The 2004 Canadian recommendations for the management of hypertension: Part III--Lifestyle modifications to prevent and control hypertension

OBJECTIVE

To provide updated, evidence-based recommendations regarding the role of lifestyle modification in the treatment and prevention of hypertension.

OUTCOMES

Lifestyle modification interventions including exercise, weight reduction, alcohol consumption, dietary modification, intake of dietary cations and stress management are reviewed. Antioxidants and fish oil supplements are also reviewed, although specific recommendations cannot be made at present.

EVIDENCE

MEDLINE searches were conducted from January 2002 to September 2003 to update the 2001 recommendations for the management of hypertension. Supplemental searches in the Cochrane Collaboration databases were also performed. Reference lists were scanned, experts were contacted, and the personal files of the subgroup members and authors were used to identify additional published studies. All relevant articles were reviewed and appraised independently using prespecified levels of evidence by content and methodology experts.

RECOMMENDATIONS

Key recommendations include the following: lifestyle modification should be extended to nonhypertensive individuals who are at risk for developing high blood pressure; 30 min to 45 min of aerobic exercise should be performed on most days (four to five days) of the week; an ideal body weight (body mass index 18.5 kg/m2 to 24.9 kg/m2) should be maintained and weight loss strategies should use a multidisciplinary approach; alcohol consumption should be limited to two drinks or fewer per day, and weekly intake should not exceed 14 standard drinks for men and nine standard drinks for women; a reduced fat, low cholesterol diet that emphasizes fruits, vegetables and low fat dairy products, and maintains an adequate intake of potassium, magnesium and calcium, should be followed; salt intake should be restricted to 65 mmol/day to 100 mmol/day in hypertensive individuals and less than 100 mmol/day in normotensive individuals at high risk for developing hypertension; and stress management should be considered as an intervention in selected individuals.

VALIDATION

All recommendations were graded according to the strength of the evidence and voted on by the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. Individuals with irreconcilable competing interests (declared by all members, compiled and circulated before the meeting) relative to any specific recommendation were excluded from voting on that recommendation. Only those recommendations achieving at least 70% consensus are reported here. These guidelines will continue to be updated annually.

Implementation of an osteopathic manipulative medicine clinic at an allopathic teaching hospital: a research-based experience

Mastery of osteopathic palpatory skills and the skilled delivery of osteopathic manipulative treatment is a life-long venture that demands from practitioners increasingly sophisticated manual skills. Specific receptors and neural networks within the brain allow for the gradual development of refined manual skills that parallel responsive alterations and refinements that develop with repeated experience. During clinical training, most graduates of colleges of osteopathic medicine are not given opportunities to hone their palpatory skills. This is unfortunate because there is an increasing public demand for the nonpharmacologic treatment modalities osteopathic physicians could supply. At Berkshire Medical Center in Pittsfield, Mass, a major teaching affiliate of the University of Massachusetts Medical School in Worcester, the authors assembled a team of osteopathic and allopathic physicians to found an osteopathic manipulative medicine clinic. In this article, the authors share their experience in the creation of this research-based osteopathic medical clinic.

Anaesthetic management of a parturient with pulmonary stenosis and aortic incompetence for Caesarean section

Anaesthetic management of Caesarean section in a parturient with severe pulmonary stenosis and aortic regurgitation is described. The valvular sequelae resulted from previous unsuccessful surgical correction (Ross procedure) of congenital aortic stenosis. This case demonstrates the importance of multi-disciplinary assessment and careful anaesthetic planning, to avoid deterioration in perioperative cardiac performance in parturients with complex valvular disease.

Biochemical correlates of thiazolidinedione-induced adipocyte differentiation by high-resolution magic angle spinning NMR spectroscopy

Thiazolidinediones, a class of synthetic ligands to the peroxisome proliferator-activated receptor-gamma, induce terminal adipocyte differentiation of 3T3 F442A cells, and have already been used as alternative therapeutic agents for the treatment of liposarcoma in clinical trials. The biochemical changes occurring in the 3T3 F442A cell line and well-differentiated liposarcoma following induction of adipocyte differentiation with the thiazolidinedione troglitazone were measured using high-resolution magic angle spinning (MAS) nuclear magnetic resonance (NMR) spectroscopy. 3T3 F442A cell differentiation was characterized by a large accumulation of intracellular triglyceride and withdrawal from the cell cycle. Phosphatidylcholine (PTC), phosphocholine (PC), myo-inositol, and glycerol were found to be possible biochemical markers for adipocyte differentiation induced by thiazolidenediones. The molar ratio of PTC to PC increased fourfold in differentiated 3T3 F442A cells compared to undifferentiated cells, suggesting a substantial increase in CTP:phosphocholine cytidylyltransferase activity with differentiation. A 2.8-fold increase in the PTC:PC ratio was observed in the lipoma-like well-differentiated liposarcoma of three patients who were treated with troglitazone when compared to liposarcoma from patients not treated with this drug. Thus, this ratio may be an NMR-detectable marker of troglitazone efficacy and response to differentiation therapy for liposarcoma.

