshouldnotexceed14stan-darddrinksperweekformenand9standarddrinksperweekforwomen(GradeB).(Note:Onestandarddrinkisconsideredtobeequivalentto13.6gor17.2mLofethanolorapproximately44mL[1.5oz]of80proof[40%]spirits,355mL[12oz]of5%beer,or148mL[5oz]of12%wine.)D.

Dietaryrecommendations

1.Itisrecommendedthathypertensivepatientsandnormotensiveindividualsatincreasedriskofdevel-opinghypertensionconsumeadietthatemphasizesfruits,vegetables,low-fatdairyproducts,dietaryandsolublefibre,wholegrains,andproteinfromplantsourcesthatisreducedinsaturatedfatandcholesterol(DietaryApproachestoStopHypertension[DASH]diet34-37;SupplementalTableS9)(GradeB).E.

Sodiumintake

1.TodecreaseBP,considerreducingsodiumintaketo-ward2000mg(5gofsaltor87mmolofsodium)perday(GradeA)(revisedrecommendation).F.

Potassium,calcium,andmagnesiumintake

1.Supplementationofpotassium,calcium,andmagne-siumisnotrecommendedforthepreventionortreat-mentofhypertension(GradeB).G.

Stressmanagement

1.InhypertensivepatientsinwhomstressmightbeacontributortohighBP,stressmanagementshouldbeconsideredasanintervention(GradeD).Individual-izedcognitive-behaviouralinterventionsaremorelikelytobeeffectivewhenrelaxationtechniquesareused(GradeB).

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Background.Therevisedrecommendation,whichincreasesthetargetsodiumthresholdfrom 1500mg/d,isprimarilybasedonclinicaltrialevidencefrom2systematicreviewspublishedin2013.38,39TheevidencefocusesonBPasasurrogateendpoint.TheRTFnotedtheinconclusivenatureofthedataexaminingmorbidityandmortalityendpointsandawaits40theresultsoffurtherstudiesexaminingtheseendpoints.Heandcolleagues38examined22crossoverandparallel-armrandomizedcontrolledtrialsthatenrolled999hyper-tensiveindividualsandcomparedreducedsaltintakewithusualsaltintakeoveraperiodof4-52weeks.Studiesdoc-umentinga40-120mmolreductionin24-hoururineso-dium(equivalentto920-2760mgofsodiumor2.3-7gofsalt)wereincluded.ThemedianbaselineBPwas148/93mmHgandthemedianbaseline24-hoururinesodiumexcretionwas162mmol(range,125-191mmol).Thepooledestimatedreductioninsodiumintakebetweenusualintakeandreducedintakewas75mmolper24hours(95%confidenceinterval[CI],53-117).Therefore,frombaselinelevelsintheusualcarearm,interventionsreducedsodiumintaketowardathresholdof87mmol(ie,162-75mmol)or2000mgperday.Reducedintakeledtoa5.39mmHgreduction(95%CI,4.15-6.62)inSBPanda2.82mmHgreduction(95%CI,2.11-3.54)inDBP(pooledmeaneffects).

ThesystematicreviewbyAburtoandcolleagues39wasconductedonbehalfoftheWorldHealthOrganizationNutritionGuidanceExpertAdvisoryGroupSubgrouponDietandHealth.In36randomizedcontrolledtrialsthatenrolled5508participantsoveralland1478subjectswithhypertension,areductioninsodiumintakeresultedinamean3.39mmHgreduction(95%CI,2.46-4.31mmHg)inSBPinallsubjectsanda4.06mmHgSBPreduction(95%CI,2.96-5.15)inthesubgroupwithhypertension.Asubgroupanalysisindicatedthatareductioninsodiumintaketolessthan2000mg/dledtoadecreaseinSBPof3.47mmHg(95%CI,0.76-6.18).Concurrentuseofantihypertensivemedicationdidnotappeartodiminishtheeffectofdecreasingsodiumintake.

II.Indicationsfordrugtherapyforadultswith

hypertensionwithoutcompellingindicationsforspecificagents

Recommendations1.AntihypertensivetherapyshouldbeprescribedforaverageDBPmeasurementsof!100mmHg(GradeA)oraverageSBPmeasurementsof!160mmHg(GradeA)inpatientswithoutmacrovasculartargetorgandamageorothercardiovascularriskfactors.

2.AntihypertensivetherapyshouldbestronglyconsideredifDBPreadingsaverage!90mmHginthepresenceofmacrovasculartargetorgandamageorotherindependentcardiovascularriskfactors(GradeA).

3.AntihypertensivetherapyshouldbestronglyconsideredifSBPreadingsaverage!140mmHginthepresenceofmacrovasculartargetorgandamage(GradeCfor140-160mmHg;GradeAfor>160mmHg).

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4.Antihypertensivetherapyshouldbeconsideredinallpa-tientsmeetingindications1-3inthissection,regardlessofage(GradeB).Cautionshouldbeexercisedinelderlypa-tientswhoarefrail.

