Guidelines
Hypertension Canada’s 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children

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Abstract

Hypertension Canada’s 2020 guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children provide comprehensive, evidence-based guidance for health care professionals and patients. Hypertension Canada develops the guidelines using rigourous methodology, carefully mitigating the risk of bias in our process. All draft recommendations undergo critical review by expert methodologists without conflict to ensure quality. Our guideline panel is diverse, including multiple health professional groups (nurses, pharmacy, academics, and physicians), and worked in concert with experts in primary care and implementation to ensure optimal usability. The 2020 guidelines include new guidance on the management of resistant hypertension and the management of hypertension in women planning pregnancy.

Résumé

Les lignes directrices 2020 d’Hypertension Canada pour la prévention, le diagnostic, l'évaluation des risques et le traitement de l'hypertension chez l’adulte et l’enfant fournissent aux professionnels de la santé et aux patients des conseils complets et fondés sur des données probantes. Hypertension Canada élabore ces lignes directrices en utilisant une méthodologie rigoureuse, en atténuant soigneusement le risque de partialité dans notre processus. Tous les projets de recommandations sont soumis à une évaluation critique par des experts en méthodologie, sans partialité, afin d'en garantir la qualité. Notre panel de lignes directrices est diversifié, comprenant de multiples groupes de professionnels de la santé (soins infirmiers, pharmacie, universitaire et médecins), et a travaillé de concert avec des experts en soins primaires et d’experts en mise en œuvre pour garantir une utilisation optimale. Les lignes directrices 2020 comprennent de nouvelles orientations sur la gestion de l'hypertension résistante et la prise en charge de l'hypertension chez les femmes qui planifient une grossesse.

Section snippets

Methods

Hypertension Canada’s guidelines are developed biennially through a highly structured and systematic process designed to minimize bias. Hypertension Canada’s guideline process has been externally reviewed and is in concordance with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument for guideline development (guidelines.hypertension.ca/about/overview-process).2 The HCGC is comprised of a multidisciplinary panel of content and methodological experts divided into 16

Implementation Methods

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

1. Diagnosis and Treatment of Hypertension in Adults

Key Messages

  • Hypertension remains the most prevalent risk factor for cardiovascular disease in Canada.

  • Standardized BP measurement, using validated protocols and devices, continues to be recommended to screen for cases of hypertension.

  • Frequency and timing of screening can be tailored to each patient’s risk of hypertension. Risk factors for hypertension are: (1) diabetes mellitus; (2) chronic kidney disease; (3) low level of consumption of fresh fruits and vegetables; and (4) sedentary behaviour.

  • Use of

Accurate measurement of BP

Revised/new recommendations for 2020

  • The recommended measurement frequency for ABPM is at 20- to 30-minute intervals throughout the day and night (Supplemental Table S1).

Most studies with data linking ABPM to clinical outcomes used a 24-hour BP measurement frequency of 30 minutes or less.3, 4, 5, 6, 7, 8 In addition, the minimum recommended number of good-quality readings is 20 daytime and 7 night-time readings. Depending on the duration of sleep, 7 good-quality readings might not be achievable

Routine and optional laboratory tests for the investigation of patients with hypertension

New recommendations for 2020

  • Consider the potential for pregnancy in women with hypertension.

Women of child-bearing potential should be asked at regular intervals about possible pregnancy. If unsure, a repeat pregnancy test may be done depending upon current or potential antihypertensive treatments. The determination of pregnancy is important in the treatment of women of reproductive age because some medications have relative contraindications in pregnancy (see part 3. Hypertension and Pregnancy

Assessment of overall cardiovascular risk in hypertensive patients

Recommendations

  • 1.

    Global cardiovascular risk should be assessed. Multifactorial risk assessment models can be used to:

    • i.

      Predict more accurately an individual’s global cardiovascular risk (Grade A);

    • ii.

      Help engage individuals in conversations about health behaviour change to lower BP (Grade D); and,

    • iii.

      Use antihypertensive therapy more efficiently (Grade D).

