44 results on '"Tobe, Sheldon"'
Search Results
2. Blood pressure in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.
- Author
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Cheung AK, Chang TI, Cushman WC, Furth SL, Ix JH, Pecoits-Filho R, Perkovic V, Sarnak MJ, Tobe SW, Tomson CRV, Cheung M, Wheeler DC, Winkelmayer WC, and Mann JFE
- Subjects
- Blood Pressure drug effects, Clinical Trials as Topic, Congresses as Topic, Humans, Renal Insufficiency, Chronic physiopathology, Treatment Outcome, Antihypertensive Agents therapeutic use, Blood Pressure physiology, Blood Pressure Determination standards, Practice Guidelines as Topic, Renal Insufficiency, Chronic therapy
- Abstract
In September 2017, KDIGO (Kidney Disease: Improving Global Outcomes) convened a Controversies Conference titled Blood Pressure in Chronic Kidney Disease (CKD). The purpose of the meeting was to consider which recommendations from the 2012 KDIGO Clinical Practice Guideline for the Management of Blood Pressure in CKD should be reevaluated based on new evidence from clinical trials. Participants included a multidisciplinary panel of clinical and scientific experts. Discussions focused on the optimal means for measuring blood pressure (BP) as well as managing BP in CKD patients. Consistent with the 2012 Guideline, the conference did not address BP management in patients on maintenance dialysis., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)
- Published
- 2019
- Full Text
- View/download PDF
3. Treatment of Hypertension.
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Tobe SW, Gilbert RE, Jones C, Leiter LA, Prebtani APH, and Woo V
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- Humans, Hypertension epidemiology, Prognosis, Antihypertensive Agents therapeutic use, Diabetes Mellitus physiopathology, Hypertension drug therapy, Practice Guidelines as Topic standards
- Published
- 2018
- Full Text
- View/download PDF
4. Thresholds and Targets for Hypertension Management in Adults With Type 2 Diabetes Should Remain at 130/80 mmHg: What's the Evidence?
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Shahi N and Tobe SW
- Subjects
- Adult, Canada epidemiology, Disease Management, Humans, Hypertension diagnosis, Hypertension epidemiology, Prevalence, Risk Factors, Antihypertensive Agents therapeutic use, Diabetes Mellitus, Type 2 physiopathology, Evidence-Based Medicine, Hypertension drug therapy
- Abstract
Hypertension and diabetes are common comorbidities and are both modifiable risk factors for cardiovascular disease and death. Lowering blood pressure reduces target organ damage and prevents cardiovascular disease outcomes. The harmonized Canadian clinical practice guidelines for managing hypertension in people with diabetes provides health-behaviour advice and medical therapy recommendations for a threshold blood pressure of 130/80 mmHg and above and to target blood pressure to below 130/80 mmHg. We have reviewed the studies supporting these recommendations and others, and they appear to be at odds with the guidelines, including those for elderly people and patients with pre-existing cardiovascular disease., (Copyright © 2017 Diabetes Canada. Published by Elsevier Inc. All rights reserved.)
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- 2018
- Full Text
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5. Hypertension Canada's 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults.
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Leung AA, Daskalopoulou SS, Dasgupta K, McBrien K, Butalia S, Zarnke KB, Nerenberg K, Harris KC, Nakhla M, Cloutier L, Gelfer M, Lamarre-Cliche M, Milot A, Bolli P, Tremblay G, McLean D, Tran KC, Tobe SW, Ruzicka M, Burns KD, Vallée M, Prasad GVR, Gryn SE, Feldman RD, Selby P, Pipe A, Schiffrin EL, McFarlane PA, Oh P, Hegele RA, Khara M, Wilson TW, Penner SB, Burgess E, Sivapalan P, Herman RJ, Bacon SL, Rabkin SW, Gilbert RE, Campbell TS, Grover S, Honos G, Lindsay P, Hill MD, Coutts SB, Gubitz G, Campbell NRC, Moe GW, Howlett JG, Boulanger JM, Prebtani A, Kline G, Leiter LA, Jones C, Côté AM, Woo V, Kaczorowski J, Trudeau L, Tsuyuki RT, Hiremath S, Drouin D, Lavoie KL, Hamet P, Grégoire JC, Lewanczuk R, Dresser GK, Sharma M, Reid D, Lear SA, Moullec G, Gupta M, Magee LA, Logan AG, Dionne J, Fournier A, Benoit G, Feber J, Poirier L, Padwal RS, and Rabi DM
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- Adult, Blood Pressure drug effects, Canada epidemiology, Comorbidity, Female, Humans, Male, Medication Therapy Management standards, Middle Aged, Risk Assessment methods, Antihypertensive Agents classification, Antihypertensive Agents therapeutic use, Blood Pressure Determination methods, Diuretics classification, Diuretics therapeutic use, Hypertension diagnosis, Hypertension drug therapy, Hypertension epidemiology, Hypertension prevention & control
- Abstract
Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension. This year, we introduce 10 new guidelines. Three previous guidelines have been revised and 5 have been removed. Previous age and frailty distinctions have been removed as considerations for when to initiate antihypertensive therapy. In the presence of macrovascular target organ damage, or in those with independent cardiovascular risk factors, antihypertensive therapy should be considered for all individuals with elevated average systolic nonautomated office blood pressure (non-AOBP) readings ≥ 140 mm Hg. For individuals with diastolic hypertension (with or without systolic hypertension), fixed-dose single-pill combinations are now recommended as an initial treatment option. Preference is given to pills containing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in combination with either a calcium channel blocker or diuretic. Whenever a diuretic is selected as monotherapy, longer-acting agents are preferred. In patients with established ischemic heart disease, caution should be exercised in lowering diastolic non-AOBP to ≤ 60 mm Hg, especially in the presence of left ventricular hypertrophy. After a hemorrhagic stroke, in the first 24 hours, systolic non-AOBP lowering to < 140 mm Hg is not recommended. Finally, guidance is now provided for screening, initial diagnosis, assessment, and treatment of renovascular hypertension arising from fibromuscular dysplasia. The specific evidence and rationale underlying each of these guidelines are discussed., (Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)
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- 2017
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6. Innovative Approaches to Hypertension Control in Low- and Middle-Income Countries.
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Vedanthan R, Bernabe-Ortiz A, Herasme OI, Joshi R, Lopez-Jaramillo P, Thrift AG, Webster J, Webster R, Yeates K, Gyamfi J, Ieremia M, Johnson C, Kamano JH, Lazo-Porras M, Limbani F, Liu P, McCready T, Miranda JJ, Mohan S, Ogedegbe O, Oldenburg B, Ovbiagele B, Owolabi M, Peiris D, Ponce-Lucero V, Praveen D, Pillay A, Schwalm JD, Tobe SW, Trieu K, Yusoff K, and Fuster V
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- Humans, Incidence, Risk Factors, Antihypertensive Agents therapeutic use, Blood Pressure, Developing Countries, Hypertension epidemiology, Hypertension physiopathology, Hypertension therapy, Telemedicine methods
- Abstract
Elevated blood pressure, a major risk factor for ischemic heart disease, heart failure, and stroke, is the leading global risk for mortality. Treatment and control rates are very low in low- and middle-income countries. There is an urgent need to address this problem. The Global Alliance for Chronic Diseases sponsored research projects focus on controlling hypertension, including community engagement, salt reduction, salt substitution, task redistribution, mHealth, and fixed-dose combination therapies. This paper reviews the rationale for each approach and summarizes the experience of some of the research teams. The studies demonstrate innovative and practical methods for improving hypertension control., (Copyright © 2016 Elsevier Inc. All rights reserved.)
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- 2017
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7. Hypertension in Russia: Changes Observed After 4 Years of a Comprehensive Health System Improvement Program in the Yaroslavl Region.