5.Intheveryelderly(age!80years)patientswhodonothavediabetesortargetorgandamage,theSBPthresholdforinitiatingdrugtherapyis!160mmHg(GradeC)(revisedrecommendation).Background.In2013,CHEPintroduceda<150mmHgSBPtreatmenttargetforadults80yearsofageorolder(seeRecommendation2insectionV.GoalsofTherapyforAdultsWithHypertensionWithoutCompellingIndicationsforSpecificAgents).Thisyear,a!160mmHgpharmacotherapytreat-mentinitiationthresholdwasadded.ThisrecommendationwasbasedondatafromtheHypertensionintheVeryElderlyTrial(HYVET)41,4243andameta-analysisbyGueyffierandcolleagues.TheHYVETenrolled3845hypertensiveadults(definedasSBPof!160mmHg)aged80yearsorolderandrandomizedtoactivevsplacebotreatmentinwhichtheactivetreatmentarmreceivedindapamide1.5mgwithorwithoutperindopril(2-4mg)toachieveatargetBPof<150/80mmHg.Theprimaryoutcomeofthetrialwasstroke(fatalandnonfatal),withall-causemortalityapredefinedsecondaryoutcome.Thetrialwasstoppedearly(medianfollow-upwas1.8years)whenaplannedinterimanalysisdemonstratedactivetreatmenttobeassociatedwithalowerriskofstroke(hazardratio[HR],0.59;95%CI,0.40-0.88)andall-causemortalityfistoppednaltime-to-event(HR,0.76;andallendpointsanalysis,95%CI,hadcompleted0.62-0.93).However,thebeencounted,after41therevealedtrialthatwastheactivetreatmenteffectwasnolongerconclusivewithrespecttostroke(HR,0.70;95%CI,0.49-1.01),butthattherewasstillaconclusive21%reductionintheriskofall-causemortality(HR,0.79;95%CI,0.65-0.95).TheCHEPthuscontinuestorecommendanSBPtreatmenttargetof<150mmHg,butinlinewithHYVETpro-cedures,theSBPthresholdfortheinitiationoftreatmentisnowspecifiedas160mmHg.Asnotedinthe2013CHEPrecommendations,theHYVETpopulationhadlowratesofcomorbiddiseaseandadverseeventsduringtreatment.Sub-jectswithorthostatichypotensionwerelikelyexcludedbecausestandingSBPhadtobe!140mmHgatthelastvisitbeforerandomization.ThereforetheRTFcontinuestorecommendcautionwhenapplyingthisrecommendationtofrailelderlypatients.ForpatientswithSBPof150-160mmHg,providersshouldexerciseclinicaljudgementwhendecidingwhethertoinitiatedrugtreatmentandshouldnotethatnonpharmacologicaltherapyisstillindicatedforallpatients.

Furthersupportforthe!160mmHgSBPpharmaco-logictreatmentthresholdintheveryelderlypopulationcomesfrom43thepre-HYVETmeta-analysisbyGueyffierandcolleagues,evaluatingtheefficacyofhypertensiontreat-mentinpatients!80yearsofage.Theseinvestigatorsincludeddatafrom7trialsthatcomparedtheefficacyofactivetreatmentwitheitherplacebo,notreatment,ordecreaseddosesofactivetreatmentontheprimaryoutcomeoffatalandnonfatalstroke.Fiveofthe7trialsenrolledpatientswithSBPlevels!160mmHg.Amongparticipants

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randomizedtoactivetreatment(n¼874),therewere57strokesand34strokedeaths,comparedwith77strokesand28strokedeathsamongparticipantsrandomizedtothecomparatorgroups(n¼796).Theriskforstrokewas34%less(relativerisk,0.66;95%CI,0.48-0.92)amongthoseintheactivetreatmentarms.Takentogether,thismeta-anal-ysis43andHYVET41,42provideevidencethattreatmentinitiatedatathresholdof!160mmHgreducescardio-vasculareventsandall-causemortalityinelderlypatients.III.ChoiceoftherapyforadultswithhypertensionwithoutcompellingindicationsforspecificagentsRecommendationsA.Recommendationsforindividualswithdiastolicand/orsystolichypertension

1.Initialtherapyshouldbeasingle-agentthiazide/thia-zide-likediuretic(GradeA),ab-blocker(inpatientsyoungerthan60years;GradeB),anACEinhibitor(innon-blackpatients;GradeB),along-actingcalciumchannelblocker(CCB)(GradeB);oranARB(GradeB).Ifthereareadverseeffects,anotherdrugfromthisgroupshouldbesubstituted.Hypokalemiashouldbeavoidedinpatientstreatedwiththiazide/thiazide-likediureticmonotherapy(GradeC).

2.AdditionalantihypertensivedrugsshouldbeusediftargetBPlevelsarenotachievedwithstandard-dosemonotherapy(GradeB).Add-ondrugsshouldbechosenfromfirst-linechoices.Usefulchoicesincludeathiazide/thiazide-likediureticorCCBwitheither:ACEinhibitor,ARBorb-blocker(GradeBforthecombi-nationofthiazide/thiazide-likediureticandadihy-dropyridineCCB;GradeCforthecombinationofdihydropyridineCCBandACEinhibitor;andGradeDforallothercombinations).Cautionshouldbeexer-cisedbincombininganondihydropyridineCCBandainhibitor-blockerand(GradeanARBD).isThenotcombinationrecommendedof(GradeanACEA).3.Combinationtherapyusing2first-lineagentsmightalsobeconsideredasinitialtreatmentofhypertension(GradeC)ifSBPis20mmHggreaterthantargetorifDBPis10mmHggreaterthantarget.However,cautionshouldbeexercisedinpatientsinwhomasubstantialdecreaseinBPfrominitialcombinationtherapyismorelikelytooccurorinwhomitwouldbepoorlytolerated(eg,elderlypatients).