Lead pollution and amelioration measures in the community of Frazers Content, St Catherine, Jamaica

Lead poisoning, especially in children, is a preventable disease. Many children are exposed to this hazard, especially in poor communities, because of a paucity of information on lead poisoning and increasing economic hardships. In 1994, the case of the poor suburban community of Frazers Content, St Catherine, Jamaica, came to the public attention because of the high frequency of hospital admissions, or outpatient treatment, of children for lead poisoning. This paper reviews a Blue Cross of Jamaica-led-initiative aimed at the clean up and education of the Frazers Content community. The following four-pronged approach was employed: environmental and biological sampling and sample analysis, health education, decontamination and community clean up and entrepreneurial activities. The project outputs included: training of 17 community wardens and 22 schoolteachers; the clean up of 64 residences which had lead levels in excess of 500 ppm; the establishment of an entombment site for the contaminated soil in accordance with the Jamaica Natural Resources Conservation Authority and training of residents in entrepreneurial skills, chicken and rabbit rearing and nursery establishment. The paper includes discussion of the lessons learnt and recommendations for future action.

The 2000 Canadian recommendations for the management of hypertension: Part one--therapy

OBJECTIVE

To provide updated, evidence-based recommendations for the therapy of hypertension in adults.

OPTIONS

For patients with hypertension, there are a number of lifestyle manoeuvres and antihypertensive agents that may control blood pressure. Randomized trials evaluating first- line therapy with thiazides, beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers, centrally acting agents or angiotensin II receptor antagonists were reviewed.

OUTCOMES

The health outcomes considered were changes in blood pressure, cardiovascular morbidity, and cardiovascular and/or all-cause mortality rates. Economic outcomes were not considered due to insufficient evidence.

EVIDENCE

Medline searches were conducted from the period of the last revision of the Canadian Recommendations for the Management of Hypertension (May 1998 to October 2000). Reference lists were scanned, experts were polled, and the personal files of the subgroup members and authors were used to identify other studies. All relevant articles were reviewed and appraised, using prespecified levels of evidence, by content experts and methodological experts.

VALUES

A high value was placed on the avoidance of cardiovascular morbidity and mortality.

BENEFITS, HARMS, AND COSTS

Various lifestyle manoeuvres and antihypertensive agents reduce the blood pressure of patients with sustained hypertension. In certain settings, and for specific classes of drugs, blood pressure lowering has been associated with reduced cardiovascular morbidity and/or mortality.

RECOMMENDATIONS

The present document contains detailed recommendations pertaining to all aspects of the therapy of patients with hypertension, including lifestyle modifications proven to lower blood pressure, treatment thresholds, target blood pressures, choice of agents in various settings and strategies to enhance adherence. Lower thresholds for blood pressure treatment are advocated for people with other cardiovascular risk factors or established hypertensive target organ damage. Implicit in the recommendations for therapy is the principle that treatment should be individualized for each patient and the choice of agent should be dictated by coexistent conditions. For the treatment of uncomplicated essential hypertension, thiazides, beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors or calcium channel blockers may be appropriate, depending on individual circumstances.

VALIDATION

All recommendations were graded according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group. Only those recommendations achieving high levels of consensus are reported here. These guidelines will be updated annually.

