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Importance: In 2016 and 2017, respectively, new Canadian and US guidelines for diagnosis and management of pediatric hypertension (HTN) were published. Six years after their publication, it is unknown whether the recommendations have led to changes in primary care practice patterns., Objectives: To determine whether HTN guidelines are associated with changes in practice patterns among primary care clinicians., Design, Setting, and Participants: This retrospective, multicenter, population-based cohort study was conducted across 3 phases: January 1, 2011, to December 31, 2015 (era 1), January 1, 2016, to December 31, 2017 (washout period), and January 1, 2018, to December 31, 2019 (era 2). Data were collected from 7 Canadian provinces using the Canadian Primary Care Sentinel Surveillance Network Electronic Medical Record database. Eligible participants included children and adolescents (aged ≥3 to <18 years) with 1 or more encounters in the database. Data analysis was conducted from February 2022 to February 2023., Exposure: Implementation of the 2016 Hypertension Canada and 2017 American Academy of Pediatrics guidelines., Main Outcomes and Measures: The primary outcomes were annual BP screening documentation, high BP follow-up documentation at 6 months and 1-year, HTN prevalence, laboratory testing rates, and medication prescription rates. Interrupted time series analysis was used to assess the association of the introduction of the Canadian and US guidelines with outcomes., Results: The study included 343 191 children and adolescents (mean [SD] age at first encounter, 6.7 (4.6) years; 173 290 female [50.5%]; 169 901 male [49.5%]), including 235 094 patients in era 1 and 193 473 patients in era 2. In era 1, 55 550 patients (23.6%) had at least 1 BP measurement, and in era 2, 45 006 patients (23.3%) had at least 1 BP measurement. There was a significant increase in BP screening in era 2 from 26 876 of 148 554 screenings (18.1%) to 28 556 of 141 192 screenings (20.2%; β = 0.202; 95% CI, 0.009 to 0.390; P = .04), and the increasing trend was sustained. There was a significant decrease in the trend of follow-up of high BP measurement at 6 months (1265 of 4941 patients with BP measurements [25.6%] to 1718 of 7321 patients with BP measurements [23.5%]; β = -0.490; 95% CI, -0.758 to -0.223; P = .001) and 1 year (1974 of 4941 measurements [40.0%] to 2314 of 7321 measurements [31.6%]; β = -1.392; 95% CI, -1.573 to -1.212; P < .001) in era 2. The proportion of patients meeting HTN criteria significantly increased from 2540 of 55 550 patients (4.6%) in era 1 to 5690 of 45 006 patients (12.6%) in era 2 (β = 0.0210; 95% CI, 0.0021 to 0.0410; P = .03). There was no significant change in the trend of laboratory testing rates in era 2 (949 of 4941 patients tested [19.2%] to 1149 of 7321 patients tested [15.7%]; β = -0.159; 95% CI, -0.364 to 0.046; P = .12). The trend in prescribing of medications to patients with HTN also decreased in era 2 (1305 of 4941 patients prescribed medication [26.4%] to 1415 of 7321 patients prescribed medication [19.3%]; β = -0.605; 95% CI, -0.830 to -0.358; P < .001)., Conclusions and Relevance: The findings of this cohort study within the Canadian primary care setting suggest that there was a significant increase in BP screening and HTN prevalence after the publication of national and international HTN guidelines; however, the follow-up of high BP was still suboptimal. Increasing rates of pediatric HTN emphasize the need for better adherence to pediatric HTN guidelines to improve care and outcomes.

Background: The association between hydrochlorothiazide (HCTZ) and skin cancer remains controversial., Objective: To determine whether HCTZ is associated with an increased risk of skin cancer compared with angiotensin-converting enzyme inhibitors and calcium channel blockers., Methods: Two new-user, active comparator cohorts were assembled using 6 Canadian databases. Site-specific hazard ratios (HRs) with 95% CIs were estimated using standardized morbidity ratio weighted Cox proportional hazard models and pooled using random-effects meta-analysis., Results: HCTZ was not associated with an overall increased risk of keratinocyte carcinoma compared with angiotensin-converting enzyme inhibitors or calcium channel blockers, although increased risks were observed with longer durations (≥10 years; HR: 1.12; 95% CI: 1.03-1.21) and higher cumulative doses (≥100,000 mg; HR: 1.49; 95% CI: 1.27-1.76). For melanoma, there was no association with angiotensin-converting enzyme inhibitors, but a 32% increased risk with calcium channel blockers (crude incidence rates: 64.2 vs 58.4 per 100,000 person-years; HR: 1.32; 95% CI: 1.19-1.46; estimated number needed to harm at 5 years of follow-up: 1627 patients), with increased risks with longer durations and cumulative doses., Limitations: Residual confounding due to the observational design., Conclusions: Increased risks of keratinocyte carcinoma and melanoma were observed with longer durations of use and higher cumulative doses of HCTZ., Competing Interests: Conflicts of interest Dr Azoulay received speaker fees from Janssen, Pfizer, and Roche for work unrelated to this study. Dr Platt received consulting fees from Biogen, Boehringer Ingelheim, Merck, Nant Pharma, and Pfizer for work unrelated to this study. Dr Abibula conducted this research during his employment as Staff Scientist at the Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital prior to his employment at Complete HEOR Solutions. Authors St-Jean and Dahl; and Drs Quail, Brophy, Chan, Bresee, Carney, Eltonsy, and Tamim have no conflicts of interest to declare., (Copyright © 2023 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Among patients having noncardiac surgery, perioperative hemodynamic abnormalities are associated with vascular complications. Uncertainty remains about what intraoperative blood pressure to target and how to manage long-term antihypertensive medications perioperatively., Objective: To compare the effects of a hypotension-avoidance and a hypertension-avoidance strategy on major vascular complications after noncardiac surgery., Design: Partial factorial randomized trial of 2 perioperative blood pressure management strategies (reported here) and tranexamic acid versus placebo. (ClinicalTrials.gov: NCT03505723)., Setting: 110 hospitals in 22 countries., Patients: 7490 patients having noncardiac surgery who were at risk for vascular complications and were receiving 1 or more long-term antihypertensive medications., Intervention: In the hypotension-avoidance strategy group, the intraoperative mean arterial pressure target was 80 mm Hg or greater; before and for 2 days after surgery, renin-angiotensin-aldosterone system inhibitors were withheld and the other long-term antihypertensive medications were administered only for systolic blood pressures 130 mm Hg or greater, following an algorithm. In the hypertension-avoidance strategy group, the intraoperative mean arterial pressure target was 60 mm Hg or greater; all antihypertensive medications were continued before and after surgery., Measurements: The primary outcome was a composite of vascular death and nonfatal myocardial injury after noncardiac surgery, stroke, and cardiac arrest at 30 days. Outcome adjudicators were masked to treatment assignment., Results: The primary outcome occurred in 520 of 3742 patients (13.9%) in the hypotension-avoidance group and in 524 of 3748 patients (14.0%) in the hypertension-avoidance group (hazard ratio, 0.99 [95% CI, 0.88 to 1.12]; P  = 0.92). Results were consistent for patients who used 1 or more than 1 antihypertensive medication in the long term., Limitation: Adherence to the assigned strategies was suboptimal; however, results were consistent across different adherence levels., Conclusion: In patients having noncardiac surgery, our hypotension-avoidance and hypertension-avoidance strategies resulted in a similar incidence of major vascular complications., Primary Funding Source: Canadian Institutes of Health Research, National Health and Medical Research Council (Australia), and Research Grant Council of Hong Kong., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-3157.