4.IfBPisstillnotcontrolledwithacombinationof2ormorefirst-lineagents,orthereareadverseeffects,otherantihypertensivedrugsmaybeadded(GradeD).

5.Possiblereasonsforpoorresponsetotherapy(SupplementalTableS10)shouldbeconsidered(GradeD).

6.a-Blockersarenotrecommendedasfirst-lineagentsforuncomplicatedhypertension(GradeA);recommendedasfirst-linetherapyb-blockersarenotforuncompli-catedhypertensioninpatients60yearsofageorolder(GradefiA);andACEinhibitorsareblackrst-linepatientstherapy(GradefornotrecommendedasA).uncomplicatedHowever,thesehypertensionagentsmaybeinusedinpatientswithcertaincomorbidconditionsorincombinationtherapy.

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Background.Therearenochangestotheserecommenda-tionsfor2014.

B.Recommendationsforindividualswithisolatedsystolichypertension

1.Initialtherapyshouldbesingle-agenttherapywithathiazide/thiazide-likediuretic(GradeA),along-actingdihydropyridineCCB(GradeA),oranARB(GradeB).Ifthereareadverseeffects,anotherdrugfromthisgroupshouldbesubstituted.Hypokalemiashouldbeavoidedinpatientstreatedwiththiazide/thiazide-likediureticmonotherapy(GradeC).

2.AdditionalantihypertensivedrugsshouldbeusediftargetBPlevelsarenotachievedwithstandard-dosemonotherapy(GradeB).Add-ondrugsshouldbechosenfromfirst-lineoptions(GradeD).

3.IfBPisstillnotcontrolledwithacombinationof2ormorefirst-lineagents,orthereareadverseeffects,otherclassesofdrugs(suchasa-blockers,ACEinhibitors,centrallyactingagents,ornondihydropyridineCCBs)maybeaddedorsubstituted(GradeD).

4.Possiblereasonsforpoorresponsetotherapy(SupplementalTableS10)shouldbeconsidered(GradeD).

5.a-Blockersarenotrecommendedasfirst-lineagentsforuncomplicatedbisolatedsystolichypertension(GradeA);and-blockersarenotrecommendedasfirst-linetherapyforisolatedsystolichypertensioninpatientsaged!60years(GradeA).However,bothagentsmaybeusedinpatientswithcertaincomorbidconditionsorincombinationtherapy.Background.TherecommendationaddressingBPtargetsintheveryelderly(age!80years)patientswhodonothavedia-betesortargetorgandamagehasbeenmovedfromsectionII.ChoiceofTherapyforAdultsWithHypertensionWithoutCompellingIndicationsforSpecificAgents;B.RecommendationsforIndividualsWithIsolatedSystolicHypertensiontosectionII.In-dicationsforDrugTherapyforAdultsWithHypertensionWithoutCompellingIndicationsforSpecificAgents,becauseitdoesnotrefertochoiceoftherapybutratherthresholdsforinitiationoftherapy.

IV.Globalvascularprotectiontherapyforadultswithhypertensionwithoutcompellingindicationsforspecificagents

Recommendations1.Statintherapyisrecommendedinhypertensivepatientswith3ormorecardiovascularriskfactorsasdefinedinSupplementalTableS11(GradeAinpatients>40years)orwithestablishedatheroscleroticdisease(GradeAregardlessofage).

2.Considerationshouldbegiventotheadditionoflow-doseASAtherapyinhypertensivepatients!50years(GradeB)(revisedrecommendation).CautionshouldbeexercisedifBPisnotcontrolled(GradeC).Background.TherecommendationtoconsiderASAfortheprimarypreventionofcardiovasculardiseaseinhypertensive

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patientsisbasedprimarilyontheHypertensionOptimalTrial(HOT).44Inthistrial,18,790patientsaged50-80years(meanage,61.5Æ7.5years)withDBPlevelsbetween100and115mmHgwererandomizedusinga3Â2factorialdesignto1of3DBPtargets( 90vs 85vs 80mmHg)andtoASAvsplacebo.Overameanfollow-uptimeof3.8years,ASAtherapyreducedtheincidenceofmajorcardiovascularevents(MACE)from10.5%to8.9%(HR,0.85;95%CI,0.73-0.99).Whensilentmyocardialin-farctionswereincludedintheMACEendpoint,theoverallresultswereinconclusive(HR,0.91;95%CI,0.79-1.04).44Itisunclearifsilentinfarctionswereanaprioricomponentoftheprimary45endpoint.Onrereviewofthetrialandprotocol,therecommendationtogivelow-doseASAinhypertensivepatientswasdowngradedtoGradeBbecauseofthisuncertainty.

Asecondalterationwasmadetotherecommendation.Previously,theRTFrecommendedthatASAtreatmentbeconsideredinallhypertensiveindividuals,28withaGradeAratingforthose50yearsofageorolder.Thisyear,therecommendationhasbeenmodifiedsuchthatitisrestrictedtohypertensivepatients!50yearsofageandismoreconsistentwiththepopulationincludedintheHOTtrial.ThischangealsotookintoconsiderationthebenefitsofASAtherapyintermsofreductionsinMACEandpreventionofcancerandASA-associatedbleedingrisks.46,47TheRTFdidnotconductin-depthmodellingofthesefactors,whicharebeyondthescopeofCHEP’smandate,butdidnotethatanagethresholdof50yearswasconsistentwiththerecom-mendations46,48ofotherorganizationsthathaveperformedsuchanalyses.V.GoalsoftherapyforadultswithhypertensionwithoutcompellingindicationsforspecificagentsRecommendations1.TheSBPtreatmentgoalisapressurelevelof<140mmHg(GradeC).TheDBPtreatmentgoalisapressurelevelof<90mmHg(GradeA).