In the absence of Canadian data to determine the accuracy of risk calculations, avoid using absolute levels of risk to support treatment decisions (Grade

Cardiovascular Health Promotion

Key Messages

  • Health behaviour change plays an important role in hypertension prevention and BP-lowering in people diagnosed with hypertension

  • Health behaviour change is strongly recommended as a first-line intervention to lower BP in people with hypertension

  • Optimization of lipid levels with the use of statins in higher-risk patients is recommended

  • The use of acetylsalicylic acid (ASA) for primary prevention of cardiovascular disease is no longer recommended in people with hypertension

Global vascular protection therapy for adults with hypertension without compelling indications for specific agents

Removed recommendations for 2020

  • The recommendation for the use of low-dose ASA in the primary prevention of cardiovascular disease has been removed.

Hypertension Canada guidelines previously recommended that low-dose ASA be considered in all adults with hypertension who are 50 years of age or older for the primary prevention of cardiovascular disease. In light of emerging evidence on the balance of risks and benefits of low-dose ASA in this population, the HCGC voted to remove this

Health behaviour management

Revised recommendations for 2020

  • Reduce alcohol consumption (or abstain) to reduce BP and prevent hypertension.

  • To prevent hypertension, there is no safe limit for alcohol consumption.59

In a systematic review and meta-analysis of original cohort studies an increase in incidence of hypertension with any amount of alcohol consumption in men, and an increase in incidence of hypertension with more than 2 drinks per day in women was reported.60 Additionally, a separate analysis of the risk thresholds

Management: Uncomplicated Pharmacotherapy

Key Messages

  • Hypertension Canada continues to promote a risk-based approach to treatment thresholds and targets (Table 5, Table 6).

  • Hypertension Canada continues to encourage the use of clinical judgement and shared decision-making when identifying BP targets to ensure feasibility in the patient’s broader clinical, social, and economic context.

  • Patients with existing cardiovascular disease or with elevated cardiovascular risk should be considered for intensive SBP targets (ie, SBP ≤ 120 mm Hg).

  • Angiotensin

Management: Complex Comorbidity

Key Messages

  • Hypertension frequently coexists with other conditions that influence therapeutic decision-making. Polypharmacy and competing risks need to be considered carefully.

  • Adults with diabetes and certain forms of chronic kidney disease (Table 9) might benefit from more intensive BP targets (ie, SPB ≤ 130 mm Hg or ≤ 120 mm Hg).

Diabetes and Hypertension

There has been significant interest in the potential role of newer diabetes therapies in the management of cardiovascular risk in adults with diabetes and hypertension. This topic has been reviewed and discussed by the HCGC at our 2017 and 2019 consensus conferences and a formal recommendation has not been developed for the use of sodium-glucose co-transporter-2 (SGLT2) inhibitors in the management of persons with comorbid diabetes and hypertension. However, the rationale for reviewing this

Hypertension in Chronic Kidney Disease

New recommendations for 2020

  • Individualize BP targets in patients with chronic kidney disease. Consider intensive targets (SBP < 120 mm Hg) in appropriate patients.

In nondiabetic chronic kidney disease patients who meet the inclusion criteria for the Systolic Blood Pressure Intervention Trial (SPRINT; age older than 50 years, at elevated cardiovascular risk with SBP 130-180 mm Hg; Table 6),71 we endorse a target SBP < 120 mm Hg. There was no evidence of heterogeneity of effect across

Treatment of hypertension in association with stroke

Recommendations

  • A.

    BP management in acute ischemic stroke (onset to 72 hours)

  • B.

    BP management after acute ischemic stroke

    • 1.

      Strong consideration should be given to the initiation of antihypertensive therapy after the acute phase of a stroke or transient ischemic attack (Grade A).

    • 2.

      After the acute phase of a stroke, BP-lowering treatment

Treatment of hypertension in association with ischemic heart disease

  • A.

    Recommendations for hypertensive patients with CAD

Recommendations

  • 1.

    For most hypertensive patients with CAD, an ACE inhibitor or ARB is recommended (Grade A).

  • 2.

    For hypertensive patients with CAD, but without coexisting systolic heart failure, the combination of an ACE inhibitor and ARB is not recommended (Grade B).

  • 3.

