The 2009 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 2--therapy

High dietary sodium intake among young children in Vancouver, British Columbia

OBJECTIVE

To determine the intake distribution and food sources of sodium among young children.

METHODS

Dietary intake was determined for 190 children, 16 months to 6 years of age, using a food frequency questionnaire completed by interviewing a parent. Dietary intake of all nutrients, including dietary sodium, was analyzed. The major food sources of sodium were assessed by grouping foods into categories based on Canada's Food Guide, with subsequent subdivision into food type categories.

RESULTS

Dietary sodium intakes were skewed, with a median intake of 2021 mg/d and 5th-95th percentile range of 888-3975 mg/d. The sodium intake of 91.6% of children was above the recommended 1000 or 1200 mg/d for children 1-3 or 3-6 years, respectively, and 85% and 54% had intakes above the tolerable upper limits of 1500 and 1900 mg/d, respectively. The 5 food sources providing the highest amount of sodium were soups, processed/fast foods, dairy products, breads, and processed meats.

CONCLUSION

Children are vulnerable to high sodium intake as a result of their food patterns and the high sodium content of these foods. This report demonstrates that Canadian children have high sodium intakes. Knowledge of feeding practices involving high-sodium foods can assist parents and caregivers in reducing the high sodium intake of young children.

Vascular compliance in blood pressure

PURPOSE OF REVIEW

Vascular stiffening is a hallmark of the aging process. Improvements in the methods used to measure central stiffness, particularly applanation tonometry, and their use as therapeutic targets have generated great interest.

RECENT FINDINGS

Vascular stiffness is associated with increases in pulse pressure (PP), aortic augmentation index, and pulse wave velocity (PWV). This last has emerged as the gold standard for evaluation of vascular stiffness, as it is an independent predictor of coronary heart disease, stroke, and mortality. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium-channel blockers with or without diuretics are all commonly used to ameliorate vascular stiffness; however, selective β-1 blockers (β-blockers) may actually worsen aortic PP and aortic augmentation index.

SUMMARY

Serial measurements of vascular stiffness, including PWV, augmentation index, and PP, may be especially beneficial in older patients to supplement brachial blood pressure. At present, given the lack of universally accepted normal values for vascular stiffness as measured by applanation tonometry, serial measurements over time may be more helpful than a single isolated value. In patients with suspected vascular stiffening, therapy should include inhibition of the renin-angiotensin-aldosterone system with ACE inhibitors or ARBs, calcium-channel blockers, and diuretics as needed to normalize blood pressure. β-Blockers should be reserved for patients with a history of myocardial infarction or congestive heart disease. It remains to be established whether β-blockers with vasodilator properties could improve the assessment of vascular compliance.

Innovative program to increase physical activity following an acute coronary syndrome: randomized controlled trial

OBJECTIVE

To evaluate the impact of a socio-cognitive intervention associated with a pedometer-based program on physical activity, cardiovascular risk factors and self-efficacy expectation during one year following an acute coronary syndrome.

METHODS

Sixty-five subjects were randomized during hospitalization in an experimental or a usual care group. Average steps/day was measured every 3 months until one year following discharge. Other dependent variables were measured at baseline, 6 and 12 months follow-up.

RESULTS

There were 32 patients in the experimental group and 33 patients in the usual care group. Group characteristics were comparable. At baseline, averages steps/day were similar between groups (5845±3246 vs. 6097±3055 steps/day; p=0.812). At 3-month follow-up, both groups increased their averages steps/day (p<0.05). This increase was higher in the experimental group (3388±844 vs. 1934±889 steps/day; p<0.001). At 12-month, interaction effects (group×time) in physical activity and waist circumference were different between groups (p<0.05), whereas self-efficacy expectation increased in both groups similarly (p<0.05).

CONCLUSION

The intervention is useful to improve average steps/day and waist circumference during the first year following an acute coronary syndrome.

PRACTICE IMPLICATIONS

This study supports development of the home-based cardiac rehabilitation program using socio-cognitive intervention associated with a pedometer after an acute coronary syndrome.

Retrospective analysis of real-world efficacy of angiotensin receptor blockers versus other classes of antihypertensive agents in blood pressure management

BACKGROUND

Efficacy of blood pressure (BP) lowering may differ between clinical trials and what is observed in clinical practice. These differences may contribute to poor BP control rates among those at risk.

OBJECTIVE

We conducted an observational study to determine the BP-lowering efficacy of angiotensin receptor blocker (ARB) versus non-ARB-based antihypertensive treatments in a large Canadian primary care database.

METHODS

We analyzed the South Western Ontario database of 170,000 adults (aged >18 years) with hypertension persisting with antihypertensive medication for ≥9 months. Routine standard of care office BP was measured using approved manual aneroid or automated devices. BP <140 mm Hg and/or <90 mm Hg ≤9 months after treatment initiation, persistence (presence of initial antihypertensive prescription at the first, second, third, and fourth year anniversary) with antihypertensive therapy, and the presence of a cardiovascular (CV) event (ie, myocardial infarction) were studied.

