743525

research-article2017
CPHXXX10.1177/1715163517743525C P J / R P CC P J / R P C

Practice guidelines Peer-reviewed

PRACTICE GUIDELINES * PEER-REVIEWED

Hypertension Canada’s 2017

guidelines for diagnosis, risk
assessment, prevention and
treatment of hypertension in adults
for pharmacists: An update
Sarah A. Lamb, BSP; Yazid N. Al Hamarneh, BSc(Pharm), PhD;
Sherilyn K. D. Houle, BSP, PhD; Alexander A. Leung, MD, MPH;
Ross T. Tsuyuki, BSc(Pharm), PharmD, MSc, FCSHP, FACC

Hypertension Canada (formerly the Canadian to improve the detection and management of
Hypertension Education Program, CHEP) has hypertension in Canada.
been publishing evidence-based guidelines for The Canadian Pharmacists Journal has regu-
the diagnosis and management of hyperten- larly published pharmacist-specific hyperten-
sion since 1999.1 The 2017 guidelines,2 released sion guidelines, with the most recent full set
earlier this year, denote the 19th annual synthe- of guidelines published in 201114 and regu-
sis and update of evidence to date in hyperten- lar updates thereafter. This article highlights
sion. These guidelines, together with knowledge updates that have been integrated into the cur-
translation programs for health care profession- rent 2017 Hypertension Canada guidelines, in
als,3 have helped to improve the levels of detec- addition to elements that the authors feel are still
tion and management of hypertension in Canada important from previous publications. Readers
and reduced associated cardiovascular mortal- requiring Hypertension Canada’s full guidelines
ity.4,5 Indeed, the proportion of patients with are encouraged to refer to the Canadian Journal
controlled blood pressure in Canada has signifi- of Cardiology,2 www.hypertension.ca or previous
cantly increased from 13.2% in 19925 to 68.1% in versions of pharmacist-specific publications in
2012-2013.4 the Canadian Pharmacists Journal.
A multidisciplinary expert panel is respon-
sible for the synthesis and dissemination of What’s new
Hypertension Canada’s guidelines. To date, the The 2017 Hypertension Canada guidelines pres-
panel has consisted of physicians, nurses and ent 6 changes relevant to pharmacists (Box 1).
pharmacists, among other disciplines.
Pharmacists are well positioned to manage Indications for drug therapy in
hypertension, as they see patients with chronic adults with hypertension
conditions more frequently than any other
The previous guideline recommendations for
health care professional.6 Furthermore, the
alternate blood pressure targets in the frail
growing body of evidence supporting pharma-
and elderly have been removed.
cist interventions is indisputable.7-13 As such,
Hypertension Canada has recognized pharma- Antihypertensive therapy should be provided © The Author(s) 2017
cists’ expanded scope of practice as one approach to all patients without macrovascular target DOI:10.1177/1715163517743525

CPJ/RPC • MONTH/MONTH 2018 • VOL XX, NO X 1

Practice guidelines

BOX 1  Changes to 2017 Hypertension Canada guidelines relevant to pharmacists

1.  Alternate blood pressure targets in the frail and elderly have been removed.
2. Longer-acting thiazide-like diuretics are preferred over traditional, short-acting thiazide
diuretics.
3. Single-pill combinations are recommended as first-line options for the treatment of
hypertension.
4. When lowering systolic blood pressure (SBP) in patients with coronary artery disease
(especially with isolated systolic hypertension), use caution when diastolic blood pressure
(DBP) is ≤60 mmHg, especially in patients with left ventricular hypertrophy.
5. Avoid lowering SBP to <140 mmHg in the hyperacute phase (first 24 hours) of intracerebral
hemorrhage.
6. Pharmacists are advised to remain vigilant when managing and monitoring patients with
hypertension, since resistant hypertension was identified as an area of concern in the 2017
guidelines.

