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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.

To understand power relations, it is important to consider that power is an attribute, and whoever has it at a given moment is in the condition of dominant and whoever is under its exercise is dominated. Moreover, we must consider that these positions are interchangeable, changing when relations of force change. Power relations represent the pursuit of supremacy through knowledge, with struggles for better positioning in the social structure. In this study, we analyze the effects of disciplinary power on daily practices of nurses and physicians in the hospital environment, more specifically in intensive care units. From the perspective of disciplines, power is exercised in a discreet, modest, calculated and permanent way, through the establishment of rules and norms. In this context, despite the strong appreciation of a medical-centered model, it is observed that nurses gain visibility through knowledge and the defense of institutional norms and rules, which can generate tensions in daily professional practices.

Objective When calculating the difference between alternating auscultatory reference standard (ARS) and the automated device-under-test (DUT) blood pressure (BP) measurements, the European Society of Hypertension International Protocol (ESH-IP) allows investigators to choose the closest ARS value to the DUT value, rather than using the mean of the ARS readings [which is mandated by the International Organization for Standardization (ISO)]. The impact of this rule on ESH-IP validation study results is unknown and was assessed. Design and methods Nine alternating BP measurements performed according to the ISO protocol were obtained in 94 subjects. The impact of using the closest rather than the mean ARS reading on mean error, SD of the difference, and proportion of readings with DUT-ARS differences within 5, 10, and 15 mmHg was determined. Results Mean age was 58.6 ± 18.3 years, screening BP was 126.4/77.7 mmHg, and arm circumference was 32.0 ± 4.7 cm. DUT-ARS difference was 0.0 ± 5.3/-0.5 ± 5.0 mmHg using the closest ARS and -0.2 ± 6.5/-0.7 ± 5.9 mmHg using the mean ARS. When using the closest rather than the mean ARS value, the proportion of systolic readings with absolute DUT-ARS differences ≤5 mmHg was 73% (vs. 60% for the mean ARS method), ≤10 mmHg was 93% (vs. 88%), and ≤15 mmHg was 99% (vs. 98%). Corresponding values for diastolic BP were 73% (vs. 62%) for differences ≤5 mmHg, 94% (vs. 91%) for ≤10 mmHg, and 99% (vs. 99%) for ≤15 mmHg. Conclusion Using the closest rather than the mean ARS value results in more favourable validation study results and increases likelihood of passing.

Background: Patient decision aids (PDAs) are tools that facilitate informed shared decision-making between patients and health care providers. To address a previously identified need in treatment decision-making in hidradenitis suppurativa (HS), we developed an HS-PDA.Methods: Development of the HS-PDA was based on International Patient Decision Aids Standards. Evidence was derived from the North American Clinical Management Guidelines for HS.Results: Content from guidelines was transformed into patient-friendly language and reviewed by three physicians and two patient representatives. Feedback on HS-PDA content, presentation and practicality was obtained from 7 HS patients and 5 physicians. Revisions were made following thematic analysis. All patients felt the content on treatment options contained the right amount of information and 5 found it helpful to see these options contextualized to their values. Each stated they would use the HS-PDA during treatment decision-making. Three and four physicians respectively indicated the content was accurate and language was patient-friendly.Limitations: Small sample sizes may limit generalizability.Conclusion: This HS-PDA was developed in accordance with international standards based on current HS guidelines with input from patients and physicians. It is available online without cost.

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 were introduced, and one existing guideline on the blood pressure thresholds and targets in the setting of thrombolysis for acute ischemic stroke was 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.