Background: Few studies describe acute kidney injury (AKI) burden during paediatric cisplatin therapy and post-cisplatin kidney outcomes. We determined risk factors for and rate of (1) AKI during cisplatin therapy, (2) chronic kidney disease (CKD) and hypertension 2-6 months post-cisplatin, and (3) whether AKI is associated with 2-6-month outcomes., Methods: This prospective cohort study enrolled children (aged < 18 years at cancer diagnosis) treated with cisplatin from twelve Canadian hospitals. AKI during cisplatin therapy (primary exposure) was defined based on Kidney Disease: Improving Global Outcomes (KDIGO) serum creatinine criteria (≥ stage one). Severe electrolyte abnormalities (secondary exposure) included ≥ grade three hypophosphatemia, hypokalemia, or hypomagnesemia (National Cancer Institute Common Terminology Criteria for Adverse Events v4.0). CKD was albuminuria or decreased kidney function for age (KDIGO guidelines). Hypertension was defined based on the 2017 American Academy of Pediatrics guidelines., Results: Of 159 children (median [interquartile range [IQR]] age: 6 [2-12] years), 73/159 (46%) participants developed AKI and 55/159 (35%) experienced severe electrolyte abnormalities during cisplatin therapy. At median [IQR] 90 [76-110] days post-cisplatin, 53/119 (45%) had CKD and 18/128 (14%) developed hypertension. In multivariable analyses, AKI was not associated with 2-6-month CKD or hypertension. Severe electrolyte abnormalities during cisplatin were associated with having 2-6-month CKD or hypertension (adjusted odds ratio (AdjOR) [95% CI]: 2.65 [1.04-6.74]). Having both AKI and severe electrolyte abnormalities was associated with 2-6-month hypertension (AdjOR [95% CI]: 3.64 [1.05-12.62])., Conclusions: Severe electrolyte abnormalities were associated with kidney outcomes. Cisplatin dose optimization to reduce toxicity and clear post-cisplatin kidney follow-up guidelines are needed. A higher resolution version of the Graphical abstract is available as Supplementary information., (© 2022. The Author(s), under exclusive licence to International Pediatric Nephrology Association.)

Objectives: The objectives of this study were to explore feline hypertension diagnostics and treatment practices among Canadian veterinarians and to identify barriers to recommending blood pressure monitoring in senior (> 7 y) feline wellness patients., Procedure: An online survey was developed and circulated by CommuniVET using email and social media., Results: A total of 114 Canadian veterinarians completed the survey. Most respondents indicated that they either do not recommend ( n = 45; 39.5%) or occasionally recommend ( n = 47; 41.2%) blood pressure monitoring in senior (> 7 y) feline wellness examinations. The most frequently reported barriers to recommending a blood pressure evaluation were the difficulty in interpreting results in stressed patients ( n = 87; 76.3%), time involved in obtaining blood pressure ( n = 73; 64.0%), and cost to the owner ( n = 54; 47.4%). When faced with a patient diagnosed with a comorbidity commonly associated with hypertension, most respondents indicated that they always recommend ( n = 38; 33.3%) or frequently recommend ( n = 27; 23.7%) blood pressure monitoring. Most veterinarians' first line treatment for hypertension was amlodipine for primary ( n = 81; 71.1%) and secondary ( n = 39; 34.2%) hypertension., Conclusion: Most veterinarians did not routinely recommend blood pressure evaluation during senior feline wellness examinations. Although the frequency of recommendation for blood pressure monitoring appeared to be better in patients diagnosed with a comorbidity associated with hypertension, there was a substantial shortfall., Clinical Relevance: This study identified the most common barriers to recommending blood pressure monitoring in senior feline wellness examinations. Normalizing blood pressure monitoring as part of a routine examination in senior feline patients may lead to increased intervention for hypertension and improved outcomes., (Copyright and/or publishing rights held by the Canadian Veterinary Medical Association.)

Background: Resistant hypertension is associated with cardiovascular morbidity and mortality. The objective of this study was to estimate the prevalence of apparent treatment-resistant hypertension in Canadian adults and examine the characteristics of those affected., Methods: A nationally representative cross-sectional study was conducted with the use of Canadian Health Measures Survey (2007-2017) data. The frequency of respondents with uncontrolled blood pressure despite 3 or more antihypertensive medications of different drug classes (and at least 1 agent being a diuretic), or treatment with 4 or more agents regardless of blood pressure, was determined., Results: A total of 245,700 people were identified to have apparent treatment-resistant hypertension, representing 5.3% (95% confidence interval [CI] 4.5%-6.2%) of adults treated for hypertension in Canada. Respondents who had uncontrolled blood pressure with 3 or more antihypertensive drugs were more likely women (55.8%, 95% CI 41.1%-70.4%), 70 years of age or older (45.3% 95% CI 32.8%-57.9%), and overweight or obese (84.2%, 95% CI 72.3%-96.1%). Respondents with apparent treatment-resistant hypertension also had a high likelihood of chronic kidney disease (36.0%, 95% CI 21.4%-50.6%), diabetes (35.2%, 95% CI 21.7%-48.7%), dyslipidemia (68.0%, 95% CI 55.2%-80.8%), and history of heart attack (9.9%, 95% CI 4.8%-15.1%) or stroke (7.1%, 95% CI 0-14.4%)., Conclusions: Despite being prescribed at least 3 antihypertensive drugs, a considerable proportion of Canadians, especially women, have difficulty achieving blood pressure control, predisposing them to a higher risk of cardiovascular complications and death., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: The combination of angiotensin-converting enzyme inhibitors and beta-blockers is recommended in a wide range of patients with hypertension, including those with stable coronary artery disease and/or elevated heart rate. This post hoc analysis of three observational studies provides effectiveness and safety data on treatment with perindopril on top of bisoprolol-based therapy, in routine clinical practice., Methods: Data were analyzed from three open-label, prospective, multicenter, observational studies of Canadian patients with mild-to-moderate hypertension, which shared the same inclusion and exclusion criteria, treatment duration, and primary outcome. This post hoc analysis focused on the subpopulation of patients treated with perindopril on top of bisoprolol-based therapy. All patients were followed for 16 weeks and underwent baseline, week 4, and week 16 visits. Primary outcomes were mean changes in blood pressure (BP) and proportion of patients achieving BP control (< 140/90 mmHg) in the full analysis set (FAS)., Results: A total of 845 patients (mean age 68.3 ± 11.3 years, mean baseline BP 151.5/86.0 mmHg) were analyzed in the FAS. After 16 weeks, mean SBP/DBP decreased by - 20.4/- 9.8 mmHg with statistically significant reductions observed at all visits in all three studies allowing 78% of patients to achieve the BP treatment goal. No statistically significant changes in heart rate were observed and no serious adverse events reported. The most frequent doses of bisoprolol and perindopril were 5 + 4 mg (34.9%), followed by 5 + 8 mg (16.9%), and 2.5 + 4 mg (12.5%)., Conclusion: The addition of perindopril on top of bisoprolol-based therapy in patients with mild-to-moderate hypertension was associated with significant reductions in BP compared with baseline and with achievement of BP targets in the majority of patients. The results suggest this strategy is safe and effective for use in routine clinical practice., (© 2021. The Author(s).)

Background: Drug shortages represent a growing global problem, with potentially serious consequences to patients and the health care system. Our study investigates the impacts of a major recall and shortage of valsartan, an angiotensin receptor blocker (ARB), in July 2018 in Canada., Methods: We conducted a time-series analysis of antihypertensive drugs dispensed in Canada between 2015 and 2019 using commercially available retail prescription data. Using autoregressive integrated moving average (ARIMA) modelling, we evaluated the change in valsartan use after the recall. We also measured the overall use of ARBs, angiotensin-converting-enzyme (ACE) inhibitors and other antihypertensive drug classes for the same period., Results: After the recall in July 2018, valsartan use decreased 57.8%, from 362 231 prescriptions dispensed in June 2018 to 152 892 in September 2018 (difference = 209 339, p < 0.0001). Overall use of the ARB drug class decreased 2.0%, from 1 577 509 prescriptions dispensed in June 2018 to 1 545 591 in September 2018 (difference = 31 918, p = 0.0003), but use of non-valsartan ARBs increased 14.6%, from 1 215 278 to 1 392 699 prescriptions dispensed (difference = 177 421, p < 0.0001) in the same time frame. Although use of ACE inhibitors initially declined, this reduction was not sustained. The valsartan recall was not associated with a significant impact on use of other antihypertensive drug classes., Interpretation: Our findings illustrate the impact of a major drug shortage, with the immediate and substantial reduction of valsartan dispensed and cascading effects on other ARBs, though future research is warranted to understand the consequences of such extensive shortages on clinical outcomes and health system costs. Improved policy strategies are needed to address the underlying causes of drug shortages and to mitigate their effects., Competing Interests: Competing interests: None declared., (© 2021 CMA Joule Inc. or its licensors.)