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Mozheyko M, Eregin S, Danilenko N, Vigdorchik A, Tobe SW, Campbell N, McLean D, Baskakova Z, Klimovskaia I, Ramanathan K, and Hughes D
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- Adult, Aged, Aged, 80 and over, Blood Pressure, Blood Pressure Determination, Cross-Sectional Studies, Disease Management, Early Diagnosis, Female, Humans, Hypertension complications, Hypertension drug therapy, Incidence, Male, Middle Aged, Russia epidemiology, Treatment Outcome, Antihypertensive Agents therapeutic use, Health Promotion organization & administration, Hypertension diagnosis, Stroke epidemiology
- Abstract
Rates of cardiovascular mortality and morbidity in Russia have been among the highest in Europe. A comprehensive health system improvement program targeting better diagnosis and control of hypertension was undertaken in the Yaroslavl Region of Russia. This initiative was a joint program between clinicians, the Department of Health and Pharmacy of the Yaroslavl Region, and Novartis Pharma LLC. From 2011 to 2014, the blood pressure control rate improved substantially (94% relative improvement), the percentage of patients with a systolic blood pressure ≥180 mm Hg decreased (from 10% to 5%), and there was a reduction in stroke incidence rate from 4.6 to 3.7 per 1000 population. During this same period, significant changes were made to the way hypertension was diagnosed and treated across all regional government polyclinics, and the use of antihypertensive therapies increased., (© 2016 The Authors. The Journal of Clinical Hypertension Published by Wiley Periodicals, Inc.)
- Published
- 2017
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8. Antihypertensive Treatment is associated with MRI-Derived Markers of Neurodegeneration and Impaired Cognition: A Propensity-Weighted Cohort Study.
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Edwards JD, Ramirez J, Callahan BL, Tobe SW, Oh P, Berezuk C, Lanctôt K, Swardfager W, Nestor S, Kiss A, Strother S, and Black SE
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- Aged, Aged, 80 and over, Angiotensin Receptor Antagonists therapeutic use, Angiotensin-Converting Enzyme Inhibitors therapeutic use, Cohort Studies, Female, Humans, Hypertension diagnostic imaging, Linear Models, Magnetic Resonance Imaging, Male, Neuropsychological Tests, Treatment Outcome, Alzheimer Disease diagnostic imaging, Alzheimer Disease prevention & control, Antihypertensive Agents therapeutic use, Brain diagnostic imaging, Brain drug effects, Brain pathology, Cognitive Dysfunction diagnostic imaging, Cognitive Dysfunction prevention & control, Hypertension drug therapy
- Abstract
Background: Hypertension is an important risk factor for Alzheimer's disease (AD) and cerebral small vessel disease. Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are common anti-hypertensive treatments, but have differential effects on cortical amyloid., Objective: The objective of this study was to evaluate associations between anti-hypertensive treatment, brain volume, and cognition, using a propensity-weighted analysis to account for confounding by indication., Methods: We identified a cohort of normal elderly adults and individuals with mild cognitive impairment (MCI) or AD (N = 886; mean age = 75.0) from the Alzheimer's Disease Neuroimaging Initiative. Primary outcomes were brain parenchymal fraction, total hippocampal volume, and white matter hyperintensity (WMH) volume. Secondary outcomes were standardized scores on neuropsychological tests. Propensity-weighted adjusted multivariate linear regression was used to estimate associations between anti-hypertensive treatment class and MRI volumes and cognition., Results: Individuals treated with ARBs showed larger hippocampal volumes (R2 = 0.83, p = 0.05) and brain parenchymal fraction (R2 = 0.83, p = 0.01) than those treated with ACEIs. When stratified by diagnosis, this effect remained only in normal elderly adults and MCI patients, and a significant association between ARBs and lower WMH volume (R2 = 0.83, p = 0.03) emerged for AD patients only. ARBs were also associated with significantly better performance on tests of episodic and verbal memory, language, and executive function (all p < 0.05)., Conclusions: Findings are consistent with evidence for a neuroprotective effect of treatment with ARBs for brain structure and cognition. This study has potential implications for the treatment of hypertension, particularly in elderly adults at risk of cognitive decline and AD.
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- 2017
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9. Hypertension Canada's 2016 Canadian Hypertension Education Program Guidelines for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension.
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Leung AA, Nerenberg K, Daskalopoulou SS, McBrien K, Zarnke KB, Dasgupta K, Cloutier L, Gelfer M, Lamarre-Cliche M, Milot A, Bolli P, Tremblay G, McLean D, Tobe SW, Ruzicka M, Burns KD, Vallée M, Prasad GV, Lebel M, Feldman RD, Selby P, Pipe A, Schiffrin EL, McFarlane PA, Oh P, Hegele RA, Khara M, Wilson TW, Penner SB, Burgess E, Herman RJ, Bacon SL, Rabkin SW, Gilbert RE, Campbell TS, Grover S, Honos G, Lindsay P, Hill MD, Coutts SB, Gubitz G, Campbell NR, Moe GW, Howlett JG, Boulanger JM, Prebtani A, Larochelle P, Leiter LA, Jones C, Ogilvie RI, Woo V, Kaczorowski J, Trudeau L, Petrella RJ, Hiremath S, Drouin D, Lavoie KL, Hamet P, Fodor G, Grégoire JC, Lewanczuk R, Dresser GK, Sharma M, Reid D, Lear SA, Moullec G, Gupta M, Magee LA, Logan AG, Harris KC, Dionne J, Fournier A, Benoit G, Feber J, Poirier L, Padwal RS, and Rabi DM
- Subjects
- Canada, Evidence-Based Medicine, Health Education, Humans, Hyperaldosteronism drug therapy, Risk Assessment, Risk Factors, Antihypertensive Agents therapeutic use, Blood Pressure Determination methods, Hypertension diagnosis, Hypertension drug therapy, Hypertension prevention & control
- Abstract
Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force provides annually updated, evidence-based recommendations to guide the diagnosis, assessment, prevention, and treatment of hypertension. This year, we present 4 new recommendations, as well as revisions to 2 previous recommendations. In the diagnosis and assessment of hypertension, automated office blood pressure, taken without patient-health provider interaction, is now recommended as the preferred method of measuring in-office blood pressure. Also, although a serum lipid panel remains part of the routine laboratory testing for patients with hypertension, fasting and nonfasting collections are now considered acceptable. For individuals with secondary hypertension arising from primary hyperaldosteronism, adrenal vein sampling is recommended for those who are candidates for potential adrenalectomy. With respect to the treatment of hypertension, a new recommendation that has been added is for increasing dietary potassium to reduce blood pressure in those who are not at high risk for hyperkalemia. Furthermore, in selected high-risk patients, intensive blood pressure reduction to a target systolic blood pressure ≤ 120 mm Hg should be considered to decrease the risk of cardiovascular events. Finally, in hypertensive individuals with uncomplicated, stable angina pectoris, either a β-blocker or calcium channel blocker may be considered for initial therapy. The specific evidence and rationale underlying each of these recommendations are discussed. Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force will continue to provide annual updates., (Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)
- Published
- 2016
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10. Is there a preferred diuretic class for patients with renal impairment and hypertension?
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Izzo JL Jr and Tobe SW
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- Drug Therapy, Combination, Humans, Hypertension complications, Practice Guidelines as Topic, Renal Insufficiency, Chronic complications, Sodium urine, Treatment Outcome, Antihypertensive Agents therapeutic use, Diuretics therapeutic use, Hypertension drug therapy, Renal Insufficiency, Chronic drug therapy, Sodium Potassium Chloride Symporter Inhibitors therapeutic use, Thiazides therapeutic use
- Abstract
It is widely believed that "high-ceiling" loop diuretics are required in patients with renal impairment and that "low-ceiling" thiazides are not sufficiently potent to cause meaningful natriuresis and diuresis. If this statement is true, at what level of renal function do thiazides lose their punch? Another related issue is the enlightened use of diuretic combinations. Use of diuretics in chronic kidney disease and hypertension has been addressed in the many guidelines, but further insight is provided in this installment of the "Controversies" series by two well-known authorities, William Elliott, M.D. Ph.D. and Rajiv Agarwal, M.D., (Copyright © 2016 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.)
- Published
- 2016
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11. Should age determine hypertension management? Recommendations from current guidelines.
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Izzo JL Jr and Tobe SW
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- Age Factors, Blood Pressure Determination methods, Canada, Europe, Evidence-Based Practice, Humans, Middle Aged, Practice Guidelines as Topic, United States, Antihypertensive Agents therapeutic use, Disease Management, Hypertension diagnosis, Hypertension therapy
- Abstract
Age is the most powerful of risk factors and is related continuously to systolic BP and cardiovascular disease risk. Yet current guidelines have dichotomized age groups around a cutoff value of 55-60 years and some guidelines now suggest that age should affect diagnostic thresholds and drug choices. These choices are not supported directly by scientific evidence but are based on expert opinion, the value of which is uncertain. This initial topic of the new Controversies in Hypertension series highlights important differences among current U.S., European, and Canadian practice guidelines, then moves on to editorial commentaries with different perspectives., (Copyright © 2016 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.)
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- 2016
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12. Regional and physician specialty-associated variations in the medical management of atherosclerotic renal-artery stenosis.
