Hipertensi 1

Canadian Journal of Cardiology 33 (2017) 557e576
Guidelines
Hypertension Canada’s 2017 Guidelines for Diagnosis, Risk
Assessment, Prevention, and Treatment of Hypertension in
Adults
Alexander A. Leung, MD, MPH,a Stella S. Daskalopoulou, MD, PhD,b
Kaberi Dasgupta, MD, MSc,b Kerry McBrien, MD, MPH,c Sonia Butalia, BSc, MD,d
Kelly B. Zarnke, MD, MSc,e Kara Nerenberg, MD, MSc,f Kevin C. Harris, MD, MHSc,g
Meranda Nakhla, MD, MSc,h Lyne Cloutier, RN, PhD,i Mark Gelfer, MD,j
Maxime Lamarre-Cliche, MD,k Alain Milot, MD, MSc, MD,l Peter Bolli, MD,m
Guy Tremblay, MD,n Donna McLean, RN, NP, PhD,o Sheldon W. Tobe, MD, MSc(HPTE),p
Marcel Ruzicka, MD, PhD,q Kevin D. Burns, MD,q Michel Vallee, MD, PhD,r
G.V. Ramesh Prasad, MBBS, MSc,p Steven E. Gryn, MD,s Ross D. Feldman, MD,t
Peter Selby, MBBS, MHSc,u Andrew Pipe, CM, MD,v Ernesto L. Schiffrin, MD, PhD,w
Philip A. McFarlane, MD, PhD,x Paul Oh, MD,y Robert A. Hegele, MD,z Milan Khara, MBChB,aa
Thomas W. Wilson, MD,bb S. Brian Penner, MD,cc Ellen Burgess, MD,dd
Praveena Sivapalan, MD,bb Robert J. Herman, MD,e Simon L. Bacon, PhD,ee
Simon W. Rabkin, MD,ff Richard E. Gilbert, MD, PhD,gg Tavis S. Campbell, PhD,hh
Steven Grover, MD, MPA,ii George Honos, MD,jj Patrice Lindsay, RN, PhD,kk
Michael D. Hill, MD, MSc,ll Shelagh B. Coutts, MD,mm Gord Gubitz, MD,nn
Norman R.C. Campbell, MD,oo Gordon W. Moe, MD, MSc,pp Jonathan G. Howlett, MD,qq
Jean-Martin Boulanger, MD,rr Ally Prebtani, MD,ss Gregory Kline, MD,dd
Lawrence A. Leiter, MD,tt Charlotte Jones, MD, PhD,uu Anne-Marie Côte, MD, MHSc,vv
Vincent Woo, MD,ww Janusz Kaczorowski, PhD,xx Luc Trudeau, MD,yy
Ross T. Tsuyuki, BSc (Pharm), PharmD, MSc,zz Swapnil Hiremath, MD, MPH,aaa
Denis Drouin, MD,bbb Kim L. Lavoie, PhD,ccc Pavel Hamet, MD, PhD,ddd
Jean C. Gregoire, MD,eee Richard Lewanczuk, MD, PhD,o George K. Dresser, MD, PhD,fff
Mukul Sharma, MD, MSc,ggg Debra Reid, PhD, DtP,hhh Scott A. Lear, PhD,iii
Gregory Moullec, PhD,jjj Milan Gupta, MD,kkk Laura A. Magee, MD, MSc,lll
Alexander G. Logan, MD,p Janis Dionne, MD,g Anne Fournier, MD,mmm
Received for publication February 21, 2017. Accepted March 5, 2017. Sciences, University of Calgary, 1820 Richmond Rd SW, Calgary, Alberta
T2T 5C7, Canada. Tel.: þ1-403-955-8358; fax: þ1-403-955-8249.
Corresponding author: Dr Alexander A. Leung, Division of Endocri-
E-mail: aacleung@ucalgary.ca
nology and Metabolism, Departments of Medicine and Community Health
See page 573 for disclosure information.
http://dx.doi.org/10.1016/j.cjca.2017.03.005
0828-282X/Ó 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
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558 Canadian Journal of Cardiology
Volume 33 2017
Geneviève Benoit, MD,nnn Janusz Feber, MD,ooo Luc Poirier, BPharm, MSc,ppp
Raj S. Padwal, MD, MSc,qqq and Doreen M. Rabi, MD, MSc;rrr for Hypertension Canada
a
Division of Endocrinology and Metabolism, Department of Medicine, University of Calgary, Calgary, Alberta, Canada; b Divisions of General Internal Medicine, Clinical
Epidemiology and Endocrinology, Department of Medicine, McGill University, McGill University Health Centre, Montreal, Quebec, Canada; c Departments of Family
Medicine and Community Health Sciences, Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; d Departments of
Medicine and Community Health Sciences, Libin Cardiovascular Institute of Alberta, O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada;
e
Division of General Internal Medicine, University of Calgary, Calgary, Alberta, Canada; f Department of Medicine and Department of Obstetrics and Gynecology,
University of Calgary, Calgary, Alberta, Canada; g Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; h Montreal Children’s
Hospital, McGill University, Montreal, Quebec, Canada; i Universite du Que bec à Trois-Rivières, Trois-Rivières, Quebec, Canada; j Department of Family Medicine,
University of British Columbia, Copeman Healthcare Centre, Vancouver, British Columbia, Canada; k Institut de Recherches Cliniques de Montre al, Universite de
Montre al, Montre al, Quebec, Canada; l Department of Medicine, Universite Laval, Que bec, Quebec, Canada; m McMaster University, Hamilton, Ontario, Canada;
n
CHU-Que bec-Hopital St Sacrement, Que bec, Quebec, Canada; o University of Alberta, Edmonton, Alberta, Canada; p University of Toronto, Toronto, Ontario, Canada;
q
Division of Nephrology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; r Hôpital Maisonneuve-Rosemont,
Universite de Montre al, Montre al, Quebec, Canada; s Department of Medicine, Division of Clinical Pharmacology, Western University, London, Ontario, Canada;
t
Discipline of Medicine, Memorial University of Newfoundland, St John’s, Newfoundland and Labrador; u Centre for Addiction and Mental Health, University of Toronto,
Toronto, Ontario, Canada; v University of Ottawa Heart Institute, Ottawa, Ontario, Canada; w Department of Medicine and Lady Davis Institute for Medical Research,
Jewish General Hospital, McGill University, Montreal, Quebec, Canada; x Division of Nephrology, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada;
y
University Health Network, University of Toronto, Toronto, Ontario, Canada; z Departments of Medicine (Division of Endocrinology) and Biochemistry, Western
University, London, Ontario, Canada; aa Vancouver Coastal Health Addiction Services, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia,
Canada; bb Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; cc Department of Internal Medicine, University of Manitoba,
Winnipeg, Manitoba, Canada; dd Department of Medicine, University of Calgary, Calgary, Alberta, Canada; ee Department of Exercise Science, Concordia University, and
Montreal Behavioural Medicine Centre, Centre inte gre universitaire de sante et de services sociaux du Nord-de-l’Île-de-Montre al (CIUSSS-NIM), Hôpital du Sacre -Coeur
de Montre al, Montre al, Quebec, Canada; ff Vancouver Hospital, University of British Columbia, Vancouver, British Columbia, Canada; gg University of Toronto, Division
of Endocrinology, St Michael’s Hospital, Toronto, Ontario, Canada; hh Department of Psychology, University of Calgary, Calgary, Alberta, Canada; ii Division of Clinical
Epidemiology, Montreal General Hospital, Montreal, Quebec, Canada; jj University of Montreal, Montreal, Quebec, Canada; kk Stroke, Heart and Stroke Foundation of
Canada, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ll Department of Clinical Neurosciences, Hotchkiss
Brain Institute, University of Calgary, Calgary, Alberta, Canada; mm Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary,
Calgary, Alberta, Canada; nn Division of Neurology, Halifax Infirmary, Dalhousie University, Halifax, Nova Scotia, Canada; oo Medicine, Community Health Sciences,
Physiology and Pharmacology, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; pp St Michael’s Hospital, University of Toronto,
Toronto, Ontario, Canada; qq Departments of Medicine and Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada; rr Charles LeMoyne Hospital Research
Centre, Sherbrooke University, Sherbrooke, Quebec, Canada; ss McMaster University, Hamilton, Ontario, Canada; tt Keenan Research Centre in the Li Ka Shing Knowledge
Institute of St Michael’s Hospital, and University of Toronto, Toronto, Ontario, Canada; uu University of British Columbia, Southern Medical Program, Kelowna, British
Columbia, Canada; vv Universite de Sherbrooke, Sherbrooke, Quebec, Canada; ww University of Manitoba, Winnipeg, Manitoba, Canada; xx Universite de Montre al and
Centre hospitalier de l’Universite de Montre al (CHUM), Montre al, Quebec, Canada; yy Division of Internal Medicine, McGill University, Montre al, Quebec, Canada;
zz
Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; aaa Faculty of Medicine, University of Ottawa, Ottawa
Hospital Research Institute, Ottawa, Ontario, Canada; bbb Faculty of Medicine, Universite Laval, Que bec, Quebec, Canada; ccc Department of Psychology, University of
Quebec at Montreal, Montre al, Quebec, Canada; ddd Faculte de Me dicine, Universite de Montre al, Montre al, Quebec, Canada; eee Universite de Montre al, Institut de
cardiologie de Montre al, Montre al, Quebec, Canada; fff Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; ggg McMaster University,
Hamilton Health Sciences Population Health Research Institute, Hamilton, Ontario, Canada; hhh Centre inte gre de sante et de services sociaux (CISSS) de l’Outaouais,
Groupes de me decine de famille (GMF) de Wakefield, Wakefield, Quebec, Canada; iii Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia,
Canada; jjj Research Center, Hôpital du Sacre -Coeur de Montre al, Public Health School, University of Montre al, Montre al, Quebec, Canada; kkk McMaster University,
Hamilton, Ontario, and Canadian Collaborative Research Network, Brampton, Ontario, Canada; lll St George’s, University of London and the St George’s Hospital
National Health Service (NHS) Foundation Trust, London, United Kingdom; mmm Service de cardiologie, Centre Hospitalier Universitaire Sainte-Justine, Universite de
Montre al, Montre al, Quebec, Canada; nnn Centre Hospitalier Universitaire Sainte-Justine, Department of Pediatrics, Universite de Montre al, Montre al, Quebec, Canada;
ooo
Division of Neurology, Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada; ppp Centre Hospitalier
Universitaire de Que bec et Faculte de Pharmacie, Universite Laval, Que bec, Quebec, Canada; qqq Department of Medicine, University of Alberta, Edmonton, Alberta,
Canada; rrr Departments of Medicine, Community Health and Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
ABSTRACT
RESUM
E
Hypertension Canada provides annually updated, evidence-based Hypertension Canada pre sente annuellement une mise à jour de ses
guidelines for the diagnosis, assessment, prevention, and treatment lignes directrices fonde es sur des donne es probantes en vue du
of hypertension. This year, we introduce 10 new guidelines. Three diagnostic, de l’evaluation, de la pre
vention et du traitement de l’hy-
previous guidelines have been revised and 5 have been removed. pertension. Cette anne e, nous pre sentons 10 nouvelles lignes di-
Previous age and frailty distinctions have been removed as consider- te
rectrices. Trois de nos lignes directrices ont e revues et cinq autres
ations for when to initiate antihypertensive therapy. In the presence of ont e te
elimine
es. Nous avons notamment retire les distinctions rela-
macrovascular target organ damage, or in those with independent du patient dans le cadre de l’e
tives à l’âge et à la fragilite valuation
cardiovascular risk factors, antihypertensive therapy should be prealable à l’instauration d’un traitement antihypertenseur. En
Hypertension affects nearly a quarter of Canadian adults and With the goal of improving the prevention, detection,
represents a major risk factor for cardiovascular morbidity, assessment, and management of hypertension, Hypertension
chronic kidney disease, and death; however, it often remains Canada (formerly the Canadian Hypertension Education
clinically silent until complications arise.1-3 Worldwide, high Program) has been producing annually-updated, evidence-
blood pressure (BP) affects > 40% of adults older than the age based guidelines for health care providers since 1999. (The
of 25 years, and is the leading global risk factor for death or rebranding of Hypertension Canada was in response to
disability.4,5 feedback and marketing research from primary care
Leung et al. 559
2017 Hypertension Canada Guidelines for Adults
considered for all individuals with elevated average systolic nonauto- presence de le sions macrovasculaires aux organes cibles ou de fac-
mated office blood pressure (non-AOBP) readings 140 mm Hg. For teurs inde pendants de risque cardiovasculaire, un traitement anti-
individuals with diastolic hypertension (with or without systolic hyper- hypertenseur doit être envisage chez tous les patients dont la pression
tension), fixed-dose single-pill combinations are now recommended as systolique moyenne s’elève à 140 mm Hg (mesure de la pression
an initial treatment option. Preference is given to pills containing an arterielle en clinique [MPAC]). En ce qui a trait aux patients qui
angiotensin-converting enzyme inhibitor or angiotensin receptor presentent une hypertension diastolique (avec ou sans hypertension
blocker in combination with either a calcium channel blocker or systolique), on recommande de sormais un traitement par une asso-
diuretic. Whenever a diuretic is selected as monotherapy, longer-acting ciation me dicamenteuse à dose fixe pre sentee en un seul comprime à
agents are preferred. In patients with established ischemic heart dis- titre d’option therapeutique initiale. Nous privile
gions notamment les
ease, caution should be exercised in lowering diastolic non-AOBP to me dicaments associant un inhibiteur de l’enzyme de conversion de
60 mm Hg, especially in the presence of left ventricular hypertrophy. l’angiotensine ou un inhibiteur des re cepteurs de l’angiotensine à un
After a hemorrhagic stroke, in the first 24 hours, systolic non-AOBP bloqueur des canaux calciques ou à un diure tique. En cas d’adminis-
lowering to < 140 mm Hg is not recommended. Finally, guidance is tration d’un diuretique en monothe rapie, il convient de privile
gier les
now provided for screening, initial diagnosis, assessment, and treat- agents à action prolonge e. Chez les patients atteints d’une car-
ment of renovascular hypertension arising from fibromuscular diopathie ische mique avere
e, il faut faire preuve de prudence lors
dysplasia. The specific evidence and rationale underlying each of these d’une baisse de la pression diastolique (MPAC) à 60 mm Hg, surtout
guidelines are discussed. en pre sence d’une hypertrophie ventriculaire gauche. Au cours des 24
premières heures suivant un accident vasculaire ce re
bral
hemorragique, il n’est pas recommande d’abaisser a pression systo-
lique (MPAC) à moins de 140 mm Hg. Enfin, nous avons inclus des
lignes directrices en vue du de pistage, du diagnostic initial, de
valuation et du traitement de l’hypertension re
l’e novasculaire associe e
à la dysplasie fibromusculaire. La justification et les donne es pro-
bantes pour chacune de nos lignes directrices sont e galement
presente es.
stakeholders.) We present herein updated guidelines for 2017, and mortality as well as total mortality outcomes were
along with discussion of the supporting evidence. Further prioritized for pharmacotherapy studies. For health
details along with supporting references pertaining to estab- behaviour guidelines, BP was considered an acceptable
lished guidelines are available in previous publications,6-32 and surrogate. Similarly, progressive renal impairment was an
online (guidelines.hypertension.ca). Pediatric-specific guide- acceptable surrogate for guidelines relevant to chronic
lines are published separately. kidney disease. Study characteristics and study quality
Our guidelines are intended to provide a framework but were assessed using prespecified, standardized algorithms
should not replace clinical judgement. Practitioners are developed by Hypertension Canada for the critical
advised to consider patient preferences, values, and clinical appraisal of randomized controlled trials and observational
factors when determining how to best apply these guidelines studies.33
at the bedside. Guidelines were individually graded according to the
supporting evidence. All guidelines, regardless of grading, are
believed to have benefits that strongly outweigh risks. In this
Methods sense, all of Hypertension Canada’s guidelines are ‘strong’ in
The Hypertension Canada Guidelines Committee nature (ie, the HCGC refrains from making ‘weak’ guide-
(HCGC) is a multidisciplinary panel of content as well as lines). For pharmacotherapy guidelines, as a general rule,
methodological experts comprised of a Chair, a Central Re- Hypertension Canada considers evidence evaluating specific
view Committee with a designated Chair, and 15 subgroups. agents to be generalizable to a ‘class effect’ unless otherwise
Each subgroup addresses a distinct content area in hyperten- stated.
sion (see Supplemental Appendix S1 for the current mem- Expert subgroup members were responsible for reviewing
bership list). All HCGC members are volunteers. annual search results and, if indicated, drafting new guidelines
Systematic literature searches to August 2016 were per- or revising existing guidelines. An independent Central
formed by a librarian from the Cochrane Collaboration in Review Committee consisting of methodological experts with
MedLine/PubMed using text words and Medical Subject no industry affiliations independently reviewed, graded, and
Headings. Details of search strategies and retrieved articles are refined proposed guidelines, which were then presented at a
available upon request. Randomized controlled trials and consensus conference of the HCGC in Montreal on October