Objective: Hypertension (HTN) is common in systemic lupus erythematosus (SLE), representing a key risk factor for cardiovascular and renal disease. We described HTN treatment patterns in SLE, evaluated uncontrolled HTN according to Canadian and American guidelines and identified factors associated with uncontrolled HTN., Methods: We performed a cross-sectional study, identifying all McGill Lupus Clinic registry patients with an annual visit between January 2017 and May 2019 who were taking HTN medications. We excluded those taking medications only for another indication (eg, Raynaud's). We determined the frequency of uncontrolled HTN according to Canadian and American College of Cardiology/American Heart Association guidelines. Multivariate logistic regression (adjusted for age, sex and race/ethnicity) evaluated if uncontrolled HTN was more common with high body mass index (BMI), longer SLE duration, high disease activity, renal damage, multiple concomitant antihypertensives, prednisone and non-steroidal anti-inflammatory drugs., Results: Of 442 patients with SLE, 108 were taking medications to treat HTN, and 38 took multiple medications concurrently. Angiotensin-receptor blockers were most common, followed by calcium channel blockers, diuretics, angiotensin-converting enzyme inhibitors and beta blockers. Among the 108 patients, 39.8% (n=43) had blood pressure (BP) >140/90 mm Hg, while 66.7% (n=72) had BP >130/80 mm Hg. In multivariate analyses, uncontrolled HTN (>130/80 mm Hg) was more likely in Caucasians (OR 2.72, 95% CI 1.12 to 6.78) and patients with higher BMI (OR 1.08, 95% CI 1.00 to 1.19). Patients with renal damage had better HTN control (OR 0.39, 95% CI 0.16 to 0.97). We could not draw definitive conclusions regarding other variables., Conclusion: Caucasians and patients with higher BMI had more uncontrolled HTN. The negative association with renal damage is reassuring, as controlled BP is key for renal protection., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Catheter ablation is an established therapy for atrial fibrillation but is limited by recurrence; efforts have been made to identify biomarkers that predict recurrence. We investigated the effect of baseline NT-proBNP on AF recurrence following catheter ablation in patients randomized to aggressive (< 120/80 mmHg) or standard blood pressure management (< 140/90 mmHg) in the Substrate Modification with Aggressive Blood Pressure Control trial (SMAC-AF)., Methods: The SMAC-AF study included 173 patients resistant or intolerant to at least one class I or III antiarrhythmic drug. We studied the effect of baseline NT-proBNP on the primary outcome of AF recurrence > 3 months post-ablation., Results: Of the 173 patients, 88 were randomized to the aggressive cohort, and 85 into the standard group. The primary outcome occurred in 61.4% of those in the aggressive arm, versus 61.2% in the standard arm. In the aggressive group, logNT-proBNP predicted recurrence (HR 1.28, p = 0.04, adjusted HR 1.43, p = 0.03), while in the standard cohort, it did not (HR 0.94, p = 0.62, adjusted HR 0.83, p = 0.22). NT-proBNP ≥ 280 pg/mL also predicted occurrence in the aggressive (HR 1.98, p = 0.02) but not the standard cohort (HR 1.00, p = 1.00)., Conclusion: We conclude that pre-ablation NT-proBNP may be useful in predicting recurrence in hypertensive patients and identifying patients who benefit from aggressive blood control and upstream therapies., Trial Registration: NCT00438113, registered February 21, 2007., (© 2021. The Author(s).)

BACKGROUND: The management of chronic diseases is a continuing challenge for health care systems and patients. OBJECTIVE: To assess the effect of a pharmacist-specific chronic diseases management incentive plan (the Comprehensive Annual Care Plan [CACP]) implemented by the government of Alberta (Canada) on adherence to lipid-lowering drugs (LLD) among patients with hypertension. METHODS: We conducted a cohort study of patients with hypertension who received the CACP between 2012 and 2015, using administrative health data. Patients who qualified to receive the CACP but did not receive it were selected as controls. Adherence was assessed 1 year before and after the CACP as the proportion of days covered (PDC) by any LLD. We conducted 2 distinct logistic regressions to assess the likelihood of an increase of the post-CACP PDC by 0.20 among patients with poor pre-CACP adherence (i.e., pre-CACP PDC < 0.80), and the post-CACP PDC decrease by 0.20 among those with previous good adherence. RESULTS: Data for 12,763 CACP patients and 14,555 controls were analysed. CACP patients who had a pre-CACP PDC < 0.80 were more likely to increase their PDC compared with controls (44.7% vs. 37.8%; adjusted odds ratio [aOR] = 1.34; 95% CI = 1.22-1.46). Conversely, CACP and control patients with a pre-CACP PDC ≥ 0.80 had similar likelihood to decrease their PDC (13.4% vs. 14.1%; aOR = 0.96; 95% CI = 0.88-1.04). CONCLUSIONS: The pharmacy CACP was associated with a modest improvement of adherence to LLD. The incentive system for improved care seemed more effective among patients who had low baseline adherence rates with minimal effect in those with previous good adherence. DISCLOSURES: This work was supported by a grant from the Institute of Health Economics, with funding from Alberta Innovates and Eli Lilly Canada. The sponsor had no role in the study design, data acquisition, analysis, interpretation of the results, and the decision to publish. The authors have no conflicts of interest to disclose. This study is based on data provided by Alberta Health. The interpretation and conclusions contained herein are those of the researchers and do not necessarily represent the views of the government of Alberta nor the funder (Institute of Health Economics). Neither the government nor Alberta Health nor the Institute of Health Economics express any opinion in relation to this study.

