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Competing Interests: Intérêts concurrents: Sheldon Tobe déclare avoir été rémunéré par la société Medtronic Canada. Andrew Dueck déclare avoir été rémunéré à titre de témoin expert au sujet de brevets portant sur des séquences d’imagerie par résonance magnétique pour l’évaluation de plaques des artères périphériques. Il est titulaire de la chaire Maggisano en chirurgie vasculaire. Mina Madan déclare avoir participé à un comité consultatif pour la société Medtronic Canada. Aucun autre intérêt concurrent n’a été déclaré.

Competing Interests: Competing interests: Sheldon Tobe reports payment from Medtronic Canada. Andrew Dueck reports payment for expert testimony, patents related to magnetic resonance imaging sequences for the evaluation of peripheral plaque. He holds the Maggisano chair in vascular surgery. Mina Madan reports participation on an advisory board for Medtronic Canada. No other competing interests were declared.

Background: Early identification of people with diabetes or prediabetes enables greater opportunities for glycemic control and management strategies to prevent related complications. To identify gaps in screening for these conditions, we examined population trends in receipt of timely glucose testing overall and in specific clinical subgroups., Methods: Using linked administrative databases, we conducted a retrospective cohort study of people aged 40 years and older without diabetes at baseline. Our primary outcome was up-to-date glucose testing, defined as having received testing at least once in the 3 years before each index year from 2010 to 2017, using linked administrative databases of people residing in Ontario, Canada. We calculated rates of up-to-date testing by age group, sex, ethnicity (South Asian, Chinese, general population) and comorbidities (hypertension, hyperlipidemia, cardiovascular disease)., Results: Over the 8-year study period, up-to-date glucose testing rates were stable at 67% for men and 77% for women (both relative risk 1.00 per year; 95% confidence interval 1.00-1.00). Testing rates were significantly lower in men than in women (all age groups p < 0.001) and lower in younger than older age groups (except those aged ≥ 80 yr). South Asian people had the highest testing rates, although among people aged 70 years or older, testing was highest in the general population ( p < 0.001). Among people with hypertension, hyperlipidemia and cardiovascular disease, annual testing rates were also stable, but only 58% overall among people with hypertension., Interpretation: We found lower glucose testing rates in younger men and people with hypertension. Our findings reinforce the need for initiatives to increase awareness of glycemic testing., Competing Interests: Competing interests: Catherine Yu reports receiving research grants from the St. Michael’s Hospital Medical Services Association, St. Michael’s Hospital (Unity Health Toronto), the Ontario SPOR SUPPORT Unit and the Royal College of Physicians and Surgeons of Canada. Kim Connelly reports receiving research grants and payment for presentations from AstraZeneca, Servier, Boehringer Ingelheim, Eli Lilly, Novartis, Novo Nordisk and Merck. Dr. Connelly also reports serving on a Data Safety Monitoring Board or Advisory Board for AstraZeneca, Servier, Boehringer Ingelheim, Eli Lilly, Novartis, Novo Nordisk and Merck. Gillian Booth reports receiving grants or contracts from the Canadian Institutes of Health Research (CIHR), Juvenile Diabetes Research Foundation and the Thistledown Foundation. Karen Tu reports receiving payments (to institutions) from CIHR, St. Michael’s Hospital Foundation, The College of Family Physicians of Canada, Foundation for Advancing Family Medicine, Canadian Medical Association Foundation, North York General Hospital, Heart and Stroke Foundation of Canada, Heart and Stroke Foundation of Ontario, Department of Defense (United States), University of Toronto (Department of Family and Community Medicine), MaRS Innovation Fund, Canadian Dermatology Foundation, Canadian Rheumatology Association (Canadian Initiative for Outcomes in Rheumatology Care), PSI Foundation, Cancer Care Ontario, Toronto Rehabilitation Institute Chair Fund, University of Toronto Practice-Based Research Network, Arthritis Society, MS Society of Canada, The Canadian Vascular Network and the Ontario SPOR SUPPORT Unit Targeted IMPACT Award. Sheldon Tobe reports receiving a KMH clinic unrestricted grant and in-kind support for the Zero to Five study, and consulting fees from AstraZeneca (all paid to Sunnybrook Research Institute). Dr. Tobe also reports receiving payment from Amgen, Astra-Zeneca, Bristol Myers Squibb, Bayer, Boehringer Ingelheim, Janssen, Lilly, Novartis, Novo Nordisk, Pfizer and Sanofi Genzyme for the CHEPPLUS education program. Dr. Tobe has worked on a volunteer basis with the American Hypertension Specialists Certification Program. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Description: The Kidney Disease: Improving Global Outcomes (KDIGO) 2021 clinical practice guideline for the management of blood pressure (BP) in patients with chronic kidney disease (CKD) not receiving dialysis is an update of the KDIGO 2012 guideline on the same topic and reflects new evidence on the risks and benefits of BP-lowering therapy among patients with CKD. It is intended to support shared decision making by health care professionals working with patients with CKD worldwide. This article is a synopsis of the full guideline., Methods: The KDIGO leadership commissioned 2 co-chairs to convene an international Work Group of researchers and clinicians. After a Controversies Conference in September 2017, the Work Group defined the scope of the evidence review, which was undertaken by an evidence review team between October 2017 and April 2020. Evidence reviews were done according to the Cochrane Handbook. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to guide the development of the recommendations and rate the strength and quality of the evidence. Practice points were included to provide guidance when evidence was insufficient to make a graded recommendation. The guideline was revised after public consultation between January and March 2020., Recommendations: The updated guideline comprises 11 recommendations and 20 practice points. This synopsis summarizes key recommendations pertinent to the diagnosis and management of high BP in adults with CKD, excluding those receiving kidney replacement therapy. In particular, the synopsis focuses on recommendations for standardized BP measurement and a target systolic BP of less than 120 mm Hg, because these recommendations differ from some other guidelines.