systematic reviews of randomized controlled trials were 19, 2016.
reviewed for treatment guidelines, whereas cross-sectional and All guidelines were finalized and submitted electronically
cohort studies were reviewed for evidence related to diagnosis to all 81 voting members of the HCGC for approval.
and prognosis. Members with potential conflicts of interest recused them-
Each subgroup examined the search results pertinent to selves from voting on specific guidelines (a list of conflicts is
its content area. Studies that assessed relevant outcomes available as Supplemental Appendix S2). Guidelines receiving
were selected for further review. Cardiovascular morbidity > 70% approval were passed. The Hypertension Canada
Volume 33 2017
Guidelines process is in accordance with the Appraisal of and the mean awake ambulatory BP monitoring is
Guidelines for Research and Evaluation II (AGREE II) < 135/85 mm Hg before diagnosing white coat
guidelines (guidelines.hypertension.ca/about/overview- hypertension (Grade D).
process),34 and has been externally reviewed (Supplemental
Table S1).
II. Criteria for diagnosis of hypertension and guidelines
for follow-up
Hypertension Canada’s 2017 Guidelines: Background. There are no changes to these guidelines for
Diagnosis and Assessment of Hypertension 2017. A hypertension diagnostic algorithm is shown in
Figure 1.
I. Accurate measurement of BP
Background. There are no changes to these guidelines for Guidelines
2017.
1. At the time of initial presentation, patients demonstrating
Guidelines features of a hypertensive urgency or emergency
(Supplemental Table S3) should be diagnosed as hyper-
1. Health care professionals who have been specifically tensive and require immediate management (Grade D).
trained to measure BP accurately should assess BP in all In all other patients, at least 2 more readings should be
adult patients at all appropriate visits to determine car- taken during the same visit. If using AOBP, the BP
diovascular risk and monitor antihypertensive treatment calculated and displayed by the device should be used. If
(Grade D). using non-AOBP measurement, the first reading should
2. Use of standardized measurement techniques and vali- be discarded and the latter readings averaged.
dated equipment for all methods (automated office BP 2. If the visit 1 office BP measurement is high-normal
[AOBP], non-AOBP, home BP monitoring, and ambu- (thresholds outlined in section I, Guideline 3) annual
latory BP monitoring) is recommended (Grade D; see follow-up is recommended (Grade C).
Supplemental Table S2; and sections III. Home BP 3. If the visit 1 mean AOBP or non-AOBP measurement is
Measurement; and IV. Ambulatory BP Measurement). high (thresholds outlined in section I, Guideline 3), a
Measurement using electronic (oscillometric) upper arm history and physical examination should be performed
devices is preferred over auscultation (Grade C). (Unless and, if clinically indicated, diagnostic tests to search for
specified otherwise, electronic [oscillometric] measure- target organ damage (Supplemental Table S4) and
ment should be used.) associated cardiovascular risk factors (Supplemental
3. Four approaches can be used to assess BP: Table S5) should be arranged within 2 visits. Exoge-
i. AOBP is the preferred method of performing in-office nous factors that can induce or aggravate hypertension
BP measurement (Grade D). When using AOBP (see should be assessed and removed if possible
Supplemental Table S2, section on Recommended (Supplemental Table S6). Visit 2 should be scheduled
Technique for Automated Office Blood Pressure within 1 month (Grade D).
[AOBP]), a displayed mean systolic BP (SBP) 135 4. If the visit 1 mean AOBP or non-AOBP SBP is 180
mm Hg or diastolic BP (DBP) 85 mm Hg DBP is mm Hg and/or DBP is 110 mm Hg then hypertension
high (Grade D). is diagnosed (Grade D).
ii. When using non-AOBP, a mean SBP 140 mm Hg 5. If the visit 1 mean AOBP SBP is 135-179 mm Hg and/or
or DBP 90 mm Hg is high, and an SBP between DBP is 85-109 mm Hg or the mean non-AOBP SBP is
130 and 139 mm Hg and/or a DBP between 85 and 140-179 mm Hg and/or DBP is 90-109 mm Hg, out-of-
89 mm Hg is high-normal (Grade C). office BP measurements should be performed before visit
iii. Using ambulatory BP monitoring (see Guidelines in 2 (Grade C).
section IV, Ambulatory BP Measurement), patients can i. Ambulatory BP monitoring is the recommended out-
be diagnosed as hypertensive if the mean awake SBP is of-office measurement method (Grade D). Patients
135 mm Hg or the DBP is 85 mm Hg or if the can be diagnosed with hypertension according to the
mean 24-hour SBP is 130 mm Hg or the DBP is thresholds outlined in section I, Guideline 3.
80 mm Hg (Grade C). ii. Home BP monitoring is recommended if ambula-
iv. Using home BP monitoring (see Guidelines in section tory BP monitoring is not tolerated, not readily
III, Home BP Measurement), patients can be diag- available, or because of patient preference (Grade
nosed as hypertensive if the mean SBP is 135 mm D). Patients can be diagnosed with hypertension
Hg or the DBP is 85 mm Hg (Grade C). If the according to the thresholds outlined in section I,
office BP measurement is high and the mean home Guideline 3.
BP is < 135/85 mm Hg, it is advisable to either iii. If the out-of-office BP average is not elevated, white
repeat home monitoring to confirm the home BP is coat hypertension should be diagnosed and pharma-
< 135/85 mm Hg or perform 24-hour ambulatory cologic treatment should not be instituted (Grade C).
BP monitoring to confirm that the mean 24-hour 6. If the out-of-office measurement, although preferred, is not
ambulatory BP monitoring is < 130/80 mm Hg performed after visit 1, then patients can be diagnosed as
Leung et al. 561
hypertensive using serial office BP measurement visits if any ambulatory BP monitoring before treatment decisions are
of the following conditions are met: made (Grade D).
i. At visit 2, mean non-AOBP measurement 4. Patients should be advised to purchase and use only
(averaged across all visits) is 140 mm Hg SBP and/ home BP monitoring devices that are appropriate for
or 90 mm Hg DBP in patients with macrovascular the individual and have met standards of the Associa-
target organ damage, diabetes mellitus, or chronic tion for the Advancement of Medical Instrumentation,
kidney disease (glomerular filtration rate < 60 mL/ the most recent requirements of the British Hyperten-
min/1.73 m2) (Grade D); sion Society protocol, or the International Protocol for
ii. At visit 3, mean non-AOBP measurement (averaged validation of automated BP measuring devices. Patients
across all visits) is 160 mm Hg systolic or 100 should be encouraged to use devices with data
mm Hg diastolic; recording capabilities or automatic data transmission to
iii. At visit 4 or 5, mean non-AOBP measurement increase the reliability of reported home BP monitoring
(averaged across all visits) is 140 mm Hg SBP or (Grade D).
90 mm Hg DBP. 5. Home SBP values 135 mm Hg or DBP values 85 mm
7. Investigations for secondary causes of hypertension Hg should be considered to be elevated and associated with
should be initiated in patients with suggestive clinical an increased overall mortality risk (Grade C).
and/or laboratory features (outlined in sections V, VII, 6. Health care professionals should ensure that patients
and VIII; Grade D). who measure their BP at home have adequate training
8. If at the last diagnostic visit the patient is not diagnosed as and, if necessary, repeat training in measuring their
hypertensive and has no evidence of macrovascular target BP. Patients should be observed to determine that
organ damage, the patient’s BP should be assessed at they measure BP correctly and should be given
yearly intervals (Grade D). adequate information about interpreting these readings
9. Hypertensive patients actively modifying their health (Grade D).
behaviours should be followed up at 3- to 6-month in- 7. Home BP monitoring for assessing white coat hypertension
tervals. Shorter intervals (every 1 or 2 months) are needed or sustained hypertension should be on the basis of
for patients with higher BP (Grade D). duplicate measures, morning and evening, for an initial 7-
10. Patients receiving antihypertensive drug treatment day period. First-day home BP values should not be
should be seen monthly or every 2 months, depending considered (Grade D).
on the level of BP, until readings on 2 consecutive
visits are below their target (Grade D). Shorter in-
tervals between visits will be needed for symptomatic IV. Ambulatory BP measurement
patients and for those with severe hypertension, intol-
erance to antihypertensive drugs, or target organ Background. There are no changes to these guidelines for
damage (Grade D). When the target BP has been 2017. A suggested protocol for ambulatory BP monitoring is
reached, patients should be seen at 3- to 6-month presented in Supplemental Table S2.
intervals (Grade D).
Guidelines
III. Home BP measurement
1. Ambulatory BP monitoring can be used in the diagnosis of
Background. There are no changes to these guidelines for hypertension (Grade C). Ambulatory BP monitoring
2017. A suggested protocol for home BP monitoring is pre- should be considered when an office-induced increase in BP
sented in Supplemental Table S2. is suspected in treated patients with:
i. BP that is not below target despite receiving appro-
Guidelines priate chronic antihypertensive therapy (Grade C);
ii. Symptoms suggestive of hypotension (Grade C);
1. Home BP monitoring can be used in the diagnosis of iii. Fluctuating office BP readings (Grade D).
hypertension (Grade C). 2. Ambulatory BP monitoring upper arm devices that
2. The use of home BP monitoring on a regular basis should have been validated independently using established
be considered for patients with hypertension, particularly protocols must be used (see www.dableducational.org)
those with: (Grade D).
i. Diabetes mellitus (Grade D); 3. Therapy adjustment should be considered in patients with
ii. Chronic kidney disease (Grade C); a mean 24-hour ambulatory BP monitoring SBP of 130
iii. Suspected nonadherence (Grade D); mm Hg and/or DBP of 80 mm Hg, or a mean awake
iv. Demonstrated white coat effect (Grade C); SBP of 135 mm Hg and/or DBP of 85 mm Hg
v. BP controlled in the office but not at home (masked (Grade D).
hypertension; Grade C). 4. The magnitude of changes in nocturnal BP should be
3. When white coat hypertension is suggested according to taken into account in any decision to prescribe or with-
home BP monitoring, its presence should be confirmed by hold drug therapy on the basis of ambulatory BP moni-
repeat home BP monitoring (Guideline 7, in this section) or toring (Grade C) because a decrease in nocturnal BP of
Volume 33 2017
< 10% is associated with increased risk of cardiovascular VII. Assessment for renovascular hypertension
events.
Background. Despite the lack of high-quality evidence, the
HCGC deemed it important to provide guidance for the
diagnosis of renal FMD. Affecting up to 4% of adults,35-40
V. Routine and optional laboratory tests for the FMD is an idiopathic condition, characterized by segmental,
investigation of patients with hypertension nonatherosclerotic narrowing of small- and medium-sized
Background. There are no changes to these guidelines arteries, which commonly affects renal blood flow.41 There
for 2017. is a marked female-to-male preponderance of 9:1, more
often affecting younger women.41,42 It is estimated that
Guidelines more than half of individuals with FMD have renal artery
stenosis, one-third have cervicocranial involvement, whereas
1. Routine laboratory tests that should be performed for the few are affected at other sites.39,43,44 Hypertension is the
investigation of all patients with hypertension include the most common manifestation, often requiring multiple
following: drugs.42 Headache, tinnitus, dizziness, neck pain, and cer-
i. Urinalysis (Grade D); vical/abdominal bruits might also be present.42 The diag-
ii. Blood chemistry (potassium, sodium, and creatinine; nosis of FMD is on the basis of diagnostic imaging with
Grade D); catheter-based angiography being the ‘gold standard.’
iii. Fasting blood glucose and/or glycated hemoglobin Noninvasive imaging modalities include captopril renal scan,
(A1c; Grade D); duplex ultrasound, computed tomographic angiography, and
iv. Serum total cholesterol, low-density lipoprotein, high- magnetic resonance angiography. Estimates of sensitivity
density lipoprotein, non-high-density lipoprotein and specificity vary widely and are generally derived from
cholesterol, and triglycerides (Grade D); lipids may be small studies.38,40,44-48 On the basis of a consensus of expert
drawn fasting or nonfasting (Grade C); opinion, we recommend either computed tomographic
v. Standard 12-lead electrocardiography (Grade C). angiography or magnetic resonance angiography as the
2. Assess urinary albumin excretion in patients with diabetes initial diagnostic test. If renal FMD is confirmed, patients
(Grade D). should be screened for cervicocephalic and intracranial
3. All treated hypertensive patients should be monitored ac- involvement, because these sites are also commonly
cording to the current Diabetes Canada guidelines for the affected.42 Screening of other vascular sites should be guided
new appearance of diabetes (Grade B). by symptoms.
4. During the maintenance phase of hypertension manage-
ment, tests (including those for electrolytes, creatinine, and Guidelines
fasting lipids) should be repeated with a frequency
reflecting the clinical situation (Grade D).
1. Patients who present with 2 of the following clinical
clues, suggestive of renovascular hypertension, should be
investigated (Grade D):
VI. Assessment of overall cardiovascular risk in
i. Sudden onset or worsening of hypertension and age >
hypertensive patients
55 or < 30 years;
Background. There are no changes to these guidelines for ii. Presence of an abdominal bruit;
2017. Examples of risk calculators include www. iii. Hypertension resistant to 3 drugs;
myhealthcheckup.com and www.score-canada.ca. iv. Increase in serum creatinine level 30% associated with
use of an angiotensin-converting enzyme (ACE) inhib-
Guidelines itor or angiotensin receptor blocker (ARB);
v. Other atherosclerotic vascular disease, particularly in
1. Global cardiovascular risk should be assessed. Multifac- patients who smoke or have dyslipidemia;
torial risk assessment models can be used to predict vi. Recurrent pulmonary edema associated with hyper-
more accurately an individual’s global cardiovascular risk tensive surges.
(Grade A) and to use antihypertensive therapy more 2. When available, the following tests are recommended to
efficiently (Grade D). In the absence of Canadian data aid in the usual screening for renal vascular disease:
to determine the accuracy of risk calculations, avoid captopril-enhanced radioisotope renal scan, Doppler so-
using absolute levels of risk to support treatment de- nography, magnetic resonance angiography, and computed
cisions (Grade C). tomography angiography (for those with normal renal
2. Consider informing patients of their global risk to function; Grade B). Captopril-enhanced radioisotope renal
improve the effectiveness of risk factor modification scan is not recommended for those with chronic kidney
(Grade B). Consider also using analogies that describe disease (glomerular filtration rate < 60 mL/min/1.73 m2;
comparative risk such as “cardiovascular age,” “vascular Grade D).
age,” or “heart age” to inform patients of their risk status 3. Patients with hypertension who present with at least 1 of
(Grade B). the following clinical clues should be investigated for
Leung et al. 563
Figure 1. Hypertension diagnostic algorithm. ABPM, ambulatory blood pressure measurement; AOBP, automated office blood pressure; BP, blood
pressure. *If AOBP is used, use the mean calculated and displayed by the device. If non-AOBP (see y) is used, take at least 3 readings, discard the
first, and calculate the mean of the remaining measurements. A history and physical exam should be performed and diagnostic tests ordered.
y
AOBP is performed with the patient unattended in a private area. Non-AOBP is performed using an electronic upper arm device with the provider in
the room. zDiagnostic thresholds for AOBP, ABPM, and home BP in patients with diabetes have yet to be established (and might be lower than
13080 mm Hg). xSerial office measurements over 3-5 visits can be used if ABPM or home measurement is not available. kFor a home BP series, 2
readings are taken each morning and evening for 7 days (28 total). Discard the first day readings and average the last 6 days. {Annual BP
measurement is recommended to detect progression to hypertension.
fibromuscular dysplasia (FMD)-related renal artery stenosis Guidelines