Aims: The CV-CARE registry provides RWE in Canadian routine clinical practice., Methods: CV-CARE is a multi-site, observational, prospective Canadian registry enrolling patients initiating treatment with metformin hydrochloride extended-release (MetER) for T2D; colesevelam (C) for HCh; and azilsartan (AZI), azilsartan/chlorthalidone (AZI/CHL) or diltiazem extended-release (TXC) for HTN. Patient characteristics/assessment were performed at baseline and 12 ± 6 months. Primary outcome was absolute change in HbA 1c and FPG (MetER); % change in LDL-C (C); and absolute change in BP (AZI-AZI/CHL-TXC)., Results: Of the 4194 patients in the primary analysis population, 24% were taking MetER, 39% were taking C, 33% were taking AZI, 12% were taking AZI/CHL, and 3% were taking TXC. At 12 months, MetER-treated patients had an absolute mean (95% CI) change in HbA 1c of -0.3% [-0.4; -0.2] and in FPG of 0.7 mmol/L [-1.0; -0.4]. C-treated patients had a mean (95% CI) % change in LDL-C of -13.0% [-14.6; -11.4]. Absolute mean (95% CI) changes in SBP were -18.7 mmHg [-19.7; -17.7](AZI), -21.3 mmHg [-23.1; -19.5](AZI/CHL), and -12.3 mmHg [-15.1; -9.6](TXC)., Conclusion: In a real-world Canadian setting, MetER, C, AZI, AZI/CHL, and TXC show improvement of the cardiometabolic profile of T2D, HCh, and HTN patients., Competing Interests: Declaration of Competing Interest RG reports research support from Abbott, AstraZeneca, Boehringer Ingelheim, Eli Lilly, GlaxoSmithKline, Janssen, Medtronic, Merck, Novartis, Novo Nordisk, Roche, Sanofi, and Takeda; serving on advisory panels for AstraZeneca, Boehringer Ingelheim, Eli Lilly, Janssen, Merck, Novo Nordisk, Roche, Sanofi, and Takeda; speaker bureaus for Abbott, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Janssen, Merck, Novo Nordisk, Sanofi, and Servier; consulting for AstraZeneca, Bausch Health, Boehringer Ingelheim, Eli Lilly, Janssen, Novo Nordisk, and Takeda. AB has received research support, consulting fees and/or speaker honorarium from the following commercial organizations: Amgen, Bristol Myers Squibb, Janssen, AstraZeneca, Pfizer, Bayer, Lilly, Boehringer Ingelheim, Canopy Growth, Sanofi, Bausch Health. WC has no conflicts of interest to declare. MB (Melonie Burrows), EP, NFA, MG and are employees of Bausch Health Companies. JB and MB (Maxime Barakat) are employees of, and shareholders in, Bausch Health Companies., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Regional differences in the profile and treatment strategies of patients with cardiometabolic diseases have been studied in several different countries. The Cardio-Vascular and metabolic treatments in Canada: Assessment of REal-life therapeutic value (CV-CARE) registry was designed to evaluate patient profiles and medical management of cardiometabolic diseases in routine clinical care settings across Canada. Primary objectives were to (1) evaluate regional variability of patient profiles with cardiometabolic disease(s) and (2) assess treatment differences of patients treated for type 2 diabetes (T2D), hypercholesterolemia (HCh), and hypertension (HTN) across Canada., Methods: CV-CARE is a multi-center, observational, prospective registry that enrolled Canadian patients treated with metformin-extended release (MetER) for T2D, colesevelam (C) for HCh, azilsartan (AZI) for mild-to-moderate essential HTN and azilsartan/chlorthalidone (AZI/CHL) for severe, essential HTN. Patient characteristics and treatments were assessed at baseline., Results: The registry enrolled 6960 patients, with a total of 4194 patients making up the primary analysis population [MetER (n=995); C (n=1639); AZI (n=1364); AZI/CHL (n=498)]. First-line use of MetER was more common in British Columbia (BC; 45.5%) compared to Ontario (ON; 29.8%), and Quebec (QC; 12.9%). C treatment for HCh was used as monotherapy most readily in BC (68.7%) compared with QC (59.7%) and ON (35.8%). Dual action of low-density lipoprotein cholesterol and hemoglobin A1c reduction was the predominant reason for C add-on therapy (46.8%), with highest usage seen in ON (62.9%). AZI treatment for HTN was most frequently used in BC (43.8%), and AZI/CHL was most commonly used in ON (12.0%). First-line use of AZI was more common in QC (50%) vs. ON (34.9%) and BC (24.1%). The primary reason for switching to AZI and AZI/CHL from prior treatment was lack of efficacy across provinces., Conclusion: This is the first regional description of the CV-CARE cohort. Significant variations in both baseline profile and treatments were observed which could have an impact on long-term outcomes., (Copyright © 2020 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Animal studies suggest that decreased vascular mitochondrial DNA copy number can promote hypertension. We conducted a chart review of blood pressure and hemodynamics in patients with either mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS, n = 36) or individuals with variants in the mitochondrial DNA polymerase gamma (POLG, n = 26). The latter included both pathogenic variants and variants of unknown significance (VUS). Hypertension rates (MELAS 50%, POLG 50%) were elevated relative to Canadian norms in 20-39 (MELAS) and 40-59 (MELAS and POLG) years of age groups. Peripheral resistance was high in the hypertensive versus normotensive patients, potentially indicative of microvascular disease. Despite antihypertensive treatment, systolic blood pressure remained elevated in the POLG versus MELAS group. The risk of hypertension was not associated with MELAS heteroplasmy. Hypertension rates were not different between individuals with known pathogenic POLG variants and those with VUS, including common variants. Hypertension (HT) also did not differ between patients with POLG variants with (n = 17) and without chronic progressive external opthalmoplegia (n = 9) (CPEO). HT was associated with variants in all three functional domains of POLG. These findings suggest that both pathogenic variants and several VUS in the POLG gene may promote human hypertension and extend our past reports that increased risk of HT is associated with MELAS., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. and Mitochondria Research Society. All rights reserved.)

Background: It is unclear whether generics are as safe as brand-name drugs in cardiology. For public health surveillance purposes, we evaluated if switching from the brand-name losartan, valsartan, or candesartan impacted the occurrence of the following outcomes: emergency room (ER) consultations, hospitalizations, or death., Study Design: This was a retrospective cohort study., Methods: This study was conducted in the Quebec Integrated Chronic Disease Surveillance System, including healthcare administrative data of the population of Quebec, Canada. We included brand-name users of losartan, valsartan, or candesartan aged ≥ 66 years who had undergone ≥ 30 days of stable treatment on the brand-name drug prior to cohort entry (substitution time-distribution matching was used to prevent immortal time bias). Outcomes up to 1 year were compared between groups using multivariable Cox proportional hazards regression models (validity assumptions were verified)., Results: In our cohorts (losartan, n =15,783; valsartan, n =16,907; candesartan, n =26,178), mean age was 76-78 years, 59-66% were female, 90-92% had hypertension, and 13-15% had heart failure. Validity assumptions were violated for losartan only. For patients switched to generic valsartan, the hazard ratio (95% confidence interval) was 1.07 (0.99-1.14) for ER consultation, 1.26 (1.14-1.39) for hospitalization, and 1.01 (0.61-1.67) for death. The corresponding rates for candesartan were 1.00 (0.95-1.05), 0.96 (0.89-1.03), and 0.57 (0.37-0.88), respectively., Conclusions: We observed an increased risk of hospitalizations for patients switched to generic valsartan, and a decreased risk of death for patients switched to generic candesartan, compared with those who continued taking the brand-name drug. The differences between generic and brand-name drugs may lead to some differences in public health outcomes, but this safety signal must be further studied using other cohorts and settings.

Volunteers support health and social care worldwide, yet there is little research on integrating these unpaid community members into primary care. 'Health Teams Advancing Patient Experience, Strengthening Quality through Health Connectors for Diabetes Management' (Health TAPESTRY-HC-DM) integrates volunteer 'health connectors' into a community- and primary care-based program supporting client self-management in Hamilton, Canada. Volunteers supported clients through goal setting, motivation, education and connections to community resources and primary care. This study aimed to create and apply a volunteer program evaluation framework to explore: (a) volunteer training effectiveness (learning online content, in-person training, self-efficacy in role tasks, training overall); (b) feasibility of program implementation (process measures, reflections on client encounters, understanding of volunteer roles/responsibilities, client perspectives on volunteer program); and (c) effects of volunteering on volunteers (health outcomes, self-efficacy, value of volunteering). A concurrent triangulation, mixed-methods design was used. Data were collected in 2016, sources included: volunteer online training quizzes, focus groups, self-efficacy survey, Veterans RAND 12-Item (VR-12) survey, in-person training feedback forms and narratives of client visits; client interviews; and quantitative implementation data. Quantitative data analysis included descriptive statistics, paired samples t tests, and effect size (Cohen's d). Qualitative data used descriptive thematic analysis. Nineteen volunteers and 12 clients participated in this evaluation. Findings demonstrate the volunteer program evaluation framework in action. Online training increased knowledge. In-person training received largely positive evaluations. Self-efficacy was high post-training and higher after volunteering. VR-12 sub-scale means increased descriptively. Volunteers understood themselves as healthcare system connectors, feeling fulfilled with their contributions and learning new skills. They identified barriers including not having the resources and skills of healthcare professionals. Clients found volunteers were a major program strength, appreciating their company and regular goals follow-up. Using a volunteer program evaluation framework generated rich and comprehensive data demonstrating the feasibility of bringing volunteers into primary care., (© 2019 John Wiley & Sons Ltd.)

Objective: We aimed to determine the adequacy of disease control and intensity of treatment for diabetes and hypertension in individuals with multiple sclerosis (MS) as compared to individuals without MS using the Canadian Primary Care Sentinel Surveillance System (CPCSSN)., Methods: We identified individuals aged ≥18 years, with ≥1 record in the CPCSSN data as of March 31, 2016. We applied a validated case definition to identify individuals with MS, hypertension and diabetes. Hypertension was defined as controlled if the average blood pressure was <140/90, while diabetes was defined as controlled if the average HbA1c was ≤7%. Treatment intensity for each condition was described as the number of related drugs prescribed per patient. We used multivariable logistic regression analysis to determine the association between MS and (i) hypertension control (BP <140/90), or (ii) diabetes control (HbA1c ≤7%) accounting for age, sex, region of residence, body mass index, number of physician visits in the last two years, and depression., Results: Among 971,799 individuals meeting the inclusion criteria, 2926 (0.3%) had MS of whom 666 (22.8%) had hypertension and 298 (10.2%) had diabetes. On univariate analysis, as compared to persons without MS, persons with MS had 25% increased odds of achieving good control of hypertension (OR 1.26; 95%CI: 1.05-1.33), and 31% increased odds of achieving good diabetes control (1.31; 95%CI: 1.00-1.71). On multivariable analysis, persons with MS no longer had increased odds of achieving good control of hypertension (OR 1.04; 95%CI: 0.79-1.37) or diabetes control (OR 1.15; 95%CI: 0.76-1.74). In a sensitivity analysis using an HbA1c ≤7%, individuals with MS had increased odds of achieving the target (OR 1.57; 95%CI: 1.02-2.44). The mean (SD) number of anti-hypertensive medications used was lower among persons with MS (0.18 [0.81]) than among persons without MS (0.40 [1.35], p = 0.001). The mean (SD) number of medications used for diabetes did not differ between persons with MS (2.4 [1.9]) and without MS (2.5 [1.8], p = 0.56)., Conclusion: In the Canadian primary care setting, comorbid MS does not adversely affect the control of hypertension or diabetes., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Out-of-office blood pressure (BP) monitoring appears to be a very useful approach to hypertension management insofar it allows to obtain multiple measurements in the usual environment of each individual, allows the detection of hypertension phenotypes, such as white-coat and masked hypertension, and appears to have superior prognostic value than the conventional office BP measurements. Out-of-office BP can be obtained through either home or ambulatory monitoring, which provide complementary and not identical information. Home BP monitoring yields BP values self-measured in subjects' usual living environment; it is an essential method for the evaluation of almost all untreated and treated subjects with suspected or diagnosed hypertension, best if combined with telemonitoring facilities, also allowing long-term monitoring. There is also increasing evidence that home BP monitoring improves long-term hypertension control rates by improving patients' adherence to prescribed treatment. In Latin American Countries, it is widely available, being relatively inexpensive, and well accepted by patients. Current US, Canadian, Japanese, and European guidelines recommend out-of-office BP monitoring to confirm and refine the diagnosis of hypertension., (© 2020 Wiley Periodicals, Inc.)