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Folt DA, Evans KL, Brahmandam S, He W, Brewster PS, Yu S, Murphy TP, Cutlip DE, Dworkin LD, Jamerson K, Henrich W, Kalra PA, Tobe S, Thomson K, Holden A, Rayner BL, Grinfeld L, Haller ST, and Cooper CJ
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- Aged, Antihypertensive Agents pharmacology, Atherosclerosis therapy, Canada, Disease Management, Europe, Female, Humans, Internationality, Linear Models, Male, Medicine, Middle Aged, Multivariate Analysis, New Zealand, Practice Patterns, Physicians', Prospective Studies, Renal Artery Obstruction pathology, Risk Assessment, Severity of Illness Index, South Africa, South America, United States, Antihypertensive Agents therapeutic use, Atherosclerosis pathology, Hypertension, Renal diagnosis, Hypertension, Renal drug therapy, Renal Artery Obstruction therapy
- Abstract
For people enrolled in Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL), we sought to examine whether variation exists in the baseline medical therapy of different geographic regions and if any variations in prescribing patterns were associated with physician specialty. Patients were grouped by location within the United States (US) and outside the US (OUS), which includes Canada, South America, Europe, South Africa, New Zealand, and Australia. When comparing US to OUS, participants in the US took fewer anti-hypertensive medications (1.9 ± 1.5 vs. 2.4 ± 1.4; P < .001) and were less likely to be treated with an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (46% vs. 62%; P < .001), calcium channel antagonist (37% vs. 58%; P < .001), and statin (64% vs. 75%; P < .05). In CORAL, the identification of variations in baseline medical therapy suggests that substantial opportunities exist to improve the medical management of patients with atherosclerotic renal-artery stenosis., (Copyright © 2015 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.)
- Published
- 2015
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13. A New Algorithm for the Diagnosis of Hypertension in Canada.
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Cloutier L, Daskalopoulou SS, Padwal RS, Lamarre-Cliche M, Bolli P, McLean D, Milot A, Tobe SW, Tremblay G, McKay DW, Townsend R, Campbell N, and Gelfer M
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- Blood Pressure Determination methods, Blood Pressure Monitoring, Ambulatory methods, Blood Pressure Monitoring, Ambulatory standards, Canada, Female, Health Education standards, Humans, Hypertension drug therapy, Hypertension epidemiology, Male, Risk Assessment, Self Care methods, Self Care standards, Algorithms, Antihypertensive Agents therapeutic use, Blood Pressure Determination standards, Guidelines as Topic, Hypertension diagnosis
- Abstract
Accurate blood pressure measurement is critical to properly identify and treat individuals with hypertension. In 2005, the Canadian Hypertension Education Program produced a revised algorithm to be used for the diagnosis of hypertension. Subsequent annual reviews of the literature have identified 2 major deficiencies in the current diagnostic process. First, auscultatory measurements performed in routine clinical settings have serious accuracy limitations that have not been overcome despite great efforts to educate health care professionals over several years. Thus, alternatives to auscultatory measurements should be used. Second, recent data indicate that patients with white coat hypertension must be identified earlier in the process and in a systematic manner rather than on an ad hoc or voluntary basis so they are not unnecessarily treated with antihypertensive medications. The economic and health consequences of white coat hypertension are reviewed. In this article evidence for a revised algorithm to diagnose hypertension is presented. Protocols for home blood pressure measurement and ambulatory blood pressure monitoring are reviewed. The role of automated office blood pressure measurement is updated. The revised algorithm strongly encourages the use of validated electronic digital oscillometric devices and recommends that out-of-office blood pressure measurements, ambulatory blood pressure monitoring (preferred), or home blood pressure measurement, should be performed to confirm the diagnosis of hypertension., (Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.)
- Published
- 2015
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14. Combining other antihypertensive drugs with β-blockers in hypertension: a focus on safety and tolerability.
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Richards TR and Tobe SW
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- Dose-Response Relationship, Drug, Drug Administration Schedule, Drug Therapy, Combination, Female, Humans, Hypertension diagnosis, Male, Prognosis, Severity of Illness Index, Treatment Outcome, Adrenergic beta-Antagonists administration & dosage, Antihypertensive Agents administration & dosage, Hypertension drug therapy, Maximum Tolerated Dose, Patient Safety
- Abstract
Combining multiple classes of antihypertensive drugs together is one of the most important factors for achieving blood pressure control in most hypertensive patients. The benefits of combination therapy in comparison with monotherapy include: a synergistic enhancement of each drug's hypertensive effects and a potential reduction of side effects if each drug is used at a lower dose. Although long-acting dihydropyridine calcium channel blockers and β-blockers are a good fit for combination therapy, because of the risk of atrioventricular block and bradycardia, the combination of verapamil and β-blockers is not advised. In addition, the combination of higher-dose diltiazem and β-blockers is also not advised. β-blockers and diuretic agents as initial lone combination therapy are not the preferred combination to be used in uncomplicated hypertension. Using an angiotensin-converting enzyme inhibitor as initial combination therapy with most β-blockers is not recommended because of a lack of antihypertensive efficacy. Nebivolol, however, appears different in this regard and might provide an opportunity for combining these 2 classes of agents with proven cardiovascular benefits for better blood pressure control. Adding an α-blocker to a β-blocker is an effective combination., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)
- Published
- 2014
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15. Contemporary use of β-blockers: clinical relevance of subclassification.
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Poirier L and Tobe SW
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- Adrenergic beta-Antagonists pharmacology, Age Factors, Angina Pectoris diagnosis, Angina Pectoris drug therapy, Canada, Cardiovascular Diseases diagnosis, Drug Utilization statistics & numerical data, Essential Hypertension, Female, Heart Failure diagnosis, Heart Failure drug therapy, Hemodynamics drug effects, Humans, Hypertension diagnosis, Male, Middle Aged, Myocardial Infarction diagnosis, Myocardial Infarction drug therapy, Reproducibility of Results, Risk Assessment, Treatment Outcome, Adrenergic beta-Antagonists administration & dosage, Antihypertensive Agents administration & dosage, Cardiovascular Diseases drug therapy, Hypertension drug therapy
- Abstract
β-Adrenergic receptor blockers or β-blockers represent one of the oldest classes of cardiovascular agents and have been considered a cornerstone therapy for hypertension and heart disease for the past 5 decades. They are advocated as a first-line treatment for uncomplicated essential hypertension in patients younger than 60 years of age as recommended by the Canadian Hypertension Education Program. However, despite the well-established antihypertensive and cardiovascular benefits of β-blockers, a number of studies argue that they might not have the same clinical advantages of other classes of agents in terms of morbidity/mortality outcomes. This review will focus on the heterogeneity of the pharmacologic characteristics of β-blockers, and we will discuss the metabolic and hemodynamic differences within the β-blocker class and try to assess the potential implications of these differences for optimal selection in hypertension., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)
- Published
- 2014
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16. The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.
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Dasgupta K, Quinn RR, Zarnke KB, Rabi DM, Ravani P, Daskalopoulou SS, Rabkin SW, Trudeau L, Feldman RD, Cloutier L, Prebtani A, Herman RJ, Bacon SL, Gilbert RE, Ruzicka M, McKay DW, Campbell TS, Grover S, Honos G, Schiffrin EL, Bolli P, Wilson TW, Lindsay P, Hill MD, Coutts SB, Gubitz G, Gelfer M, Vallée M, Prasad GV, Lebel M, McLean D, Arnold JM, Moe GW, Howlett JG, Boulanger JM, Larochelle P, Leiter LA, Jones C, Ogilvie RI, Woo V, Kaczorowski J, Burns KD, Petrella RJ, Hiremath S, Milot A, Stone JA, Drouin D, Lavoie KL, Lamarre-Cliche M, Tremblay G, Hamet P, Fodor G, Carruthers SG, Pylypchuk GB, Burgess E, Lewanczuk R, Dresser GK, Penner SB, Hegele RA, McFarlane PA, Khara M, Pipe A, Oh P, Selby P, Sharma M, Reid DJ, Tobe SW, Padwal RS, and Poirier L
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- Blood Pressure, Canada, Humans, Life Style, Prognosis, Antihypertensive Agents therapeutic use, Blood Pressure Determination standards, Health Promotion organization & administration, Hypertension diagnosis, Hypertension drug therapy, Hypertension prevention & control, Patient Education as Topic, Practice Guidelines as Topic, Program Evaluation
- Abstract
Herein, updated evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in Canadian adults are detailed. For 2014, 3 existing recommendations were modified and 2 new recommendations were added. The following recommendations were modified: (1) the recommended sodium intake threshold was changed from ≤ 1500 mg (3.75 g of salt) to approximately 2000 mg (5 g of salt) per day; (2) a pharmacotherapy treatment initiation systolic blood pressure threshold of ≥ 160 mm Hg was added in very elderly (age ≥ 80 years) patients who do not have diabetes or target organ damage (systolic blood pressure target in this population remains at < 150 mm Hg); and (3) the target population recommended to receive low-dose acetylsalicylic acid therapy for primary prevention was narrowed from all patients with controlled hypertension to only those ≥ 50 years of age. The 2 new recommendations are: (1) advice to be cautious when lowering systolic blood pressure to target levels in patients with established coronary artery disease if diastolic blood pressure is ≤ 60 mm Hg because of concerns that myocardial ischemia might be exacerbated; and (2) the addition of glycated hemoglobin (A1c) in the diagnostic work-up of patients with newly diagnosed hypertension. The rationale for these recommendation changes is discussed. In addition, emerging data on blood pressure targets in stroke patients are discussed; these data did not lead to recommendation changes at this time. The Canadian Hypertension Education Program recommendations will continue to be updated annually., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)
- Published
- 2014
- Full Text
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17. A Canadian perspective on the Eighth Joint National Committee (JNC 8) hypertension guidelines.