RESULTS

After 9 months of monotherapy, 28% (978 of 3490) of patients on ARBs achieved target BP versus 27% (839 of 3110) on angiotensin-converting enzyme inhibitors (ACEIs) (P > 0.05), 26% (265 of 1020) on calcium channel blockers (CCBs) (P > 0.05), 21% (221 of 1050) on β-blockers (P = 0.002), and 19% (276 of 1450) on diuretics (P = 0.001). Attainment rates were significantly higher with irbesartan (38%; 332 of 873) versus losartan (32%; 335 of 1047; P = 0.01), valsartan (19%; 186 of 977; P = 0.001), and candesartan (25%; 148 of 593; P = 0.001). BP goal attainment rates were significantly higher when ARB was compared with non-ARB-based dual therapy (39%; 1007 of 2584 vs 31%; 1109 of 3576; P = 0.004); irbesartan + hydrochlorothiazide (HCTZ) was significantly higher than losartan + HCTZ (36%; 500 of 1390 vs 20%; 252 of 1261; P = 0.001). For patients receiving dual or tri-therapy, 48% (667 of 1390) of patients receiving irbesartan reached target BP versus 41% to 42% for losartan (517 of 1261), valsartan (194 of 462), and candesartan (168 of 401) (P = 0.001 for each). After 4 years, persistence rates were not statistically different among ARB, CCB, and diuretic monotherapies, but appeared somewhat higher with ACEIs and β-blockers (78%, 78%, 79%, 91%, and 84%, respectively). Persistence was not significantly different between irbesartan and losartan monotherapy (76% for both; P > 0.05), but was significantly higher with irbesartan + HCTZ versus losartan + HCTZ (96% vs 73%, respectively; P = 0.001). Patients treated with ARBs reported fewer CV events than those receiving ACEIs or CCBs (4.3% vs 7.0% and 11.0%, respectively; P < 0.001). Within the ARB class, the lowest rate was with irbesartan (3.0% vs 4.6%-5.0% for other ARBs; P < 0.02).

CONCLUSIONS

In this real-world setting, hypertensive adults treated with ARBs versus β-blockers or diuretics were more likely to have evidence-based target BP recorded. In addition, patients using ARBs versus ACEIs or CCBs had fewer reports of CV events.

Antihypertensive effects and safety of eprosartan: a meta-analysis of randomized controlled trials

PURPOSE

The benefits of reducing blood pressure (BP) have been well established, but uncertainty remains about the comparative effects of different BP-lowering regimens. We aimed to estimate the efficacy and the tolerability of eprosartan compared with other agents as monotherapy.

METHODS

PubMed, EMBASE, and Cochrane Library were searched for relevant studies. A meta-analysis of randomized controlled trials (RCTs) meeting the criteria was performed using Review Manager and Stata/SE.

RESULTS

Twenty-two articles were ultimately included out of 78 studies, involving 6,460 patients. Eprosartan had a greater systolic blood pressure (SBP) reduction than placebo [weighted mean difference (WMD): 6.55, 95% confidence interval (CI) 4.86-8.25] and losartan (WMD: 2.24, 95% CI 0.08-4.40) and a greater diastolic blood pressure (DBP) reduction than placebo (WMD 3.95, 95% CI 2.77-5.13). Therapeutic response rate of BP favored eprosartan [risk ratio (RR) 1.13, 95% CI 1.03-1.24] compared with enalapril. There were no statistical differences in SBP or DBP reductions comparing eprosartan with enalapril or telmisartan. Original RCTs included comparing eprosartan with valsartan and nitrendipine reported no differences in BP-lowering efficacy.

CONCLUSIONS

Eprosartan monotherapy is equivalent to many first-line antihypertensive agents and is effective for the treatment of essential hypertension, especially for isolated systolic hypertension. The favorable efficacy and tolerability make eprosartan worthwhile to be taken into consideration by physicians.

Hypertension and type 2 diabetes: what family physicians can do to improve control of blood pressure--an observational study

BACKGROUND

The prevalence of type 2 diabetes is rising, and most of these patients also have hypertension, substantially increasing the risk of cardiovascular morbidity and mortality. The majority of these patients do not reach target blood pressure levels for a wide variety of reasons. When a literature review provided no clear focus for action when patients are not at target, we initiated a study to identify characteristics of patients and providers associated with achieving target BP levels in community-based practice.

METHODS

We conducted a practice-based, cross-sectional observational and mailed survey study. The setting was the practices of 27 family physicians and nurse practitioners in 3 eastern provinces in Canada. The participants were all patients with type 2 diabetes who could understand English, were able to give consent, and would be available for follow-up for more than one year. Data were collected from each patient's medical record and from each patient and physician/nurse practitioner by mailed survey. Our main outcome measures were overall blood pressure at target (< 130/80), systolic blood pressure at target, and diastolic blood pressure at target. Analysis included initial descriptive statistics, logistic regression models, and multivariate regression using hierarchical nonlinear modeling (HNLM).

RESULTS

Fifty-four percent were at target for both systolic and diastolic pressures. Sixty-two percent were at systolic target, and 79% were at diastolic target. Patients who reported eating food low in salt had higher odds of reaching target blood pressure. Similarly, patients reporting low adherence to their medication regimen had lower odds of reaching target blood pressure.

CONCLUSIONS

When primary care health professionals are dealing with blood pressures above target in a patient with type 2 diabetes, they should pay particular attention to two factors. They should inquire about dietary salt intake, strongly emphasize the importance of reduction, and refer for detailed counseling if necessary. Similarly, they should inquire about adherence to the medication regimen, and employ a variety of patient-oriented strategies to improve adherence.

Canadians continue to consume too much sodium and not enough potassium

OBJECTIVES

Excessive sodium (Na) intakes and insufficient potassium (K) intakes are known contributors to hypertension. In July 2010, the Health Canada-led multi-stakeholder Sodium Working Group issued recommendations to lower Na intakes of Canadians. Baseline data and ongoing monitoring are needed.

METHODS

Na and K content based on recently analyzed food composite samples from the Canadian marketplace were matched with over 35,000 dietary recalls from the Canadian Community Health Survey (CCHS 2.2). The distributions of usual intakes for Na and K were constructed using SIDE software and estimates by age and sex for the 5th, 10th, 25th, mean, median, 75th, 90th and 95th percentiles were determined.