Congenital chylothorax

The objective of this paper is a retrospective study of all infants treated for congenital chylothorax at the Royal Children's Hospital (RCH), Melbourne, Australia and King Fahad National Guard Hospital (KFNGH), Riyadh, Kingdom of Saudi Arabia. The charts of all infants with congenital chylothorax admitted to RCH over a period of 13 years, June 1982-August 1994, and admissions to KFNGH over a 7-year period, June 1992-August 1998 inclusive, were reviewed including management outcome and complications. There were 19 infants, 13 from RCH and 6 from KFNGH; 11 females and 8 males. Three infants were managed antenatally. Fifteen infants presented immediately after birth. Seven were born with hydrops fetalis, 6 infants had syndromes and 10 infants were born prematurely. Regular infant feeding formula and/or breast milk were used successfully in 12 infants, while in 7 infants medium chain triglycerides (MCT) rich formula was used. Sixteen infants were mechanically ventilated with 75% of them ventilated for < or = 28 days. Fifteen infants received total parenteral nutrition (TPN), and in 80% for < or = 32 days. Hydropic infants had longer duration of mechanical ventilation and hospital stay with mean (range) of 33.9 (3-120) and 115 (23-225) days, respectively, compared with 18 (1-62) and 34.3 (14-88) days for nonhydropic infants. Five infants underwent surgery with failure in four. Sepsis and bronchopulmonary dysplasia were the main complications. The survival rate was 100% regardless of the mode of therapy. The prognosis of Isolated congenital chylothorax in term, and preterm infants is good even in the presence of hydrops. Breast milk and/or regular infant feeding formula should be used initially before proceeding to MCT-rich formula, which may be necessary in some cases. Surgery should be considered if conservative management of congenital chylothorax fails after 4-5 weeks.

Canadian national high blood pressure prevention and control strategy

Despite major efforts to prevent and control high blood pressure, it is one of the most common and important health problems facing Canadians. To address this issue, Health Canada, in collaboration with the Canadian Coalition for High Blood Pressure Prevention and Control, established an Expert Working Group to prepare a national strategy. The present report outlines a strategy to prevent and control high blood pressure. It is directed at policy makers at the local, provincial, and/or territorial and national levels in both the health and nonhealth sectors. The strategy is based on current research and expertise. A multifaceted, comprehensive approach is proposed because there is no one intervention that will accomplish the goal of improving the health of Canadians through high blood pressure prevention and control. The present report focuses on the general population. It does not address the unique needs of children, pregnant women or aboriginal peoples. Each of these groups needs to be studied in its own right, and, in particular, with the involvement of aboriginal people themselves. An implementation committee has been established to realize this strategy, and the Canadian Hypertension Society is a key stakeholder in this effort. Several initiatives are underway. Strong advocates are necessary to increase public awareness and to support the system changes required for a successful public health approach to reduce the prevalence of hypertension and its complications.

1999 Canadian recommendations for the management of hypertension. Task Force for the Development of the 1999 Canadian Recommendations for the Management of Hypertension

OBJECTIVE

To provide updated, evidence-based recommendations for health care professionals on the management of hypertension in adults.

OPTIONS

For patients with hypertension, there are both lifestyle options and pharmacological therapy options that may control blood pressure. For those patients who are using pharmacological therapy, a range of antihypertensive drugs is available. The choice of a specific antihypertensive drug is dependent upon the severity of the hypertension and the presence of other cardiovascular risk factors and concurrent diseases.

OUTCOMES

The health outcomes considered were changes in blood pressure and in morbidity and mortality rates. Because of insufficient evidence, no economic outcomes were considered.

EVIDENCE

MEDLINE searches were conducted from the period of the last revision of the Canadian Recommendations for the Management of Hypertension (January 1993 to May 1998). Reference lists were scanned, experts were polled and the personal files of the authors were used to identify other studies. All relevant articles were reviewed, classified according to study design and graded according to levels of evidence.

VALUES

A high value was placed on the avoidance of cardiovascular morbidity and premature death caused by untreated hypertension.

BENEFITS

Harms and costs: The diagnosis and treatment of hypertension with pharmacological therapy will reduce the blood pressure of patients with sustained hypertension. In certain settings, and for specific drugs, blood pressure lowering has been associated with reduced cardiovascular morbidity and mortality.

RECOMMENDATIONS

This document contains detailed recommendations pertaining to all aspects of the diagnosis and pharmacological therapy of hypertensive patients. With respect to diagnosis, the recommendations endorse the greater use of non-office-based measures of blood pressure control (i.e., using home blood pressure and automatic ambulatory blood pressure monitoring equipment) and greater emphasis on the identification of other cardiovascular risk factors, both in the assessment of prognosis in hypertension and in the choice of therapy. On the treatment side, lower targets for blood pressure control are advocated for some subgroups of hypertensive patients, in particular, those with diabetes and renal disease. Implicit in the recommendations for therapy is the principle that for the vast majority of hypertensive patients treated pharmacologically, practitioners should not follow a stepped-care approach. Instead, therapy should be individualized, based on consideration of concurrent diseases, both cardiovascular and noncardiovascular.

VALIDATION

All recommendations were graded according to the strength of the evidence and the consensus of all relevant stakeholders.

SPONSORS

The Canadian Hypertension Society and the Canadian Coalition for High Blood Pressure Prevention and Control.