Introduction: First Nations communities are known to have high rates of diabetes. The rural First Nations communities in northwest (NW) Ontario are particularly affected. Regional studies in 1985 and 1994 found a high prevalence of diabetes. More recently, they are estimated to have the highest prevalence in Ontario at 19%, double the provincial norm. The purpose of this study is to examine the epidemiology and prevalence of diabetes in the total population and cardiovascular comorbidities in the adult population of 25 First Nations communities in NW Ontario., Methods: This retrospective diabetes prevalence study used primary care electronic medical record data for a 3-year period, 1 August 2014-31 July 2017. Diabetes prevalence was calculated for both the total and the adult (18+) populations and comorbid hypertension and dyslipidaemia were identified in adults., Results: The age-adjusted diabetes prevalence for the total population was 15.1% versus a Canadian prevalence of 8.8%. The age-adjusted adult prevalence was 14.1%, double Canada's average of 7.1%. The average age of adults with diabetes was 52 years (±14.9); 57% were female. Comorbid hypertension (58%) and dyslipidaemia (73%) were common. Metformin was the most commonly used medication (58%), followed by insulin/analogues (23%) and sulphonylureas (13%)., Conclusion: The diabetes prevalence in the First Nations population of NW Ontario is double Canada's norm. Addressing it will require addressing relevant social determinants of health, including poverty and food security., Competing Interests: None