RESULTS

Based on recent analyses of Canadian foods, the majority of Canadians exceeded the Tolerable Upper Intake Level (UL) for Na for their age and sex group, including infants, children, adolescents and adults. In sharp contrast, few had Adequate Intakes (AI) of K.

CONCLUSION

Canadians of all ages need to decrease Na intakes below the UL. At the same time, increased consumption of dairy products, fruits and vegetables must be promoted to increase K intakes to current recommendations. Both dietary interventions are required to help lower hypertension in the Canadian population. We provide the first report based on direct analysts of Canadian foods, confirming the high Na and low K intakes of the Canadian population. With its annual sampling program of foods commonly consumed in Canada, the Total Diet Study provides an important sentinel system for monitoring these dietary risk factors for hypertension.

Development and validation of the PAIR (Pharmacotherapy Assessment in Chronic Renal Disease) criteria to assess medication safety and use issues in patients with CKD

BACKGROUND

Explicit criteria for judging medication safety and use issues in patients with chronic kidney disease (CKD) are lacking.

STUDY DESIGN

Quality improvement report.

SETTING & PARTICIPANTS

Nephrologists (n = 4), primary care physicians (n = 2), hospital pharmacists with expertise in nephrology (n = 4), and community pharmacists (n = 2). The PAIR (Pharmacotherapy Assessment in Chronic Renal Disease) criteria were applied retrospectively to 90 patients with CKD in a randomized study.

QUALITY IMPROVEMENT PLAN

Development of an explicit set of criteria to enable rapid and systematic detection of drug-related problems (DRPs). Using a RAND method, experts judged the clinical significance of DRPs and the appropriateness of a community pharmacist intervention. The PAIR criteria include 50 DRPs grouped into 6 categories.

OUTCOMES

DRPs detected using the PAIR criteria compared with implicit clinical judgment by nephrology pharmacists.

MEASUREMENTS

Prevalence of DRPs and reliability, validity, and responsiveness of the PAIR criteria.

RESULTS

A mean of 2.5 DRPs/patient (95% CI, 2.0-3.1) was identified based on the PAIR criteria compared with 3.9 DRPs/patient (95% CI, 3.4-4.5) based on clinical judgment of nephrology pharmacists. Inter-rater reliability coefficients (κ) by PAIR category varied from 0.80-1.00, with an intraclass correlation coefficient (ICC) of 0.93 (95% CI, 0.89-0.95) for total DRPs per patient. Test-retest reliability coefficients by category varied from 0.74-1.00, with an ICC of 0.91 (95% CI, 0.82-0.96) for total DRPs per patient. During the study, the mean number of DRPs per patient did not change significantly when assessed using the PAIR criteria and clinical judgment.

LIMITATION

The prevalence of PAIR DRPs may be underestimated due to the retrospective nature of the validation.

CONCLUSION

The prevalence of DRPs requiring the intervention of community pharmacists is high in patients with CKD. The PAIR criteria are reliable, but their responsiveness remains to be shown.

Underrepresentation of individuals 80 years of age and older in chronic disease clinical practice guidelines

OBJECTIVE

To determine whether Canadian clinical practice guidelines (CPGs), and the evidence used to create CPGs, include individuals 80 years of age and older.

DESIGN

Descriptive analysis of 14 CPGs for 5 dominant chronic conditions (diabetes, hypertension, heart failure, osteoporosis, stroke) and descriptive analysis of all research-based references with human participants in the 14 guidelines.

MAIN OUTCOME MEASURES

To identify recommendations for individuals 65 years of age and older or 80 years of age and older and for those with multiple chronic conditions.

RESULTS

Although 12 of 14 guidelines provided specific recommendations for individuals 65 years of age and older, only 5 provided recommendations for frail older individuals (≥ 80 years). A total of 2559 studies were used as evidence to support the recommendations in the 14 CPGs; 2272 studies provided the mean age of participants, of which only 31 (1.4%) reported a mean age of 80 years of age and older.

CONCLUSION

There is very low representation of individuals in advanced old age in CPGs and in the studies upon which these guidelines are based, calling into question the applicability of current chronic disease CPGs to older individuals. The variety of medical and functional issues occurring in the elderly raises the concern of whether or not evidence-based disease-specific CPGs are appropriate for such a diverse population.

The feasibility and effectiveness of emergency department based hypertension screening: a systematic review

PURPOSE

Hypertension is a highly prevalent risk factor for cardiovascular disease, and its early identification and management results in reductions in morbidity and mortality. Our objectives were to: (1) determine the extent to which the emergency department (ED) has been used to screen patients for undiagnosed hypertension; (2) estimate the incidence of undiagnosed hypertension in the ED population; (3) identify and describe the programs for ED hypertension screening; and (4) determine the feasibility of ED-based hypertension screening programs and the requirements for further study.

DATA SOURCES

An online search of databases (i.e., OVID Search, CINAHL, Scopus, Web of Science), unpublished sources (i.e., ProQuest Dissertation & Theses and Papers First), and grey literature (i.e., OpenSIGLE and the New York Academy of Grey Literature) was conducted. A manual search of the reference lists of relevant studies was also completed.

CONCLUSION

Hypertension screening in the ED is feasible. Individuals with elevated blood pressure (BP) in the ED should be referred for follow-up. Further study is needed to develop an ED screening tool that is predictive of persistently elevated BP in undiagnosed individuals.

IMPLICATIONS FOR PRACTICE

Nurse practitioners in the ED should identify patients with elevated BP, provide hypertension education, and ensure appropriate intervention and referral.

The Canadian effort to prevent and control hypertension: can other countries adopt Canadian strategies?