BACKGROUND Fixed-ratio and slope-based algorithms are used to derive oscillometric blood pressure (BP). However, a paucity of published data exists assessing the accuracy of these methods. Our objective was to determine the accuracy of fixed-ratio and slope-based algorithms in healthy adults and in adults with cardiovascular risk factors. PATIENTS AND METHODS Overall, 85 healthy adults (age≥18 years) and 85 adults with cardiovascular risk factors were studied. Three oscillometric and four two-observer mercury-based auscultation measurements were performed in each, according to International Standards Organization 2013 methodology. Two fixed-ratio algorithms and one slope-based algorithm were applied to process oscillometric waveform envelopes and derive oscillometric BP. Paired and unpaired t-tests were used to compare mean oscillometric BP within and between each group, respectively. RESULTS For healthy adults, mean age was 50.3±17.8 years, mean arm circumference was 30.4±3.8 cm, and 62% were female. In the cardiovascular risk group, mean age was 63.8±12.4 years, mean arm circumference was 31.9±4.2 cm, and 62% were female. For systolic BP, the fixed-ratio algorithms produced the lowest mean error and narrowest SD. For diastolic BP, mean errors were similar for all three algorithms, but the fixed-ratio algorithms had higher precision. The comparison of healthy adults and those with cardiovascular risk factor showed high variability for systolic and diastolic BP (SD: 8.113.9 mmHg). CONCLUSION In both healthy adults and in those with cardiovascular risk factors, the fixed-ratio technique performed better than the slope-based algorithm. High between-group variability indicates that subject-specific algorithms may be needed.

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.

Patient- and stakeholder-oriented research is vital to improving the relevance of research. The authors aimed to identify the 10 most important research priorities of patients, caregivers, and healthcare providers (family physicians, nurses, nurse practitioners, pharmacists, and dietitians) for hypertension management. Using the James Lind Alliance approach, a national web-based survey asked patients, caregivers, and care providers to submit their unanswered questions on hypertension management. Questions already answered from randomized controlled trial evidence were removed. A priority setting process of patient, caregiver, and healthcare providers then ranked the final top 10 research priorities in an in-person meeting. There were 386 respondents who submitted 598 questions after exclusions. Of the respondents, 78% were patients or caregivers, 29% lived in rural areas, 78% were aged 50 to 80 years, and 75% were women. The 598 questions were distilled to 42 unique questions and from this list, the top 10 research questions prioritized included determining the combinations of healthy lifestyle modifications to reduce the need for antihypertensive medications, stress management interventions, evaluating treatment strategies based on out-of-office blood pressure compared with conventional (office) blood pressure, education tools and technologies to improve patient motivation and health behavior change, management strategies for ethnic groups, evaluating natural and alternative treatments, and the optimal role of different healthcare providers and caregivers in supporting patients with hypertension. These priorities can be used to guide clinicians, researchers, and funding bodies on areas that are a high priority for hypertension management research for patients, caregivers, and healthcare providers. This also highlights priority areas for improved knowledge translation and delivering patient-centered care.

OBJECTIVE To examine the accuracy of home blood pressure (BP) devices, on their owners, compared to auscultatory reference standard BP measurements. METHODS Eighty-five consecutive consenting subjects ≥18 years of age, who owned an oscillometric home BP device (wrist or upper-arm device), with BP levels between 80–220/50–120 mm Hg, and with arm circumferences between 25–43 cm were studied. Pregnancy and atrial fibrillation were exclusion criteria. Device measurements from each subject’s home BP device were compared to simultaneous 2-observer auscultation using a mercury sphygmomanometer. Between-group mean comparisons were conducted using paired t-tests. The proportion of patients with device-to-auscultatory differences of ≥5, 10, and 15 mm Hg were tabulated and predictors of systolic and diastolic BP differences were identified using linear regression. RESULTS Mean age was 66.4 ± 11.0 years, mean arm circumference was 32.7 ± 3.7 cm, 54% were female and 78% had hypertension. Mean BPs were 125.7 ± 14.0/73.9 ± 10.4 mm Hg for home BP devices vs. 129.0 ± 14.7/72.9 ± 9.3 for auscultation (difference of −3.3 ± 7.3/0.9 ± 6.1; P values CONCLUSIONS Although mean differences from 2-observer auscultation were acceptable, when tested on their owners, most home BP devices were not accurate to within 5 mm Hg. Ensuring acceptable accuracy of the device-owner pairing should be prioritized.