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

We present Hypertension Canada's inaugural evidence-based recommendations for the diagnosis and management of resistant hypertension. Hypertension is present in 21% of the Canadian population, and among those with hypertension, resistant hypertension has an estimated prevalence from 10% to 30%. This subgroup of hypertensive individuals is important, because resistant hypertension portends a high cardiovascular risk. Because of its importance, Hypertension Canada formed a Guidelines Committee to conduct a review of the evidence and develop recommendations for the diagnosis and management of resistant hypertension. The Hypertension Canada Guidelines Committee recommends that patients with blood pressure above target, despite use of 3 or more blood pressure-lowering drugs at optimal doses, preferably including a diuretic, be identified as those with apparent resistant hypertension. Patients identified with apparent resistant hypertension should be assessed for white coat effect, nonadherence, and therapeutic inertia, investigated for secondary hypertension, and referred to a provider with expertise in hypertension. There is no randomized controlled trial evidence for better cardiovascular outcomes with any class of antihypertensive agent at this time, so recommendations for a preferred drug class cannot be made. Furthermore, we provide a summary of the current evidence concerning the role of device therapy in the management of resistant hypertension. We will continue updating the guidelines as additional high-quality evidence with relevance to daily practice becomes available., (Copyright © 2020 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: DREAM-GLOBAL (Diagnosing hypertension-Engaging Action and Management in Getting Lower Blood Pressure in Indigenous and low- and middle-income countries) studied a SMS text messaging-based system for blood pressure measurement and hypertension management in Canadian Aboriginal and Tanzanian communities. The use of SMS text messages is an emerging point of interest in global health care initiatives because of their scalability, customizability, transferability, and cost-effectiveness., Objective: The study aim was to assess the effect on the difference in blood pressure reduction of active hypertension management messages or passive health behavior messages. The system was designed to be implemented in remote areas with wireless availability. This study described the implementation and evaluation of technical components, including quantitative data from the transmission of blood pressure measurements and qualitative data collected on the operational aspects of the system from participants, health care providers, and community leadership., Methods: The study was implemented in six remote Indigenous Canadian and two rural Tanzanian communities. Blood pressure readings were taken by a community health worker and transmitted to a mobile phone via Bluetooth, then by wireless to a programmed central server. From the server, the readings were sent to the participant's own phone as well. Participants also received biweekly tailored SMS text messages on their phones. Quantitative data on blood pressure reading transmissions were collected from the study central server. Qualitative data were collected by surveys, focus groups, and key informant interviews of participants, health care providers, and health leadership., Results: In Canada, between February 2014 and February 2017, 2818 blood pressure readings from 243 patients were transmitted to the central server. In Tanzania, between October 2014 and August 2015, 1165 readings from 130 patients were transmitted to the central server. The use of Bluetooth technology enabled the secure, reliable transmission of information from participants to their health care provider. The timing and frequency were satisfactory to 137 of 187 (73.2%) of participants, supporting the process of sending weekly messages twice on Mondays and Thursdays at 11 am. A total of 97.0% (164/169) of the participants surveyed said they would recommend participation in the DREAM-GLOBAL program to a friend or relative with hypertension., Conclusions: In remote communities, the DREAM-GLOBAL study helped local health care providers deliver a blood pressure management program that enabled patients and community workers to feel connected. The technical components of the study were implemented as planned, and patients felt supported in their management through the SMS text messaging and mobile health program. Technological issues were solved with troubleshooting. Overall, the technical aspects of this research program enhanced clinical care and study evaluation and were well received by participants, health care workers, and community leadership., Trial Registration: Clinicaltrials.gov NCT02111226; https://clinicaltrials.gov/ct2/show/NCT02111226., (©Jordan Andrea Barsky, Rebekah Hunter, Colin McAllister, Karen Yeates, Norm Campbell, Peter Liu, Nancy Perkins, Diane Hua-Stewart, Marion A Maar, Sheldon W Tobe. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 09.12.2019.)

Recent studies have found an increasing burden of noncommunicable diseases in sub-Saharan Africa. A compressive search of PubMed, Medline, EMBASE, and the World Health Organization Global Health Library databases was undertaken to identify studies reporting on the prevalence, risk factors, and interventions for hypertension and diabetes in Malawi. The findings from 23 included studies revealed a high burden of hypertension and diabetes in Malawi, with estimates ranging from 15.8% to 32.9% and from 2.4% to 5.6%, respectively. Associated risk factors included old age, tobacco smoking, excessive alcohol consumption, obesity, physical inactivity, high salt and sugar intake, low fruit and vegetable intake, high body mass index, and high waist-to-hip ratio. Certain antiretroviral therapy regimens were also associated with increased diabetes and hypertension risk in human immunodeficiency virus patient populations. Nationwide, the quality of clinical care was generally limited and demonstrated a need for innovative and targeted interventions to prevent, control, and treat noncommunicable diseases in Malawi., (Copyright © 2019 World Heart Federation (Geneva). Published by Elsevier B.V. All rights reserved.)