organ damage, such as myocardial infarction and the HYVET and SPRINT trials, limiting gen-
stroke, or other cardiovascular risk factors (e.g., eralizability to these groups. These findings are
dyslipidemia, smoking, diabetes mellitus, seden- supported by a meta-analysis conducted by Xie
tary lifestyle and obesity) with average diastolic and colleagues,19 which demonstrated a favour-
blood pressure (DBP) readings of ≥100 mmHg able relationship between intensive blood pres-
(Grade A) and/or average systolic blood pres- sure lowering and reduced major cardiovascular
sure (SBP) readings of ≥160 mmHg (Grade A).15 events in older adults (≥62 years) (relative risk
In addition, antihypertensive therapy should be [RR], 0.81; 95% CI, 0.69-0.96).
strongly considered for all patients with macro-
vascular target organ damage or other indepen- Choice of therapy for adults with
dent cardiovascular risk factors with average hypertension without compelling
DBP readings of ≥90 mmHg (Grade A) and/or indications for specific agents
average SBP readings of ≥140 mmHg (Grade B
Long-acting, thiazide-like diuretics
for 140-160 mmHg, Grade A for >160 mmHg).
(chlorthalidone and indapamide) are
All patients should be treated to achieve a SBP
preferred to thiazide diuretics for the initial
target of <140 mmHg (Grade C) and/or a DBP
management of hypertension (Grade B),
target of <90 mmHg (Grade A); however, cau-
although both thiazide and thiazide-like
tion should be used in elderly patients experi-
diuretics remain first-line options.
encing orthostasis.
A post hoc analysis of the HYVET trial16 and This preference is guided by evidence sup-
a subgroup analysis of the SPRINT trial17,18 dem- porting the use of long-acting diuretics to reduce
onstrated that blood pressure lowering in elderly blood pressure and cardiovascular events.20-22 A
patients (age ≥80 years and ≥75 years in HYVET meta-analysis conducted by Olde Engberink and
and SPRINT, respectively) significantly reduced colleagues20 showed that after adjusting for dif-
the incidence of major cardiovascular events ferences in blood pressure reduction, thiazide-
(hazard ratio [HR], 0.66; 95% confidence inter- like diuretics reduced the risk of cardiovascular
val [CI], 0.51-0.85),17 mortality (HR, 0.67; 95% events and heart failure by an additional 12% (p
CI, 0.49-0.91)17 and stroke (HR, 0.64; 95% CI, = 0.049) and 21% (p = 0.023), respectively, com-
0.42-0.96),16 regardless of age or baseline frailty. pared to thiazide diuretics. Moreover, only thia-
There was no difference in the rates of serious zide-like diuretics reduced the risk of coronary
adverse events, however, rates of renal dysfunc- events (RR, 0.76; CI, 0.61-0.96; I2 = 0%) and all-
tion were significantly increased in the intensive cause mortality (RR, 0.84; CI, 0.74-0.96; I2 = 0%)
treatment group in SPRINT.17 Moreover, indi- compared to placebo.20 In addition, Roush and
viduals with dementia, limited life expectancy colleagues21 and Pareek and colleagues22 dem-
and those institutionalized were excluded from onstrated a greater reduction in blood pressure

2  CPJ/RPC • MONTH/MONTH 2018 • VOL XX, NO X

 Practice guidelines

with extended-release hydrochlorothiazide and benazepril plus amlodipine compared to bena-

thiazide-like diuretics compared to conventional zepril plus hydrochlorothiazide (HR, 0.80; 95%
hydrochlorothiazide. CI, 0.72-0.90). The HOPE-327 and STITCH25 tri-
als support the use of an ACE inhibitor or ARB
Single-pill combinations (SPCs) are combined with a diuretic. While the HOPE-3
recommended as an initial treatment option trial reported no significant difference in the 2
(Grade A) based on evidence supporting coprimary outcomes for individuals with an inter-
their effectiveness in reducing blood mediate risk of cardiovascular events with cande-
pressure and cardiovascular events.23-27 In sartan-hydrochlorothiazide vs placebo overall, a
addition, SPCs have been shown to improve significant reduction in the coprimary endpoints
adherence and reduce the incidence of was demonstrated in those with higher blood
adverse events.28,29 pressure or hypertension (SBP >143.5 mmHg).27