PURPOSE OF REVIEW

To indicate the key elements of current Canadian programs to treat and control hypertension.

RECENT FINDINGS

In the early 1990s Canada had a hypertension treatment and control rate of 13%. A Canadian strategy to prevent and control hypertension was developed and a coalition of national organizations and volunteers formed to develop increasingly extensive programs. The Canadian effort was largely based on annually updated hypertension management recommendations, an integrated and extensive hypertension knowledge translation program and an increasingly comprehensive outcomes assessment program. After the start of the annual process in 1999, there were very large increases in diagnosis and hypertension treatment coupled with dropping rates of cardiovascular disease. More recent initiatives include an extensive education program for the public and people with hypertension, a program to reduce dietary salt and a funded leadership position. The treatment and control rate increased to 66% when last assessed (2007-2009).

SUMMARY

The study describes important aspects of the Canadian hypertension management programs to aid those wishing to develop similar programs. Many of the programs could be fully or partially implemented by other countries.

Trends in co-prescribing of angiotensin converting enzyme inhibitors and angiotensin receptor blockers in Ireland

AIMS

(i) To examine the trends in co-prescribing of angiotensin converting enzyme inhibitor (ACEI) and angiotensin-II receptor blocker (ARB) therapy and (ii) to examine the influence of major clinical trials (CALM, COOPERATE, VALIANT and ONTARGET) on co-prescribing.

METHODS

The Irish HSE-Primary Care Reimbursement Services database was used to identify patients ≥16 years old co-prescribed ACEIs and ARBs between January 2000 and April 2009 (n= 266 554 prescriptions). The rate of prescribing per 1000 general medical services (GMS) scheme population was calculated for each month. Patients with diabetes, hypertension, heart failure and ischaemic heart disease were also identified by prescribing of certain medications. A linear trend test was used to examine prescribing trends. Logistic regression was used to examine prescribing according to patient characteristics. The effects of the major trials on prescribing were examined using segmented regression analysis for 12 months pre- and post-trials.

RESULTS

There was a significant linear trend in overall ACEI and ARB co-prescribing over the study period (P < 0.001). Rate of co-prescribing in January 2000 and April 2009 was 0.16 and 5.72, per 1000 eligible population, respectively. Those 45-64 years old (OR = 2.88, 95% confidence interval (CI) 2.71, 3.06) and ≥65 years (OR = 2.52, 95% CI 2.36, 2.68) were more likely to receive dual therapy compared with those <45 years old. Those with hypertension (OR = 8.85, 95% CI 8.45, 9.27), diabetes (OR = 4.10, 95% CI 3.97, 4.23) and heart failure (OR = 1.78, 95% CI 1.72, 1.84) were more likely to receive dual therapy compared with the general population. Significant increases in prescribing were observed only after the CALM (P= 0.03) and VALIANT (P= 0.007) trials.

CONCLUSION

Increased co-prescribing of ACEIs and ARBs was observed in Ireland during 2000-09. Prescribing patterns did not appear to be affected by results from major trials.

Canadians continue to consume too much sodium and not enough potassium

OBJECTIVES

Excessive sodium (Na) intakes and insufficient potassium (K) intakes are known contributors to hypertension. In July 2010, the Health Canada-led multi-stakeholder Sodium Working Group issued recommendations to lower Na intakes of Canadians. Baseline data and ongoing monitoring are needed.

METHODS

Na and K content based on recently analyzed food composite samples from the Canadian marketplace were matched with over 35,000 dietary recalls from the Canadian Community Health Survey (CCHS 2.2). The distributions of usual intakes for Na and K were constructed using SIDE software and estimates by age and sex for the 5th, 10th, 25th, mean, median, 75th, 90th and 95th percentiles were determined.

RESULTS

Based on recent analyses of Canadian foods, the majority of Canadians exceeded the Tolerable Upper Intake Level (UL) for Na for their age and sex group, including infants, children, adolescents and adults. In sharp contrast, few had Adequate Intakes (AI) of K.

CONCLUSION

Canadians of all ages need to decrease Na intakes below the UL. At the same time, increased consumption of dairy products, fruits and vegetables must be promoted to increase K intakes to current recommendations. Both dietary interventions are required to help lower hypertension in the Canadian population. We provide the first report based on direct analysts of Canadian foods, confirming the high Na and low K intakes of the Canadian population. With its annual sampling program of foods commonly consumed in Canada, the Total Diet Study provides an important sentinel system for monitoring these dietary risk factors for hypertension.

Management of hypertension and diabetes in obesity: non-pharmacological measures

Obesity has become a global epidemic over the past few decades because of unhealthy dietary habits and reduced physical activity. Hypertension and diabetes are quite common among obese individuals and there is a linear relationship between the degree of obesity and these diseases. Lifestyle interventions like dietary modifications and regular exercise are still important and safe first-line measures for treatment. Recently, bariatric surgery has emerged as an important and very effective treatment option for obese individuals especially in those with comorbidities like hypertension and diabetes. Though there are few effective drugs for the management of obesity, their efficacy is only modest, and they should always be combined with lifestyle interventions for optimal benefit. In this paper we aim to outline the non-pharmacological measures for the management of hypertension and diabetes in obesity.