Hypertension, the leading cause of cardiovascular morbidity and mortality, affects more than 1 billion people globally. The rise in mobile health in particular the use of mobile phones and short message service (SMS) to support disease management provides an opportunity to improve hypertension awareness, treatment, and control, in remote and vulnerable patient populations. The primary objective of this randomized controlled study was to assess the effect of active (with hypertension specific management SMS) or passive (health behaviors SMS alone) on the difference in blood pressure (BP) reduction between the active and passive SMS groups in hypertensive Canadian First Nations people from six rural and remote communities. Pragmatic features of the study included shifting of BP measures to non-medical health workers. Despite an overall reduction in BP over the study, there was no difference in the BP change between groups from baseline to final for systolic 0.8 (95% CI -4.2 to 5.8 mm Hg) or diastolic -1.0 (95% CI -3.7 to 1.8 mm Hg, P = 0.5) BP. Achieved BP control was 37.5% (25.6%-49.4%, 95% CI) in the active group and 32.8% (20.6%-44.8%, 95% CI) in the passive group (difference in proportions -4.74% (-21.7% to 12.2%, 95% CI, P = 0.6). The study looked at changes in health services delivery, mobile health technologies, and patient engagement to support better management of hypertension in Canadian First Nations communities. The active hypertension specific SMS did not lead to improvements in BP control., (©2018 Wiley Periodicals, Inc.)

Aim: The SONAR trial uses an enrichment design based on the individual response to the selective endothelin receptor antagonist atrasentan on efficacy (the degree of the individual response in the urinary albumin-to-creatinine ratio [UACR]) and safety/tolerability (signs of sodium retention and acute increases in serum creatinine) to assess the effects of this agent on major renal outcomes. The patient population and enrichment results are described here., Methods: Patients with type 2 diabetes with an estimated glomerular filtration rate (eGFR) within 25 to 75 mL/min/1.73 m 2 and UACR between 300 and 5000 mg/g were enrolled. After a run-in period, eligible patients received 0.75 mg/d of atrasentan for 6 weeks. A total of 2648 responder patients in whom UACR decreased by ≥30% compared to baseline were enrolled, as were 1020 non-responders with a UACR decrease of <30%. Patients who experienced a weight gain of >3 kg and in whom brain natriuretic peptide exceeded ≥300 pg/mL, or who experienced an increase in serum creatinine >20% (0.5 mg/dL), were not randomized., Results: Baseline characteristics were similar for atrasentan responders and non-responders. Upon entry to the study, median UACR was 802 mg/g in responders and 920 mg/g in non-responders. After 6 weeks of treatment with atrasentan, the UACR change in responders was -48.8% (95% CI, -49.8% to -47.9%) and in non-responders was -1.2% (95% CI, -6.4% to 3.9%). Changes in other renal risk markers were similar between responders and non-responders except for a marginally greater reduction in systolic blood pressure and eGFR in responders., Conclusions: The enrichment period has successfully identified a population with a profound UACR reduction without clinical signs of sodium retention in whom a large atrasentan effect on clinically important renal outcomes is possible. The SONAR trial aims to establish whether atrasentan confers renal protection., (© 2018 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Background: Although it is well established that heavy alcohol consumption increases the risk of hypertension, the risk associated with low levels of alcohol intake in men and women is unclear., Methods and Results: We searched Medline and Embase for original cohort studies on the association between average alcohol consumption and incidence of hypertension in people without hypertension. Random-effects meta-analyses and metaregressions were conducted. Data from 20 articles with 361 254 participants (125 907 men and 235 347 women) and 90 160 incident cases of hypertension (32 426 men and 57 734 women) were included. In people drinking 1 to 2 drinks/day (12 g of pure ethanol per drink), incidence of hypertension differed between men and women (relative risk women vs men =0.79; 95% confidence interval, 0.67-0.93). In men, the risk for hypertension in comparison with abstainers was relative risk=1.19 (1.07-1.31; I 2 =59%), 1.51 (1.30-1.76), and 1.74 (1.35-2.24) for consumption of 1 to 2, 3 to 4, and 5 or more standard drinks per day, respectively. In women, there was no increased risk for 1 to 2 drinks/day (relative risk=0.94; 0.88-1.01; I 2 =73%), and an increased risk for consumption beyond this level (relative risk=1.42; 1.22-1.66)., Conclusions: Any alcohol consumption was associated with an increase in the risk for hypertension in men. In women, there was no risk increase for consumption of 1 to 2 drinks/day and an increased risk for higher consumption levels. We did not find evidence for a protective effect of alcohol consumption in women, contrary to earlier meta-analyses., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children. This year, the adult and pediatric guidelines are combined in one document. The new 2018 pregnancy-specific hypertension guidelines are published separately. For 2018, 5 new guidelines are introduced, and 1 existing guideline on the blood pressure thresholds and targets in the setting of thrombolysis for acute ischemic stroke is revised. The use of validated wrist devices for the estimation of blood pressure in individuals with large arm circumference is now included. Guidance is provided for the follow-up measurements of blood pressure, with the use of standardized methods and electronic (oscillometric) upper arm devices in individuals with hypertension, and either ambulatory blood pressure monitoring or home blood pressure monitoring in individuals with white coat effect. We specify that all individuals with hypertension should have an assessment of global cardiovascular risk to promote health behaviours that lower blood pressure. Finally, an angiotensin receptor-neprilysin inhibitor combination should be used in place of either an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in individuals with heart failure (with ejection fraction < 40%) who are symptomatic despite appropriate doses of guideline-directed heart failure therapies. The specific evidence and rationale underlying each of these guidelines are discussed., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