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2013. This year's update includes 2 new recommendations. First, among nonhypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise does not adversely influence blood pressure (BP) (Grade D). Thus, such patients need not avoid this type of exercise for fear of increasing BP. Second, and separately, for very elderly patients with isolated systolic hypertension (age 80 years or older), the target for systolic BP should be150 mm Hg (Grade C) rather than140 mm Hg as recommended for younger patients. We also discuss 2 additional topics at length (the pharmacological treatment of mild hypertension and the possibility of a diastolic J curve in hypertensive patients with coronary artery disease). In light of several methodological limitations, a recent systematic review of 4 trials in patients with stage 1 uncomplicated hypertension did not lead to changes in management recommendations. In addition, because of a lack of prospective randomized data assessing diastolic BP thresholds in patients with coronary artery disease and hypertension, no recommendation to set a selective diastolic cut point for such patients could be affirmed. However, both of these issues will be examined on an ongoing basis, in particular as new evidence emerges.

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.

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.

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2012. The new recommendations are: (1) use of home blood pressure monitoring to confirm a diagnosis of white coat syndrome; (2) mineralocorticoid receptor antagonists may be used in selected patients with hypertension and systolic heart failure; (3) a history of atrial fibrillation in patients with hypertension should not be a factor in deciding to prescribe an angiotensin-receptor blocker for the treatment of hypertension; and (4) the blood pressure target for patients with nondiabetic chronic kidney disease has now been changed to < 140/90 mm Hg from < 130/80 mm Hg. We also reviewed the recent evidence on blood pressure targets for patients with hypertension and diabetes and continue to recommend a blood pressure target of less than 130/80 mm Hg.

The diagnosis of hypertension is fundamental to the practice of medicine. Increased blood pressure (BP) is the second leading global risk factor for death and disability (behind unhealthy diets), accounting for 18% of global deaths (>9 million deaths per year).1 Contemporary guidelines recommend assessing BP at every care visit; thus, BP measurement is probably the most commonly performed diagnostic maneuver in medicine.2 Importantly, evolving technology is making the diagnosis of hypertension more accurate, reliable, and rapid.

The diagnosis of hypertension is fundamental to the practice of medicine. Increased blood pressure (BP) is the second leading global risk factor for death and disability (behind unhealthy diets), accounting for 18% of global deaths (>9 million deaths per year).1 Contemporary guidelines recommend assessing BP at every care visit; thus, BP measurement is probably the most commonly performed diagnostic maneuver in medicine.2 Importantly, evolving technology is making the diagnosis of hypertension more accurate, reliable, and rapid.

Despite progress in automated blood pressure measurement (BPM) technology, there is limited research linking hard outcomes to automated office BPM (OBPM) treatment targets and thresholds. Equivalences for automated BPM devices have been estimated from approximations of standardized manual measurements of 140/90 mmHg. Until outcome-driven targets and thresholds become available for automated measurement methods, deriving evidence-based equivalences between automated methods and standardized manual OBPM is the next best solution. The MeasureBP study group was initiated by the Canadian Hypertension Education Program to close this critical knowledge gap. MeasureBP aims to define evidence-based equivalent values between standardized manual OBPM and automated BPM methods by synthesizing available evidence using a systematic review and individual subject-level data meta-analyses. This manuscript provides a review of the literature and MeasureBP study protocol. These results will lay the evidenced-based foundation to resolve uncertainties within blood pressure guidelines which, in turn, will improve the management of hypertension.

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.

Objective: To determine the current practices of community pharmacists in the management of hypertension. Methods: This was a cross-sectional, observational study of pharmacist practice using unannounced standardized patients (SPs) with hypertension visiting a random stratified sample of 101 community pharmacies in Edmonton, Alberta. Consent was not obtained from pharmacists. Results: Knowledge of current blood pressure guidelines and target values: Of the 101 community pharmacists who were visited by the SPs, 69% offered a general blood pressure target value (Conclusions: Pharmacists took reasonable steps to determine the accuracy of the blood pressure measurement, explain the diagnosis of hypertension, and refer to a physician. Major deficiencies were observed in assessment of target blood pressure and review of medical history. Pharmacists, alone or in collaboration with other health professionals, are urgently needed to play a major role in identifying, screening, and managing individuals with hypertension. Can Pharm J 2006;139(5):38–44.

