1. Hypertension as a Public Health Risk
2011 Canadian Hypertension Education Program Recommendations 1

2. The full slide set of the 2011 CHEP Recommendations are available at www.hypertension.ca

3. Key CHEP Messages for the Management of Hypertension
Assess blood pressure at all appropriate visits.
Promote a healthy lifestyle to lower blood pressure and reduce the risk of cardiovascular disease at each visit with interventions to reduce high dietary sodium, for smoking cessation, to reduce abdominal obesity, to promote a healthy weight, to increase physical activity and to manage dyslipidemia and dysglycemia.
Treat blood pressure to less than 140/90 mmHg in most people and to less than 130/80 mmHg in people with diabetes or chronic kidney disease using a combination of drugs and lifestyle modifications.
Advocate for healthy public policies to prevent hypertension and advance the health of patients and populations.
Keep up to date with resources for the prevention and control of hypertension by registering at and downloading and ordering tools at 3

4. CHEP 2011 Recommendations What’s new?
Harmonization with Canadian Stroke Network for the management of hypertension during the acute phase of a stroke and following the acute phase
Knowledge translation to improve guidelines uptake starting with diabetes recommendations to improve wording
For people with diabetes and hypertension requiring a combination therapy with an ACEi, a dihydropyridine CCB is preferable to hydrochlorothiazide
Calculating the cardiovascular age and coordinating with pharmacists are effective adherence strategies

5. What’s Still Important in 2011
Keep up to date on the prevention and control of hypertension
Register for automatic notification of new hypertension resources for you and your patients, at:
Have your patients sign up at to access latest hypertension resources

6. Information and Resources for Public
Please encourage your patients to sign up for free access to the latest information and resources on high blood pressure 6

7. The Canadian Hypertension Education Program: 2011 Recommendations
What’s still important?
The management of hypertension is all about global risk management and vascular protection
The management of hypertension is all about achieving “buy-in”
Combinations of antihypertensives are more effective than dose escalation and combination pills enhance adherence to therapy 7

8. Overview What is hypertension?
Age-related blood pressure creep and hypertension is common
High blood pressure is a significant risk factor for morbidity and mortality
Hypertension is costly
Hypertension keeps bad company
Hypertension can be prevented or delayed
The complications of hypertension are ameliorated by effective therapy
Healthy public policies reduce the risk of hypertension 8

9. Attributable Mortality
Proportion of Deaths Attributable to Leading Risk Factors Worldwide (2000)
High blood pressure
Tobacco
High cholesterol
Underweight
Unsafe sex
Systolic blood pressure
greater than 115 mmHg
High BMI
Physical inactivity
Alcohol
The slide is from an analysis conducted by the World Health Organization that estimates the proportion of deaths in the world caused by major health risks. Overall elevated blood pressure (systolic > 115 mmHg) is estimated to be the leading risk for death. Elevated blood pressure is a greater health risk in developed than under developed nations and in Europe than in North America.
Indoor smoke from solid fuels
Iron deficiency 1 2 3 4 5 6 7 8
Attributable Mortality
WHO 2000 Report. Lancet. 2002;360: 9

10. Hypertension as a Risk Factor
Hypertension is a significant risk factor for:
cerebrovascular disease
coronary artery disease
congestive heart failure
renal failure
peripheral vascular disease
dementia
atrial fibrillation
erectile dysfunction 10

11. Blood Pressure Distribution in the Population According to Age
30-39
40-49
50-59
60-69
70-79
 80 70 80
110
130
150
Age
Men
Women PP
PP=Pulse Pressure.
Adapted from : Third National Health and Nutrition. Examination Survey, Hypertension 1995;25: 11

12. European Society of Hypertension Classification of Blood Pressure
Category
Systolic
Diastolic
Optimal
<120
and / or
<80
Normal
<130
<85
High-Normal
85-89
Grade 1 (mild hypertension )
90-99
Grade 2 (moderate hypertension)
Grade 3 (severe hypertension)
 180
 110
Isolated Systolic Hypertension (ISH)
140
and
<90
The category pertains to the highest risk blood pressure
*ISH=Isolated Systolic Hypertension.
J Hypertens 2007;25: 12

13. JNC VII (American) Classification of Blood Pressure
Category
Systolic
Diastolic
Optimal
<120
and / or
<80
Normal
<130
<85
High-Normal
85-89
Stage 1 (mild hypertension )
90-99
Stage 2 (moderate to severe hypertension)
160 
Isolated Systolic Hypertension (ISH)
140
and
<90
The category pertains to the highest risk blood pressure
*ISH=Isolated Systolic Hypertension.
JAMA 2003;289: 13

