The 2007 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 - therapy.
OBJECTIVE
To provide updated, evidence-based recommendations for the prevention and management of hypertension in adults.


METHODS
For lifestyle and pharmacological interventions, evidence was reviewed from randomized controlled trials and systematic reviews of trials. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field. For treatment of patients with kidney disease, the progression of kidney dysfunction was also accepted as a clinically relevant primary outcome.


METHODS
A Cochrane collaboration librarian conducted an independent MEDLINE search from 2005 to August 2006 to update the 2006 Canadian Hypertension Education Program recommendations. In addition, reference lists were scanned and experts were contacted to identify additional published studies. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence.


CONCLUSIONS
Dietary lifestyle modifications for prevention of hypertension, in addition to a well-balanced diet, include a dietary sodium intake of less than 100 mmol/day. In hypertensive patients, the dietary sodium intake should be limited to 65 mmol/day to 100 mmol/day. Other lifestyle modifications for both normotensive and hypertensive patients include: performing 30 min to 60 min of aerobic exercise four to seven days per week; maintaining a healthy body weight (body mass index of 18.5 kg/m2 to 24.9 kg/m2) and waist circumference (less than 102 cm in men and less than 88 cm in women); limiting alcohol consumption to no more than 14 units per week in men or nine units per week in women; following a diet reduced in saturated fat and cholesterol, and one that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and considering stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should take into account each individual's global atherosclerotic risk, target organ damage and any comorbid conditions: blood pressure should be lowered to lower than 140/90 mmHg in all patients and lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease. Most patients require more than one agent to achieve these blood pressure targets. In adults without compelling indications for other agents, initial therapy should include thiazide diuretics; other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin-converting enzyme (ACE) inhibitors (except in black patients), long-acting calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). First-line therapy for isolated systolic hypertension includes long-acting dihydropyridine CCBs or ARBs. Certain comorbid conditions provide compelling indications for first-line use of other agents: in patients with angina, recent myocardial infarction, or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor plus diuretic combination is preferred; in patients with nondiabetic chronic kidney disease, ACE inhibitors are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered.


RESULTS
All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.
Khan
Nadia A
NA
Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia. nakhan@shaw.ca
Hemmelgarn
Brenda
B
Padwal
Raj
R
Larochelle
Pierre
P
Mahon
Jeff L
JL
Lewanczuk
Richard Z
RZ
McAlister
Finlay A
FA
Rabkin
Simon W
SW
Hill
Michael D
MD
Feldman
Ross D
RD
Schiffrin
Ernesto L
EL
Campbell
Norman R C
NR
Logan
Alexander G
AG
Arnold
Malcolm
M
Moe
Gordon
G
Campbell
Tavis S
TS
Milot
Alain
A
Stone
James A
JA
Jones
Charlotte
C
Leiter
Lawrence A
LA
Ogilvie
Richard I
RI
Herman
Robert J
RJ
Hamet
Pavel
P
Fodor
George
G
Carruthers
George
G
Culleton
Bruce
B
Burns
Kevin D
KD
Ruzicka
Marcel
M
deChamplain
Jacques
J
Pylypchuk
George
G
Gledhill
Norm
N
Petrella
Robert
R
Boulanger
Jean-Martin
JM
Trudeau
Luc
L
Hegele
Robert A
RA
Woo
Vincent
V
McFarlane
Phil
P
Touyz
Rhian M
RM
Tobe
Sheldon W
SW
D000959:Antihypertensive Agents / Q000627:therapeutic use; D002170:Canada; D004039:Diet, Sodium-Restricted; D006293:Health Promotion; D006801:Humans; D006973:Hypertension / Q000188:drug therapy / Q000517:prevention & control* / Q000628:therapy*; D010353:Patient Education as Topic; D016032:Randomized Controlled Trials as Topic; D040242:Risk Reduction Behavior
D000959:Antihypertensive Agents