OBJECTIVES This project evaluated if by focusing on process changes and tool use rather than key indicator rates, the use of evidence-based therapies in patients with acute myocardial infarction (AMI) would increase. BACKGROUND The use of tools designed to improve quality of care in the American College of Cardiology AMI Guidelines Applied in Practice Pilot Project resulted in improved adherence to evidence-based therapies for patients, but overall, tool use was modest. METHODS The current project, implemented in five hospitals, was modeled after the previous project, but with greater emphasis on tool use. This allowed early identification of barriers to tool use and strategies to overcome barriers. Main outcome measures were AMI quality indicators in pre-measurement (January 1, 2001 to June 30, 2001) and post-measurement (December 15, 2001 to March 31, 2002) samples. RESULTS One or more tools were used in 93% of patients (standard orders = 82%, and discharge document = 47%). Tool use was associated with significantly higher adherence to most discharge quality indicator rates with increases in aspirin, angiotensin-converting enzyme inhibitors, and smoking cessation and dietary counseling. Patients undergoing coronary artery bypass grafting (CABG) had low rates of discharge indicators. Patients undergoing percutaneous coronary revascularization were more likely to receive evidence-based therapies. CONCLUSIONS These data validate the results of the pilot project that quality of AMI care can be improved through the use of guideline-based tools. Identifying and overcoming barriers to tool use led to substantially higher rates of tool use. The low rates of adherence to quality indicators in patients undergoing CABG suggest that these patients should be particularly targeted for quality improvement efforts.

Objective To determine the adequacy of hypertension management in institutionalized elderly patients. Methods Retrospective chart review of all patients with a physician-documented diagnosis of hypertension at 15 long-term care facilities in Edmonton, Alberta. Results Of 2063 long-term care residents, 733 (36%) were diagnosed with hypertension (mean age 84 years), and 566 (77%) of this cohort were receiving antihypertensive medication. The most frequently prescribed antihypertensive drugs were angiotensin-converting enzyme inhibitors (341 patients [60%]). Of the long-term residents prescribed antihypertensive therapy, 274 (48%) were on one medication, 203 (36%) were on two and 89 (16%) received three or more agents. Blood pressure readings were taken every 14 days on average (interquartile range two to 31 days). Overall, 467 (64%) of these residents with a diagnosis of hypertension achieved target blood pressure. Conclusion Hypertension treatment and control rates are better in elderly patients who are institutionalized than those reported in studies of patients who reside in the community. Determining the reasons for this discrepancy will be important for the design of strategies to improve hypertension control rates in the community.

SummaryThe effects of thrombin (0.2 U/ml) and native (n-LDL), malon- dialdehyde-modified (MDA-LDL) and auto-oxidized (ox-LDL) low-density lipoproteins (20 μg of protein/ml) on platelet activation were evaluated in seven hyperlipidemic patients and compared to seven controls (fasting serum cholesterol 8.49 ± 0.5 and 4.61 ± 0.4 mM, respectively). Basal and thrombin-induced increases in platelet intracellular free calcium ion concentration ([Ca2+; fura-2) were similar in hyperlipidemic patients and controls (45 ± 5 vs 42 ± 3 and 635 ±51 vs 599 ± 69 mM, respectively). n-LDL, MDA-LDL and ox-LDL increased basal [Ca2+]; (16, 36 and 81 percent, p In conclusion, modified LDL activated platelets to a greater extent than n-LDL, suggesting different types of LDL-receptors. Their agonistic effect was inversely related to the fasting serum lipid profile, suggesting that blunting of platelet responses to LDL could represent a protective mechanism in hyperlipidemic patients.