Lifestyle Intervention Strategies for the Prevention and Treatment of Hypertension: A Review

Hypertension (HTN) is an extraordinarily common progressive cardiovascular syndrome in the United States, afflicting approximately one third of the adult population. HTN is a powerful and unequivocal independent risk factor for cardiovascular and renal diseases, including coronary heart disease, stroke, and renal failure. Despite major advances in the understanding and treatment of HTN over the past several decades, the disease remains the most common primary diagnosis in the United States and is a major public health concern. Adoption of healthy lifestyle modifications has proven to be highly effective in both the prevention of new-onset HTN and in the treatment of those diagnosed with HTN. In view of the continuing epidemic of HTN and blood pressure (BP)—related diseases and the invaluable role of applying nonpharmacological therapy in the prevention and management of HTN, a review of current therapeutic lifestyle strategies appears warranted. This review will define 6 well-established nonpharmacological lifestyle modifications for preventing and managing HTN in addition to 3 novel lifestyle interventions that show promise as effective adjunct strategies for lowering BP. A healthy lifestyle prescription ideally comprising a number of these BP-lowering lifestyle intervention strategies should be dispensed by all primary care physicians for both the prevention and treatment of elevated BP, an action that would have major, positive public health ramifications.

Lifestyle advice for Korean Americans and native Koreans with hypertension

AIM

This paper is a report of a comparison of advice on lifestyle given by healthcare providers and subsequent action by recipients between Korean Americans and native Koreans with hypertension.

BACKGROUND

High blood pressure is controllable by having a healthy lifestyle, such as weight control, dietary change, exercise, low-sodium diet, alcohol restriction and smoking cessation, and by taking medication. Healthcare providers play an important role in teaching individuals with hypertension on healthy lifestyles.

METHOD

This descriptive comparative study was conducted with a convenience sample of 100 Korean Americans and 100 native Koreans with hypertension. They were interviewed between May 2003 and June 2004 on the advice they received from healthcare providers on lifestyle and their subsequent action in terms of taking medication, weight control, dietary change, exercise, low-sodium diet, smoking cessation, alcohol restriction and tension reduction. Nutrient profiles were examined using the 24-hour dietary recall method.

FINDINGS

Korean Americans received advice on lifestyle less than did native Koreans, but more Korean Americans followed healthy lifestyle advice on dietary change and exercise than did native Koreans (P<0.001). Weight control was the least adhered to behaviour among the Korean Americans, although almost two-thirds of them were overweight or obese. Both groups exceeded the Dietary Reference Intakes of sodium, but perceived their sodium consumption as low.

CONCLUSION

Native Korean participants need to pay closer attention to carrying out the advice, whereas healthcare providers to Korean Americans need to give more advice on culturally acceptable healthy lifestyles, particularly on dietary changes and weight control. Both groups need to monitor their sodium intake more realistically. It is not only advice from healthcare providers that is integral to control of hypertension, but also that patients should follow that advice.

Canadian efforts to prevent and control hypertension

Suboptimum blood pressure is estimated to be the leading risk factor for death worldwide and is associated with 13.5% of deaths globally. The clinical diagnosis of hypertension affects one in four adults globally and is expected to increase by 60% between 2000 and 2025. Clearly, global efforts to prevent and control hypertension are important health issues. While Canada had a prevalence of hypertension similar to that of the United States in the early 1990 s, the treatment and control rate was only 13% compared with 25% in the United States. A national strategic plan was developed, and a coalition of organizations and health care professional and scientist volunteers actively implemented parts of the strategy. Specific initiatives that have evolved include the development of hypertension knowledge translation programs for health professionals, the public and people with hypertension, an outcomes research program to assess the impact of hypertension and guide national-, regional- and community-based knowledge translation interventions, and a program to reduce the prevalence of hypertension by decreasing sodium additives in food. These initiatives have relied on the active involvement of health care professional volunteers, health care professional and scientific organizations and various government departments. There have been large increases in the diagnosis and treatment of hypertension, with corresponding reductions in cardiovascular disease and total mortality associated with the start of the hypertension initiatives. As a result, Canada is becoming recognized as a world leader in the prevention, treatment and control of hypertension.

24-Hour ambulatory blood pressure response to combination valsartan/hydrochlorothiazide and amlodipine/hydrochlorothiazide in stage 2 hypertension by ethnicity: the EVALUATE study

Several studies reported racial/ethnic differences in blood pressure (BP) response to antihypertensive monotherapy. In a 10-week study of stage 2 hypertension, 320/25 mg valsartan/hydrochlorothiazide (HCTZ) reduced ambulatory BP (ABP) significantly more effectively than 10/25 mg amlodipine/HCTZ. Results (post hoc analysis) are described in Caucasians (n=256), African Americans (n=79), and Hispanics (n=86). Compared with clinic-measured BP (no significant treatment-group differences in ethnic subgroups), least-squares mean reductions from baseline to week 10 in mean ambulatory systolic BP (MASBP) and mean ambulatory diastolic BP (MADBP) favored valsartan/HCTZ over amlodipine/HCTZ in Caucasians (-21.9/-12.7 mm Hg vs -17.6/-9.5 mm Hg; P=.0004/P<.0001). No treatment-group differences in MASBP/MADBP were observed in African Americans (-17.3/-10.6 vs -17.9/-9.5; P=.76/P=.40) or Hispanics (-17.9/-9.7 vs -14.2/-7.2; P=.20/P=.17). Based on ABP monitoring, valsartan/HCTZ is more effective than amlodipine/HCTZ in lowering ABP in Caucasians. In African Americans and Hispanics, both regimens are similarly effective.

Addressing poor nutrition to promote heart health: moving upstream

Current dietary recommendations for cardiovascular disease prevention suggest dietary patterns that promote achieving healthy weight, emphasize vegetables, legumes, fruit, whole grains, fish and nuts, substituting mono-unsaturated fats for saturated fats and restricting dietary sodium to less than 2300 mg/day. However, trends in nutrient intake and food consumption patterns suggest that the need for improvement in the dietary patterns of Canadians is clear. Influencing eating behaviour requires more than addressing nutrition knowledge and perceptions of healthy eating - it requires tackling the context within which individuals make choices. A comprehensive approach to improving nutrition includes traditional downstream strategies such as counselling to improve knowledge and skills; midstream strategies such as using the media to change social norms; and upstream strategies such as creating supportive environments through public policy including regulatory measures. While the evidence base for more upstream strategies continues to grow, key examples of comprehensive approaches to population change provide a call to action.