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Myers MG and Tobe SW
- Subjects
- Blood Pressure physiology, Blood Pressure Determination methods, Canada, Humans, Hypertension diagnosis, Hypertension physiopathology, Internationality, Societies, Medical, Antihypertensive Agents therapeutic use, Hypertension drug therapy, Practice Guidelines as Topic standards
- Published
- 2014
- Full Text
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18. Changes in hypertension treatment in the yaroslavl region of Russia: improvements observed between 2 cross-sectional surveys.
- Author
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Mozheyko M, Eregin S, Vigdorchik A, Tobe S, Campbell N, Riahi F, and Hughes D
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- Aged, Cross-Sectional Studies, Female, Humans, Male, Middle Aged, Outpatients, Prospective Studies, Quality Improvement, Russia, Treatment Outcome, Antihypertensive Agents therapeutic use, Blood Pressure drug effects, Hypertension drug therapy
- Abstract
This prospective before-and-after survey of hypertensive patients visiting government-run outpatient health facilities in the Yaroslavl Region of Russia assessed blood pressure (BP)-related endpoints following initiation of a comprehensive health system improvement program for hypertension. Two cross-sectional surveys, one at baseline and the other approximately 1 year after program initiation, evaluated the primary measure of BP control rate. Secondary measures included mean BP levels and distribution, cardiovascular risk factors, and associated conditions, heart rate levels, and antihypertensive therapy. From the 2011 survey (n=1794) to the 2012 survey (n=2992), BP control rate (<140/90 mm Hg) significantly increased from 16.8% to 23.0%, reflecting a 37% relative improvement (P<.0001). Mean BP level was significantly reduced from 151/90 mm Hg to 147/88 mm Hg (P<.0001). Severe uncontrolled hypertension (systolic BP ≥180 mm Hg) was reduced from 9.7% to 6.4% (P<.0001). Implementing a guidelines-based treatment protocol with medical and patient education programs resulted in physician behavior change and improved patient BP control., (© 2013 The Authors. The Journal of Clinical Hypertension published by Wiley Periodicals, Inc on behalf of the American Society of Hypertension, Inc.)
- Published
- 2013
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19. Risks and benefits of intensive blood pressure lowering in patients with type 2 diabetes.
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Rabi DM, Padwal R, Tobe SW, Gilbert RE, Leiter LA, Quinn RR, and Khan N
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- Aged, Comorbidity, Diabetes Mellitus, Type 2 diagnosis, Diabetes Mellitus, Type 2 drug therapy, Dose-Response Relationship, Drug, Drug Administration Schedule, Evidence-Based Medicine, Female, Humans, Hypertension diagnosis, Male, Middle Aged, Prognosis, Risk Assessment, Treatment Outcome, Antihypertensive Agents administration & dosage, Diabetes Mellitus, Type 2 epidemiology, Hypertension drug therapy, Hypertension epidemiology
- Published
- 2013
- Full Text
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20. Challenges and scientific considerations in hypertension management reflected in the 2012 recommendations of the Canadian Hypertension Education Program.
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Tobe SW, Poirier L, Tremblay G, Lindsay P, Reid D, Campbell NR, Khan N, Quinn RR, and Rabi D
- Subjects
- Canada epidemiology, Humans, Life Style ethnology, Practice Guidelines as Topic, Prevalence, Randomized Controlled Trials as Topic, Risk Reduction Behavior, Antihypertensive Agents therapeutic use, Blood Pressure Monitoring, Ambulatory methods, Disease Management, Health Education methods, Health Education organization & administration, Health Promotion methods, Health Promotion statistics & numerical data, Hypertension diagnosis, Hypertension epidemiology, Hypertension etiology, Hypertension therapy
- Abstract
This article provides the scientific rationale and background information for the Canadian Hypertension Education Program's 2012 recommendations for the management of hypertension. It also summarizes the key new recommendations and the theme for 2012, which is the prevention of hypertension. The full recommendations are available at www.hypertension.ca.
- Published
- 2012
21. The 2012 Canadian hypertension education program recommendations for the management of hypertension: blood pressure measurement, diagnosis, assessment of risk, and therapy.
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Daskalopoulou SS, Khan NA, Quinn RR, Ruzicka M, McKay DW, Hackam DG, Rabkin SW, Rabi DM, Gilbert RE, Padwal RS, Dawes M, Touyz RM, Campbell TS, Cloutier L, Grover S, Honos G, Herman RJ, Schiffrin EL, Bolli P, Wilson T, Feldman RD, Lindsay MP, Hemmelgarn BR, Hill MD, Gelfer M, Burns KD, Vallée M, Prasad GV, Lebel M, McLean D, Arnold JM, Moe GW, Howlett JG, Boulanger JM, Larochelle P, Leiter LA, Jones C, Ogilvie RI, Woo V, Kaczorowski J, Trudeau L, Bacon SL, Petrella RJ, Milot A, Stone JA, Drouin D, Lamarre-Cliché M, Godwin M, Tremblay G, Hamet P, Fodor G, Carruthers SG, Pylypchuk G, Burgess E, Lewanczuk R, Dresser GK, Penner B, Hegele RA, McFarlane PA, Sharma M, Campbell NR, Reid D, Poirier L, and Tobe SW
- Subjects
- Adult, Aged, Blood Pressure Determination methods, Canada, Cardiovascular Diseases etiology, Education, Medical, Continuing standards, Evidence-Based Medicine standards, Female, Health Education standards, Humans, Hypertension complications, Male, Middle Aged, Monitoring, Physiologic methods, Prognosis, Risk Assessment, Treatment Outcome, Antihypertensive Agents therapeutic use, Cardiovascular Diseases prevention & control, Hypertension diagnosis, Hypertension therapy, Practice Guidelines as Topic standards
- Abstract
We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2012. The new recommendations are: (1) use of home blood pressure monitoring to confirm a diagnosis of white coat syndrome; (2) mineralocorticoid receptor antagonists may be used in selected patients with hypertension and systolic heart failure; (3) a history of atrial fibrillation in patients with hypertension should not be a factor in deciding to prescribe an angiotensin-receptor blocker for the treatment of hypertension; and (4) the blood pressure target for patients with nondiabetic chronic kidney disease has now been changed to < 140/90 mm Hg from < 130/80 mm Hg. We also reviewed the recent evidence on blood pressure targets for patients with hypertension and diabetes and continue to recommend a blood pressure target of less than 130/80 mm Hg., (Copyright © 2012 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)
- Published
- 2012
- Full Text
- View/download PDF
22. Canadian Hypertension Education Program: the science supporting New 2011 CHEP recommendations with an emphasis on health advocacy and knowledge translation.