2.InVI.TreatmentofhypertensioninassociationwithischemicheartdiseaseRecommendationsA.RecommendationsforhypertensivepatientswithCAD1.AnACEinhibitororARBisrecommendedformostpatientswithhypertensionandCAD(GradeA).

2.Forpatientswithstableangina,b-blockersarepreferredasinitialtherapy(GradeB).CCBsmayalsobeused(GradeB).

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3.Short-actingnifedipineshouldnotbeused(GradeD).4.ForpatientswithCAD,butwithoutcoexistingsystolicheartfailure,thecombinationofanACEinhibitorandARBisnotrecommended(GradeB).

5.Inhigh-riskpatients,whencombinationtherapyisbeingused,choicesshouldbeindividualized.ThecombinationofanACEinhibitorandadihydropyr-idineCCBispreferabletoanACEinhibitorandathiazide/thiazide-likediureticinselectedpatients(GradeA).

6.WhendecreasingSBPtotargetlevelsinpatientswithestablishedCAD(especiallyifisolatedsystolichy-pertension ispresent),becautiouswhentheDBPischemia60mmmightHgbecausebeexacerbatedofconcernsis(GradethatmyocardialD)(newrecommendation).Background.Posthocanalysesoflargeclinicaltrialsinpa-tientswithCADsuggesttheexistenceofapossibleJ-curve,inwhichBPloweringtolessthanaspecificnadirdwhichvariesbetweenstudiesdisassociatedwithanincreasedriskofcor-onaryevents.49-51Thisissuewasdiscussedindetailinthe2013CHEPrecommendations.28For2014,afterarereviewoftheevidence,theRTFvotedtoaddanewrecommendationtoadvisecautioniftheDBPapproaches60mmHgorlesswhenstrivingtoreachpatient-specificSBPtargetsinpatientswithconcomitantCAD.Thissituationarisesmostcommonlywhenisolatedsystolichypertensionispresent.

TherecommendationtoexercisecautionwithloweringDBPto<60mmHgisprimarilyderivedfrom3studies;posthocanalysesoftheSystolicHypertensioninEurope(Syst-Eur)53trial,52anobservationalcoronarycatheterizationstudy,andasystematicreviewofthebenefitsofBPreductioninpatientswithCAD.54IntheSyst-Eurtrial,52cardiovasculareventrateswereincreasedwhenon-treatmentDBPlevelswere 70mmHg(independentofSBPlevels)inolderindividuals(age!60years)withCADreceivingactiveantihypertensivetreatment.Thisincreaseincardiovas-culareventsappearedtoreachstatisticalsignificanceataDBPvalueofapproximately60mmHg.Anobservationalcoronarycatheterizationstudy53demonstratedthatwhencentralDBPwas60mmHgorlessinhypertensivepatientswithCAD,theprobabilityofreducedcoronarybloodflowdistaltocoronarystenosiswasincreased.Finally,arecentsystematicreview54examiningthebeneficialandharmfuleffectsofBP-loweringdrugsinpatientswithCADindicatedthatfurtherreductionincardiovasculardiseaseeventrateswassmallatSBPvalueslessthan140mmHgandshouldbeweighedagainsttheriskofhypotension.

Thus,thereisGradeDevidencesupportingthepossi-bilityofharmwithexcessiveloweringofDBPinpatientswithestablishedCAD.AnalternativeexplanationmightbethatalowerDBPisamarkerforfrailtyormedicalillnessandnotcausallyrelatedtoincreasedevents.55Nevertheless,theRTFbelievedthattheevidencewassufficientlyrobusttowarrantbringingthisissuetotheattentionofpractitioners.TheRTFwishestoemphasizethatthissuggestscautionwhenloweringBPbutdoesnotprecludeBP-lowering,especiallyinpatientswithmoderateorseverelyincreasedSBPlevels.Acautiousapproachmightinvolveobserving

496

morecarefullyforsignsandsymptomsofreducedcoronarybloodflowwhileloweringSBP.ThisnewrecommendationdoesnotapplytohypertensivepatientswithoutCAD.Finally,eveninthecontextofCAD,otherdiagnosessuchasdiabetesorCKDmightsupportfurtherincreasesinantihy-pertensive 60mmtherapyHg.

tolowerSBPevenwhenDBPvaluesareB.Recommendationsforpatientswithhypertensionwhohavehadarecentmyocardialinfarction

1.Initialtherapyshouldincludeab-blockerandanACEinhibitor(GradeA).

2.AnARBcanbeusedifthepatientisintolerantofanACEinhibitor(GradeAinpatientswithleftventricularsystolicdysfunction).