14. Blood Pressure and Risk of Stroke Mortality
Lancet 2002;360: 14

15. Blood Pressure and Risk of Ischemic Heart Disease (IHD) Mortality
Lancet 2002;360: 15

16. Effect of SBP and DBP on Age-Adjusted CAD Mortality: MRFIT
CAD Death Rate per 10,000 Person-years
80.6
48.3
43.8
37.4
34.7
38.1
31.0
25.8
24.6
25.3
25.2
24.9
23.8
160+
16.9
13.9
12.8
12.6
11.8
Multiple Risk Factor Intervention Trial (MRFIT)
Diastolic rates at systolic <140 mm Hg
Systolic rates at diastolic <90 mm Hg
Systolic blood pressure (SBP) and diastolic blood pressure (DBP) have been shown to correlate strongly with coronary artery disease (CAD) mortality. The combined effect of SBP and DBP on age-adjusted CAD mortality is shown on this slide. These data, from a cohort of men screened for the Multiple Risk Factor Intervention Trial (MRFIT) and followed for an average of 12 years, show that SBP is actually a stronger predictor of death from CAD than DBP.
Source:
Neaton JD and Wentworth D for the Multiple Risk Factor Intervention Trial (MRFIT) Research Group. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Arch Intern Med 1992; 152:56-64.
20.6
10.3
11.8
8.8
8.5
9.2
<120
Systolic BP (mmHg)
100+
90-99
80-89
75-79
70-74
<70
Diastolic BP (mmHg)
Neaton et al. Arch Intern Med 1992; 152:56-64. 16

17. Impact of High-Normal Blood Pressure on the Risk of Cardiovascular Disease
Cumulative incidence of cv events in men without hypertension according to baseline blood pressure
( ) mmHg
( ) mmHg
(< 120) mmHg
IMPACT OF HIGH-NORMAL BLOOD PRESSURE ON THE RISK
OF CARDIOVASCULAR DISEASE
Background
Information is limited regarding the risk of cardiovascular disease in persons with highnormal blood pressure (systolic pressure of 130 to
139 mm Hg, diastolic pressure of 85 to 89 mm Hg, or both).
Conclusions
High-normal blood pressure is associated
with an increased risk of cardiovascular disease.
Our findings emphasize the need to determine
whether lowering high-normal blood pressure can
reduce the risk of cardiovascular disease.
N Engl J Med 2001;345:1291-7
N Engl J Med 2001;345: 17

18. The Concept of Masked Hypertension
200
180
True
hypertensive
Masked HTN
160
Home/Ambulatory SBP mmHg
140
135
120
True
Normotensive
White Coat HTN
100
100
120
140
160
180
200
Office SBP mmHg
Derived from Pickering et al. Hypertension 2002: 40: 18

19. The Prognosis of White Coat and Masked Hypertension
Prevalence is approximately 10% of the adult population
Cardiovascular Event
Odds Ratio of a
J Hypertension 2007;25: 19

20. Cumulative hazard of stroke (%)
Long term follow-up of Normotensive, White Coat Hypertension, and Ambulatory Hypertension 8
Ambulatory
Hypertension
White Coat Hypertension 7 6
Normotensive
group 5
Cumulative hazard of stroke (%) 4 3 2
p =
The increase in stroke in patients with white coat hypertension after 5 years might be because of a higher rate of conversion to true hypertension.
All patients with white coat hypertension require follow-up of their blood pressure. 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Time to stroke (years)
Hypertension. 2005;45(2): 20

21. Benefits of Treating Hypertension
Younger than 60 (reducing BP 10/5-6 mmHg)
reduces the risk of stroke by 42%
reduces the risk of coronary event by 14%
Older than 60 (reducing BP 15/6 mmHg)
reduces overall mortality by 15%
reduces cardiovascular mortality by 36%
reduces incidence of stroke by 35%
reduces coronary artery disease by 18%
Lancet 1990;335: Arch Fam Med 1995;4: 21

22. Benefits of Treating to Target
Older than 60 with isolated systolic hypertension (SBP 160 mm Hg and DBP <90 mm Hg)
42% reduction in the risk of stroke
26% reduction in the risk of coronary events
Lancet 1997;350: 22

23. Correlation Between Reduction in SBP and Stroke or MI
Myocardial Infarction
Risk reduction observed in ASCOT BP-LA trial is concordant with blood pressure reduction as predicted by the Staessen model..
Cardiovascular protection and blood pressure reduction:
a meta-analysis
Jan A Staessen, Ji-Guang Wang, Lutgarde Thijs
Background Whether antihypertensive drugs offer cardiovascular protection beyond blood pressure lowering has not been established. We aimed to investigate whether pharmacological properties of antihypertensive drugs or reduction of systolic pressure accounted for cardiovascular outcome in hypertensive or high-risk patients.
Interpretation: Our findings emphasize that blood pressure control is important. All antihypertensive drugs have similar long-term efficacy and safety. Calcium-channel blockers might be especially effective in stroke prevention. We did not find that converting-enzyme inhibitors or -blockers affect cardiovascular prognosis beyond their antihypertensive effects.
Lancet 2001; 358: 1305–15
Staessen et al. Lancet 2001;358: 23