The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension: part I - blood pressure measurement, diagnosis and assessment of risk

OBJECTIVE

To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension.

EVIDENCE

MEDLINE searches were conducted from November 2008 to October 2009 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed full-text articles only.

RECOMMENDATIONS

Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Changes to the recommendations for 2010 relate to automated office blood pressure measurements. Automated office blood pressure measurements can be used in the assessment of office blood pressure. When used under proper conditions, an automated office systolic blood pressure of 135 mmHg or higher or diastolic blood pressure of 85 mmHg or higher should be considered analogous to a mean awake ambulatory systolic blood pressure of 135 mmHg or higher and diastolic blood pressure of 85 mmHg or higher, respectively.

VALIDATION

All recommendations were graded according to strength of the evidence and voted on by the 63 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. To be approved, all recommendations were required to be supported by at least 70% of task force members. These guidelines will continue to be updated annually.

Identification of factors driving differences in cost effectiveness of first-line pharmacological therapy for uncomplicated hypertension

BACKGROUND

Published practice guidelines and economic evaluations have come to different conclusions regarding optimal pharmacotherapy for the treatment of uncomplicated hypertension. The drivers of these disparities are not clear. Greater understanding is needed for clinicians, researchers and policy makers to determine the most effective and sustainable strategies.

OBJECTIVES

To identify how cost and cost-effectiveness considerations are used to generate recommendations by major hypertension guidelines, and determine key drivers of cost-effectiveness conclusions in available economic evaluations.

METHODS

A systematic search and narrative review of major hypertension guidelines and health technology assessments of first-line antihypertensive therapy were performed.

RESULTS

Of the eight guidelines identified, formal cost-effectiveness analysis was rarely integrated in the formulation of recommendations. When guidelines considered costs, recommendations remained incongruent. Two economic evaluations were identified (United Kingdom and Canada); however, these differed in their conclusion of the most cost-effective agent and attractiveness of calcium channel blockers. Review of these economic evaluations suggests that cost-effectiveness conclusions are strongly influenced by relative costs of drug classes; when relative differences in drug costs are lower, the impact on associated conditions such as heart failure and diabetes influences cost-effectiveness conclusions.

CONCLUSION

In the setting of finite health care resources and significant budget impact due to high population prevalence, cost effectiveness is an important consideration in the treatment of uncomplicated hypertension. Identification of key drivers of cost effectiveness will assist interpretation and conduct of current and future economic evaluations.

2010 Canadian Hypertension Education Program (CHEP) recommendations: the scientific summary - an update of the 2010 theme and the science behind new CHEP recommendations

The present article is a summary of the theme, the key recommendations for management of hypertension and the supporting clinical evidence of the 2010 Canadian Hypertension Education Program (CHEP). In 2010, CHEP emphasizes the need for health care professionals to stay informed about hypertension through automated updates at www.htnupdate.ca. A new interactive Internet-based lecture series will be available in 2010 and a program to train community hypertension leaders will be expanded. Patients can also sign up to receive regular updates in a pilot program at www.myBPsite.ca. In 2010, the new recommendations include consideration for using automated office blood pressure monitors, new targets for dietary sodium for the prevention and treatment of hypertension that are aligned with the national adequate intake values, and recommendations for considering treatment of selected hypertensive patients at high risk with calcium channel blocker/angiotensin-converting enzyme inhibitor combinations and the use of angiotensin receptor blockers.

The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 - therapy

OBJECTIVE

To update the evidence-based recommendations for the prevention and treatment of hypertension in adults for 2010.

OPTIONS AND OUTCOMES

For lifestyle and pharmacological interventions, randomized trials and systematic reviews of trials were 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 general lack of long-term morbidity and mortality data in this field. Progressive renal impairment 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 2008 to August 2009 to update the 2009 recommendations. To identify additional 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 1500 mg (65 mmol) per day in adults 50 years of age or younger, to 1300 mg (57 mmol) per day in adults 51 to 70 years of age, and to 1200 mg (52 mmol) per day in adults older than 70 years of age; perform 30 min to 60 min of moderate 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 (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week for men or nine standard drinks per week for women; follow a diet that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources, and that is low in saturated fat and cholesterol; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in patients 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, considerations for initial therapy should include thiazide diuretics, angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. The combination of ACE inhibitors and ARBs should not be used, unless compelling indications are present to suggest consideration of dual therapy. Agents appropriate for first-line therapy for isolated systolic hypertension include thiazide diuretics, long-acting dihydropyridine CCBs or ARBs. In patients with coronary artery disease, ACE inhibitors, ARBs or betablockers 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. In selected high-risk patients in whom combination therapy is being considered, an ACE inhibitor plus a long-acting dihydropyridine CCB is preferable to an ACE inhibitor plus a thiazide diuretic. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian lipid treatment guidelines. Selected patients with hypertension who do not achieve thresholds for statin therapy, but who are otherwise at high risk for cardiovascular events, should nonetheless receive statin therapy. Once blood pressure is controlled, low-dose acetylsalicylic acid therapy should be considered.

VALIDATION

All recommendations were graded according to the strength of the evidence and voted on by the 63 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 80% consensus. These guidelines will continue to be updated annually.