3.CCBsmaybeusedinpatientsaftermyocardialinfarc-tionwhenb-blockersarecontraindicatedornoteffec-tive.NondihydropyridineCCBsshouldnotbeusedwhenthereisheartfailure,evidencedbypulmonarycongestionattimeofexaminationorradiography(GradeD).VII.Treatmentofhypertensioninassociationwithheartfailure

Recommendations1.Inpatientswithsystolicdysfunction(ejectionfraction<40%),ACEinhibitors(GradeA)andb-blockers(GradeA)arerecommendedforinitialtherapy.Aldosteroneantago-nists(mineralocorticoidreceptorantagonists)mightbeaddedforpatientswitharecentcardiovascularhospitali-zation,acutemyocardialinfarction,elevatedB-typenatri-ureticpeptideorN-terminalpro-B-typenatriureticpeptidelevel,orNewYorkHeartAssociationclassII-IVsymptoms(GradeA).Carefulmonitoringforhyperkalemiaisrec-ommendedwhenaddinganaldosteroneantagonisttoanACEinhibitororARB.Otherdiureticsarerecommendedasadditionaltherapyifneeded(GradeBforthiazide/thiazide-likediureticsforBPcontrol,GradeDforloopdiureticsforvolumecontrol).BeyondconsiderationsofBPcontrol,dosesofACEinhibitorsorARBsshouldbetitratedtothosefoundtobeeffectiveintrialsunlessadverseeffectsbecomemanifest(GradeB).

2.AnARBisrecommendedifACEinhibitorsarenottoler-ated(GradeA).

3.AcombinationofhydralazineandisosorbidedinitrateisrecommendedifACEinhibitorsandARBsarecontra-indicatedornottolerated(GradeB).

4.ForhypertensivepatientswhoseBPisnotcontrolled,anARBmaybeaddedtoanACEinhibitorandotheranti-hypertensivedrugtreatment(GradeA).Carefulmoni-toringshouldbeusedifcombininganACEinhibitorandanARBbecauseofpotentialadverseeffectssuchashy-potension,hyperkalemia,andworseningrenalfunction(GradeC).Additionaltherapiesmightalsoincludedihy-dropyridineCCBs(GradeC).Background.Therearenochangestotheserecommenda-tionsfor2014.

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Volume302014

VIII.Treatmentofhypertensioninassociationwithstroke

RecommendationsA.BPmanagementinacutestroke(onsetto72hours)1.Forpatientswithischemicstrokenoteligibleforthrombolytictherapy,treatmentofhypertensioninthesettingofacuteischemicstrokeortransientischemicattackshouldnotberoutinelyundertaken(GradeD).Extreme>BPincreases(eg,approximately120mmHg)15%may(GradebeSBPtreated>220D),tommHgorDBPandreducenotmoretheBPthanby25%,overthefirst24hourswithgradualreductionthereafter(GradeD).AvoidexcessiveloweringofBPbecausethismightexacerbateexistingischemiaormightinduceischemia,particularlyinthesettingofintracranialarterialocclusionorextracranialcarotidorvertebralarteryocclusion(GradeD).PharmacologicalagentsandroutesofadministrationshouldbechosentoavoidprecipitousdecreasesinBP(GradeD).

2.Forpatientswithischemicstrokeeligibleforthrombo-lytictherapy,veryhighBP(>185/110mmHg)shouldbetreatedconcurrentlyinpatientsreceivingthrombo-lytictherapyforacuteischemicstroketoreducetheriskofsecondaryintracranialhemorrhage(GradeB).B.BPmanagementafteracutestroke

1.Strongconsiderationshouldbegiventotheinitiationofantihypertensivetherapyaftertheacutephaseofastrokeortransientischemicattack(GradeA).

2.Aftertheacutephaseofastroke,BP-loweringtreatmentisrecommendedtoatargetofconsistently<140/90mmHg(GradeC).

3.TreatmentwithanACEinhibitorandthiazide/thiazide-likediureticcombinationispreferred(GradeB).

4.Forpatientswithstroke,thecombinationofanACEinhibitorandARBisnotrecommended(GradeB).Background.Therearenochangestotheserecommenda-tionsfor2014.However,3recent56-58trialsthatexaminedSBPtargetsinstrokewerediscussed,andarebrieflyreviewedherein.TwoexaminedBP-loweringafterspontaneousintra-cerebralhemorrhage(ICH),56,57and1addressedBP-lowering2ormoreweeksafterasymptomaticlacunarinfarction.58TheresultsofthesetrialsdidnotconclusivelyindicatebenefitforgreaterBPreductionandnoalterationsweremadetotherecommendationsatthepresenttime.

TheIntensiveBloodPressureReductioninAcuteCerebralHemorrhageTrial-2(INTERACT-2)trial56enrolled2839individualswithin6hoursofspontaneousICH.InvestigatorsexaminedastrategyofloweringSBPwithin1hourofpre-sentationto<140mmHgcomparedwith<180mmHg;thesetargetsweretobemaintainedforatleast7days.Theprimaryoutcomewasacompositeofdeathanddisabilitydefinedbyascoreof3-6onthemodifiedRankinscale90daysaftertheevent.Theoutcomeratewasgreaterthanex-pectedinbothtrialarmsandthebetween-groupdifferenceswerelessthanexpected.Therewasasuggestionofa13%relativereduction(0.87;95%CI,0.75-1.01)intheprimaryoutcomefavouringthelowerSBPtargetgroupbutas

Dasguptaetal.

2014CHEPRecommendations

demonstratedbythe95%CI,thisfindingwasnotconclusive.Therefore,theRTFwasoftheviewthatthestrengthofevi-dencedidnotwarrantachangeinrecommendations.