(Grade D; new guideline):
i. Age < 30 years, especially in nonobese women; 1. Screening for hyperaldosteronism should be consid-
ii. Hypertension resistant to 3 drugs; ered in hypertensive patients with the following
iii. Significant (> 1.5 cm), unexplained asymmetry in (Grade D):
kidney sizes; i. Unexplained spontaneous hypokalemia (Kþ < 3.5
iv. Abdominal bruit without apparent atherosclerosis; Mmol/L) or marked diuretic-induced hypokalemia
v. FMD in another vascular territory; (Kþ < 3.0 Mmol/L);
viii. Positive family history for FMD. ii. Resistance to treatment with 3 drugs;
4. In patients with confirmed renal FMD (Grade D; new iii. An incidental adrenal adenoma.
guideline): 2. Screening for hyperaldosteronism should include
i. Screening for cervicocephalic lesions and intracranial assessment of plasma aldosterone and plasma renin ac-
aneurysm is recommended; tivity or plasma renin (Supplemental Table S7).
ii. Screening for FMD in other vascular beds in the pres- 3. For patients with suspected hyperaldosteronism (on
ence of suggestive symptoms is recommended. the basis of the screening test, Supplemental
5. The following tests are recommended to screen for renal Table S7, item iii), a diagnosis of primary aldoste-
FMD (both with similar sensitivity and specificity; Grade ronism should be established by showing inappro-
D; new guideline): magnetic resonance angiography and priate autonomous hypersecretion of aldosterone
computed tomography angiography. using at least 1 of the manoeuvres listed in
Supplemental Table S7, item iv. When the diagnosis
VIII. Assessment for endocrine hypertension is established, the abnormality should be localized
using any of the tests described in Supplemental
A. Hyperaldosteronism: screening and diagnosis
Table S7, item v.
Background. There are no changes to these guidelines 4. In patients with primary aldosteronism and a definite
for 2017. adrenal mass who are eligible for surgery, adrenal
Volume 33 2017
venous sampling is recommended to assess for left ventricular dysfunction or coronary artery disease
lateralization of aldosterone hypersecretion. Adrenal (CAD; Grade D).
vein sampling should be performed exclusively by 4. Patients with hypertension and evidence of heart failure
experienced teams working in specialized centres should have an objective assessment of left ventricular
(Grade C). ejection fraction, either using echocardiogram or nuclear
imaging (Grade D).
B. Pheochromocytoma and paraganglioma: screening and
diagnosis Hypertension Canada’s 2017 Guidelines:
Background. There are no changes to these guidelines for Prevention and Treatment of Hypertension
2017. Please note, hereafter, all treatment thresholds and targets
1. If pheochromocytoma or paraganglioma is strongly refer to non-AOBP measurements performed in-office (see
suspected, the patient should be referred to a specialized Supplemental Table S2, section on Recommended Technique
hypertension centre, particularly if biochemical for Automated Office Blood Pressure [AOBP]), because most of
screening tests (Supplemental Table S8) have already the supporting evidence is derived from studies using this
been found to be positive (Grade D). method of BP measurement. Please refer to the section on
2. The following patients should be considered for Hypertension Canada’s 2017 Guidelines: Diagnosis and Assess-
screening for pheochromocytoma or paraganglioma ment of Hypertension, section II, Criteria for Diagnosis of
(Grade D): Hypertension and Guidelines for Follow-up, for corresponding
i. Patients with paroxysmal, unexplained, labile, and/ values using other measurement methods. A summary of the
or severe (BP 180/110 mm Hg) sustained potential factors that should be considered when selecting
hypertension refractory to usual antihypertensive specific drug therapy for individualized treatment is presented
therapy; in Table 1.
ii. Patients with hypertension and multiple symp-
toms suggestive of catecholamine excess (eg, I. Health behaviour management
headaches, palpitations, sweating, panic attacks, Background. There are no changes to these guidelines
and pallor); for 2017.
iii. Patients with hypertension triggered by b-blockers,
monoamine oxidase inhibitors, micturition, changes
Guidelines
in abdominal pressure, surgery, or anaesthesia;
iv. Patients with an incidentally discovered adrenal
A. Physical exercise
mass;
1. For nonhypertensive individuals (to reduce the pos-
v. Patients with a predisposition to hereditary causes
sibility of becoming hypertensive) or for hypertensive
(eg, multiple endocrine neoplasia 2A or 2B, von
patients (to reduce their BP), prescribe the accumu-
Recklinghausen neurofibromatosis type 1, or Von
lation of 30-60 minutes of moderate intensity dy-
Hippel-Lindau disease);
namic exercise (eg, walking, jogging, cycling, or
vi. For patients with positive biochemical screening
swimming) 4-7 days per week in addition to the
tests, localization of pheochromocytomas or para-
routine activities of daily living (Grade D). Higher
gangliomas should use magnetic resonance imaging
intensities of exercise are not more effective (Grade
(preferable), computed tomography (if magnetic
D). For nonhypertensive or stage 1 hypertensive in-
resonance imaging unavailable), and/or iodine
dividuals, the use of resistance or weight training
I-131 meta-iodobenzylguanidine scintigraphy
exercise (such as free weight-lifting, fixed weight-
(Grade C for each modality).
lifting, or handgrip exercise) does not adversely in-
fluence BP (Grade D).
IX. Role of echocardiography
B. Weight reduction
Background. There are no changes to these guidelines 1. Height, weight, and waist circumference should be
for 2017. measured and body mass index calculated for all adults
(Grade D).
Guidelines 2. Maintenance of a healthy body weight (body mass
index 18.5-24.9, and waist circumference < 102
cm for men and < 88 cm for women) is recom-
1. Routine echocardiographic evaluation of all hypertensive mended for nonhypertensive individuals to prevent
patients is not recommended (Grade D). hypertension (Grade C) and for hypertensive pa-
2. An echocardiogram for assessment of left ventricular hy- tients to reduce BP (Grade B). All overweight hy-
pertrophy (LVH) is useful in selected cases to help define pertensive individuals should be advised to lose
the future risk of cardiovascular events (Grade C). weight (Grade B).
3. Echocardiographic assessment of left ventricular mass, as 3. Weight loss strategies should use a multidisciplinary
well as of systolic and diastolic left ventricular function is approach that includes dietary education, increased
recommended for hypertensive patients suspected to have physical activity, and behavioural intervention (Grade B).
Leung et al. 565
Table 1. Considerations in the individualization of pharmacological therapy