- Author
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Campbell NR, Poirier L, Tremblay G, Lindsay P, Reid D, and Tobe SW
- Subjects
- Canada, Comorbidity, Health Education, Humans, Patient Advocacy, Antihypertensive Agents therapeutic use, Hypertension drug therapy
- Abstract
This is a summary of the theme, key new recommendations, and supporting science of the 2011 Canadian Hypertension Education Program (CHEP). In 2011, the ACCORD trial challenged current blood pressure treatment targets for people with diabetes. After consideration of multiple factors relating to the ACCORD trial design and its reporting, the current treatment target of <130/80 mm Hg was not changed. A meta-analysis implicated angiotensin receptor blockers in causing cancer; however, weaknesses in the meta-analysis and ongoing close scrutiny of the issue by the U.S. Food and Drug Administration precluded any changes in current CHEP recommendations. New expert opinion-based recommendations were added to assist the management of hypertension in the setting of acute stroke. To promote healthier blood pressure in Canadians, CHEP emphasizes the need for all Canadians-in particular, health care professionals and their organizations-to more actively work with different levels of government to implement healthy public policies. These should build community capacity to promote healthy behaviours with the goal of the prevention of hypertension and its consequences. To aid a substantive knowledge translation gap, health care professionals and people with hypertension can now receive regular CHEP updates by signing up at the Web sites htnupdate.ca and www.myBPsite.ca., (Copyright © 2011 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)
- Published
- 2011
- Full Text
- View/download PDF
23. Management of hypertension: Regional variations in a greatly improved landscape.
- Author
-
Tobe SW
- Subjects
- Canada epidemiology, Diagnosis, Differential, Humans, Hypertension diagnosis, Hypertension drug therapy, Prevalence, Treatment Outcome, Antihypertensive Agents therapeutic use, Delivery of Health Care statistics & numerical data, Hypertension epidemiology, Practice Patterns, Physicians'
- Published
- 2010
- Full Text
- View/download PDF
24. 2010 Canadian Hypertension Education Program (CHEP) recommendations: the scientific summary - an update of the 2010 theme and the science behind new CHEP recommendations.
- Author
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Campbell NR, Kaczorowski J, Lewanczuk RZ, Feldman R, Poirier L, Kwong MM, Lebel M, McAlister FA, and Tobe SW
- Subjects
- Canada, Diet, Sodium-Restricted, Female, Humans, Hypertension therapy, Life Style, Male, Randomized Controlled Trials as Topic, Risk Reduction Behavior, Antihypertensive Agents administration & dosage, Health Promotion, Hypertension prevention & control, Patient Education as Topic, Practice Guidelines as Topic
- Abstract
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.
- Published
- 2010
- Full Text
- View/download PDF
25. The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 - therapy.
- Author
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Hackam DG, Khan NA, Hemmelgarn BR, Rabkin SW, Touyz RM, Campbell NR, Padwal R, Campbell TS, Lindsay MP, Hill MD, Quinn RR, Mahon JL, Herman RJ, Schiffrin EL, Ruzicka M, Larochelle P, Feldman RD, Lebel M, Poirier L, Arnold JM, Moe GW, Howlett JG, Trudeau L, Bacon SL, Petrella RJ, Milot A, Stone JA, Drouin D, Boulanger JM, Sharma M, Hamet P, Fodor G, Dresser GK, Carruthers SG, Pylypchuk G, Burgess ED, Burns KD, Vallée M, Prasad GV, Gilbert RE, Leiter LA, Jones C, Ogilvie RI, Woo V, McFarlane PA, Hegele RA, and Tobe SW
- Subjects
- Adult, Canada, Combined Modality Therapy, Diet, Sodium-Restricted, Evidence-Based Medicine, Female, Humans, Hypertension diagnosis, Hypertension prevention & control, Male, Middle Aged, Patient Education as Topic, Primary Prevention standards, Prognosis, Risk Assessment, Antihypertensive Agents therapeutic use, Cardiovascular Diseases prevention & control, Hypertension therapy, Life Style, Practice Guidelines as Topic
- Abstract
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.
- Published
- 2010
- Full Text
- View/download PDF
26. Blood pressure 2 years after a chronic disease management intervention study.
- Author
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Tobe S, Vincent L, Wentworth J, Hildebrandt D, Kiss A, Perkins N, Hartman S, Ironstand L, Hoppe J, Hunter K, and Pylypchuk G
- Subjects
- Canada, Chronic Disease, Diabetes Mellitus, Type 2 complications, Diabetes Mellitus, Type 2 ethnology, Female, Humans, Hypertension complications, Hypertension drug therapy, Hypertension physiopathology, Male, Middle Aged, Randomized Controlled Trials as Topic, Antihypertensive Agents therapeutic use, Blood Pressure, Hypertension ethnology, Indians, North American
- Abstract
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.
- Published
- 2010
- Full Text
- View/download PDF
27. Outcomes of antiproteinuric RAAS blockade: high-dose compared with dual therapy.
- Author
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Tobe SW and Dai MO
- Subjects
- Angiotensin II Type 1 Receptor Blockers therapeutic use, Angiotensin-Converting Enzyme Inhibitors therapeutic use, Antihypertensive Agents administration & dosage, Humans, Kidney drug effects, Kidney Diseases prevention & control, Risk Factors, Antihypertensive Agents therapeutic use, Drug Therapy, Combination, Hypertension drug therapy, Proteinuria prevention & control, Renin-Angiotensin System drug effects, Treatment Outcome
- Abstract
Proteinuria is both a marker and a mediator of progressive renal damage; higher levels are associated with greater cardiovascular and renal risk. At normal and low levels of proteinuria (in the microalbuminuria range), the rate of hard renal events (dialysis and doubling of creatinine) is much lower than the mortality rate. At higher levels of proteinuria, the renal event rate surpasses the mortality rate. In the overt nephropathy range (proteinuria > 0.5 g/L), patients who achieve lower proteinuria with therapy have improved hard renal outcomes, but this result has not been demonstrated in the micro-albuminuria range. For patients with more severe overt nephropathy, there is a basic rationale for additional blockade of the renin-angiotensin-aldosterone system (RAAS). Dual blockade of this system and supramaximal dosing with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) have been demonstrated to reduce proteinuria in these patients more than therapy using the maximum recommended doses of these agents. However, evidence that dual blockade provides additional benefits for hard renal and cardiovascular outcomes is lacking, and only one study shows a benefit for supramaximal dosing. Both treatment strategies increase the risk for complications such as hyperkalemia. Therapy for patients with nephropathy should include treatment with the maximum recommended doses of an ACE inhibitor or ARB in addition to lowering blood pressure to target. For patients with overt nephropathy, more research is required on the role of dual therapy or supramaximal dosing to reduce hard renal and cardiovascular outcomes. Practitioners using either of these strategies to manage proteinuria should monitor their patients carefully.
- Published
- 2009
- Full Text
- View/download PDF
28. The 2009 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 1--blood pressure measurement, diagnosis and assessment of risk.
- Author
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Padwal RS, Hemmelgarn BR, Khan NA, Grover S, McKay DW, Wilson T, Penner B, Burgess E, McAlister FA, Bolli P, Hill MD, Mahon J, Myers MG, Abbott C, Schiffrin EL, Honos G, Mann K, Tremblay G, Milot A, Cloutier L, Chockalingam A, Rabkin SW, Dawes M, Touyz RM, Bell C, Burns KD, Ruzicka M, Campbell NR, Vallée M, Prasad R, Lebel M, and Tobe SW
- Subjects
- Adult, Aged, Canada, Clinical Competence, Combined Modality Therapy, Education, Medical, Continuing standards, Female, Guideline Adherence, Humans, Life Style, Male, Middle Aged, Prognosis, Randomized Controlled Trials as Topic, Risk Management, Treatment Outcome, Antihypertensive Agents therapeutic use, Blood Pressure Determination standards, Health Promotion organization & administration, Hypertension diagnosis, Hypertension therapy
- Abstract
Objective: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension., Options and Outcomes: The diagnosis of hypertension is dependent on appropriate blood pressure measurement, the timely assessment of serially elevated readings, the degree of blood pressure elevation, the method of measurement (office, ambulatory, home) and associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk and determine the urgency, intensity and type of treatment required., Evidence: MEDLINE searches were conducted from November 2007 to October 2008 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. Key messages include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of global risk assessment and the need for ongoing monitoring of hypertensive patients to identify incident type 2 diabetes., 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 were required to be supported by at least 70% of task force members. These guidelines will continue to be updated annually.
- Published
- 2009
- Full Text
- View/download PDF
29. 2009 Canadian Hypertension Education Program recommendations: the scientific summary--an annual update.