Diagnosis and treatment of high blood pressure: internationals standards and divergences. High blood pressure affects more than 1.4 billion people worldwide and this number is increasing. Three international recommendations were published between 2017 and 2018. Essential hypertension is defined differently from one recommendation to another; AHA/ACC recommendations retain 130/80 mmHg, compared to 140/90 mmHg for Canada and Europe, resulting in a higher prevalence of hypertension. The management of hypertensive patients is based on 2 axes: a non-pharmacological axis that must be recalled at each consultation, and a pharmacological axis; for which the American and European guidelines recommend the introduction of a dual therapy, pharmacologically complementary, when initiating treatment in hypertensive patients. Blood pressure targets are lower in the United States than in Canada and Europe., Competing Interests: A. Fayol déclare n’avoir aucun lien d’intérêts. P. Boutouyrie déclare avoir été pris en charge lors de congrès par les laboratoires Servier, être président de la société Artery, soutenue par un « unconditionnal grant » accordé par Servier, et avoir participé à la rédaction des recommandations ESH/ESC.

Alpha-blockers (ABs) are commonly prescribed as part of a multidrug regimen in the management of hypertension. We set out to assess the risk of hypotension and related adverse events with AB use compared with other blood pressure (BP) lowering drugs using a population-based, retrospective cohort study of women (≥66 years) between 1995 and 2015 in Ontario, Canada. Cox proportional hazards examined the association of AB use and hypotension and related events (syncope, fall, and fracture) compared with other BP lowering drugs matched via a high dimensional propensity score. The primary outcome was a composite of hospitalizations for hypotension and related events (syncope, fractures, and falls) within 1 year. From 734 907 eligible women, 14 106 were dispensed an AB (mean age, 75.7; standard deviation 6.9 years, median follow-up 1 year) and matched to 14 106 dispensed other BP lowering agents. The crude incidence rate of hypotension and related events was 95.7 (95% CI [confidence interval], 90.4-101.1, events 1214 [8.6%]) with AB and 79.8 (95% CI, 74.9-84.7 per 1000 person-years, events 1025 [7.3%]) with other BP lowering medications (incident rate ratio, 1.20; 95% CI, 1.10-1.30). The risk was higher for hypotension (hazard ratio, 1.71; 95% CI, 1.33-2.20) and syncope (hazard ratio, 1.44; 95% CI, 1.18-1.75) with no difference in falls, fractures, adverse cardiac events, or all-cause mortality. Treatment of hypertension in women with ABs is associated with a higher risk of hypotension and hypotension-related events compared with other BP lowering agents. Our findings suggest that ABs should be used with caution, even as add on therapy for hypertension.

Background: Vascular surgeons have a central role in managing peripheral artery disease (PAD). This study assessed their knowledge, attitudes, and behaviors regarding pharmacologic risk reduction in PAD and results were compared to a similar 2004 survey conducted by our group., Methods: An online questionnaire was administered to 161 active members of the Canadian Society for Vascular Surgery., Results: Forty-eight participants (30%) completed the survey. Recommended targets for low-density lipoprotein cholesterol, blood pressure, and glucose were known by 52%, 38%, and 50% of vascular surgeons, respectively. Almost all participants recognized antiplatelet dosages and statin indications, but less than half could identify indications (29%) and precautions (44%) for angiotensin converting enzyme (ACE) inhibitor therapy. A majority (58%) routinely evaluate risk factors in <50% of their patients. Most vascular surgeons regularly provide risk reduction counseling, but less than 10% initiate or modify antihypertensive or ACE inhibitor therapy. Compared to 2004, knowledge of targets and indications/precautions for common cardiovascular medications and frequency of risk factor assessment have not changed. Rates of counseling for diabetes control and statin prescription have improved, but remain suboptimal. Regarding newer medications with cardiovascular benefit, less than 10% would prescribe proprotein convertase subtilisin/kexin type 9 and sodium-glucose cotransporter 2 inhibitors if they were available. The majority of vascular surgeons rate their PAD risk reduction knowledge as average and support an up-to-date Canadian PAD guideline. Most participants believe that risk reduction therapy is best provided by family physicians and internists, but also acknowledge that vascular surgeons should be well-versed in assessing and managing risk factors in PAD., Conclusions: Significant knowledge and action gaps exist among Canadian vascular surgeons with regards to pharmacologic cardiovascular risk reduction in PAD. Although there is recognition that vascular surgeons are central to the medical management of patients with PAD, few routinely evaluate risk factors and prescribe medications. There is little evidence of sufficient improvement since 2004. New educational and clinical strategies are needed to improve PAD risk reduction pharmacotherapy among Canadian vascular surgeons., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Importance: The 2017 American College of Cardiology and American Heart Association (ACC/AHA) blood pressure (BP) guidelines redefined hypertension using a BP threshold of 130/80 mm Hg or greater and applied a treatment target of less than 130/80 mm Hg., Objective: To evaluate the potential change in the diagnosis, treatment, and control of hypertension in a Canadian cohort of patients with hypertension attending primary care practices using the ACC/AHA guidelines., Design, Setting, and Participants: This cross-sectional study used primary care practices across Canada electronic medical record data from the Canadian Primary Care Sentinel Surveillance Network, extracted as of June 30, 2015. Adults with at least 1 primary care encounter in the previous 2 years (July 1, 2013, to June 30, 2015) were included in the study. Those with current hypertension were identified using a validated definition consisting of diagnoses, billing codes, and/or antihypertensive medication from within the primary care electronic medical record. Data analysis was conducted from December 2017 to July 2018., Main Outcomes and Measures: Proportion of individuals with a diagnosis of hypertension, prescribed antihypertensive medication, and meeting treatment BP targets., Results: Of the 594 492 Canadian participants included in the study, 144 348 (24.2%) had hypertension (45.6% male; mean [SD] age, 65.5 [14.5] years). On applying the ACC/AHA guidelines, 252 279 individuals (42.4%) were considered hypertensive and half (51.0%; 95% CI, 50.8%-51.2%) were prescribed an antihypertensive medication. Individuals who were not previously considered to have hypertension but were reclassified as having elevated BP using the lower cutoff of 130/80 mm Hg or greater tended to be younger and were at lower cardiovascular risk. There was a shift toward more individuals requiring antihypertensive treatment, particularly in the lower-risk categories. The crude prevalence of hypertension increased from 13.3% to 32.0% in those aged 18 to 64 years, and of those aged 65 years and older, 16.6% more individuals were reclassified as having hypertension (from 55.2% to 71.8%). Only 12.3% of those who were considered at high risk were reclassified as hypertensive., Conclusions and Relevance: Adoption of the ACC/AHA BP guidelines would result in a near doubling in the prevalence of hypertension in Canada. The changes would largely affect individuals who are younger and at low to moderate cardiovascular risk.