IntracerebralHemorrhageAcutelyDecreasingArterialPressureTrial(ICHADAPT)57enrolledpatientswithin24hoursofaspontaneousICHiftheirSBPwas!150mmHg.TheSBPtargetswere<150mmHgvs<180mmHg.Theprimaryoutcomewasradiographically-determinedperi-hematomarelativecerebralbloodflow(rCBF)andthemainobjectivewastoexaminewhetherSBP-loweringhadadetri-mentaleffectonrCBF.Seventy-fiveparticipantswereenrolled.NoconclusivedifferencesinperihematomarCBFweredemonstrated(perihematomarCBFdifference,0.03;95%CI,À0.018to0.078).TheipsilateralhemisphericrCBFwasslightlylessinthelowerBPtargetgroup(0.04difference),suggestinglowerperfusionwithalowerBPtarget,althoughthemagnitudeofthedifferencewassmall.TheinvestigatorsinterpretedtheirfindingsassuggestingnodetrimentaleffectonperihematomarCBFwithBPreductionafterICH.

TheSecondaryPreventionofSmallSubcorticalStrokes(SPS3)trial58enrolled3020patientswithmagneticresonanceimaging-definedsymptomaticlacunarinfarctions(ie,smallsubcorticalstrokes)andwithoutsurgicallyamenableipsilateralcarotidarterystenosisorhigh-riskcardioembolicsources.Participantswereenrolled2weeksafterstrokeandwereran-domizedto<130mmHgvs130-149mmHgSBPtargets.After3.7years,therewasnoconclusivedifferenceineithertheincidenceofrecurrentstroke(HR,0.81;95%CI,0.64-1.03)ortheoccurrenceofadverseevents(orthostaticsyncopeHR,2.19;95%CI,0.76-6.27;alladverseeventsHR,1.53;95%CI,0.80-2.93);theRTFnoted,however,thatthepointesti-matessuggestedlowerrecurrentstrokeratesbuthigheradverseeventratesinthe<130mmHgSBPtargetgroup.IX.TreatmentofhypertensioninassociationwithleftventricularhypertrophyRecommendations1.Hypertensivepatientswithleftventricularhypertrophyshouldbetreatedwithantihypertensivetherapytolowertherateofsubsequentcardiovascularevents(GradeC).2.Thechoiceofinitialtherapycanbeinfluencedbythepresenceofleftventricularhypertrophy(GradeD).InitialtherapycanbedrugtreatmentusingACEinhibitors,ARBs,long-actingCCBs,orthiazide/thiazide-likedi-uretics.Directarterialvasodilatorssuchashydralazineorminoxidilshouldnotbeused.Background.Therearenochangestotheserecommenda-tionsfor2014.

X.TreatmentofhypertensioninassociationwithnondiabeticCKDRecommendations1.ForpatientswithnondiabeticCKD,targetBPis<140/90mmHg(GradeB).

2.ForpatientswithhypertensionandproteinuricCKD(urinaryprotein>500mgper24hoursoralbuminto

497

creatinineratio>30mg/mmol),initialtherapyshouldbeanACEinhibitor(GradeA)oranARBifthereisintol-erancetoACEinhibitors(GradeB).

3.Thiazide/thiazide-likediureticsarerecommendedasaddi-tiveantihypertensivetherapy(GradeD).ForpatientswithCKDandvolumeoverload,loopdiureticsareanalterna-tive(GradeD).

4.Inmostcases,combinationtherapywithotherantihyper-tensiveagentsmightbeneededtoreachtargetBPlevels(GradeD).

5.ThecombinationofanACEinhibitorandARBisnotrecommendedforpatientswithnonproteinuricCKD(GradeB).Background.Therearenochangestotheserecommenda-tionsfor2014.

XI.TreatmentofhypertensioninassociationwithrenovasculardiseaseRecommendations1.Renovascularhypertensionshouldbetreatedinthesamemannerashypertensionwithoutcompellingindications,exceptforcautionintheuseofACEinhibitorsorARBsbecauseoftheriskofacuterenalfailureinbilateraldiseaseorunilateraldiseasewithasolitarykidney(GradeD).2.Closefollow-upandearlyintervention(angioplastyandstentingorsurgery)shouldbeconsideredforpatientswithuncontrolledhypertensiondespitetherapywith!3drugs,deterioratingkidneyfunction,bilateralatheroscleroticrenalarterylesions(ortightatheroscleroticstenosisinasinglekidney),orrecurrentepisodesofflashpulmonaryedema(GradeD).Background.Therearenochangestotheserecommenda-tionsfor2014.

XII.TreatmentofhypertensioninassociationwithdiabetesmellitusRecommendations1.PersonswithdiabetesmellitusshouldbetreatedtoattainSBPof<130mmHg(GradeC)andDBPof<80mmHg(GradeA)(thesetargetBPlevelsarethesameastheBPtreatmentthresholds).Combinationtherapyusing2first-lineagentsmightalsobeconsideredasinitialtreatmentofhypertension(GradeB)ifSBPis20mmHggreaterthantargetorifDBPis10mmHggreaterthantarget.However,cautionshouldbeexercisedinpatientsinwhomasubstantialdecreaseinBPismorelikelyorpoorlytolerated(eg,elderlypatientsandpatientswithautonomicneuropathy).