- Author
-
Campbell NR, Khan NA, Hill MD, Tremblay G, Lebel M, Kaczorowski J, McAlister FA, Lewanczuk RZ, and Tobe S
- Subjects
- Attitude to Health, Blood Pressure Determination, Canada, Combined Modality Therapy, Diet, Sodium-Restricted, Female, Health Knowledge, Attitudes, Practice, Health Promotion organization & administration, Humans, Hypertension diagnosis, Male, Program Evaluation, Randomized Controlled Trials as Topic, Severity of Illness Index, Antihypertensive Agents therapeutic use, Hypertension therapy, Life Style, Patient Education as Topic
- Abstract
The present report highlights the key messages of the 2009 Canadian Hypertension Education Program (CHEP) recommendations for the management of hypertension and the supporting clinical evidence. In 2009, the CHEP emphasizes the need to improve the control of hypertension in people with diabetes. Intensive reduction in blood pressure (to less than 130/80 mmHg) in people with diabetes leads to significant reductions in mortality rates, disability rates and overall health care system costs, and may lead to improved quality of life. The CHEP recommendations continue to emphasize the important role of patient self-efficacy by promoting lifestyle changes to prevent and control hypertension, and encouraging home measurement of blood pressure. Unfortunately, most Canadians make only minor changes in lifestyle after a diagnosis of hypertension. Routine blood pressure measurement at all appropriate visits, and screening for and management of all cardiovascular risks are key to blood pressure management. Many young hypertensive Canadians with multiple cardiovascular risks are not treated with antihypertensive drugs. This is despite the evidence that individuals with multiple cardiovascular risks and hypertension should be strongly considered for antihypertensive drug therapy regardless of age. In 2009, the CHEP specifically recommends not to combine an angiotensin-converting enzyme inhibitor with an angiotensin receptor blocker in people with uncomplicated hypertension, diabetes (without micro- or macroalbuminuria), chronic kidney disease (without nephropathy [micro- or overt proteinuria]) or ischemic heart disease (without heart failure).
- Published
- 2009
- Full Text
- View/download PDF
30. Resistant hypertension.
- Author
-
Tobe SW and Lewanczuk R
- Subjects
- Adult, Aged, Blood Pressure Determination methods, Dose-Response Relationship, Drug, Drug Administration Schedule, Drug Therapy, Combination, Female, Follow-Up Studies, Humans, Hypertension diagnosis, Male, Middle Aged, Monitoring, Physiologic methods, Patient Compliance, Risk Assessment, Severity of Illness Index, Treatment Outcome, Antihypertensive Agents therapeutic use, Diuretics therapeutic use, Drug Resistance, Hypertension drug therapy
- Abstract
Resistant hypertension is most often due to insufficient medical therapy. With a patient history, physical examination and focused laboratory tests, sufficient information can be gathered to lead to further directed medical therapy, which most often includes a diuretic as part of the drug regimen. Patients may require four or more classes of antihypertensives, some at high doses to achieve control. The clinician must be prepared to use sufficient medications at sufficient doses to achieve blood pressure targets. Referral to a hypertension specialist is appropriate if blood pressure remains uncontrolled despite therapy with three antihypertensive medications.
- Published
- 2009
- Full Text
- View/download PDF
31. Hypertension in diabetes: a call to action.
- Author
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Campbell NR, Leiter LA, Larochelle P, Tobe S, Chockalingam A, Ward R, Morris D, and Tsuyuki R
- Subjects
- Aged, Blood Pressure Determination standards, Canada, Cardiovascular Diseases prevention & control, Combined Modality Therapy, Comorbidity, Diabetes Mellitus, Type 2 diagnosis, Diabetes Mellitus, Type 2 drug therapy, Female, Follow-Up Studies, Humans, Hypertension diagnosis, Male, Middle Aged, Risk Assessment, Severity of Illness Index, Treatment Outcome, Antihypertensive Agents therapeutic use, Diabetes Mellitus, Type 2 epidemiology, Hypertension epidemiology, Hypertension therapy, Life Style
- Abstract
The Canadian Hypertension Education Program, Blood Pressure Canada, Canadian Hypertension Society, Heart and Stroke Foundation of Canada, Canadian Diabetes Association, College of Family Physicians of Canada, Canadian Pharmacists Association and the Canadian Council of Cardiovascular Nurses call on Canadian health care professionals to redouble efforts to help patients achieve treatment targets (blood pressure less than 130 mmHg systolic and less than 80 mmHg diastolic) in people with diabetes. Treatment of high blood pressure in people with diabetes results in large reductions in death and disability within a short period of time and needs to be a therapeutic priority. Achieving blood pressure targets requires sustained lifestyle modification, and three or more drugs including a diuretic are often required. Antihypertensive treatment in people with diabetes is one of the few medical treatments estimated to reduce overall health costs. The cost of treatment is less than the cost of complications prevented. Blood pressure needs to be assessed at all visits and home blood pressure assessment is encouraged. Management strategies need to include assessment and management of cardiovascular risks including smoking, unhealthy eating, physical inactivity, abdominal obesity, dyslipidemia as well as dysglycemia. The risks and benefits of acetylsalicylic acid in primary prevention of cardiovascular disease are uncertain in people with hypertension and diabetes. Intensive individualized lifestyle modification is recommended to prevent and treat hypertension, dyslipidemia, dysglycemia and other vascular risks in people with diabetes.
- Published
- 2009
- Full Text
- View/download PDF
32. The 2009 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 2--therapy.
- Author
-
Khan NA, Hemmelgarn B, Herman RJ, Bell CM, Mahon JL, Leiter LA, Rabkin SW, Hill MD, Padwal R, Touyz RM, Larochelle P, Feldman RD, Schiffrin EL, Campbell NR, Moe G, Prasad R, Arnold MO, Campbell TS, Milot A, Stone JA, Jones C, Ogilvie RI, Hamet P, Fodor G, Carruthers G, Burns KD, Ruzicka M, DeChamplain J, Pylypchuk G, Petrella R, Boulanger JM, Trudeau L, Hegele RA, Woo V, McFarlane P, Vallée M, Howlett J, Bacon SL, Lindsay P, Gilbert RE, Lewanczuk RZ, and Tobe S
- Subjects
- Adult, Aged, Blood Pressure Determination standards, Canada, Case Management standards, Combined Modality Therapy, Diet, Sodium-Restricted, Female, Health Promotion organization & administration, Humans, Hypertension diagnosis, Male, Middle Aged, Prognosis, Program Evaluation, Randomized Controlled Trials as Topic, Treatment Outcome, Antihypertensive Agents therapeutic use, Hypertension therapy, Life Style, Patient Education as Topic
- Abstract
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.
- Published
- 2009
- Full Text
- View/download PDF
33. Hypertension in dialysis and kidney transplant patients.
- Author
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Prasad GV, Ruzicka M, Burns KD, Tobe SW, and Lebel M
- Subjects
- Adult, Aged, Blood Pressure Determination methods, Canada, Combined Modality Therapy, Diet, Sodium-Restricted, Female, Graft Rejection, Graft Survival, Humans, Hypertension diagnosis, Hypertension epidemiology, Hypertension etiology, Incidence, Kidney Failure, Chronic diagnosis, Kidney Failure, Chronic mortality, Kidney Transplantation methods, Life Style, Male, Middle Aged, Prognosis, Renal Dialysis methods, Risk Assessment, Severity of Illness Index, Survival Analysis, Treatment Outcome, Antihypertensive Agents administration & dosage, Hypertension therapy, Kidney Failure, Chronic therapy, Kidney Transplantation adverse effects, Renal Dialysis adverse effects
- Abstract
For the first time, the Canadian Hypertension Education Program has studied the evidence supporting blood pressure control in people requiring renal replacement therapy for end-stage kidney disease, including those on dialysis and with renal transplants. According to the Canadian Organ Replacement Registry's 2008 annual report, there were an estimated 33,832 people with end-stage renal disease in Canada at the end of 2006, an increase of 69.7% since 1997. Of these, 20,465 were on dialysis and 13,367 were living with a functioning kidney transplant. Thus, it is becoming more likely that primary care practitioners will be helping to care for these complex patients. With the lack of large controlled clinical trials, the consensus recommendation based on interpretation of the existing literature is that blood pressure should be lowered to below 140/90 mmHg in hypertensive patients on renal replacement therapy and to below 130/80 mmHg for renal transplant patients with diabetes or chronic kidney disease.