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.)

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.)

Background: Although it is well established that heavy alcohol consumption increases the risk of hypertension, little is known about the effect of a reduction of alcohol intake on blood pressure. We aimed to assess the effect of a reduction in alcohol consumption on change in blood pressure stratified by initial amount of alcohol consumption and sex in adults., Methods: In this systematic review and meta-analysis, we searched MedLine, Embase, CENTRAL, and ClinicalTrials.gov from database inception up to July 13, 2016, for trials investigating the effect of a change of alcohol consumption on blood pressure in adults using keywords and MeSH terms related to alcohol consumption, blood pressure, and clinical trials, with no language restrictions. We also searched reference lists of identified articles and published meta-analyses and reviews. We included full-text articles with original human trial data for the effect of a change of alcohol consumption on blood pressure in adults, which reported a quantifiable change in average alcohol consumption that lasted at least 7 days and a corresponding change in blood pressure. We extracted data from published reports. We did random-effects meta-analyses stratified by amount of alcohol intake at baseline. All meta-analyses were done with Stata (version 14.1). For the UK, we modelled the effect of a reduction of alcohol consumption for 50% of the population drinking more than two standard drinks per day (ie, 12 g pure alcohol per drink)., Findings: 36 trials with 2865 participants (2464 men and 401 women) were included. In people who drank two or fewer drinks per day, a reduction in alcohol was not associated with a significant reduction in blood pressure; however, in people who drank more than two drinks per day, a reduction in alcohol intake was associated with increased blood pressure reduction. Reduction in systolic blood pressure (mean difference -5·50 mm Hg, 95% CI -6·70 to -4·30) and diastolic blood pressure (-3·97, -4·70 to -3·25) was strongest in participants who drank six or more drinks per day if they reduced their intake by about 50%. For the UK, the results would translate into more than 7000 inpatient hospitalisations and 678 cardiovascular deaths prevented every year., Interpretation: Reducing alcohol intake lowers blood pressure in a dose-dependent manner with an apparent threshold effect. Implementation of effective alcohol interventions in people who drink more than two drinks per day would reduce the disease burden from both alcohol consumption and hypertension, and should be prioritised in countries with substantial alcohol-attributable risk., Funding: National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health (NIH)., (Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND license. Published by Elsevier Ltd.. All rights reserved.)

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.)

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.)

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.

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.)

The sympathetic nervous system plays a permissive, if not primary causal role in the genesis and maintenance of human essential hypertension. Excessive sympathetic nervous system activity in man is most apparent in early forms of hypertension (prehypertension and white-coat type). Renal nerves are of particular interest because of their roles in modulating the activity of the renin-angiotensin system and renal sodium excretion. Renal denervation substantially ameliorates the development of hypertension in animal models such as renovascular, spontaneously hypertensive, and steroid-induced hypertension in rats and aortic coarctation in dogs. In man, catheter ablation of renal nerves has been undertaken in the late phases of hypertension; in a rigorously controlled trial in resistant hypertension (SYMPLICITY HTN-3), renal denervation did not reduce blood pressure over the long term. Is this because renal denervation is more appropriate to prevent than treat late-stage hypertension? Are there anatomical or technical barriers yet to be overcome in the procedure? These and other issues are addressed by two experts in this issue of the controversies series: Deepak L. Bhatt and Murray Epstein., (Copyright © 2016 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.)