Background: Hypertension, or high blood pressure, is a major cause of disability and the leading risk factor for death around the world. Ongoing surveillance is necessary to monitor and assess the population burden of hypertension in Canada., Data and Methods: Using measured data from the Canadian Health Measures Survey, this analysis estimates average systolic blood pressure (BP), average diastolic BP, and hypertension prevalence, awareness, treatment and control in the population aged 20 to 79 years in the period from 2012 to 2015 by sex and age group. Crude and age-standardized overall estimates for 2007-2009, 2009-2011, 2012-2013 and 2014-2015 are also presented., Results: Among adults aged 20 to 79 years, 24% of males and 23% of females had hypertension, defined as measured BP ≥140/90 mm Hg or past-month use of antihypertensive medication. Hypertension prevalence increased to 40% for males and 32% for females when the BP threshold was lowered to ≥130/80 mm Hg. Among adults, 84% of people with hypertension were aware of their condition, 80% of hypertensive people were treated for their condition, and 66% had controlled hypertension (measured BP ⟨140/90 mm Hg), though those aged 20 to 39 were less likely than older age groups to be aware, treated or controlled. Crude and age-standardized rates remained fairly stable during the period from 2007-2009 to 2014-2015., Discussion: Hypertension prevalence among adults has remained stable over time in Canada, and hypertension awareness, treatment and control have remained high. However, rates of awareness, treatment and control are lower among younger adults. This finding highlights the importance of initiatives to encourage this population to have their blood pressure checked and treated.

Background: Hypertension (or high blood pressure) affects almost one in four adults in Canada. Quantifying risk factors associated with hypertension may help to inform prevention efforts., Data and Methods: Data from the first four cycles of the Canadian Health Measures Survey (including 13,407 respondents) were used to identify hypertension status by systolic and diastolic blood pressure levels and the use of antihypertensive medications. Logistic regression analysis was employed to estimate the association between six cardiovascular risk factors (individually and as a composite score) and hypertension., Results: Engaging in less than 150 minutes per week of moderate-to-vigorous physical activity, eating fruits and vegetables fewer than five times per day, being overweight or obese, having diabetes, and having chronic kidney disease were all independently associated with an increased risk of hypertension. When these factors were combined into a risk score, there was a linear increase in the predicted risk of hypertension with each additional risk factor. The predicted prevalence of hypertension for those with all six risk factors was 55% in women and 44% in men aged 20 to 39 years, and 80% in women and 76% in men aged 70 to 79 years. Being overweight or obese, consuming fruits and vegetables less often, being inactive, and having diabetes contributed to the largest attributable fractions for hypertension in the Canadian population., Discussion: Physical activity, diet, body mass index, the presence of diabetes, and the presence of chronic kidney disease were strong risk factors for hypertension. Many of these risk factors are modifiable and highlight targets for future prevention strategies.

Background and Objectives: Management of hypertension and dyslipidemia is important when considering cardiovascular disease risk; however, achievement of optimal lipid and blood pressure (BP) targets in clinical practice remains inadequate. This analysis sought to estimate the frequency, effectiveness, and safety of co-administrated atorvastatin and perindopril in routine care., Methods: We conducted a post hoc analysis of four Canadian, prospective, multi-center, observational studies assessing real-life effectiveness and safety of perindopril + atorvastatin in mild-to-moderate hypertensive patients with concomitant dyslipidemia over 16 weeks. The safety population comprised patients receiving one or more doses of free combination perindopril + atorvastatin; the full analysis set (FAS) received perindopril + atorvastatin at baseline, with one or more post-baseline systolic BP measurements while on treatment., Results: A total of 3541 and 3172 patients were included in the safety population and FAS, respectively. At the last observation carried forward, significant reductions in mean systolic BP (- 18.0 mmHg; p < 0.001) and diastolic BP (- 8.9 mmHg; p < 0.001) were observed; target BP was achieved by 73.1% of patients. Emergent adverse events (AEs) were reported in 8.0% of patients, the most common being cough (4.5% of patients), headache (0.9%), and dizziness (0.8%). Four serious AEs were reported among three (0.1%) patients. No differences were observed in effectiveness or safety between studies., Conclusions: Concomitant perindopril + atorvastatin therapy demonstrated similar efficacy across all studies, with significant reductions in BP and achievement of target BP levels observed in a real-world setting. Results align with known safety profiles of atorvastatin and perindopril, with no unexpected AEs observed when compared with data from treatment with the individual drugs.

Background: In Canada, hypertension control is significantly less likely in older women taking antihypertensive medication than in older men. This study examines factors that may explain some of the differences in hypertension control between women and men., Data and Methods: The analysis is based on data collected for 2,111 adults aged 60 to 79 who were treated for hypertension in the first four cycles of the Canadian Health Measures Survey. Hypertension, treatment and control were estimated based on measured systolic and diastolic blood pressure and on the Drug Identification Numbers of antihypertensive medications. Risk factors included health behaviours, comorbidities and a family history of hypertension. Sex-specific logistic regression models examined associations between risk factors and hypertension control., Results: The systolic blood pressure of women taking antihypertensive medication was higher than that of men, regardless of hypertension control. For women, older age and diabetes were significantly associated with poorer hypertension control, while older age, ethnicity, diabetes, no cardiovascular disease, and nonsteroidal anti-inflammatory drug use were significant for men., Discussion: Based on current blood pressure targets, women and men aged 60 to 79 taking antihypertensive medication in Canada continue to differ in control and factors associated with control. Further research to better understand the underlying cause of these associations may help reduce disparities in hypertension control rates between women and men in Canada.

Background: The Systolic Blood Pressure Intervention Trial (SPRINT) showed significant reductions in major cardiovascular events and all-cause mortality with a systolic blood pressure (BP) goal of < 120 mm Hg compared with < 140 mm Hg. We sought to determine the proportion of Canadian adults who meet SPRINT eligibility criteria., Methods: We conducted a cross-sectional study using cycles 1-3 of the nationally representative Canadian Health Measures Survey to estimate the prevalence and characteristics of Canadian adults between the ages of 20 and 79 who meet SPRINT eligibility criteria: age ≥ 50 years, elevated systolic BP of 130-180 mm Hg, and increased cardiovascular risk (with chronic kidney disease, Framingham Risk Score ≥ 15% in 10 years, and/or cardiovascular disease) but without diabetes, stroke, or end-stage renal disease., Results: An estimated 1.3 million (5.2%) Canadian adults met SPRINT eligibility criteria; 14.3% (95% confidence interval, 10.6%-17.9%), or 182,600 people, were not previously considered to have hypertension or need for antihypertensive therapy. Of adults aged 50-79 years treated for hypertension, 18.7% (95% confidence interval, 15.5%-21.8%), or 754,400 individuals, would potentially benefit from treatment intensification., Conclusions: If fully implemented, intensive systolic BP lowering to < 120 mm Hg in SPRINT-eligible high-risk individuals would substantially increase the proportion of Canadian adults receiving BP treatment initiation or intensification., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

In this report we examine the differences between the 2017 Hypertension Canada and 2017 American College of Cardiology and American Heart Association (ACC/AHA) blood pressure (BP) guidelines regarding the proportions of individuals with a diagnosis of hypertension, BP above thresholds for treatment initiation, and BP below targets using the CARTaGENE cohort. Compared with the 2017 Canadian guidelines, the 2017 ACC/AHA guidelines would result in increases of 8.7% in hypertension diagnosis and 3.4% of individuals needing treatment, with 17.2% having a different BP target. In conclusion, implementing the 2017 ACC/AHA hypertension guidelines in Canada could result in major effects for millions of Canadians., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Recent evidence suggests that the mineralocorticoid receptor antagonist spironolactone should be the preferred fourth-line antihypertensive treatment in resistant hypertension (RHTN). Whether spironolactone improves blood pressure (BP) control in heart failure with preserved ejection fraction (HFpEF) and RHTN is unknown., Methods: We identified patients with RHTN, defined as baseline systolic blood pressure (SBP) between 140 and 160 mm Hg on 3 or more medications, in the Americas cohort of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial, in which patients with HFpEF were randomized to spironolactone vs. placebo. We evaluated the effects of spironolactone vs. placebo on BP reduction in this group and related this to the primary composite outcome of death from cardiovascular causes, aborted cardiac arrest, or hospitalization for heart failure., Results: We identified 403 participants in the Americas with RHTN. Compared to people without RHTN, those with RHTN were more frequently women, non-White, diabetics, with a higher left ventricular ejection fraction and body mass index, and a lower hemoglobin concentration. In the RHTN group, spironolactone resulted in a decrease of SBP: -6.1 (-8.9, -3.3); P < 0.001 and diastolic BP: -2.9 (-4.6, -1.2); P = 0.001 mm Hg during the first 8 months. BP became controlled after 4 weeks in 63% of patients receiving spironolactone vs. 46% receiving placebo (P = 0.003), with similar responses at 8 weeks, 4 and 8 months. Patients with RHTN derived similar overall benefit from spironolactone on the primary outcomes as those without., Conclusions: In HFpEF patients with RHTN, spironolactone lowered BP substantially and was associated with similar benefit as those without RHTN., Clinical Trials Registration: Trial Number NCT00094302 (ClinicalTrials.gov identifier).