24. Cardiovascular mortality Cardiovascular events
Correlation Between Reduction in SBP and Cardiovascular Mortality or Events
Cardiovascular mortality
Cardiovascular events
Risk reduction observed in ASCOT BP-LA trial is concordant with blood pressure reduction as predicted by the Staessen model..
Cardiovascular protection and blood pressure reduction:
a meta-analysis
Jan A Staessen, Ji-Guang Wang, Lutgarde Thijs
Background Whether antihypertensive drugs offer cardiovascular protection beyond blood pressure lowering has not been established. We aimed to investigate whether pharmacological properties of antihypertensive drugs or reduction of systolic pressure accounted for cardiovascular outcome in hypertensive or high-risk patients.
Interpretation Our findings emphasize that blood pressure control is important. All antihypertensive drugs have similar long-term efficacy and safety. Calcium-channel blockers might be especially effective in stroke prevention. We did not find that converting-enzyme inhibitors or -blockers affect cardiovascular prognosis beyond their antihypertensive effects.
Lancet 2001; 358: 1305–15
Staessen et al. Lancet 2001;358: 24

25. 90% of Hypertensive Canadians have other Cardiovascular Risk factors
45% Reduction in CVD =
10% Reduction in Total-C +
10% Reduction in BP
Emberson et al. Eur Heart J. 2004;25: 25

26. Treating Hypertension and Other Risk Factors
Treatment Based on lipids
(statin)
Treatment Based on BP
Treatment Based on Overall Absolute Risk (ASA, lipids, BP) -5 -6 -6
-10 -8 -9
-10
-15
-12
Predicted Reduction in Major CVD (%)
-20
-17
Treatment thresholds
-25
Estimates of the relative risk reductions from meta-analyses of randomized trials were used in combination with data from a prospective observational study of CVD (the British Regional Heart Study) to analyze the impact of different risk reduction strategies in primary prevention. High-risk strategies involving treatment decisions based on individual risk factors (BP or TC) were compared with high-risk strategies based on overall global risk. For each of these strategies, further analyses looked at the impact of expanding the group identified for treatment from the thresholds of the top 10%, top 20%, and top 30% of the distribution. As shown here, preventive approaches based on overall global risk were associated with greater risk reductions than preventive strategies based on individual risk factors. Furthermore, extending the group identified for treatment from the top 10% to the top 20% or 30% was associated with increases in the risk reduction associated with each strategy.
Top 10%
-30
-28
Top 20%
-35
Top 30%
-40
-37
Adapted from Emberson et al. Eur Heart J. 2004;25: 26

27. Challenges to Hypertension Management: Public Perceptions
44% of people could not identify a normal or a high blood pressure reading
80% of people were unaware of the association between hypertension and heart disease
63% believed that hypertension was not a serious condition
38% of people thought they could control high blood pressure without the help of a health professional
Can J Cardiol 2005;21: 27

28. The Canadian Hypertension Education Program (CHEP)
Goal
To reduce the burden of cardiovascular disease in Canada through optimized hypertension management
Activities
Regularly updated evidence-based recommendations for the management of hypertension
Knowledge translation and exchange of the recommendations to support implementation
Regular evaluation and revision of the program
Assessment of patient outcomes 28

29. Leading Diagnoses Resulting in Visits to Physician Offices in Canada25 20 15
Depression
Routine medical
exams
Acute respiratory
tract infection
Million visits/year
Diabetes
Hypertension 10
URTI: Upper Respiratory Tract Infections.
Patient visits to office-based physicians for essential hypertension numbered 18.9 million in 2002, a 10% increase from the previous year. Most visits were to GP/FMs (90%). 55% of visits were made by female patients and 45% were made by males. The age distribution was as follows: More than 81% of visits involved a drug recommendation. • Community retail pharmacies dispensed an estimated 52.7 million prescriptions for anti-hypertensive  agents in 2002, compared with 34 million in Source IMS Canada with permission. 5
Source: IMS HEALTH Canada 2002 29

30. New Patient Resources for Hypertension Online
- Download current resources for the prevention and control of hypertension
-To keep up to date with the latest evidence and resources
- Have your patients sign up to access the latest hypertension resources
- Tools and resources for healthcare professionals to use in educating other healthcare professionals, the public or patients about the risks of high dietary sodium in Canada.
-To access a simple to use demonstration of food sodium content for your patients
-To monitor home blood pressure and encourage self management of lifestyle
- Société Québécoise d’hypertension artérielle 30

31. For your patients – ask them to sign up at www. myBPsite
For your patients – ask them to sign up at for free access to the latest information & resources on HBP
For health care professionals – sign up at for automatic updates and on current hypertension educational resources
Special efforts are being made for health care professionals to have greater accessibility to hypertension resources.
Health care professionals can enroll at to get automated notices when new or updated hypertension resources are available for you and for your patients.
A case-based interactive lecture series on clinically important hypertension topics will also be launched on the internet to provide additional learning opportunities, and for you to interact with national hypertension experts.
The lecture series will feature important clinical topics provided by national experts, with case presentations and an opportunity to ask questions and make comments. Sign up at to be notified when they start.
We will also continue and expand our programs to train community leaders in hypertension.
Hypertension Canada has also developed a hypertension association for Canadians with high blood pressure.
Please encourage your patients to sign up for 2011 membership at
Your patients will receive notices of updated and new educational resources, a regular newsletter, incentives to encourage a healthy lifestyles, lectures, and possibly, in the future, personalized health care professional advice. 31