title: The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 - therapy.
abstract: OBJECTIVE
  To update the evidence-based recommendations for the prevention and treatment of hypertension in adults for 2010.
  
  
  METHODS
  For lifestyle and pharmacological interventions, randomized trials and systematic reviews of trials were preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the general lack of long-term morbidity and mortality data in this field. Progressive renal impairment was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease.
  
  
  METHODS
  A Cochrane Collaboration librarian conducted an independent MEDLINE search from 2008 to August 2009 to update the 2009 recommendations. To identify additional studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence.
  
  
  CONCLUSIONS
  For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to 1500 mg (65 mmol) per day in adults 50 years of age or younger, to 1300 mg (57 mmol) per day in adults 51 to 70 years of age, and to 1200 mg (52 mmol) per day in adults older than 70 years of age; perform 30 min to 60 min of moderate aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week for men or nine standard drinks per week for women; follow a diet that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources, and that is low in saturated fat and cholesterol; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in patients with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, considerations for initial therapy should include thiazide diuretics, angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. The combination of ACE inhibitors and ARBs should not be used, unless compelling indications are present to suggest consideration of dual therapy. Agents appropriate for first-line therapy for isolated systolic hypertension include thiazide diuretics, long-acting dihydropyridine CCBs or ARBs. In patients with coronary artery disease, ACE inhibitors, ARBs or betablockers are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. In selected high-risk patients in whom combination therapy is being considered, an ACE inhibitor plus a long-acting dihydropyridine CCB is preferable to an ACE inhibitor plus a thiazide diuretic. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian lipid treatment guidelines. Selected patients with hypertension who do not achieve thresholds for statin therapy, but who are otherwise at high risk for cardiovascular events, should nonetheless receive statin therapy. Once blood pressure is controlled, low-dose acetylsalicylic acid therapy should be considered.
  
  
  RESULTS
  All recommendations were graded according to the strength of the evidence and voted on by the 63 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 80% consensus. These guidelines will continue to be updated annually.
  
  
  BACKGROUND
  The Canadian Hypertension Education Program process is sponsored by the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the College of Family Physicians of Canada, the Canadian Pharmacists Association, the Canadian Council of Cardiovascular Nurses, and the Heart and Stroke Foundation of Canada.
authors.affiliation: Department of Medicine and Epidemiology, Division of Clinical Pharmacology and Clinical Neurological Sciences, University of Western Ontario, London, Ontario. dhackam@uwo.ca
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Hackam
authors.forename: Nadia A
authors.initials: NA
authors.lastname: Khan
authors.forename: Brenda R
authors.initials: BR
authors.lastname: Hemmelgarn
authors.forename: Simon W
authors.initials: SW
authors.lastname: Rabkin
authors.forename: Rhian M
authors.initials: RM
authors.lastname: Touyz
authors.forename: Norman R C
authors.initials: NR
authors.lastname: Campbell
authors.forename: Raj
authors.initials: R
authors.lastname: Padwal
authors.forename: Tavis S
authors.initials: TS
authors.lastname: Campbell
authors.forename: M Patrice
authors.initials: MP
authors.lastname: Lindsay
authors.forename: Michael D
authors.initials: MD
authors.lastname: Hill
authors.forename: Robert R
authors.initials: RR
authors.lastname: Quinn
authors.forename: Jeff L
authors.initials: JL
authors.lastname: Mahon
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Herman
authors.forename: Ernesto L
authors.initials: EL
authors.lastname: Schiffrin
authors.forename: Marcel
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authors.lastname: Ruzicka
authors.forename: Pierre
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authors.lastname: Larochelle
authors.forename: Ross D
authors.initials: RD
authors.lastname: Feldman
authors.forename: Marcel
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authors.lastname: Lebel
authors.forename: Luc
authors.initials: L
authors.lastname: Poirier
authors.forename: J Malcolm O
authors.initials: JM
authors.lastname: Arnold
authors.forename: Gordon W
authors.initials: GW
authors.lastname: Moe
authors.forename: Jonathan G
authors.initials: JG
authors.lastname: Howlett
authors.forename: Luc
authors.initials: L
authors.lastname: Trudeau
authors.forename: Simon L
authors.initials: SL
authors.lastname: Bacon
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Petrella
authors.forename: Alain
authors.initials: A
authors.lastname: Milot
authors.forename: James A
authors.initials: JA
authors.lastname: Stone
authors.forename: Denis
authors.initials: D
authors.lastname: Drouin
authors.forename: Jean-Martin
authors.initials: JM
authors.lastname: Boulanger
authors.forename: Mukul
authors.initials: M
authors.lastname: Sharma
authors.forename: Pavel
authors.initials: P
authors.lastname: Hamet
authors.forename: George
authors.initials: G
authors.lastname: Fodor
authors.forename: George K
authors.initials: GK
authors.lastname: Dresser
authors.forename: S George
authors.initials: SG
authors.lastname: Carruthers
authors.forename: George
authors.initials: G
authors.lastname: Pylypchuk
authors.forename: Ellen D
authors.initials: ED
authors.lastname: Burgess
authors.forename: Kevin D
authors.initials: KD
authors.lastname: Burns
authors.forename: Michel
authors.initials: M
authors.lastname: Vallée
authors.forename: G V Ramesh
authors.initials: GV
authors.lastname: Prasad
authors.forename: Richard E
authors.initials: RE
authors.lastname: Gilbert
authors.forename: Lawrence A
authors.initials: LA
authors.lastname: Leiter
authors.forename: Charlotte
authors.initials: C
authors.lastname: Jones
authors.forename: Richard I
authors.initials: RI
authors.lastname: Ogilvie
authors.forename: Vincent
authors.initials: V
authors.lastname: Woo
authors.forename: Philip A
authors.initials: PA
authors.lastname: McFarlane
authors.forename: Robert A
authors.initials: RA
authors.lastname: Hegele
authors.forename: Sheldon W
authors.initials: SW
authors.lastname: Tobe
mesh_terms: D000328:Adult; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D002170:Canada; D002318:Cardiovascular Diseases / Q000517:prevention & control*; D003131:Combined Modality Therapy; D004039:Diet, Sodium-Restricted; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000517:prevention & control / Q000628:therapy*; D008019:Life Style; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic; D017410:Practice Guidelines as Topic; D011322:Primary Prevention / Q000592:standards; D011379:Prognosis; D018570:Risk Assessment
chemical_list: D000959:Antihypertensive Agents