Guidelines
Hypertension Canada's 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults

https://doi.org/10.1016/j.cjca.2017.03.005Get rights and content

Abstract

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension. This year, we introduce 10 new guidelines. Three previous guidelines have been revised and 5 have been removed. Previous age and frailty distinctions have been removed as considerations for when to initiate antihypertensive therapy. In the presence of macrovascular target organ damage, or in those with independent cardiovascular risk factors, antihypertensive therapy should be considered for all individuals with elevated average systolic nonautomated office blood pressure (non-AOBP) readings ≥ 140 mm Hg. For individuals with diastolic hypertension (with or without systolic hypertension), fixed-dose single-pill combinations are now recommended as an initial treatment option. Preference is given to pills containing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in combination with either a calcium channel blocker or diuretic. Whenever a diuretic is selected as monotherapy, longer-acting agents are preferred. In patients with established ischemic heart disease, caution should be exercised in lowering diastolic non-AOBP to ≤ 60 mm Hg, especially in the presence of left ventricular hypertrophy. After a hemorrhagic stroke, in the first 24 hours, systolic non-AOBP lowering to < 140 mm Hg is not recommended. Finally, guidance is now provided for screening, initial diagnosis, assessment, and treatment of renovascular hypertension arising from fibromuscular dysplasia. The specific evidence and rationale underlying each of these guidelines are discussed.

Résumé

Hypertension Canada présente annuellement une mise à jour de ses lignes directrices fondées sur des données probantes en vue du diagnostic, de l’évaluation, de la prévention et du traitement de l’hypertension. Cette année, nous présentons 10 nouvelles lignes directrices. Trois de nos lignes directrices ont été revues et cinq autres ont été éliminées. Nous avons notamment retiré les distinctions relatives à l’âge et à la fragilité du patient dans le cadre de l’évaluation préalable à l’instauration d’un traitement antihypertenseur. En présence de lésions macrovasculaires aux organes cibles ou de facteurs indépendants de risque cardiovasculaire, un traitement antihypertenseur doit être envisagé chez tous les patients dont la pression systolique moyenne s'elève à ≥ 140 mm Hg (mesure de la pression artérielle en clinique [MPAC]). En ce qui a trait aux patients qui présentent une hypertension diastolique (avec ou sans hypertension systolique), on recommande désormais un traitement par une association médicamenteuse à dose fixe présentée en un seul comprimé à titre d’option thérapeutique initiale. Nous privilégions notamment les médicaments associant un inhibiteur de l’enzyme de conversion de l’angiotensine ou un inhibiteur des récepteurs de l’angiotensine à un bloqueur des canaux calciques ou à un diurétique. En cas d’administration d’un diurétique en monothérapie, il convient de privilégier les agents à action prolongée. Chez les patients atteints d’une cardiopathie ischémique avérée, il faut faire preuve de prudence lors d'une baisse de la pression diastolique (MPAC) à ≤ 60 mm Hg, surtout en présence d’une hypertrophie ventriculaire gauche. Au cours des 24 premières heures suivant un accident vasculaire cérébral hémorragique, il n’est pas recommandé d’abaisser a pression systolique (MPAC) à moins de 140 mm Hg. Enfin, nous avons inclus des lignes directrices en vue du dépistage, du diagnostic initial, de l’évaluation et du traitement de l’hypertension rénovasculaire associée à la dysplasie fibromusculaire. La justification et les données probantes pour chacune de nos lignes directrices sont également présentées.

Section snippets

Methods

The Hypertension Canada Guidelines Committee (HCGC) is a multidisciplinary panel of content as well as methodological experts comprised of a Chair, a Central Review Committee with a designated Chair, and 15 subgroups. Each subgroup addresses a distinct content area in hypertension (see Supplemental Appendix S1 for the current membership list). All HCGC members are volunteers.

Systematic literature searches to August 2016 were performed by a librarian from the Cochrane Collaboration in

I. Accurate measurement of BP

Background. There are no changes to these guidelines for 2017.

Guidelines

  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 and validated equipment for all methods (automated office BP [AOBP], non-AOBP, home BP monitoring, and ambulatory BP monitoring) is recommended (Grade D; see

Hypertension Canada's 2017 Guidelines: Prevention and Treatment of Hypertension

Please note, hereafter, all 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 method of BP measurement. Please refer to the section on Hypertension Canada's 2017 Guidelines: Diagnosis and Assessment of Hypertension, section II, Criteria for Diagnosis of Hypertension and Guidelines

Implementation

Implementation and dissemination of the guidelines is a priority for Hypertension Canada. We use many strategies to reach out to a variety of providers who care for patients with hypertension. Our 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

Acknowledgements

We thank Ms Susan Carter for providing technical assistance with the manuscript and administrative support.

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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