Objective: We aimed to estimate the proportion of underdiagnosis and undertreatment of cardiovascular risk factors (CVRF) in an international multicenter cohort of patients with psoriasis and psoriatic arthritis (PsA)., Methods: A cross-sectional analysis was conducted of patients with psoriatic disease from the International Psoriasis and Arthritis Research Team cohort. The presence of modifiable CVRF [diabetes, hypertension (HTN), dyslipidemia, smoking, elevated body mass index, and central obesity] and the use of appropriate therapies for HTN and dyslipidemia were determined. The 10-year CV risk was calculated according to the Framingham Risk Score. Physician adherence with guidelines for the treatment of dyslipidemia and HTN was assessed. Regression analysis was used to assess predictors of undertreatment of HTN and dyslipidemia., Results: A total of 2254 patients (58.9% PsA, 41.1% psoriasis) from 8 centers in Canada, the United States, and Israel were included. Their mean age was 52 ± 13.8 years and 53% were men. Of the patients, 87.6% had at least 1 modifiable CVRF, 45.1% had HTN, 49.4% dyslipidemia, 13.3% diabetes, 75.3% were overweight or obese, 54.3% central obesity, and 17.3% were current smokers. We found 59.2% of patients with HTN and 65.6% of patients with dyslipidemia were undertreated. Undertreatment was associated with younger age (≤ 50 yrs), having psoriasis, and male sex., Conclusion: In real-world settings, a large proportion of patients with psoriasis and PsA were underdiagnosed and undertreated for HTN and dyslipidemia. Strategies to improve the management of CVRF in psoriatic patients are warranted.

Background: Drug expenditures are responsible for an increasing proportion of health costs, accounting for $1.1 trillion in annual expenditure worldwide. As hundreds of billions of dollars are being spent each year on overtreatment with prescribed medications that are either unnecessary or are in excess of lowest cost-effective therapy, programs are needed that optimize fiscally appropriate use. We evaluated whether providing physicians with information on the patient out-of-pocket payment consequences of prescribing decisions that were in excess of lowest cost-effective therapy would alter prescribing decisions using the treatment of uncomplicated hypertension as an exemplar., Methods: A single-blind cluster randomized trial was conducted over a 60-month follow-up period in 76 primary care physicians in Quebec, Canada, and their patients with uncomplicated hypertension who were using the MOXXI integrated electronic health record for drug and health problem management. Physicians were randomized to an out-of-pocket expenditure module that provided alerts for comparative out-of-payment costs, thiazide diuretics as recommended first-line therapy, and tools to monitor blood pressure targets and medication compliance, or alternatively the basic MOXXI system. System software and prescription claims were used to analyze the impact of the intervention on treatment choice, adherence, and overall and out-of-pocket payment costs using generalized estimating equations., Results: Three thousand five-hundred ninety-two eligible patients with uncomplicated hypertension were enrolled, of whom 1261 (35.1%) were newly started (incident patient) on treatment during follow-up. There was a statistically significant increase in the prescription of diuretics in the newly treated intervention (26.6%) compared to control patients (19.8%) (RR 1.65, 95% CI 1.17 to 2.33). For patients already treated (prevalent patient), there was a statistically significant interaction between the intervention and patient age, with older patients being less likely to be switched to a diuretic. Among the incident patients, physicians with less than 15 years of experience were much more likely to prescribe a diuretic (OR 10.69; 95% CI 1.49 to 76.64) than physicians with 15 to 25 years (OR 0.67; 95%CI 0.25 to 1.78), or more than 25 years of experience (OR 1.80; 95% CI 1.23 to 2.65). There was no statistically significant effect of the intervention on adherence or out-of-pocket payment cost., Conclusions: The provision of comparative information on patient out-of-pocket payments for treatment of uncomplicated hypertension had a statistically significant impact on increasing the initiation of diuretics in incident patients and switching to diuretics in younger prevalent patients. The impact of interventions to improve the cost-effectiveness of prescribing may be enhanced by also targeting patients with tools to participate in treatment decision-making and by providing physicians with comparative out-of-pocket information on all evidence-based alternatives that would enhance clinical decision-making., Trial Registration: ISRCTN96253624.

Background: Although clinical practice guidelines for the management of hypertension exist in Canada, the rate of contemporary blood pressure (BP) control remains unclear., Methods: In the Primary Care Audit of Global Risk Management (PARADIGM) study, 3015 healthy, middle-aged Canadians, free of cardiovascular disease (CVD) or diabetes were evaluated. In this analysis, we characterized the CVD risk factors, treatment patterns, and BP control rates in subjects with uncomplicated hypertension., Results: A total of 917 subjects (30.4%) had a diagnosis of hypertension. The median age was 59 ± 8 years. The mean treated systolic/diastolic BP were 134 ± 14 mm Hg/82 ± 9 mm Hg, respectively. CVD risk factors included past/current smoking (35.9%), abdominal obesity (62.5%), and dyslipidemia (59.4%). Using the Framingham Risk Score, 20.4%, 41.0%, and 38.5% of the subjects were at low, intermediate, and high risk, respectively. Of the 88% with treated hypertension, 46.9%, 38.7%, and 14.3% received 1, 2, or ≥3 drugs, respectively. The rate of BP control was 57.4% (systolic BP < 140 and diastolic BP < 90 mm Hg). The rate of BP control was lower in patients prescribed diuretic monotherapy (53.2%) vs those who received angiotensin converting enzyme inhibitor/angiotensin receptor blocker monotherapy (66.5%; P < 0.01). Importantly, BP control deteriorated with increasing Framingham Risk Score, and was lower in patients with metabolic syndrome vs those without (P < 0.00001 for both)., Conclusions: PARADIGM demonstrated that CVD risk factors are prevalent in Canadians with uncomplicated hypertension. BP control was modest (57.4%) and was lowest in patients prescribed diuretic monotherapy and in those at highest CVD risk. Despite the success of national hypertension strategies, enhanced efforts are warranted to improve BP control in Canada., (Copyright © 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

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.)

Background: Few studies have evaluated adherence to antihypertensive medication in Chinese and South Asian populations and little is known about the long-term outcome. Our objectives were to compare adherence to antihypertensive medications and assess the association of adherence and long-term mortality in Chinese, South Asian, and white patients with newly diagnosed hypertension., Methods: We conducted a retrospective cohort study of patients with hypertension who were new users of antihypertensive medications (1997-2005) using administrative data and a province-wide prescription database from British Columbia, Canada. Antihypertensive medication adherence within 1 year from the date of the first antihypertensive drug prescription was assessed using the 'proportion of days covered' metric. Proportion of days covered ≥ 80% indicated optimal adherence. Patients were followed for up to 10 years for mortality., Results: There were 16,471 (11.1%) Chinese, 6099 (4.1%) South Asian, and 126,081 (84.8%) white patients who were prescribed antihypertensive medications. Compared with white patients, Chinese (odds ratio, 0.69; 95% confidence interval [CI], 0.67-0.72) and South Asian patients (odds ratio, 0.38; 95% CI, 0.36-0.40) were less likely to be optimally adherent to antihypertensive medications. Optimal adherence was associated with reduced mortality in white patients (risk-adjusted hazard ratio [aHR], 0.89; 95% CI, 0.85-0.93) but not associated with mortality in Chinese (aHR, 0.98; 95% CI, 0.83-1.17) and South Asian patients (aHR, 1.10; 95% CI, 0.84-1.44)., Conclusions: Chinese and South Asian patients with newly diagnosed hypertension were significantly less likely to adhere to antihypertensive medications than their white counterparts. However, optimal adherence in Chinese and South Asian patients was not associated with mortality., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

The authors, who are members of the Dalhousie Academic Detailing Service and the Palliative and Therapeutic Harmonization program, recommend that antihypertensive treatment be less intense in elderly patients who are frail. This paper reviews their recommendations and the evidence behind them., (Copyright© 2014 The Cleveland Clinic Foundation.)