2.Forpersonswithcardiovascularorkidneydisease,includingmicroalbuminuria,orwithcardiovascularriskfactorsinadditiontodiabetesandhypertension,anACEinhibitororanARBisrecommendedasinitialtherapy(GradeA).

3.Forpersonswithdiabetesandhypertensionnotincludedinotherrecommendationsinthissection,appropriatechoices

498

Table1.ConsiderationsintheindividualizationofpharmacologicaltherapyInitialtherapySecond-linetherapyCanadianJournalofCardiology

Volume302014

Notesand/orcautionsNotrecommendedformonotherapy:a-blockers,b-blockersinthose!60yearsofage,andACEinhibitorsinblackpeople.Hypokalemiashouldbeavoidedinthoseprescribeddiuretics.ACEinhibitors,ARBs,anddirectrenininhibitorsarepotentialteratogens,andcautionisrequiredifprescribingtowomenwithchild-bearingpotential.

CombinationofanACE-inhibitorwithanARBisnotrecommendedSameasdiastolichypertensionwithorwithoutsystolichypertension

HypertensionwithoutothercompellingindicationsDiastolichypertensionwithorThiazide/thiazide-likediuretics,b-Combinationsoffirst-linedrugswithoutsystolichypertensionblockers,ACEinhibitors,ARBs,or(targetBP<140/90mmHg)long-actingCCBs(considerASA

andstatinsinselectedpatients).Considerinitiatingtherapywithacombinationoffirst-linedrugsiftheBPis!20mmHgsystolicor!10mmHgdiastolicgreaterthantarget

IsolatedsystolichypertensionThiazide/thiazide-likediuretics,ARBswithoutothercompellingorlong-actingdihydropyridineindications(targetBPforageCCBs<80is<140/90mmHg;forage!80:targetSBPis<150mmHg

Diabetesmellitus(targetBP<130/80mmHg)DiabetesmellituswithACEinhibitorsorARBsmicroalbuminuria,*renaldisease,cardiovasculardisease,oradditionalcardiovascularriskfactors

DiabetesmellitusnotincludedinACEinhibitors,ARBs,theabovecategorydihydropyridineCCBs,orthiazide/

thiazide-likediureticsCardiovasculardisease(targetBP<140/90mmHg)CoronaryarterydiseaseACEinhibitorsorARBs;b-blockers

forpatientswithstableangina

Combinationsoffirst-linedrugs

AdditionofadihydropyridineCCBisAloopdiureticcouldbeconsideredinpreferredoverathiazide/thiazide-hypertensiveCKDpatientswith

likediureticextracellularfluidvolumeoverloadCombinationoffirst-linedrugs.IfNormalurinemicroalbumintocombinationwithACEinhibitoriscreatinineratio<2.0mg/mmolbeingconsidered,adihydropyridineCCBispreferabletoathiazide/thiazide-likediureticLong-actingCCBs.When

combinationtherapyisbeingusedforhigh-riskpatients,anACEinhibitor/dihydropyridineCCBispreferred

Avoidshort-actingnifedipine.

CombinationofanACEinhibitorwithanARBisspecificallynotrecommended.ExercisecautionwhendecreasingSBPtotargetifDBPis 60mmHg

Long-actingCCBsifb-blockerNondihydropyridineCCBsshouldnotcontraindicatedornoteffectivebeusedwithconcomitantheart

failure

ACEinhibitorandARBcombined.TitratedosesofACEinhibitorsandHydralazine/isosorbidedinitrateARBstothoseusedinclinicaltrials.combinationifACEinhibitorandCarefullymonitorpotassiumandARBcontraindicatedornotrenalfunctionifcombininganyoftolerated.ACEinhibitor,ARB,and/orThiazide/thiazide-likeorloopdiureticsaldosteroneantagonistarerecommendedasadditive

therapy.DihydropyridineCCBscanalsobeused

Hydralazineandminoxidilshouldnotbeused

TreatmentofhypertensionshouldnotberoutinelyundertakeninacutestrokeunlessextremeBPincrease.CombinationofanACEinhibitorwithanARBisnotrecommendedCarefullymonitorrenalfunctionandpotassiumforthosetakinganACEinhibitororARB.CombinationsofanACEinhibitorandARBarenotrecommendedinpatientswithoutproteinuria

AvoidACEinhibitorsorARBsifbilateralrenalarterystenosisorunilateraldiseasewithsolitarykidney

RecentmyocardialinfarctionHeartfailure

b-BlockersandACEinhibitors(ARBs

ifACEinhibitor-intolerant)

LeftventricularhypertrophyPaststrokeorTIA

ACEinhibitors(ARBsifACE

inhibitor-intolerant)andb-blockers.Aldosteroneantagonists(mineralocorticoidreceptorantagonists)maybeaddedfor

patientswitharecentcardiovascularhospitalization,acutemyocardialinfarction,elevatedBNPorNT-proBNPlevel,orNYHAclassII-IVsymptoms

ACEinhibitor,ARB,long-actingCCBCombinationofadditionalagentsorthiazide/thiazide-likediuretics.

ACEinhibitorandathiazide/thiazide-Combinationofadditionalagentslikediureticcombination

NondiabeticCKD(targetBP<140/90mmHg)

NondiabeticCKDwithproteinuriayACEinhibitors(ARBsifACE

inhibitor-intolerant)ifthereisproteinuria;diureticsasadditivetherapyRenovasculardisease

Doesnotaffectinitialtreatmentrecommendations

Combinationsofadditionalagents

Combinationsofadditionalagents

Dasguptaetal.

