Department of Medicine Publications

The 2009 Canadian Hypertension Education Program Recommendations for the Management of Hypertension: Part 2--Therapy


Nadia A. Khan, University of British Columbia
Brenda Hemmelgarn, University of Calgary
Robert J. Herman, University of Calgary
Chaim M. Bell, University of Toronto
Jeff L. Mahon, University of Western Ontario
Lawrence A. Leiter, University of Toronto
Simon W. Rabkin, University of British Columbia
Michael D. Hill, University of Calgary
Raj Padwal, University of Alberta
Rhian M. Touyz, University of Ottawa
Pierre Larochelle, University of Montreal
Ross D. Feldman, Robarts Research Institute
Ernesto L. Schiffrin, McGill University
Norman R. C. Campbell, University of Calgary
Gordon Moe, University of Toronto
Ramesh Prasad, University of Toronto
Malcolm O. Arnold, University of Western Ontario
Tavis S. Campbell, University of Calgary
Alain Milot, Université Laval
James A. Stone, University of Calgary
Charlotte Jones, University of Calgary
Richard I. Ogilvie, University of Toronto
Pavel Hamet, Université de Montréal
George Fodor, University of Ottawa
George Carruthers, United Arab Emirates University
Kevin D. Burns, University of Ottawa
Marcel Ruzicka, University of Saskatchewan
Jacques deChamplain, University of Montreal
George Pylypchuk, University of Saskatchewan
Robert Petrella, University of Western Ontario
Jean-Martin Boulanger, University of Calgary
Luc Trudeau, McGill University
Robert A. Hegele, University of Western Ontario
Vincent Woo, University of Manitoba
Phil McFarlane, University of Toronto
Michel Vallée, Université de Montréal
Jonathan Howlett, Queen Elizabeth II Health Sciences Centre, Halifax, NS
Simon L. Bacon, Concordia University, Montreal, QC
Patrice Lindsay, Canadian Stroke Network
Richard E. Gilbert, University of Toronto
Richard Z. Lewanczuk, University of Alberta
Sheldon Tobe, University of Toronto
Canadian Hypertension Education Program

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Canadian Journal of Cardiology





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OBJECTIVE: To update the evidence-based recommendations for the prevention and management of hypertension in adults for 2009.

OPTIONS AND OUTCOMES: For lifestyle and pharmacological interventions, evidence from randomized controlled trials and systematic reviews of trials was preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field. Progression of kidney dysfunction was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease.

EVIDENCE: A Cochrane collaboration librarian conducted an independent MEDLINE search from 2007 to August 2008 to update the 2008 recommendations. To identify additional published studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence.

RECOMMENDATIONS: For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to less than 2300 mg (100 mmol)/day (and 1500 mg to 2300 mg [65 mmol to 100 mmol]/day in hypertensive patients); perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (smaller than 102 cm for men and smaller than 88 cm for women); limit alcohol consumption to no more than 14 units per week in men or nine units per week in women; follow a diet that is reduced in saturated fat and cholesterol, and that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on by the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to lower than 140/90 mmHg in all patients, and to lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor antagonists (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as the initial treatment of hypertension if the systolic blood pressure is 20 mmHg above the target or if the diastolic blood pressure is 10 mmHg above the target. The combination of ACE inhibitors and ARBs should not be used. Other agents appropriate for first-line therapy for isolated systolic hypertension include long- acting dihydropyridine CCBs or ARBs. In patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered.

VALIDATION: All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

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