    For high-risk hypertensive patients, when combination therapy is being used, choices should be individualized. The combination of an ACE inhibitor and a dihydropyridine CCB is preferable

Resistant Hypertension

Key Messages

  • Resistant hypertension is defined as BP above target despite 3 or more BP-lowering drugs at optimal doses preferably including a diuretic (and usually a renin-angiotensin-aldosterone system blocker and a CCB).

  • Accurate office and out-of-office BP measurement is essential.

  • Other reasons for apparent resistant hypertension should be eliminated before diagnosing true resistant hypertension, including nonadherence, white coat effect, and secondary hypertension.

  • Pharmacotherapy with the additional use

Renal/Renovascular Hypertension

New recommendations for 2020

  • When investigating renovascular hypertension, carefully consider renal function.

For patients with severely reduced kidney function (eGFR < 30 mL/min/1.73 m2), the preferred diagnostic test for renal artery stenosis screening should be considered on a case-by-case basis and in consultation with a nephrologist. Magnetic resonance angiography with gadolinium-based contrast agents is not universally recommended in this patient population, and alternative diagnostic tests

Assessment for endocrine hypertension

  • A.

    Primary aldosteronism: screening and diagnosis

Recommendations

  • 1.

    Screening for primary aldosteronism should be considered in hypertensive patients with the following (Grade D):

    • i.

      Unexplained spontaneous hypokalemia (K+ < 3.5 mmol/L) or marked diuretic-induced hypokalemia (K+ < 3.0 mmol/L);

    • ii.

      Resistance to treatment with ≥ 3 drugs;

    • iii.

      An incidental adrenal adenoma.

  • 2.

    Screening for primary aldosteronism should include assessment of plasma aldosterone and plasma renin activity or plasma renin (Table 13).

  • 3.

    For

Care Delivery

New recommendations for 2020

  • Adherence should be routinely evaluated in adults being treated for hypertension.

Adherence with a small cluster of health behaviours, including physical activity/exercise, smoking cessation, healthy diet, reduction in alcohol consumption, and medication adherence, have been identified as key behaviours aimed at controlling hypertension. Published research in the area typically uses 1 of 3 terms to refer to interventions aimed at changing behaviour:

Adherence strategies for patients

Recommendations

  • 1.

    Adherence to an antihypertensive prescription can be improved by using a multipronged approach (Table 12).

Digital and e-health strategies

Key Messages

  • Use of e-health interventions may be used as a means to improve the management of hypertension, reduce the risk of cardiovascular disease, and improve health and well-being.

Despite strong clinical trial evidence supporting the notion that control of hypertension prevents heart disease and strokes, there remains room for improvement in managing hypertension in primary care

Special Populations 2. Hypertension and Pediatrics

Key Messages

  • BP should be measured regularly in children 3 years of age or older; the auscultatory method is the gold-standard at present.

  • Simplified diagnostic thresholds can be used (in addition to or as an alternative to normative tables) to diagnose hypertension in children and adolescents.

  • If office BP readings are elevated, ABPM is recommended using devices independently validated in children and interpreted with appropriate pediatric normative data.

  • In children with confirmed hypertension, routine

Hypertension and Pregnancy

Key Messages

  • Up to 7% of pregnancies are complicated by a hypertensive disorder of pregnancy, and approximately 5% of women will have chronic hypertension when they become pregnant.

  • The prevalence of hypertension in pregnancy is expected to increase with women becoming pregnant later in their reproductive years and the increasing prevalence of cardiovascular comorbidities such as increased preconception body mass index and maternal diabetes.96, 97, 98

  • The possibility of pregnancy should be considered when

Summary/Future Directions

These guidelines are a summary of the best available evidence to guide clinicians in the measurement, diagnosis, and treatment of hypertension in adults and children (key similarities and differences are summarized in Table 19). The next update for the Hypertension Canada guidelines is planned for 2022 to allow for optimal dissemination of the 2020 guidelines although literature searches will be continued on an annual basis. New evidence identified as being “practice changing” for clinicians

Acknowledgements

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

Funding Sources

Activities of the HCGC are supported by Hypertension Canada. The members of the HCGC are unpaid volunteers who contribute their time and expertise to the annual development and dissemination of the Hypertension Canada guidelines. To maintain professional

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