2014CHEPRecommendationsTable1.Continued.Initialtherapy

Otherconditions(targetBP<140/90mmHg)PeripheralarterialdiseaseDoesnotaffectinitialtreatment

recommendations

DyslipidemiaDoesnotaffectinitialtreatment

recommendations

OverallvascularprotectionStatintherapyforpatients!3

cardiovascularriskfactorsoratheroscleroticdisease;low-doseASAinpatients!50years

Second-linetherapy

CombinationsofadditionalagentsCombinationsofadditionalagents

d

Notesand/orcautions

499

Avoidb-blockerswithseveredisease

d

CautionshouldbeexercisedwiththeASArecommendationifBPisnotcontrolled

ACE,angiotensin-convertingenzyme;ACR,albumintocreatinineratio;ARB,angiotensinreceptorblocker;ASA,acetylsalicylicacid;BNP,B-typenatriureticpeptide;BP,bloodpressure;CCB,calciumchannelblocker;CKD,chronickidneydisease;DBP,diastolicbloodpressure;NT,N-terminal;NYHA,NewYorkHeartAssociation;SBP,systolicbloodpressure;TIA,transientischemicattack.

*MicroalbuminuriaisdefinedaspersistentACR>2.0mg/mmol.yProteinuriaisdefinedasurinaryprotein>500mgper24hoursorACR>30mg/mmolin2of3specimens.ReproducedwithpermissionoftheCanadianHypertensionEducationProgram.

include(inalphabeticalorder):ACEinhibitors(GradeA),ARBs(GradeB),dihydropyridineCCBs(GradeA),andthiazide/thiazide-likediuretics(GradeA).

4.IftargetBPlevelsarenotachievedwithstandard-dosemonotherapy,additionalantihypertensivetherapyshouldbeused.ForpersonsinwhomcombinationtherapywithanACEinhibitorisbeingconsidered,adihydropyridineCCBispreferabletoathiazide/thiazide-likediuretic(GradeA).Background.Therearenochangestotheserecommenda-tionsfor2014.

XIII.AdherencestrategiesforpatientsRecommendations1.Adherencetoanantihypertensiveprescriptioncanbeimprovedbyamultiprongedapproach(SupplementalTableS12).Background.Therearenochangestotheserecommenda-tionsfor2014.

XIV.TreatmentofsecondaryhypertensionbecauseofendocrinecausesRecommendations1.TreatmentofhyperaldosteronismandpheochromocytomaareoutlinedinSupplementalTablesS7andS8,respectively.Background.Therearenochangestotheserecommenda-tionsfor2014.

Implementation

Theimplementationtaskforceconductsanextensiveknowledgetranslationefforttoenhanceuptakeandapplica-bilityoftheserecommendations.Theseeffortsincludeknowledgeexchangeforums,targetededucationalmaterialsforprimarycareprovidersandpatients,andfreelyavailable

slidekitsandsummarydocumentsofallrecommendationsontheCanadianHypertensionSocietyWebsite,HypertensionCanada(www.hypertension.ca).DocumentsareavailableinFrenchandEnglish,andsomedocumentsaretranslatedintootherlanguages.Theimplementationtaskforcealsoregularlyreceivesfeedbackfromenduserstoimproveguidelinepro-cessesandcontent.AlthoughthenumberofprimarycareproviderswhodirectlyreceiveCHEPmaterialsonaregularbasishasdramaticallyincreased,CHEPiscontinuingtoaddressthechallengeofidentifyingandreachingallactiveprimarycareprovidersacrossCanada,throughuseoftheHypertensionCanadaWebsite,“TraintheTrainer”teachingsessions,andwidedisseminationofeducationalmaterials.TheCHEPoutcomestaskforceconductshypertensionsurveillancestudiesandreviewsexistingCanadianhealthsurveystoidentifygapsbetweencurrentandbestpractices.FutureDirections

Table1containsasummaryofpharmacologicalmanage-mentrecommendationsforhypertension.Thepresentarticlerepresentsthe14thiterationoftheannuallyupdatedCHEPrecommendationsforthemanagementofhypertension.TheRTFwillcontinuetoconductsystematicreviewsoftheclinicaltrialevidenceandupdatetheserecommendationsannually.

Acknowledgements

TheauthorsthankMsSusanCarterforexperttechnicalassistancewiththemanuscript.

FundingSources

TheCHEPisoperatedandfundedbyHypertensionCanada.ThemembersoftheCHEPCommitteeareunpaidvolunteerswhocontributetheirtimeandexpertisetotheannualdevelopmentanddisseminationoftheCHEPrec-ommendations.Tomaintainprofessionalcredibilityofthecontent,theprocessforthedevelopmentoftherecommen-dationsisfullyindependentandfreefromexternalinfluence.Externalpartnersassistwiththedisseminationoftheapprovedrecommendations.

500

Disclosures

PleaseseeSupplementalAppendixS2foracompletelistofauthordisclosures.References

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SupplementaryMaterial

Toaccessthesupplementarymaterialaccompanyingthisarticle,visittheonlineversionoftheCanadianJournalofCardiologyatwww.onlinecjc.caandathttp://dx.doi.org/10.1016/j.cjca.2014.02.002.