Hypertension guidelines provide up-to-date information and recommendations for hypertension management to healthcare providers, and they facilitate translation of new knowledge into clinical practice. Guidelines represent consensus statements by expert panels, and the process of guideline development has inherent vulnerabilities. Between 1977 and 2003, under the direction of the National Institutes of Health (NIH), the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC) issued 7 reports. The evolution of the JNC recommendations reflects the acquisition of observational and clinical trial data and the availability of newer antihypertensive drugs. Despite 5 years in preparation, NIH did not release a JNC 8 report and recently made the decision to withdraw from issuing guidelines. The responsibility for issuing hypertension-related guidelines was transferred to the American Heart Association (AHA) and the American College of Cardiology. Without the endorsement of the NIH or the AHA, JNC 8 committee members recently published their guideline report. Notably, there have been discrepancies of JNC recommendations over time as well as discrepancies with recommendations of other professional organizations. The Institute of Medicine recently recommended criteria for "trustworthy" guidelines. Criticisms of the guideline process, and of the guidelines themselves, should not obscure their likely contribution to improved hypertension control and to decreases of mortality rates of stroke and cardiovascular disease over the past several decades. Nevertheless, translation of guidelines into clinical practice remains a challenge.

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.)

β-adrenergic blocking agents, a pharmacologically diverse class of cardiovascular medications, are recommended as first-line treatment for patients with hypertension and concomitant structural heart disease, and for angina and heart failure. Many within-class differences exist, from pharmacokinetics and pharmacodynamics to ancillary effects, such as intrinsic sympathomimetic activity, antiarrhythmic activity, α-1 adrenergic receptor blockade affinity, and direct vasodilation. Nebivolol is a third-generation, β1 selective, long acting β-blocker, which causes direct vasodilation via endothelium-dependent nitric oxide stimulation. The vasodilatory actions of nebivolol might result in clinical effects with some distinct properties. Differences from other β-blockers might include improvement of endothelial function, enhancement of forward flow in muscular resistance arteries, maintenance of exercise tolerance, and overall improved tolerability, side effect profile, and adherence. Nebivolol has been shown to be a clinically effective β-blocker for treatment as initial or add-on therapy for systemic hypertension, as an antianginal agent, and as therapy for patients with heart failure. These properties position nebivolol as a treatment option for patients with hypertension and/or structural heart disease, although its precise role in the therapeutic armamentarium remains to be clarified., (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: Previous reviews have shown that β-blocker use for the treatment of hypertension without compelling indications was associated with increased risk of stroke in the elderly. It remains unclear whether this increased risk was driven by the type of β-blocker. We sought to compare the efficacy of atenolol vs nonatenolol β-blockers in clinical trials enrolling young (< 60 years) and older patients with hypertension., Methods: The Cochrane and MEDLINE databases were searched (January 2006-May 2013) for randomized trials evaluating stroke, myocardial infarction, death, or composite cardiovascular end points. Twenty-one hypertension trials with data on 145,811 participants were identified: 15 used atenolol, 7 were placebo-controlled trials, and 14 were active comparator trials. There were no trials of newer generation β-blockers identified., Results: Among the elderly, atenolol was associated with an increased risk of stroke (relative risk [RR], 1.17; 95% confidence interval [CI], 1.05-1.30) compared with other antihypertensive agents. The risk of stroke for nonatenolol β-blockers compared with other agents (RR, 1.22; 95% CI, 0.99-1.50) did not reach statistical significance in the elderly. In the young, atenolol was associated with reduced risk of stroke compared with other agents (RR, 0.78; 95% CI, 0.64-0.95), whereas nonatenolol β-blockers were associated with a lower risk of composite cardiac events (RR, 0.86; 95% CI, 0.75-0.996) compared with placebo, with no significant difference in events compared with active controls., Conclusions: In the young, both atenolol and nonatenolol β-blockers are effective in reducing cardiovascular end points for hypertension without compelling indications. Atenolol is associated with increased stroke in the elderly but whether this extends to nonatenolol β-blockers remains uncertain., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

The measurement of central blood pressure has generated interest as a tool in predicting cardiovascular events. The purpose of this article is to review the meaning and measurement of the central blood pressure and consider its potential value as an index of the antihypertensive response. Indirect estimation of central aortic pressures is obtained by the study of the radial pulse wave compared with a central pulse wave contour measured at the carotid or femoral artery level. The sum of the forward pressure wave created by ventricular contraction and of the reflected pressure wave from the peripheral arterial system produce the peak systolic blood pressure in the aorta. Measurement of the peripheral reflected-wave contribution to aortic blood pressure can be quantified as the augmentation index. Also, the increase in the rapidity of this travelling wave can be measured as the pulse wave velocity. These 2 parameters are considered to be valid indices of the peripheral arterial stiffness. Along with the calculation of systolic and diastolic aortic pressures, these measurements can give a better understanding of the actual central blood pressure to which core organs like heart, brain, and kidneys are submitted. There is tantalizing evidence for the potential value of central blood pressure as a useful index of antihypertensive action, but until clear evidence is obtained, its use should continue to be considered exploratory., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Regulation of sympathoadrenal activity has been a long-time target in the management of hypertension. Regulation of β-adrenoceptor (βAR) function has been the most therapeutically important of these targets. The development of effective antihypertensive treatments based on βAR antagonism paralleled the elucidation of the molecular basis of β-adrenergic effects by the family of βARs, which are members of the G-protein-coupled receptor (GPCR) superfamily. βARs serve as the extracellular face of the transmembrane signalling pathway that results in the consequent activation of heterotrimeric G-proteins and the activation of several other newly appreciated signalling molecules that include β-arrestins and GPCR kinases (GRKs). The aggregate effect of the activation of these signalling pathways mediates the response to βAR activation. Paradoxically, the hypertensive state is characterized by impaired βAR responsiveness. This defect is common to many other receptor systems linked to the stimulator G protein (Gs) and adenylyl cyclase activation. This impairment is principally mediated by receptor-G-protein uncoupling, which has been linked to increased expression and activity of GRK2., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Purpose/introduction: The Canadian Hypertension Education Program (CHEP) has identified blood pressure (BP) control as a key target for an overall reduction in cardiovascular disease risk. The POWER survey (Physicians' Observational Work on Patient Education According to their Vascular Risk) used Framingham methodology to investigate the impact of an angiotensin-receptor-blocker-based regimen on arterial BP and total coronary heart disease (CHD) risk in a subset of patients recruited in Canada., Methods: 309 Canadian practices screened for patients with either newly diagnosed or uncontrolled mild/moderate hypertension (sitting systolic blood pressure [SBP] >140 mmHg with diastolic blood pressure [DBP] <110 mmHg). Treatment comprised eprosartan 600 mg/day with add-on antihypertensive therapy after 1 month if required. The primary efficacy variable was change in SBP at 6 months; the secondary variable was the absolute change in the Framingham 10-year CHD risk score., Results: 1,385 patients were identified, of whom 1,114 were included in the intention-to-treat (ITT) cohort. Thirty-eight point four percent of ITT patients were managed with monotherapy at 6 months, versus 35.2% and 13.7% with two-drug or multiple-drug therapy, respectively. SBP in the ITT cohort declined 22.4 (standard deviation [SD] 14.8) mmHg and DBP declined 10.5 (SD 10.3) mmHg during that time. The absolute mean Framingham score declined 2.1 (SD 3.1) points with significant age and sex variation (P<0.001) and differences between the various Framingham methods used., Discussion/conclusion: Primary care physicians were able to use a strategy of BP lowering and CHD risk assessment to achieve significant reductions in BP and Framingham-assessed CHD risk. The effect size estimate of the different Framingham methods varied noticeably; reasons for those differences warrant further investigation.