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2011. The major guideline changes this year are: (1) a recommendation was made for using comparative risk analogies when communicating a patient's cardiovascular risk; (2) diagnostic testing issues for renal artery stenosis were discussed; (3) recommendations were added for the management of hypertension during the acute phase of stroke; (4) people with hypertension and diabetes are now considered high risk for cardiovascular events if they have elevated urinary albumin excretion, overt kidney disease, cardiovascular disease, or the presence of other cardiovascular risk factors; (5) the combination of an angiotensin-converting enzyme (ACE) inhibitor and a dihydropyridine calcium channel blocker (CCB) is preferred over the combination of an ACE inhibitor and a thiazide diuretic in persons with diabetes and hypertension; and (6) a recommendation was made to coordinate with pharmacists to improve antihypertensive medication adherence. We also discussed the recent analyses that examined the association between angiotensin II receptor blockers (ARBs) and cancer.

The Canadian Hypertension Education Program (CHEP), Canadian Hypertension Society, Blood Pressure Canada, Canadian Diabetes Association, College of Family Physicians of Canada, Canadian Pharmacists Association, Heart and Stroke Foundation of Canada, and the Canadian Council of Cardiovascular Nurses issued a recent call for all health care professionals in Canada to double their efforts to assist patients with diabetes in maintaining target blood pressures (Campbell et al., 2009b). Blood pressure (B/P) in diabetic individuals should be less than 130 mmHg systolic and less than 80 mmHg diastolic (CHEP 2009). Considering recognition and treatment of hypertension in people with diabetes can result in reductions in disability and death, control of hypertension must become an interdisciplinary priority. Maintaining B/P less than 130/80 mmHg requires lifestyle modification as the cornerstone to treatment and often two or more B/P medications (Campbell et al., 2009a). The cost of multiple drugs required for B/P control in diabetic individuals is one of the few treatments estimated to reduce overall health costs and related cardiovascular disease complications (Gillies, Abrams,Lambert, 2007). Nurses are essential partners in assessing and assisting diabetic patients and all patients with hypertension to reduce overall cardiovascular risks. Nurses may also be key practitioners in assessing and monitoring patient difficulties with adherence to lifestyle or pharmacological interventions (Jayasinghe, 2009; McLean et al., 2008). Individualized lifestyle counselling and treatment modification are recommended to maintain target B/P and treat dysglycemia, dyslipidemia, smoking or any other cardiovascular risks in diabetic individuals.

Blood pressure (BP) control in patients with diabetes mellitus is difficult to achieve and current patterns are suboptimal. Given increasing problems with access to primary care physicians, community pharmacists and nurses are well positioned to identify and observe these patients. This study aimed to determine the efficacy of a community-based multidisciplinary intervention on BP control in patients with diabetes mellitus.We performed a randomized controlled trial in 14 community pharmacies in Edmonton, Alberta, Canada, of patients with diabetes who had BPs higher than 130/80 mm Hg on 2 consecutive visits 2 weeks apart. Care from a pharmacist and nurse team included a wallet card with recorded BP measures, cardiovascular risk reduction education and counseling, a hypertension education pamphlet, referral to the patient's primary care physician for further assessment or management, a 1-page local opinion leader-endorsed evidence summary sent to the physician reinforcing the guideline recommendations for the treatment of hypertension and diabetes, and 4 follow-up visits throughout 6 months. Control-arm patients received a BP wallet card, a pamphlet on diabetes, general diabetes advice, and usual care by their physician. The primary outcome measure was the difference in change in systolic BP between the 2 groups at 6 months.A total of 227 eligible patients were randomized to intervention and control arms between May 5, 2005, and September 1, 2006. The mean (SD) patient age was 64.9 (12.1) years, 59.9% were male, and the mean (SD) baseline systolic/diastolic BP was 141.2 (13.9)/77.3 (8.9) mm Hg at baseline. The intervention group had an adjusted mean (SE) greater reduction in systolic BP at 6 months of 5.6 (2.1) mm Hg compared with controls (P = .008). In the subgroup of patients with a systolic BP greater than 160 mm Hg at baseline, BP was reduced by an adjusted mean (SE) of 24.1 (1.9) mm Hg more in intervention patients than in controls (P.001).Even in patients who have diabetes and hypertension that are relatively well controlled, a pharmacist and nurse team-based intervention resulted in a clinically important improvement in BP. Trial Registration clinicaltrials.gov Identifier: NCT00374270.