SPONSORS

The Canadian Hypertension Education Program process is sponsored by the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the College of Family Physicians of Canada, the Canadian Pharmacists Association, the Canadian Council of Cardiovascular Nurses, and the Heart and Stroke Foundation of Canada.

Association between physical activity and cardiovascular risk in Chinese youth independent of age and pubertal stage

Background

Childhood and adolescence are critical periods of habit formation with substantial tracking of lifestyle and cardiovascular risk into adulthood. There are various guidelines on recommended levels of physical activity in youth of school-age. Despite the epidemic of obesity and diabetes in China, there is a paucity of data in this regard in Chinese youth. We examined the association of self-reported level of physical activity and cardiovascular risk in Hong Kong Chinese youth of school-age.

Methods

This was a cross-sectional study conducted in 2007-8 in a school setting with 2119 Hong Kong Chinese youth aged 6-20 years. Physical activity level was assessed using a validated questionnaire, CUHK-PARCY (The Chinese University of Hong Kong: Physical Activity Rating for Children and Youth). A summary risk score comprising of waist circumference, blood pressure, fasting plasma glucose and lipids was constructed to quantify cardiovascular risk.

Results

In this cohort, 21.5% reported high level of physical activity with boys being more active than girls (32.1% versus 14.1%, p < 0.001). Regression analysis showed physical activity level, sex and pubertal stage were independently associated with cardiovascular risk score.

Conclusion

Self-reported level of physical activity is associated with cardiovascular risk factors in Chinese youth after adjusting for sex and pubertal stage.

Blood pressure 2 years after a chronic disease management intervention study

OBJECTIVES

To follow blood pressure change over time in participants who had participated in a 1- year chronic disease management program focused on blood pressure reduction. The expectation was that blood pressure would return back to the baseline once the study was completed.

STUDY DESIGN

Prospective, single-arm observational study.

METHODS

Study participants were Status Indians living on-reserve with type 2 diabetes and persistent hypertension who had participated in the DREAM3 study. Blood pressure was measured with the BpTRU automated device every 6 months for 2 years. The primary endpoint was the change in systolic blood pressure over the follow-up period.

RESULTS

Sixty of the original 96 participants agreed to participate in the follow-up. Mean blood pressure at the beginning of the follow-up was 130/76 (SD 18/12) mmHg. Mean blood pressure at the end of the follow-up period was 132/76 (17/9 SD) mmHg. Target blood pressure (<130/80 mmHg) was present in 53%. The 99% confidence limit around change of blood pressure over the 24 months of follow-up was +/-4.7 mmHg.

CONCLUSIONS

Contrary to expectations, the participants maintained their blood pressure control and did not revert to baseline levels. Community awareness and engagement resulting from the chronic disease management program led to a sustainable improvement in the health parameters of the participants and the community that lasted beyond the duration of the 1-year DREAM3 project.

Disparities in management patterns and outcomes of patients with non-ST-elevation acute coronary syndrome with and without a history of cerebrovascular disease

Cerebrovascular (CVD) disease is commonly associated with coronary artery disease and adversely affects outcome. The goal of the present study was to examine the temporal management patterns and outcomes in relation to previous CVD in a contemporary "real-world" spectrum of patients with acute coronary syndrome (ACS). From 1999 to 2008, 14,070 patients with non-ST-segment elevation ACS were recruited into the Canadian Acute Coronary Syndrome I (ACS I), ACS II, Global Registry of Acute Coronary Events (GRACE/GRACE(2)), and Canadian Registry of Acute Coronary Events (CANRACE) prospective multicenter registries. We stratified the study patients according to a history of CVD and compared their treatment and outcomes. Patients with a history of CVD were older, more likely to have pre-existing coronary artery disease, elevated creatinine, higher Killip class, and ST-segment deviation on admission. Despite presenting with greater GRACE risk scores (137 vs 117, p <0.001), patients with previous CVD were less likely to receive evidence-based antiplatelet and antithrombin therapies during the initial 24 hours of hospital admission. They were also less likely to undergo in-hospital coronary angiography and revascularization. These disparities in medical and invasive management were preserved temporally across all 4 registries. Patients with concomitant CVD had worse in-hospital outcomes. Previous CVD remained an independent predictor of in-hospital mortality (adjusted odds ratio 1.43, 95% confidence interval 1.06 to 1.92, p = 0.019) after adjusting for other powerful prognosticators in the GRACE risk score. However, it was independently associated with a lower use of in-hospital coronary angiography (adjusted odds ratio 0.70, 95% confidence interval 0.60 to 0.83, p <0.001). Underestimation of patient risk was the most common reason for not pursuing an invasive strategy. Revascularization was independently associated with lower 1-year mortality (adjusted odds ratio 0.48, 95% confidence interval 0.33 to 0.71, p <0.001), irrespective of a history of CVD. In conclusion, for patients presenting with non-ST-segment elevation-ACS, a history of CVD was independently associated with worse outcomes, which might have been, in part, because of the underuse of evidence-based medical and invasive therapies.

Circulatory therapeutics: use of antihypertensive agents and their effects on the vasculature

This review addresses the use of the different antihypertensive agents currently available and some in development, and their effects on the vasculature. The different classes of agents used in the treatment of hypertension, and the results of recent large clinical trials, dosing protocols and adverse effects are first briefly summarized. The consequences on blood vessels of the use of antihypertensive drugs and the differential effects on the biology of large and small arteries resulting in modulation of vascular remodelling and dysfunction in hypertensive patients are then described. Large elastic conduit arteries exhibit outward hypertrophic remodelling and increased stiffness, which contributes to raise systolic blood pressure and afterload on the heart. Small resistance arteries undergo eutrophic or hypertrophic inward remodelling, and impair tissue perfusion. By these mechanisms both large and small arteries may contribute to trigger cardiovascular events. Some antihypertensive agents correct these changes, which could contribute to improved outcome. The mechanisms that at the level of the vascular wall lead to remodelling and can be beneficially affected by antihypertensive agents will also be addressed. These include vasoconstriction, growth and inflammation. The molecular pathways contributing to growth and inflammation will be summarily described. Further identification of these signalling pathways should allow identification of novel targets leading to development of new and improved medications for the treatment of hypertension and cardiovascular disease.