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.)

Canada has an extremely successful hypertension detection and treatment program. The aim of this review was to highlight the historic and current infrastructure and initiatives that have led to this success, and the outlook moving forward into the future. We discuss the evolution of hypertension awareness and control in Canada; contributions made by organizations such as the Canadian Hypertension Society, Blood Pressure Canada, and the Canadian Hypertension Education Program; the amalgamation of these organizations into Hypertension Canada; and the impact that Hypertension Canada has had on hypertension care in Canada. The important contribution that public policy and advocacy can have on prevention and control of blood pressure in Canada is described. We also highlight the importance of population-based strategies, health care access and organization, and accurate blood pressure measurement (including ambulatory, home, and automated office modalities) in optimizing hypertension prevention and management. We end by discussing how Hypertension Canada will move forward in the near and longer term to address the unmet residual risk attributable to hypertension and associated cardiovascular risk factors. Hypertension Canada will continue to strive to enhance hypertension prevention and control rates, thereby improving the quality of life and cardiovascular outcomes of Canadians, while at the same time creating a hypertension care model that can be emulated across the world., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Hypertension (persistent diastolic blood pressure of 90 mmHg or greater or systolic blood pressure 140 mmHg or greater) affects 20% to 35% of the world's adult population and increases the risk of cardiovascular disease, end-stage renal disease, and mortality., Methods and Outcomes: We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of selected dietary modification for people with hypertension? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2013 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview)., Results: At this update, searching of electronic databases retrieved 669 studies. After deduplication and removal of conference abstracts, 464 records were screened for inclusion in this overview. Appraisal of titles and abstracts led to the exclusion of 376 studies and the further review of 88 full publications. Of the 88 full articles evaluated, three systematic reviews and three RCTs were added. We performed a GRADE evaluation for eight PICO combinations., Conclusions: In this systematic overview, we categorised the efficacy for five interventions based on information about the effectiveness and safety of calcium supplements, a low-salt diet (including the DASH diet), magnesium supplements, a Mediterranean diet, and potassium supplements.

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.)

Endothelin receptor antagonists (ERAs) have the potential to be a new paradigm in the treatment of chronic kidney disease (CKD). ERAs inhibit the effects of endothelin-1 (ET-1), which is known to promote CKD by causing renal cellular injury, proteinuria, inflammation, fibrosis, and hypertrophy. ERAs have been extensively studied preclinically in models of CKD and now in a large clinical trial to determine their effect on slowing the progression of CKD. Initial clinical trials show promise with regard to ERA effects on reducing proteinuria in patients with diabetic nephropathy (DN) who are already on renin-angiotensin system (RAS) blocking agents. A common side effect of peripheral edema has been consistently reported in clinical trials using ERAs; hence, finding a safe balance between renoprotective actions and side effects needs to be achieved.

Background: Non-communicable chronic diseases are the leading causes of mortality globally, and nearly 80% of these deaths occur in low- and middle-income countries (LMICs). In high-income countries (HICs), inequitable distribution of resources affects poorer and otherwise disadvantaged groups including Aboriginal peoples. Cardiovascular mortality in high-income countries has recently begun to fall; however, these improvements are not realized among citizens in LMICs or those subgroups in high-income countries who are disadvantaged in the social determinants of health including Aboriginal people. It is critical to develop multi-faceted, affordable and realistic health interventions in collaboration with groups who experience health inequalities. Based on community-based participatory research (CBPR), we aimed to develop implementation tools to guide complex interventions to ensure that health gains can be realized in low-resource environments., Methods: We developed the I-RREACH (Intervention and Research Readiness Engagement and Assessment of Community Health Care) tool to guide implementation of interventions in low-resource environments. We employed CBPR and a consensus methodology to (1) develop the theoretical basis of the tool and (2) to identify key implementation factor domains; then, we (3) collected participant evaluation data to validate the tool during implementation., Results: The I-RREACH tool was successfully developed using a community-based consensus method and is rooted in participatory principles, equalizing the importance of the knowledge and perspectives of researchers and community stakeholders while encouraging respectful dialogue. The I-RREACH tool consists of three phases: fact finding, stakeholder dialogue and community member/patient dialogue. The evaluation for our first implementation of I-RREACH by participants was overwhelmingly positive, with 95% or more of participants indicating comfort with and support for the process and the dialogue it creates., Conclusions: The I-RREACH tool was designed to (1) pinpoint key domains required for dialogue between the community and the research team to facilitate implementation of complex health interventions and research projects and (2) to identify existing strengths and areas requiring further development for effective implementation. I-RREACH has been found to be easily adaptable to diverse geographical and cultural settings and can be further adapted to other complex interventions. Further research should include the potential use of the I-RREACH tool in the development of blue prints for scale-up of successful interventions, particularly in low-resource environments.