- Published
- 2009
- Full Text
- View/download PDF
34. Supramaximal dose of candesartan in proteinuric renal disease.
- Author
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Burgess E, Muirhead N, Rene de Cotret P, Chiu A, Pichette V, and Tobe S
- Subjects
- Adult, Aged, Biphenyl Compounds, Blood Pressure drug effects, Blood Pressure physiology, Dose-Response Relationship, Drug, Female, Humans, Hypertension complications, Hypertension drug therapy, Hypertension etiology, Kidney Diseases drug therapy, Kidney Diseases etiology, Kidney Diseases urine, Kidney Function Tests, Kidney Glomerulus physiopathology, Male, Middle Aged, Proteinuria prevention & control, Pulse, Antihypertensive Agents therapeutic use, Benzimidazoles therapeutic use, Diabetic Nephropathies drug therapy, Kidney Diseases prevention & control, Proteinuria drug therapy, Tetrazoles therapeutic use
- Abstract
High levels of proteinuria predict renal deterioration, suggesting that interventions to reduce proteinuria may postpone the development of severe renal impairment. This multicenter Canadian trial evaluated whether supramaximal dosages of candesartan would reduce proteinuria to a greater extent than the maximum approved antihypertensive dosage. The authors randomly assigned 269 patients who had persistent proteinuria (> or =1 g/d) despite 7 wk of treatment with the highest approved dosage of candesartan (16 mg/d) to 16, 64, or 128 mg/d candesartan for 30 wk. The median serum creatinine level was 130.0 micromol/L (1.47 mg/dl), and the median urinary protein excretion was 2.66 g/d; most (53.9%) patients had diabetic nephropathy. The mean difference of the percentage change in proteinuria for patients receiving 128 mg/d candesartan compared with those receiving 16 mg/d candesartan was -33.05% (95% confidence interval -45.70 to -17.44; P < 0.0001). Reductions in BP were not different across the three treatment groups. Elevated serum potassium levels (K+ > 5.5 mEq/L) led to the early withdrawal of 11 patients, but there were no dosage-related increases in adverse events. In conclusion, proteinuria that persists despite treatment with the maximum recommended dosage of candesartan can be reduced by increasing the dosage of candesartan further, but serum potassium levels should be monitored during treatment.
- Published
- 2009
- Full Text
- View/download PDF
35. The 2008 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 - therapy.
- Author
-
Khan NA, Hemmelgarn B, Herman RJ, Rabkin SW, McAlister FA, Bell CM, Touyz RM, Padwal R, Leiter LA, Mahon JL, Hill MD, Larochelle P, Feldman RD, Schiffrin EL, Campbell NR, Arnold MO, Moe G, Campbell TS, Milot A, Stone JA, Jones C, Ogilvie RI, Hamet P, Fodor G, Carruthers G, Burns KD, Ruzicka M, dechamplain J, Pylypchuk G, Petrella R, Boulanger JM, Trudeau L, Hegele RA, Woo V, McFarlane P, Vallée M, Howlett J, Katzmarzyk P, Tobe S, and Lewanczuk RZ
- Subjects
- Canada, Humans, Treatment Outcome, Antihypertensive Agents therapeutic use, Education, Medical, Continuing standards, Hypertension drug therapy, Practice Guidelines as Topic, Program Evaluation trends
- Abstract
Objective: To update the evidence-based recommendations for the prevention and management of hypertension in adults., Options and Outcomes: For lifestyle and pharmacological interventions, evidence was preferentially reviewed from randomized controlled trials and systematic reviews of trials. 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 2006 to August 2007 to update the 2007 recommendations. To identify additional published studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by content and methodological experts using prespecified levels of evidence., Recommendations: For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium intake to less than 100 mmol/day (and 65 mmol/day 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 one 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. 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 nonblack patients), 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 for initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. 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 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 but 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.
- Published
- 2008
- Full Text
- View/download PDF
36. The 2008 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 1 - blood pressure measurement, diagnosis and assessment of risk.
- Author
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Padwal RS, Hemmelgarn BR, Khan NA, Grover S, McAlister FA, McKay DW, Wilson T, Penner B, Burgess E, Bolli P, Hill MD, Mahon J, Myers MG, Abbott C, Schiffrin EL, Honos G, Mann K, Tremblay G, Milot A, Cloutier L, Chockalingam A, Rabkin SW, Dawes MD, Touyz RM, Bell C, Burns KD, Ruzicka M, Campbell NR, Lebel M, and Tobe SW
- Subjects
- Canada, Clinical Competence, Diagnosis, Differential, Humans, Antihypertensive Agents therapeutic use, Blood Pressure physiology, Blood Pressure Determination standards, Education, Medical, Continuing standards, Hypertension diagnosis, Hypertension drug therapy, Hypertension physiopathology, Practice Guidelines as Topic, Program Evaluation trends, Risk Assessment methods
- Abstract
Objective: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension., Options and Outcomes: The diagnosis of hypertension is dependent on appropriate blood pressure measurement, the timely assessment of serially elevated readings, degree of blood pressure elevation, method of measurement (office, ambulatory, home) and associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk and determine the urgency, intensity and type of treatment required., Evidence: MEDLINE searches were conducted from November 2006 to October 2007 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. Key messages in 2008 include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of global risk assessment and the need for ongoing monitoring of hypertensive patients to identify incident type 2 diabetes., 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 received at least 70% consensus. These guidelines will continue to be updated annually.
- Published
- 2008
- Full Text
- View/download PDF
37. IMPPACT: Investigation of Medical Professionals and Patients Achieving Control Together.
- Author
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Tobe SW, Hunter K, Geerts R, Raymond N, and Pylypchuk G
- Subjects
- Aged, Blood Pressure drug effects, Canada, Effect Modifier, Epidemiologic, Female, Humans, Male, Middle Aged, Office Visits, Self Care, Treatment Outcome, Antihypertensive Agents administration & dosage, Blood Pressure Monitoring, Ambulatory, Diltiazem administration & dosage, Hypertension diagnosis, Hypertension drug therapy
- Abstract
Objective: To determine whether home blood pressure monitoring (HBPM) led to physician-initiated medication titration and improved achievement of target BP levels compared with standard, office-based management., Methods: Physicians were randomly assigned to a treatment group or a control group. Patients in the control group were monitored by their physician and were drug-adjusted according to the usual approach. In the treatment group, patients were given home BP monitors (UA-767P [A&D Medical/Lifesource, USA]), and drug dosing was adjusted according to HBPM readings and protocol. Long-acting diltiazem (240 mg/day) was added at baseline, which was adjusted as necessary (other medications were added if more than 360 mg/day of diltiazem was required). A final BP measurement was taken in the office after six weeks., Results: Nineteen physicians were randomly assigned to the office BP monitoring group and 34 were assigned to the HBPM group. Of the 270 subjects recruited, 97 were in the office BP monitoring group and 173 were in the HBPM group. From baseline to the final visit, there was a statistically significant time by group interaction with lower BP in the HBPM group (P=0.034 for both systolic BP and diastolic BP). BP fell from 159/91+/-11/10 mmHg at baseline in the HBPM group to 138/80+/-13/8 mmHg on the final visit, and from 160/88+/-14/10 mmHg to 141/78+/-10/9 mmHg in the control group., Conclusions: BP was lowered significantly in both groups, and to a statistically greater degree in the HBPM group. The Hawthorne effect might have led to altered care by the physicians with improvement in BP control in both groups.
- Published
- 2008
- Full Text
- View/download PDF
38. More medications, fewer pills: combination medications for the treatment of hypertension.
- Author
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Lewanczuk R and Tobe SW
- Subjects
- Antihypertensive Agents administration & dosage, Drug Therapy, Combination, Humans, Antihypertensive Agents therapeutic use, Hypertension drug therapy
- Abstract
Achieving blood pressure targets in hypertension can be challenging. Often, patients require multiple medications to reach these targets. The Canadian Hypertension Education Program has updated its past recommendations to reflect current knowledge regarding effective antihypertensive combinations. Evidence for the use of specific drug combinations in achieving blood pressure targets has been reviewed, and the inventory of effective drug combinations has been expanded. From a clinical perspective, fixed-dose antihypertensive combinations offer certain advantages in terms of efficacy, adherence, cost, convenience, patient-perceived 'wellness' and side effects. Consequently, in the future, fixed-dose combination formulations are likely to become increasingly used in the treatment of cardiovascular disease.
- Published
- 2007
- Full Text
- View/download PDF
39. Amlodipine added to quinapril vs quinapril alone for the treatment of hypertension in diabetes: the Amlodipine in Diabetes (ANDI) trial.