Antihypertensive efficacy of perindopril 5-10 mg/day in primary health care: an open-label, prospective, observational study

BACKGROUND AND OBJECTIVES

Optimal control of hypertension reduces the risk of long-term cardiovascular complications, and current guidelines recommend blood pressure (BP) targets of <140/90 mmHg for patients. Despite this, the BP of many patients with hypertension in primary health care remains poorly controlled. The ACE inhibitor perindopril has proven BP-lowering efficacy as well as protective effects against cardiovascular events among patients with additional cardiovascular risk factors. The PREFER study assessed the antihypertensive efficacy and safety of perindopril 5-10 mg/day among hypertensive patients who were unresponsive to treatment with other ACE-inhibitor-based regimens.

METHODS

The PREFER study was an open-label, prospective, observational study conducted in primary health-care centres throughout Romania. Patients selected for the study (n = 824; mean + or - SD age 60.3 + or - 9.8 years) had uncontrolled hypertension (i.e. seated BP > or =140/90 mmHg, or > or = 130/80 mmHg in patients with diabetes mellitus or at high cardiovascular risk) despite receiving ACE inhibitors either alone or in free combination with other antihypertensive classes. At study entry, current ACE inhibitor treatment was replaced by perindopril 5 mg/day. Patients were followed up monthly for 3 months and the dosage of perindopril could be increased to 10 mg/day in cases of failure to achieve BP control. No other change in antihypertensive therapy was permitted.

RESULTS

Replacing the previous ACE inhibitor with perindopril 5-10 mg/day resulted in decreases of 26.2 mmHg (from 162.6 + or - 15.6 to 136.4 + or - 14.6 mmHg [p < 0.001]) in systolic BP and of 12.6 mmHg (from 96.9 + or - 17.2 to 84.3 + or - 12.8 mmHg [p < 0.001]) in diastolic BP. Mean pulse pressure (PP) was reduced by 13.6 mmHg (from 65.7 to 52.1 mmHg) with greater decreases seen in patients aged >70 years or with isolated systolic hypertension. BP control was achieved in 48.1% of the previously uncontrolled population. Antihypertensive efficacy was observed across patient subgroups regardless of the severity of hypertension at baseline and number of cardiovascular risk factors. Patient compliance with treatment was high throughout the study.

CONCLUSIONS

Perindopril 5-10 mg/day lowers BP and PP and improves BP control among hypertensive patients who were previously unresponsive to other ACE inhibitor-based regimens.

A review of international pharmacoeconomic models assessing the use of aspirin in primary prevention

PURPOSE

The aim of this narrative review was to summarise the cost analyses and supporting trial data for aspirin prophylaxis in primary prevention.

METHODS

A PubMed search using the term 'aspirin and cost-effective and primary prevention' was performed. Professional meetings (2009) were also searched for any relevant abstracts contacting the terms 'aspirin' and 'cost effectiveness'. Where possible, outcomes were discussed in terms of cost implications (expressed as quality-adjusted life-year [QALY], disability-adjusted life-year or incremental cost-effectiveness ratio) in relation to the annual risk of cardiovascular disease. Aspirin was included in cost-effectiveness models that determined direct cost savings.

RESULTS

A total of 67 papers were identified using PubMed, and 17 cost-effectiveness studies, which assessed aspirin in primary prevention (largely based on the key primary prevention studies), and two abstracts were included in the review. These analyses showed that low-dose aspirin was cost effective in a variety of scenarios. In the UK, Germany, Spain, Italy and Japan, the mean 10-year direct cost saving (including follow-up costs and aspirin costs) per patient was €201, €281, €797, €427 and €889 with aspirin use in patients with an annual coronary heart disease risk of 1.5%. Cost-effectiveness analyses were affected by age, risk level for stroke and myocardial infarction (MI), risk of bleeds and adherence to aspirin. Underutilisation is a major limiting factor, as the appropriate use of aspirin in an eligible population (n=301,658) based on the NHANES database would prevent 1273 MIs, 2184 angina episodes and 565 ischaemic strokes in patients without previous events; this would result in a direct cost saving of $79.6 million (€54.7 million; 2010 values), which includes aspirin costs.

CONCLUSIONS

Most analyses in primary prevention have shown that low-dose aspirin is a cost-effective option, and is likely to meet the willingness of a healthcare system to pay for any additional QALY gained in the majority of healthcare systems.

Valsartan plus hydrochlorothiazide for first-line therapy in hypertension

Goal blood pressure levels are only being achieved in approximately a third of hypertensive patients, which suggests that there is a need for new and/or improved approaches to the treatment of hypertension. The majority of patients with hypertension require combination therapy to control their blood pressure. The use of a combination of drugs with complementary mechanisms of action may provide greater efficacy and tolerability compared with monotherapy, and may allow more rapid achievement of target blood pressure. Moreover, the use of single-pill combinations has the potential to increase adherence and persistence, and reduce costs. The single-pill combination of valsartan plus hydrochlorothiazide was recently approved by the US FDA for first-line use in hypertensive patients who are likely to need multiple drugs to achieve their blood pressure goals. The focus of this article is on those randomized, double-blind trials in which this combination was administered as first-line therapy in patients with essential hypertension.