The Canadian Hypertension Education Program reviews the hypertension literature annually and provides detailed recommendations regarding hypertension diagnosis, assessment, prevention, and treatment. This report provides the updated evidence-based recommendations for 2015. This year, 4 new recommendations were added and 2 existing recommendations were modified. A revised algorithm for the diagnosis of hypertension is presented. Two major changes are proposed: (1) measurement using validated electronic (oscillometric) upper arm devices is preferred over auscultation for accurate office blood pressure measurement; (2) if the visit 1 mean blood pressure is increased but < 180/110 mm Hg, out-of-office blood pressure measurements using ambulatory blood pressure monitoring (preferably) or home blood pressure monitoring should be performed before visit 2 to rule out white coat hypertension, for which pharmacologic treatment is not recommended. A standardized ambulatory blood pressure monitoring protocol and an update on automated office blood pressure are also presented. Several other recommendations on accurate measurement of blood pressure and criteria for diagnosis of hypertension have been reorganized. Two other new recommendations refer to smoking cessation: (1) tobacco use status should be updated regularly and advice to quit smoking should be provided; and (2) advice in combination with pharmacotherapy for smoking cessation should be offered to all smokers. The following recommendations were modified: (1) renal artery stenosis should be primarily managed medically; and (2) renal artery angioplasty and stenting could be considered for patients with renal artery stenosis and complicated, uncontrolled hypertension. The rationale for these recommendation changes is discussed., (Copyright © 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

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.)

The KDIGO (Kidney Disease: Improving Global Outcomes) 2012 clinical practice guideline for the management of blood pressure (BP) in chronic kidney disease (CKD) provides the structural and evidence base for the Canadian Society of Nephrology (CSN) commentary on this guideline's relevancy and application to the Canadian health care system. While in general agreement, we provide commentary on 13 of the 21 KDIGO guideline statements. Specifically, we agreed that nonpharmacological interventions should play a significant role in the management of hypertension in patients with CKD. We also agreed that the approach to the management of hypertension in elderly patients with CKD should be individualized and take into account comorbid conditions to avoid adverse outcomes from excessive BP lowering. In contrast to KDIGO, the CSN Work Group believes there is insufficient evidence to target a lower BP for nondiabetic CKD patients based on the presence and severity of albuminuria. The CSN Work Group concurs with the Canadian Hypertension Education Program (CHEP) recommendation of a target BP for all non-dialysis-dependent CKD patients without diabetes of ≤140 mm Hg systolic and ≤90 mm Hg diastolic. Similarly, it is our position that in diabetic patients with CKD and normal urinary albumin excretion, raising the threshold for treatment from <130 mm Hg systolic BP to <140 mm Hg systolic BP could increase stroke risk and the risk of worsening kidney disease. The CSN Work Group concurs with the CHEP and the Canadian Diabetic Association recommendation for diabetic patients with CKD with or without albuminuria to continue to be treated to a BP target similar to that of the overall diabetes population, aiming for BP levels < 130/80 mm Hg. Consistent with this, the CSN Work Group endorses a BP target of <130/80 mm Hg for diabetic patients with a kidney transplant. Finally, in the absence of evidence for a lower BP target, the CSN Work Group concurs with the CHEP recommendation to target BP<140/90 mm Hg for nondiabetic patients with a kidney transplant., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