Initial Therapy Second-Line Therapy Notes and/or Cautions
Hypertension without other compelling indications
Diastolic hypertension with or Monotherapy or SPC. Recommended Further combination of first-line drugs Not recommended for monotherapy: a
without systolic hypertension monotherapy choices include blockers, b-blockers in those 60
thiazide/thiazide-like diuretics (with years of age or older, ACE inhibitors
longer-acting diuretics preferred), in black people. Hypokalemia
b-blockers, ACE inhibitors, ARBs, should be avoided in those
or long-acting CCB. Recommended prescribed diuretics. ACE inhibitors,
SPC choices include combinations ARBs and direct renin inhibitors are
of an ACE inhibitor with CCB, potential teratogens, and caution is
ARB with CCB, or ACE inhibitor/ required if prescribing to women
ARB with a diuretic (consider ASA with child-bearing potential.
and statins in selected patients) Combination of an ACE-inhibitor
with an ARB is not recommended
Isolated systolic hypertension Thiazide/thiazide-like diuretics, ARBs, Combinations of first-line drugs Same as diastolic hypertension with or
without other compelling or long-acting dihydropyridine without systolic hypertension
indications CCBs
Diabetes mellitus
Diabetes mellitus with ACE inhibitors or ARBs Combination of a dihydropyridine A loop diuretic could be considered in
microalbuminuria,* renal disease, CCB is preferred over a thiazide/ hypertensive chronic kidney disease
cardiovascular disease or thiazide-like diuretic patients with extracellular fluid
additional cardiovascular risk volume overload
factors
Diabetes mellitus not included in ACE inhibitors, ARBs, Combination of first-line drugs. If Normal urine micro-ACR < 2.0
the above category dihydropyridine CCBs, or thiazide/ combination with ACE inhibitor is mg/Mmol
thiazide-like diuretics being considered, a dihydropyridine
CCB is preferable to a thiazide/
thiazide-like diuretic
Cardiovascular disease
Coronary artery disease ACE inhibitors or ARBs; b-blockers or When combination therapy is being Avoid short-acting nifedipine.
CCBs for patients with stable angina used for high-risk patients, an ACE Combination of an ACE-inhibitor
inhibitor/dihydropyridine CCB is with an ARB is specifically not
preferred recommended. Exercise caution
when lowering systolic BP to target
if diastolic BP is 60 mm Hg,
especially in patients with LVH
Recent myocardial infarction B-Blockers and ACE inhibitors (ARBs Long-acting CCBs if b-blocker Nondihydropyridine CCBs should not
if ACE inhibitor-intolerant) contraindicated or not effective be used with concomitant heart
failure
Heart failure ACE inhibitors (ARBs if ACE ACE inhibitor and ARB combined. Titrate doses of ACE inhibitors and
inhibitor-intolerant) and b-blockers. Hydralazine/isosorbide dinitrate ARBs to those used in clinical trials.
Aldosterone antagonists combination if ACE inhibitor and Carefully monitor potassium and
(mineralocorticoid receptor ARB contraindicated or not renal function if combining any of
antagonists) may be added for tolerated. ACE inhibitor, ARB, and/or
patients with a recent cardiovascular Thiazide/thiazide-like or loop diuretics aldosterone antagonist
hospitalization, acute myocardial are recommended as additive
infarction, elevated BNP or NT- therapy. Dihydropyridine CCB can
proBNP level, or NYHA class II-IV also be used
symptoms
LVH ACE inhibitor, ARB, long-acting Combination of additional agents Hydralazine and minoxidil should not
CCB, or thiazide/thiazide-like be used
diuretics
Past stroke or TIA ACE inhibitor and a thiazide/thiazide- Combination of additional agents Treatment of hypertension should
like diuretic combination not be routinely undertaken in
acute stroke unless extreme BP
elevation. Combination of an ACE
inhibitor with an ARB is not
recommended
Nondiabetic chronic kidney disease
Nondiabetic chronic kidney disease ACE inhibitors (ARBs if ACE Combinations of additional agents Carefully monitor renal function and
with proteinuriay inhibitor-intolerant) if there is potassium for those receiving an
proteinuria. Diuretics as additive ACE inhibitor or ARB.
therapy Combinations of an ACE inhibitor
and ARB are not recommended in
patients without proteinuria
Continued
Volume 33 2017
Table 1. Continued.
Initial Therapy Second-Line Therapy Notes and/or Cautions
Renovascular disease Does not affect initial treatment Combinations of additional agents Caution with ACE inhibitors or ARB if
recommendations. Atherosclerotic bilateral renal artery stenosis or
renal artery stenosis should be unilateral disease with solitary
primarily managed medically, kidney. Renal artery angioplasty and
whereas revascularization should be stenting could be considered for
considered for renal fibromuscular patients with renal artery stenosis
dysplasia and complicated, uncontrolled
hypertension
Other conditions
Peripheral arterial disease Does not affect initial treatment Combinations of additional agents Avoid b-blockers with severe disease
recommendations
Dyslipidemia Does not affect initial treatment Combinations of additional agents e
recommendations
Overall vascular protection Statin therapy for patients with 3 e Caution should be exercised with the
cardiovascular risk factors or ASA recommendation if BP is not
atherosclerotic disease. Low-dose controlled
ASA in patients aged 50 years or
older. Advise on smoking cessation
and use pharmacotherapy for
smoking cessation if indicated
ACE, angiotensin-converting enzyme; ACR, albumin to creatinine ratio; ARB, angiotensin receptor blocker; ASA, acetylsalicylic acid; BNP, B-type natriuretic
peptide; BP, blood pressure; CCB, calcium channel blocker; LVH, left ventricular hypertrophy; NT-proBNP, N-terminal pro-BNP; NYHA, New York Heart
Association; SPC, single pill combination; TIA, transient ischemic attack.
* Microalbuminuria is defined as persistent albumin to creatinine ratio > 2.0 mg/Mmol.
y
Proteinuria is defined as urinary protein > 500 mg per 24 hours or ACR > 30 mg/Mmol in 2 of 3 specimens.
C. Alcohol consumption H. Stress management