Recent data from the World Health Organization (WHO) indicate that nearly one billion people in the world are suffering from hypertension. Forecasts suggest that, with the aging of the population, this number could reach 1.5 billion by 2025 (Kearney, Whelton,Reynolds, 2005). In developed countries, more than one in five adults have hypertension (Vasan, Beiser, Seshadri, Larson, Kannel,D'Agostino, 2002). Statistics for Canada reveal that fewer than 15% of those diagnosed with hypertension are adequately controlled (Joffres, Hamet, MacLean, L'italien,Fodor, 2001). Part of the effort to improve hypertension detection, assessment and treatment is an annual process to produce and update evidence-based recommendations for the management of hypertension and to implement the recommendations (Zarnke, Campbell, McAlister,Levine, 2000; Campbell, Nagpal,Drouin, 2001). The most up-to-date 2007 Canadian recommendations for the assessment and management of hypertension are presented. Contemporary nursing practice requires that nurses take responsibility and a role in the primary prevention, detection and treatment of hypertension.

Background Many patients with diabetes also have hypertension, greatly increasing their risk for cardiovascular disease. It has been suggested that hypertension is poorly treated in those with diabetes. Objective To examine treatment and control of hypertension in people with diabetes. Data Sources Data sources included MEDLINE, EMBASE, HealthSTAR, CINAHL, Web of Science, clinical evidence and government health and statistical Web sites. Method Databases were systematically reviewed and hand searches of the bibliographies of relevant studies (1990 to 2004) were conducted. Two investigators selected studies and extracted the data independently. Results A total of 44 studies (77,649 subjects with diabetes, 47,964 [62%] of whom also had hypertension) were included. While 83% (range 32% to 100%) of patients with hypertension received drug therapy, only 12% (range 6% to 30%) had their blood pressure (BP) controlled to 130/85 mmHg or less. While BP control rates differed by definition of control (those studies with the least stringent definitions for BP control – 160/90 mmHg or less – reported mean control rates of 37%), treatment and control rates did not differ appreciably between countries or health care settings. Conclusions Fewer than one in eight people with diabetes and hypertension have adequately controlled BP, with remarkable uniformity across studies conducted in a variety of settings. There is an urgent need for multidisciplinary, community-based approaches to manage these high-risk patients.

This project evaluated if by focusing on process changes and tool use rather than key indicator rates, the use of evidence-based therapies in patients with acute myocardial infarction (AMI) would increase.The use of tools designed to improve quality of care in the American College of Cardiology AMI Guidelines Applied in Practice Pilot Project resulted in improved adherence to evidence-based therapies for patients, but overall, tool use was modest.The current project, implemented in five hospitals, was modeled after the previous project, but with greater emphasis on tool use. This allowed early identification of barriers to tool use and strategies to overcome barriers. Main outcome measures were AMI quality indicators in pre-measurement (January 1, 2001 to June 30, 2001) and post-measurement (December 15, 2001 to March 31, 2002) samples.One or more tools were used in 93% of patients (standard orders = 82%, and discharge document = 47%). Tool use was associated with significantly higher adherence to most discharge quality indicator rates with increases in aspirin, angiotensin-converting enzyme inhibitors, and smoking cessation and dietary counseling. Patients undergoing coronary artery bypass grafting (CABG) had low rates of discharge indicators. Patients undergoing percutaneous coronary revascularization were more likely to receive evidence-based therapies.These data validate the results of the pilot project that quality of AMI care can be improved through the use of guideline-based tools. Identifying and overcoming barriers to tool use led to substantially higher rates of tool use. The low rates of adherence to quality indicators in patients undergoing CABG suggest that these patients should be particularly targeted for quality improvement efforts.

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.