β-Blockers are among the most commonly used medications in the treatment of hypertension. However, 45 years after their initial indication for that treatment, their place in the treatment of hypertensive patients is under evaluation and their usefulness has been questioned based on evidence from meta-analyses of clinical trials. The β-blocker class consists of various agents with diverse pharmacokinetic and pharmacodynamic properties including lipo- and hydrophilicity, duration of action, intrinsic sympathomimetic activity, vasodilation, and metabolism linked to genetic polymorphisms. Because of their various properties, some β-blockers are indicated for cardiovascular conditions such as angina, rate control of atrial fibrillation, chronic heart failure, and after myocardial infarction, and other indications such as migraine and essential tremor. There have been more than 17 large trials influencing the recommendations on the use of these agents in the treatment of hypertension. The results of these trials initially led to the widespread recommendation for the use of β-blockers in the management of hypertension. However, the recent multiple meta-analyses using these trials have raised a controversy on their place in that treatment. The Canadian Hypertension Education Program recommendations have included β-blockers as a first-line treatment option for patients younger than 60 years of age based on the evidence from these large trials, and this has been supported by 2 of the meta-analyses. This article reviews these studies to help clinicians better understand the role of β-blockers in managing hypertension., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

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.)

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.)

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.)

Background: The HARMONY study was a randomized, controlled trial examining the efficacy of an 8-week mindfulness-based stress reduction (MBSR) program for blood pressure (BP) lowering among unmedicated stage 1 hypertensive participants., Methods: Participants diagnosed with stage 1 hypertension based on ambulatory BP were randomized to either immediate treatment of MBSR for 8 weeks or wait-list control. Primary outcome analysis evaluated whether change in awake and 24-hour ambulatory BP from baseline to week 12 was significantly different between the 2 groups. A within-group before and after MBSR analysis was also performed., Results: The study enrolled 101 adults (38% male) with baseline average 24-hour ambulatory BP of 135±7.9/82±5.8mm Hg and daytime ambulatory BP of 140±7.7/87±6.3 mmHg. At week 12, the change from baseline in 24-hour ambulatory BP was 0.4±6.7/0.0±4.9mm Hg for the immediate intervention and 0.4±7.8/-0.4±4.6mm Hg for the wait-list control. There were no significant differences between intervention and wait-list control for all ambulatory BP parameters. The secondary within-group analysis found a small reduction in BP after MBSR compared with baseline, a finding limited to female subjects in a sex analysis., Conclusions: MBSR did not lower ambulatory BP by a statistically or clinically significant amount in untreated, stage 1 hypertensive patients when compared with a wait-list control group. It leaves untested whether MBSR might be useful for lowering BP by improving adherence in treated hypertensive participants., Clinical Trials Registration: NCT00825526.

Renal denervation is a novel catheter-based, percutaneous procedure using radiofrequency energy to ablate nerves within the renal arteries. This procedure might help to significantly lower blood pressure (BP) in patients with resistant hypertension, defined as BP > 140/90 mm Hg (> 130/80 mm Hg for those with diabetes) despite use of ≥ 3 optimally dosed antihypertensive agents, ideally including 1 diuretic agent. The Canadian Hypertension Education Program Recommendations Task Force reviewed the current evidence on safety and efficacy of this procedure. Eleven studies on renal denervation were examined and most of the evidence evaluating renal denervation was derived from the Symplicity studies. In patients with systolic BP ≥ 160 mm Hg (≥ 150 mm Hg for patients with type 2 diabetes) despite use of ≥ 3 antihypertensive agents, bilateral renal denervation was associated with significantly lower BP (-22/11 to -34/13 mm Hg) at 6 months with a low periprocedural complication rate. Few patients underwent 24-hour ambulatory BP monitoring and ambulatory BP monitoring showed more modest BP lowering (0 to -11/7 mm Hg). Although early results on short-term safety and blood pressure-lowering are encouraging, there are no long-term efficacy and safety data, or hard cardiovascular end point data. The discrepancy between office BP reductions and 24-hour ambulatory BP monitor reductions needs to be further investigated. Until more data are available, renal sympathetic denervation should be considered as a treatment option of last resort for patients with resistant hypertension who have exhausted all other available medical management options., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

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.)