1. To prevent hypertension and reduce BP in hyper- 1. In hypertensive patients in whom stress might be
tensive adults, individuals should limit alcohol con- contributing to high BP, stress management should be
sumption to 2 drinks per day, and consumption considered as an intervention (Grade D). Individual-
should not exceed 14 standard drinks per week for ized cognitive-behavioural interventions are more
men and 9 standard drinks per week for women likely to be effective when relaxation techniques are
(Grade B). (Note: One standard drink is considered to used (Grade B).
be the equivalent of 13.6 g or 17.2 mL of ethanol or
approximately 44 mL [1.5 oz] of 80 proof [40%]
II. Indications for drug therapy for adults with
spirits, 355 mL [12 oz] of 5% beer, or 148 mL [5 oz]
hypertension without compelling indications for specific
of 12% wine.)
agents
D. Diet
1. It is recommended that hypertensive patients and
normotensive individuals at increased risk of devel- Background. Age and frailty distinctions have been removed
oping hypertension consume a diet that emphasizes from our guidelines for the treatment of uncomplicated hy-
fruits, vegetables, low-fat dairy products, whole pertension. This revision is on the basis of evidence that
grain foods rich in dietary fibre, and protein from suggests that older individuals with hypertension benefit from
plant sources that is reduced in saturated fat and BP reduction irrespective of baseline frailty.53,54 In those with
cholesterol (Dietary Approaches to Stop Hyperten- a baseline SBP of 140-160 mm Hg, treatment reduces the rate
sion [DASH] diet;49-52 Supplemental Table S9) of major adverse cardiovascular events, myocardial infarction,
(Grade B). stroke, and mortality, but might also increase the risk of renal
E. Sodium intake dysfunction.53-56 Caution should be exercised in elderly pa-
1. To prevent hypertension and reduce BP in hyperten- tients with orthostasis.
sive adults, consider reducing sodium intake toward In a post hoc analysis of the Hypertension in the Very
2000 mg (5 g of salt or 87 mmol of sodium) per day Elderly Trial (HYVET), investigators examined the associ-
(Grade A). ation between frailty and treatment outcomes in 2656
F. Calcium and magnesium intake individuals, aged 80 years and older, and with a baseline SBP
1. Supplementation of calcium and magnesium is not 160 mm Hg.53 The benefits of BP reduction were similar
recommended for the prevention or treatment of irrespective of frailty for the outcomes of stroke, cardiovas-
hypertension (Grade B). cular events, and mortality (P for interaction ¼ 0.52, 0.73,
G. Potassium intake and 0.61, respectively). Similarly, a prespecified subgroup
1. For patients not at risk of hyperkalemia (see Table 2), analysis of 2636 adults 75 years of age and older without
increase dietary potassium intake to reduce BP (Grade A). history of diabetes, stroke, or baseline orthostasis from the
Leung et al. 567
Table 2. Risk factors for hyperkalemia trials showed that the use of thiazide-like diuretics resulted in
Before advising an increase in potassium intake, the following types of an additional 12% risk reduction for cardiovascular events
patients, who are at high risk of developing hyperkalemia, should be (P ¼ 0.049) and 21% risk reduction in heart failure (P ¼
assessed for suitability, and monitored closely: 0.023) compared with thiazide diuretics, after adjusting for
Patients receiving renin-angiotensin-aldosterone inhibitors
Patients receiving other drugs that can cause hyperkalemia (eg, trimetho-
differences in BP reduction.57 Compared with placebo, only
prim and sulfamethoxazole, amiloride, triamterene) thiazide-like diuretics reduced the risk of coronary events and
Chronic kidney disease (glomerular filtration rate < 60 mL/min/1.73m2) all-cause mortality. In another meta-analysis of 14 random-
Baseline serum potassium > 4.5 Mmol/L ized controlled trials, the use of indapamide or chlorthali-
done resulted in greater SBP reduction compared with
hydrochlorothiazide (5.1 mm Hg; 95% CI, 8.7 to 1.6
mm Hg; and 3.6 mm Hg; 95% CI, 7.3 to 0.0 mm Hg,
Systolic Blood Pressure Intervention Trial (SPRINT) respectively) without any detectable difference in adverse
showed that intensive treatment (SBP target < 120 mm Hg) effects.58 Consistent with these findings, a 12-week double-
compared with standard treatment (< 140 mm Hg) resulted blind randomized controlled trial of 54 patients showed a
in a significant reduction in major adverse cardiovascular greater reduction in mean 24-hour BP compared with
events (hazard ratio [HR], 0.66; 95% confidence interval baseline with chlorthalidone and extended-release hydro-
[CI], 0.51-0.85) and mortality (HR, 0.67; 95% CI, 0.49- chlorothiazide, but not with conventional, short-acting hy-
0.91) over 3.14 years with no detectable difference in drochlorothiazide.59 Collectively, evidence supports the use
outcome benefit with intensive treatment when examined of longer-acting diuretics for reducing cardiovascular events
according to baseline frailty.54,55 Rates of serious adverse and BP.
events were not statistically different when examined ac- We recommend SPCs as an initial treatment option, on
cording to frailty. However, there was a significant increase the basis of a global body of evidence, showing their effec-
in renal dysfunction with intensive treatment for those tiveness in reducing cardiovascular events,60,61 improving
without preexisting kidney disease (HR, 3.14; 95% CI, BP control,60-64 promoting adherence,65,66 and reducing
1.66-6.37). Individuals with limited life expectancy (ie, < 1 medication side effects.67 The therapeutic efficacy of com-
year or < 3 years, respectively), dementia, or those needing bination therapy is well established. A meta-analysis of 42
institutionalized care were ineligible for HYVET or randomized trials testing the combined use of 2 drugs of
SPRINT.53,54 Altogether, these findings are consistent with different classes compared with doubling the dose of 1 drug
those from a large meta-analysis of 19 randomized controlled showed a 5-fold greater reduction in BP with combination
trials (n ¼ 44,989) showing that intensive BP reduction is treatment compared with increasing the dose of 1 drug
just as beneficial for the reduction of major cardiovascular alone.68 Further supporting evidence is derived from the
events in older adults (62 years of age and older) as it is in Simplified Treatment Intervention to Control Hypertension
those who are younger.56 (STITCH) study, a cluster randomized trial of 45 family
practices in Ontario.62 A total of 2111 patients with un-
Guidelines controlled hypertension were assigned to initial fixed-dose
combination therapy with an ACE inhibitor or ARB and
1. Antihypertensive therapy should be prescribed for average diuretic vs monotherapy with uptitration as appropriate.
DBP measurements of 100 mm Hg (Grade A) or After 6 months, there was a larger reduction in BP (5.2/
average SBP measurements of 160 mm Hg (Grade A) in 2.2 mm Hg) and greater proportion of target BP control
patients without macrovascular target organ damage or (64.7% vs 52.7%; P ¼ 0.03) in those who received initial
other cardiovascular risk factors. fixed-dose combination therapy compared with a single
2. Antihypertensive therapy should be strongly considered agent. Consistent with these findings, observational data also
for average DPB readings 90 mm Hg (Grade A) or suggest that initial combination treatment compared with
for average SBP readings 140 mm Hg (Grade B for monotherapy is associated with a lower likelihood of
140-160 mm Hg; Grade A for > 160 mm Hg; revised developing a cardiovascular event, shorter median time to
guideline) in the presence of macrovascular target or- achieve target BP control, and less health care utiliza-
gan damage or other independent cardiovascular risk tion.60,61 Moreover, fixed-dose antihypertensive combina-
factors. tions (ie, SPCs) are reasonable as first-line treatment because
most patients require 2 or even 3 antihypertensive agents to
reach target BP control in practice.55,69-73
III. Choice of therapy for adults with hypertension
When an SPC is selected, the combination of an ACE
without compelling indications for specific agents
inhibitor with a CCB, ARB with a CCB, or ACE inhibitor or
A. Indications for drug therapy for adults with diastolic ARB with a diuretic is recommended. The most compelling
and with or without systolic hypertension evidence comes from the Avoiding Cardiovascular Events
through Combination Therapy in Patients Living with Sys-
Background. This year, we introduce a number of new and tolic Hypertension (ACCOMPLISH) trial, which randomized
revised guidelines for the initial treatment of hypertension. 11,506 adults at high risk for cardiovascular disease to either a
Although thiazide as well as thiazide-like diuretics remain combination of benazepril with amlodipine or benazepril with
initial treatment options, preference is now given to the hydrochlorothiazide.63 A reduction in the composite of car-
longer-acting, thiazide-like diuretics (eg, chlorthalidone and diovascular death and major adverse cardiovascular events was
indapamide). A meta-analysis of 21 randomized controlled noted with benazepril with amlodipine vs benazepril with
Volume 33 2017
hydrochlorothiazide (HR, 0.80; 95% CI, 0.72-0.90). More 3. If BP is still not controlled with a combination of 2 or
recently, the Heart Outcomes Prevention Evaluation more first-line agents, or there are adverse effects, other
(HOPE)-3 trial evaluated 12,705 individuals at intermediate antihypertensive drugs may be added (Grade D).
risk of cardiovascular disease and randomized them to receive 4. Possible reasons for poor response to therapy
a fixed-dose combination of candesartan and hydrochloro- (Supplemental Table S10) should be considered
thiazide or placebo.64 Although there were no significant (Grade D).
differences in outcomes overall, there appeared to be benefit 5. a-Blockers are not recommended as first-line agents for
favouring fixed-dose combination therapy in the subgroup of uncomplicated hypertension (Grade A); b-blockers are
patients with hypertension. For individuals with a baseline not recommended as first-line therapy for uncompli-
SBP > 143.5 mm Hg, treatment with candesartan and hy- cated hypertension in patients 60 years of age or older
drochlorothiazide vs placebo reduced the risk of the first (Grade A); and ACE inhibitors are not recommended as
coprimary outcome (a composite of cardiovascular death, first-line therapy for uncomplicated hypertension in
nonfatal myocardial infarction, or nonfatal stroke; HR, 0.73; black patients (Grade A). However, these agents may be
95% CI, 0.56-0.94) and second coprimary outcome used in patients with certain comorbid conditions or in
(a composite of the first coprimary outcome, plus resuscitated combination therapy.
cardiac arrest, heart failure, or revascularization; HR, 0.76;
95% CI, 0.60-0.96). Finally, as discussed previously, B. Guidelines for individuals with isolated systolic
STITCH provided additional supporting evidence for the use hypertension
of an ACE inhibitor with a diuretic or an ARB with a diuretic
Background. There are no changes to these guidelines
as initial therapy.62
for 2017.
Guidelines
Guidelines
1. Initial therapy should be with either monotherapy or
1. Initial therapy should be single-agent therapy with a
single pill combination (SPC).
thiazide/thiazide-like diuretic (Grade A), a long-acting
i. Recommended monotherapy choices are:
a. A thiazide/thiazide-like diuretic (Grade A), with dihydropyridine CCB (Grade A), or an ARB (Grade
B). If there are adverse effects, another drug from this
longer-acting diuretics preferred (Grade B; new
group should be substituted. Hypokalemia should be
guideline);
b. A b-blocker (in patients younger than 60 years; avoided in patients treated with thiazide/thiazide-like
diuretic monotherapy (Grade C).
Grade B);
2. Additional antihypertensive drugs should be used if
c. An ACE inhibitor (in nonblack patients;
target BP levels are not achieved with standard-dose
Grade B);
monotherapy (Grade B). Add-on drugs should be
d. An ARB (Grade B); or
chosen from first-line options (Grade D).
e. A long-acting calcium channel blocker (CCB;
3. If BP is still not controlled with a combination of 2
Grade B).
first-line agents, or there are adverse effects, other classes
ii. Recommended SPC choices are those in which an
of drugs (such as a-blockers, ACE inhibitors, centrally
ACE inhibitor is combined with a CCB (Grade A;
acting agents, or nondihydropyridine CCBs) may be
new guideline), ARB with a CCB (Grade B; new
guideline), or ACE inhibitor or ARB with a diuretic combined or substituted (Grade D).
4. Possible reasons for poor response to therapy
(Grade B; new guideline).
(Supplemental Table S10) should be considered
iii. Hypokalemia should be avoided in patients treated
(Grade D).
with thiazide/thiazide-like diuretic monotherapy
5. a-Blockers are not recommended as first-line agents for
(Grade C).
uncomplicated isolated systolic hypertension (Grade A);
2. Additional antihypertensive drugs should be used if
and b-blockers are not recommended as first-line ther-
target BP levels are not achieved with standard-dose
apy for isolated systolic hypertension in patients aged 60
monotherapy (Grade B). Add-on drugs should be
years or older (Grade A). However, both agents may be
chosen from first-line choices. Useful choices include a
used in patients with certain comorbid conditions or in
thiazide/thiazide-like diuretic or CCB with either:
ACE inhibitor, ARB, or b-blocker (Grade B for the combination therapy.
combination of thiazide/thiazide-like diuretic and a
dihydropyridine CCB; Grade C for the combination of
IV. Global vascular protection therapy for adults with
dihydropyridine CCB and ACE inhibitor; and Grade
hypertension without compelling indications for specific
D for all other combinations). Caution should be
agents
exercised in combining a nondihydropyridine CCB
and a b-blocker (Grade D). The combination of an
ACE inhibitor and an ARB is not recommended Background. There are no changes to these guidelines
(Grade A). for 2017.
Leung et al. 569
Guidelines Table 4. Generalizability of intensive blood pressure-lowering:

cautions and contraindications
1. Statin therapy is recommended in hypertensive patients Limited or no evidence
with 3 cardiovascular risk factors as defined in Heart failure (ejection fraction < 35%) or recent myocardial infarction
Supplemental Table S11 (Grade A in patients older than (within past 3 months)
Indication for, but not currently receiving, a b-blocker
40 years) or with established atherosclerotic disease (Grade Institutionalized elderly patient
A regardless of age). Inconclusive evidence
2. Consideration should be given to the combination of low- Diabetes mellitus
dose acetylsalicylic acid therapy in hypertensive patients 50 Previous stroke
years of age or older (Grade B). Caution should be exer- eGFR < 20 mL/min/1.73 m2
Contraindications
cised if BP is not controlled (Grade C). Patient unwilling or unable to adhere to multiple medications
3. Tobacco use status of all patients should be updated on a Standing SBP < 110 mm Hg
regular basis and health care providers should clearly advise Inability to measure SBP accurately
patients to quit smoking (Grade C). Known secondary cause(s) of hypertension
4. Advice in combination with pharmacotherapy eGFR, estimated glomerular filtration rate; SBP, systolic blood pressure.
(eg, varenicline, bupropion, nicotine replacement therapy)
should be offered to all smokers with a goal of smoking
cessation (Grade C). Guidelines
5. For high-risk patients (Table 3),74 aged 50 years or older,
with SBP levels 130 mm Hg, intensive management to 1. The SBP treatment goal is a pressure level of < 140 mm
target a SBP of 120 mm Hg should be considered. Hg (Grade C). The DBP treatment goal is a pressure level
Intensive management should be guided by AOBP mea- of < 90 mm Hg (Grade A).
surements (see Hypertension Canada’s 2017 Guidelines:
Diagnosis and Assessment of Hypertension, section
I. Accurate Measurement of BP, and Supplemental
Table S2, section on Recommended Technique for Auto- VI. Treatment of hypertension in association with
mated Office Blood Pressure [AOBP]). Patient selection for ischemic heart disease
intensive management is recommended and caution
A. Guidelines for hypertensive patients with CAD
should be taken in certain high-risk groups (Table 4;
Grade B).
Background. Post hoc analyses of several large clinical trials in
patients with CAD suggest the possible existence of a J-curve,
V. Goals of therapy for adults with hypertension without whereby reducing BP below a specific nadir might be asso-
compelling indications for specific agents ciated with an increased risk of coronary events.30,75-77 This
might be of greatest concern in individuals with LVH because
Background. Consistent with the changes made to section II. of increased myocardial demand and decreased coronary
Indications for Drug Therapy for Adults With Hypertension perfusion during diastole.
Without Compelling Indications for Specific Agents, we have In a retrospective cohort of 92 patients with CAD,
removed the previous guideline for different BP goals for the there was reduced coronary blood flow with increasing left
elderly. Evidence suggests that older patients with hyperten- ventricular mass, even after adjustment.78 This association
sion similarly benefit from intensive BP reduction as younger was present for all levels of DBP, but was most
adults.53-56 pronounced for those with a DBP < 70 mm Hg. These
findings are consistent with and extend those from a
systematic review of 8 studies (n ¼ 362), which reported
an inverse association between coronary blood flow and
Table 3. Clinical indications defining high-risk patients as candidates
left ventricular mass, especially in those with
for intensive management hypertension.79
Nevertheless, it should be acknowledged that for most
Clinical or subclinical cardiovascular disease
or
high-risk individuals, BP reduction is well tolerated and
Chronic kidney disease (nondiabetic nephropathy, proteinuria < 1 g/d, beneficial. As such, although we advise exercising caution
estimated glomerular filtration rate 20-59 mL/min/1.73m2*) when lowering BP, antihypertensive therapy is still strongly
or recommended for individuals with hypertension who
y
Estimated 10-year global cardiovascular risk 15% tolerate antihypertensive treatment, especially for patients
or
Age 75 years or older with moderate or severely increased SBP.
Patients with 1 clinical indication should consent to intensive
management Guidelines
MDRD, Modification of Diet in Renal Disease.
* Four-variable MDRD equation. 1. For most hypertensive patients with CAD, an ACE
y
Framingham Risk Score.74 inhibitor or ARB is recommended (Grade A).
Volume 33 2017
2. For hypertensive patients with CAD, but without (Grade A). Careful monitoring for hyperkalemia is
coexisting systolic heart failure, the combination of an recommended when combining an aldosterone antago-
ACE inhibitor and ARB is not recommended nist with ACE inhibitor or ARB treatment. Other di-
(Grade B). uretics are recommended as additional therapy if
3. For high-risk hypertensive patients, when combination needed (Grade B for thiazide/thiazide-like diuretics for
therapy is being used, choices should be individualized. BP control, Grade D for loop diuretics for volume
The combination of an ACE inhibitor and a dihy- control). Beyond considerations of BP control, doses of
dropyridine CCB is preferable to an ACE inhibitor and ACE inhibitors or ARBs should be titrated to those
a thiazide/thiazide-like diuretic in selected patients reported to be effective in trials unless adverse effects
(Grade A). become manifest (Grade B).
4. For patients with stable angina pectoris but without 2. An ARB is recommended if ACE inhibitors are not toler-
previous heart failure, myocardial infarction, or ated (Grade A).
coronary artery bypass surgery, either a b-blocker or 3. A combination of hydralazine and isosorbide dinitrate is
CCB can be used as initial therapy (Grade B). recommended if ACE inhibitors and ARBs are contra-
5. Short-acting nifedipine should not be used (Grade D). indicated or not tolerated (Grade B).
6. When decreasing SBP to target levels in patients 4. For hypertensive patients whose BP is not controlled, an
with established CAD (especially if isolated systolic ARB may be combined with an ACE inhibitor and other
hypertension is present), be cautious when the antihypertensive drug treatment (Grade A). Careful
DBP is 60 mm Hg because of concerns that monitoring should be used if combining an ACE inhibitor
myocardial ischemia might be exacerbated, especially and an ARB because of potential adverse effects such as
in patients with LVH (Grade D; revised guideline). hypotension, hyperkalemia, and worsening renal function
(Grade C). Additional therapies may also include dihy-
B. Guidelines for patients with hypertension who have had
dropyridine CCBs (Grade C).
a recent myocardial infarction
Background. There are no changes to these guidelines
for 2017.
VIII. Treatment of hypertension in association with
Guidelines stroke
1. Initial therapy should include a b-blocker as well as an Background. BP is often elevated after ICH. In recent
ACE inhibitor (Grade A). years, several trials have studied the effect of BP-lowering in
2. An ARB can be used if the patient is intolerant of an the context of ICH. The Intensive Blood Pressure
ACE inhibitor (Grade A in patients with left ventricular Reduction in Acute Cerebral Hemorrhage Trial
systolic dysfunction). (INTERACT)-2 enrolled 2839 patients within 6 hours of
3. CCBs may be used in patients after myocardial infarction spontaneous ICH, and compared the SBP targets of < 140
when b-blockers are contraindicated or not effective. mm Hg vs < 180 mm Hg.80 Targets were applied within
Nondihydropyridine CCBs should not be used when the first hour of presentation and maintained for 7 days.
there is heart failure, evidenced by pulmonary congestion No statistical difference was observed between the 2 stra-
on examination or radiography (Grade D). tegies for the primary outcome, a composite of death or
stroke-related disability at 90 days (52.0% vs 55.6% for
intensive compared with standard treatment, respectively;
VII. Treatment of hypertension in association with heart
odds ratio, 0.87; 95% CI, 0.75-1.01). In the Antihyper-
failure
tensive Treatment of Acute Cerebral Hemorrhage
(ATACH)-2 trial, 1000 patients who presented within 4.5
Background. There are no changes to these guidelines hours of spontaneous ICH were randomly assigned to SBP
for 2017. targets of 110-139 mm Hg vs 140-179 mm Hg for the first
24 hours.81 The primary outcome was the same as in
Guidelines INTERACT-2. There was no difference between the 2
treatment strategies for the main outcome, and the trial was
1. In patients with systolic dysfunction (ejection fraction terminated early because of futility. In addition, there was a
< 40%), ACE inhibitors (Grade A) and b-blockers trend toward more adverse events in the lower SBP target
(Grade A) are recommended for initial therapy. Aldo- arm. Considered together, these 2 important trials showed
sterone antagonists (mineralocorticoid receptor antago- no measurable benefit to lowering SBP < 140 mm Hg in
nists) may be combined in treatment for patients with a the acute period after spontaneous ICH. There is no trial
recent cardiovascular hospitalization, acute myocardial evidence to delineate an appropriate SBP target, if any, >
infarction, elevated B-type natriuretic peptide or N- 140 mm Hg. All trials to date have followed the conven-
terminal pro-B-type natriuretic peptide level, or New tion in limiting SBP increases beyond 180 mm Hg in their
York Heart Association Class II-IV symptoms control arms.
Leung et al. 571
Guidelines treatment using ACE inhibitors, ARBs, long-acting