- Author
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Tobe S, Kawecka-Jaszcz K, Zannad F, Vetrovec G, Patni R, and Shi H
- Subjects
- Amlodipine adverse effects, Antihypertensive Agents adverse effects, Blood Pressure Determination, Calcium Channel Blockers adverse effects, Drug Therapy, Combination, Female, Humans, Male, Middle Aged, Quinapril, Tetrahydroisoquinolines adverse effects, Treatment Outcome, Amlodipine therapeutic use, Antihypertensive Agents therapeutic use, Calcium Channel Blockers therapeutic use, Diabetes Complications drug therapy, Hypertension drug therapy, Tetrahydroisoquinolines therapeutic use
- Abstract
This randomized, comparative, parallel-group trial investigated strategies of blood pressure (BP)-lowering in patients with diabetes and hypertension. Patients not reaching goal BP (<130/80 mm Hg) after 4-week open-label treatment with quinapril 20 mg/d (n=374) received 40 mg/d quinapril (n=167) or 20 mg/d quinapril plus amlodipine besylate (5 mg/d; n=162) for 6 weeks. Patients receiving combination therapy vs monotherapy had significantly greater reductions in mean +/- SE sitting systolic BP (9.9+/-1.0 mm Hg vs 4.3+/-1.1 mm Hg; P<.001) and diastolic BP (6.5+/-0.6 mm Hg vs 2.7+/-0.6 mm Hg; P<.001). No significant differences between groups were observed in percentage of patients achieving goal BP (10.1% with combination therapy vs 8.2% with monotherapy). A clinically neutral effect was observed on high-sensitivity C-reactive protein in both groups. Treatments were well tolerated; fewer than 3% of patients in any group discontinued due to treatment-emergent or treatment-related adverse events. In diabetic hypertensive patients, 20 mg/d quinapril plus 5 mg/d amlodipine besylate was a more effective BP-lowering strategy than monotherapy with 40 mg/d quinapril.
- Published
- 2007
- Full Text
- View/download PDF
40. Effect of nurse-directed hypertension treatment among First Nations people with existing hypertension and diabetes mellitus: the Diabetes Risk Evaluation and Microalbuminuria (DREAM 3) randomized controlled trial.
- Author
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Tobe SW, Pylypchuk G, Wentworth J, Kiss A, Szalai JP, Perkins N, Hartman S, Ironstand L, and Hoppe J
- Subjects
- Adult, Aged, Algorithms, Canada, Diabetes Complications ethnology, Diabetes Complications prevention & control, Diabetes Mellitus, Type 2 complications, Female, Humans, Hypertension complications, Male, Middle Aged, Prospective Studies, Rural Population, Antihypertensive Agents therapeutic use, Diabetes Mellitus, Type 2 ethnology, Diabetes Mellitus, Type 2 prevention & control, Home Care Services, Hypertension drug therapy, Hypertension ethnology, Indians, North American, Inuit, Rural Health Services
- Abstract
Background: First Nations people with diabetes mellitus and hypertension are at greater risk of renal and cardiovascular complications than are non-native patients because of barriers to health care services. We conducted this randomized controlled trial to assess whether a community-based treatment strategy implemented by home care nurses would be effective in controlling hypertension in First Nations people with existing hypertension and type 2 diabetes., Methods: We compared 2 community-based strategies for controlling hypertension in First Nations people with existing hypertension and diabetes. In the intervention group, a home care nurse followed a predefined treatment algorithm of pharmacologic antihypertensive therapy. In the control group, treatment decisions were made by each subject's primary care physician. The primary outcome measure was the difference between the 2 groups in the change in systolic blood pressure after 12 months. Secondary outcome measures were the change in diastolic blood pressure over time, the change in urine albumin status and the incidence of adverse events., Results: Both groups experienced a significant reduction in systolic blood pressure by the final visit (by 24.0 [standard deviation (SD) 13.5] mm Hg in the intervention group and by 17.0 [SD 18.6] mm Hg in the control group); p < 0.001 in each case). However, the difference between the 2 groups in this change was not significant. Patients in the intervention group had a larger decrease in diastolic blood pressure over time than did those in the control group (by 11.6 [SD 10.6] mm Hg v. 6.8 [SD 11.1] mm Hg respectively; p = 0.05). The groups did not differ significantly in terms of changes in urine albumin excretion or incidence of adverse events., Interpretation: High rates of blood pressure control in the community were achieved in both groups in the DREAM 3 study. The addition of a home care nurse to implement a treatment strategy for blood pressure control was more effective in lowering diastolic than systolic blood pressure compared with home care visits for blood pressure monitoring alone and follow-up treatment by a family physician.
- Published
- 2006
- Full Text
- View/download PDF
41. Applying the 2005 Canadian Hypertension Education Program recommendations: 5. Therapy for patients with hypertension and diabetes mellitus.
- Author
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Tobe S, McAlister FA, and Leiter L
- Subjects
- Canada, Humans, Hypertension complications, Male, Middle Aged, Risk Factors, Antihypertensive Agents therapeutic use, Diabetes Complications prevention & control, Hypertension drug therapy, Patient Education as Topic, Practice Guidelines as Topic
- Published
- 2005
- Full Text
- View/download PDF
42. Microalbuminuria in diabetes mellitus.
- Author
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Tobe SW, McFarlane PA, and Naimark DM
- Subjects
- Algorithms, Angiotensin-Converting Enzyme Inhibitors therapeutic use, Clinical Trials as Topic, Female, Humans, Hypertension complications, Hypertension drug therapy, Kidney Failure, Chronic prevention & control, Male, Middle Aged, Treatment Outcome, Albuminuria complications, Albuminuria diagnosis, Albuminuria etiology, Antihypertensive Agents therapeutic use, Diabetes Mellitus, Type 2 complications, Diabetes Mellitus, Type 2 drug therapy, Diabetes Mellitus, Type 2 prevention & control, Diabetic Nephropathies etiology, Diabetic Nephropathies prevention & control, Kidney Failure, Chronic etiology
- Published
- 2002
43. The 2001 Canadian recommendations for the management of hypertension: Part two--Therapy.
- Author
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McAlister FA, Zarnke KB, Campbell NR, Feldman RD, Levine M, Mahon J, Grover SA, Lewanczuk R, Leenen F, Tobe S, Lebel M, Stone J, Schiffrin EL, Rabkin SW, Ogilvie RI, Larochelle P, Jones C, Honos G, Fodor G, Burgess E, Hamet P, Herman R, Irvine J, Culleton B, and Wright JM
- Subjects
- Antihypertensive Agents administration & dosage, Canada, Cardiovascular Diseases prevention & control, Humans, Randomized Controlled Trials as Topic, Antihypertensive Agents therapeutic use, Hypertension prevention & control
- Abstract
Objective: To provide updated, evidence-based recommendations for the therapy of hypertension in adults., Options: For patients with hypertension, a number of antihypertensive agents 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 that were 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 was searched for the period March 1999 to October 2001 to identify studies not included in the 2000 revision of the Canadian Recommendations for the Management of Hypertension. Reference lists were scanned, experts were polled, and the personal files of the subgroup members and authors were used to identify other published 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 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 treatment thresholds, target blood pressures, and choice of agents in various settings in patients with hypertension. The main changes from the 2000 Recommendations are the addition of a section on the treatment of hypertension in patients with diabetes mellitus, the amalgamation of the previous sections on treatment of hypertension in the young and old into one section, increased emphasis on the role of combination therapies over repeated trials of single agents and expansion of the section on the treatment of hypertension after stroke. Implicit in the recommendations for therapy is the principle that treatment for an individual patient should take into consideration global cardiovascular risk, the presence and/or absence of target organ damage, and comorbidities., Validation: All recommendations were graded according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group. Individuals with potential conflicts of interest relative to any specific recommendation were excluded from voting on that recommendation. Only those recommendations achieving high levels of consensus are reported here. These guidelines will continue to be updated annually.
- Published
- 2002
44. Applying the 2005 Canadian Hypertension Education Program recommendations: 5. Therapy for patients with hypertension and diabetes mellitus.
- Author
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Tobe, Sheldon, McAlister, Finlay A., and Leiter, Lawrence
- Subjects
HYPERTENSION ,THERAPEUTICS ,TREATMENT of diabetes ,ANTIHYPERTENSIVE agents ,BLOOD pressure ,ACE inhibitors - Abstract
Answers several questions about the therapy for patients with hypertension and diabetes mellitus. Reason for the lower threshold for initiating antihypertensive treatment and the target blood pressures in people with diabetes compared with people with uncomplicated hypertension; Antihypertensive therapies recommended for people with diabetes; Possibility of combining an angiotensin-converting enzyme inhibitor and angiotensin-receptor blocker because of the nephropathy.
- Published
- 2005
- Full Text
- View/download PDF
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