CCBs, or thiazide/thiazide-like diuretics. Direct arterial
A. BP management in acute ischemic stroke (onset to 72 vasodilators such as hydralazine or minoxidil should not
hours) be used.
1. For patients with ischemic stroke not eligible for
thrombolytic therapy, treatment of hypertension in
X. Treatment of hypertension in association with
the setting of acute ischemic stroke or transient
nondiabetic chronic kidney disease
ischemic attack should not be routinely undertaken
(Grade D). Extreme BP increases (eg, SBP > 220
mm Hg or DBP > 120 mm Hg) may be treated to Background. There are no changes to these guidelines
reduce the BP by approximately 15% (Grade D), for 2017.
and not more than 25%, over the first 24 hours with
gradual reduction thereafter (Grade D). Avoid Guidelines
excessive lowering of BP because this might exacer-
bate existing ischemia or might induce ischemia, 1. For patients with nondiabetic chronic kidney disease,
particularly in the setting of intracranial arterial target BP is < 140/90 mm Hg (Grade B).
occlusion or extracranial carotid or vertebral artery 2. For patients with hypertension and proteinuric chronic
occlusion (Grade D). Pharmacological agents and kidney disease (urinary protein > 500 mg per 24 hours
routes of administration should be chosen to avoid or albumin to creatinine ratio > 30 mg/Mmol), initial
precipitous decreases in BP (Grade D). therapy should be an ACE inhibitor (Grade A) or an
2. For patients with ischemic stroke eligible for thrombo- ARB if there is intolerance to ACE inhibitors
lytic therapy, very high BP (> 185/110 mm Hg) should (Grade B).
be treated concurrently in patients receiving thrombo- 3. Thiazide/thiazide-like diuretics are recommended as
lytic therapy for acute ischemic stroke to reduce the risk additive antihypertensive therapy (Grade D). For
of secondary intracranial hemorrhage (Grade B). patients with chronic kidney disease and volume
overload, loop diuretics are an alternative (Grade D).
B. BP management after acute ischemic stroke 4. In most cases, combination therapy with other antihyper-
1. Strong consideration should be given to the initiation of tensive agents might be needed to reach target BP levels
antihypertensive therapy after the acute phase of a (Grade D).
stroke or transient ischemic attack (Grade A). 5. The combination of an ACE inhibitor and ARB is not
2. After the acute phase of a stroke, BP-lowering treatment recommended for patients with nonproteinuric chronic
is recommended to a target of consistently < 140/90 kidney disease (Grade B).
mm Hg (Grade C).
3. Treatment with an ACE inhibitor and thiazide/thiazide-
XI. Treatment of hypertension in association with
like diuretic combination is preferred (Grade B).
renovascular disease
4. For patients with stroke, the combination of an
ACE inhibitor and ARB is not recommended
(Grade B). Background. Accompanying our guidelines for the assess-
ment of renal FMD (see Hypertension Canada’s 2017
C. BP management in hemorrhagic stroke (onset to 72 Guidelines: Diagnosis and Assessment of Hypertension, section
hours) VII. Assessment for Renovascular Hypertension), we introduce
1. For patients with intracerebral hemorrhage (ICH) in the 3 new guidelines for the treatment of this condition. Evi-
hyperacute phase (in the first 24 hours) SBP lowering to dence guiding treatment is primarily on the basis of small
< 140 mm Hg should be avoided because of an absence case series and case reports. Treatment decisions should be
of benefit (relative to a target of < 180 mm Hg; Grade individualized and take into consideration the nature and
A; new guideline) and some suggestion of harm. location of the vascular lesions, severity of symptoms, pre-
vious vascular events, and comorbid conditions.41 Because of
the complexity in care, consultation with a hypertension
expert is advised.
IX. Treatment of hypertension in association with LVH
Hypertension arising from renal FMD is primarily
mediated by the renin-angiotensin-aldosterone system.
Background. There are no changes to these guidelines Medical therapy should be directed toward BP control and
for 2017. vascular risk reduction. Revascularization should be
considered for individuals with elevated BP, particularly for
Guidelines those with recent-onset or resistant hypertension. Highest
cure rates are associated with younger age and shorter
1. Hypertensive patients with LVH should be treated with duration of hypertension.82,83 Although there are no data
antihypertensive therapy to decrease the rate of subsequent to inform the most appropriate initial revascularization
cardiovascular events (Grade C). strategy, percutaneous renal transluminal angioplasty is
2. The choice of initial therapy can be influenced by the usually preferred over surgery because it is less costly, less
presence of LVH (Grade D). Initial therapy can be drug invasive, has a lower morbidity, and can be performed on
Volume 33 2017
an outpatient basis.41,44 It is associated with a combined factors in addition to diabetes and hypertension, an ACE
rate of cure or BP improvement of 86.4%.44,83 Stenting is inhibitor or an ARB is recommended as initial therapy
not routinely recommended for FMD because the risk of (Grade A).
restenosis is generally believed to be low,44 but might be 3. For persons with diabetes and hypertension not included in
considered for lesions for which angioplasty fails or those other guidelines in this section, appropriate choices include
associated with flow-limiting dissection. It is reasonable to (in alphabetical order): ACE inhibitors (Grade A), ARBs
consider surgery for complex lesions less amendable to (Grade B), dihydropyridine CCBs (Grade A), and thiazide/
angioplasty, stenosis associated with complex aneurysm, thiazide-like diuretics (Grade A).
and restenosis despite 2 unsuccessful attempts of angio- 4. If target BP levels are not achieved with standard-dose
plasty.41,44 monotherapy, additional antihypertensive therapy should
be used. For persons in whom combination therapy with
Guidelines an ACE inhibitor is being considered, a dihydropyridine
CCB is preferable to a thiazide/thiazide-like diuretic
1. Patients with hypertension attributable to atheroscle- (Grade A).
rotic renal artery stenosis should be primarily medically
managed because renal angioplasty and stenting XIII. Adherence strategies for patients
offers no benefit over optimal medical therapy alone
(Grade B).
2. Renal artery angioplasty and stenting for atherosclerotic Background. There are no changes to this guideline for 2017.
hemodynamically significant renal artery stenosis could be
considered for patients with uncontrolled hypertension Guidelines
resistant to maximally tolerated pharmacotherapy, pro-
gressive renal function loss, and acute pulmonary edema 1. Adherence to an antihypertensive prescription can be
(Grade D). improved by a multipronged approach (Supplemental
3. Patients with confirmed renal FMD should be referred to a Table S12).
hypertension specialist (Grade D; new guideline).
4. In patients with hypertension attributable to XIV. Treatment of secondary hypertension due to
FMD-related renal artery stenosis, revascularization endocrine causes
should be considered (Grade D; new guideline).
5. Renal artery angioplasty without stenting is recommended
for treatment of FMD-related renal artery stenosis. Stent- Background. There are no changes to this guideline for 2017.
ing is not recommended unless needed because of a peri-
procedural dissection. Surgical revascularization should be Guidelines
considered in cases of complex lesions less amendable to
angioplasty, stenosis associated with complex aneurysm, 1. Treatment of hyperaldosteronism and pheochromocytoma
and restenosis despite 2 unsuccessful attempts of angio- are outlined in Supplemental Tables S7 and S8,
plasty (Grade D; new guideline). respectively.
XII. Treatment of hypertension in association with XV. Treatment of resistant hypertension

diabetes mellitus
Background. Resistant hypertensionddefined by uncon-
Background. There are no changes to these guidelines trolled BP despite the use of 3 antihypertensive agents of
for 2017. different classes including a diuretic, or controlled BP with
4 agentsdis present in 10%-20% of individuals treated for
Guidelines hypertension.84-87 Accordingly, the HCGC has identified
resistant hypertension as an area of importance needing to be
1. Persons with diabetes mellitus should be treated to attain explicitly addressed in our guidelines. A decision was made to
SBP of < 130 mm Hg (Grade C) and DBP of < 80 mm assemble a dedicated subgroup committee to conduct a
Hg (Grade A; these target BP levels are the same as the BP comprehensive literature review and to develop specific
treatment thresholds). Combination therapy using 2 first- guidelines in the coming years.
line agents may also be considered as initial treatment of Preliminary discussion was held regarding the Preven-
hypertension (Grade B) if SBP is 20 mm Hg greater than tion And Treatment of Hypertension With Algorithm-
target or if DBP is 10 mm Hg greater than target. How- based therapy number 2 (PATHWAY-2) trial, which
ever, caution should be exercised in patients in whom a enrolled 335 individuals with uncontrolled hypertension
substantial decrease in BP is more likely or poorly tolerated and were receiving 3 drugs, and compared spironolactone,
(eg, elderly patients and patients with autonomic doxazosin, bisoprolol, or placebo as add-on therapy.88
neuropathy). Spironolactone was most effective in lowering SBP. After
2. For persons with cardiovascular or kidney disease, 3 months, 58% of patients treated with spironolactone
including microalbuminuria, or with cardiovascular risk achieved target BP control vs 42% treated with doxazosin
Leung et al. 573
and 43% treated with bisoprolol. Although noteworthy, the clusters in 21 regions, 1990-2010: a systematic analysis for the Global
committee decided not to generate any formal guidelines Burden of Disease Study 2010. Lancet 2012;380:2224-60.
on the basis of PATHWAY-2 alone at this time, because of 5. Chow CK, Teo KK, Rangarajan S, et al. Prevalence, awareness, treat-
the lack of event-related outcomes. Consistent with our ment, and control of hypertension in rural and urban communities in
overall guidelines process, studies that assessed cardiovas- high-, middle-, and low-income countries. JAMA 2013;310:959-68.
cular morbidity and mortality, as well as total mortality
are prioritized for establishing guidelines related to 6. Feldman RD, Campbell N, Larochelle P, et al. 1999 Canadian recom-
pharmacotherapy. mendations for the management of hypertension. Task Force for the
Development of the 1999 Canadian Recommendations for the Man-
agement of Hypertension. CMAJ 1999;161(suppl 12):S1-17.
Implementation
7. McAlister FA, Wilkins K, Joffres M, et al. Changes in the rates of
Implementation and dissemination of the guidelines is a
awareness, treatment and control of hypertension in Canada over the past
priority for Hypertension Canada. We use many strategies to two decades. CMAJ 2011;183:1007-13.
reach out to a variety of providers who care for patients with
hypertension. Our efforts include knowledge exchange fo- 8. Zarnke KB, Levine M, McAlister FA, et al. The 2000 Canadian rec-
rums, targeted educational materials for primary care pro- ommendations for the management of hypertension: part twoediagnosis
viders and patients, “Train the Trainer” teaching sessions, as and assessment of people with high blood pressure. Can J Cardiol
well as slide kits and summary documents, which are freely 2001;17:1249-63.
available online in French and English (www.hypertension. 9. Zarnke KB, McAlister FA, Campbell NR, et al. The 2001 Canadian
ca). Hypertension Canada receives feedback from end recommendations for the management of hypertension: part onee
users to continually improve guideline processes and con- assessment for diagnosis, cardiovascular risk, causes and lifestyle modifi-
tent. The Research and Evaluation Committee conducts cation. Can J Cardiol 2002;18:604-24.
hypertension surveillance studies and reviews existing Ca-
nadian health surveys to identify gaps between current and 10. McAlister FA, Zarnke KB, Campbell NR, et al. The 2001 Canadian
best practices. recommendations for the management of hypertension: part twoether-
apy. Can J Cardiol 2002;18:625-41.
11. Canadian Hypertension Education Program. The Canadian recommenda-

Acknowledgements
tions for the management of hypertension. Can Pharm J 2003;136:45-52.
We thank Ms Susan Carter for providing technical assis-
tance with the manuscript and administrative support. 12. Hemmelgarn BR, Zarnke KB, Campbell NR, et al. The 2004 Canadian
Hypertension Education Program recommendations for the management
of hypertension: part ieblood pressure measurement, diagnosis and
Funding Sources assessment of risk. Can J Cardiol 2004;20:31-40.
Activities of the HCGC are supported by Hypertension
Canada. The members of the HCGC are unpaid volunteers 13. Khan NA, McAlister FA, Campbell NR, et al. The 2004 Canadian
who contribute their time and expertise to the annual recommendations for the management of hypertension: part IIetherapy.
development and dissemination of the Hypertension Canada Can J Cardiol 2004;20:41-54.
guidelines. To maintain professional credibility of the con- 14. Touyz RM, Campbell N, Logan A, et al. The 2004 Canadian recom-
tent, the process for the development of the guidelines is mendations for the management of hypertension: part IIIelifestyle
fully independent and free from external influence. External modifications to prevent and control hypertension. Can J Cardiol
partners assist with the dissemination of the approved 2004;20:55-9.
guidelines.
15. Hemmelgarn BR, McAllister FA, Myers MG, et al. The 2005 Canadian
Disclosures of hypertension: part 1- blood pressure measurement, diagnosis and
Please see Supplemental Appendix S2 for a complete list of assessment of risk. Can J Cardiol 2005;21:645-56.
disclosures.
16. Khan NA, McAlister FA, Lewanczuk RZ, et al. The 2005 Canadian
Hypertension Education Program recommendations for the manage-
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Volume 33 2017
ambulatory blood pressure monitoring. Hypertension 2011;57: for drug-resistant hypertension (PATHWAY-2): a randomised, double-
898-902. blind, crossover trial. Lancet 2015;386:2059-68.
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health system. Mayo Clin Proc 2013;88:1099-107. article, visit the online version of the Canadian Journal of
88. Williams B, MacDonald TM, Morant S, et al. Spironolactone versus Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10.
placebo, bisoprolol, and doxazosin to determine the optimal treatment 1016/j.cjca.2017.03.005.

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Canadian Journal of Cardiology 33 (2017) 557e576

ﬁbromuscular dysplasia (FMD)-related renal artery stenosis Guidelines

Table 1. Considerations in the individualization of pharmacological therapy

C. Alcohol consumption H. Stress management

Guidelines Table 4. Generalizability of intensive blood pressure-lowering:

Guidelines treatment using ACE inhibitors, ARBs, long-acting

XII. Treatment of hypertension in association with XV. Treatment of resistant hypertension

11. Canadian Hypertension Education Program. The Canadian recommenda-

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