Combination antihypertensive therapy is Treatment of hypertension in

associated with a reduced likelihood of cardio- association with ischemic heart disease
vascular events compared to monotherapy.23,30
When treating SBP to target in patients with
Furthermore, SPCs have been shown to be more
established coronary artery disease (CAD)
effective at reducing blood pressure compared to
(especially in those with isolated systolic
monotherapy. A meta-analysis of 42 randomized
hypertension), exercise caution when
clinical trials demonstrated that the combination
DBP is ≤60 mmHg due to concerns with
of 2 drugs of different classes resulted in a 5-fold
exacerbating myocardial ischemia, especially
greater reduction in systolic blood pressure com-
for patients with left ventricular hypertrophy
pared to doubling the dose of 1 drug.24 These
(Grade D).
findings are supported by evidence from the
STITCH study,25 where a larger blood pressure This recommendation is supported by post hoc
reduction (–5.2/–2.2) was observed in individu- analyses of several studies showing that in patients
als receiving initial fixed-dose combination ther- with CAD, reducing blood pressure below a spe-
apy of an angiotensin-converting enzyme (ACE) cific threshold was associated with an increased
inhibitor or angiotensin-receptor blocker (ARB) risk of coronary events.31-34 Individuals with left
and diuretic, compared to monotherapy with ventricular hypertrophy may be at greatest risk due
uptitration at 6 months.25 Moreover, a greater to increased myocardial demand and decreased
percentage of individuals reached their target coronary perfusion during diastole. Indeed, an
blood pressure (64.7% vs 52.7%, p = 0.03).25 association between reduced coronary blood flow
A meta-analysis conducted by Sherrill and and increased left ventricular mass was noted in
colleagues28 found that the use of SPCs was asso- patients with CAD and was most pronounced at
ciated with improved adherence rates and lower DBP <70 mmHg.35 These findings are in line with
health care costs compared to the use of the a meta-analysis conducted by Rabkin.36
individual components. Furthermore, another Even so, the 2017 guidelines2 still strongly
meta-analysis conducted by Law and colleages29 recommend antihypertensive therapy for most
found that fixed-dose antihypertensive combi- patients who can tolerate blood pressure reduc-
nations were associated with a lower incidence tion, especially those with moderate or severe
of adverse events and improved efficacy. hypertension, due to the benefits of blood pres-
When choosing an SPC, it is recommended sure reduction in these high-risk individuals,
to use an ACE inhibitor combined with a cal- which likely outweigh the associated risks.
cium channel blocker (CCB) (Grade A), an ARB
combined with a CCB (Grade B) or an ACE or Treatment of hypertension in
ARB combined with a diuretic (Grade B). This association with hemorrhagic stroke
recommendation is supported by the ACCOM-
In patients in the hyperacute phase (first
PLISH trial,26 which randomized high-risk adults
24 hours) of intracerebral hemorrhage, avoid
to either benazepril plus amlodipine or benaz-
SBP lowering to <140 mmHg due to a lack of
epril plus hydrochlorothiazide. The composite of
benefit (relative to a target of <180 mmHg)
cardiovascular death and major adverse cardio-
and the potential for harm (Grade A).
vascular events was significantly reduced with

CPJ/RPC • MONTH/MONTH 2018 • VOL XX, NO X 3

Practice guidelines

Trial evidence demonstrated no benefit What is still important

and potential harm with SBP targets of <140
mmHg in the acute phase of intracerebral hem- Diagnosis and accurate measurement of blood
orrhage.37,38 INTERACT-2 randomized 2839 pressure
patients who had a spontaneous intracerebral Using standardized measurements and validated
hemorrhage within 6 hours of onset to a tar- equipment (Grade D), trained health care pro-
get SBP of either <140 mmHg or <180 mmHg fessionals, including pharmacists, should assess
(applied within the first hour of spontaneous blood pressure in all patients at appropriate
intracerebral hemorrhage presentation).37 There visits to monitor antihypertensive therapy and
was no statistical difference in the primary out- evaluate cardiovascular risk (Grade D). Phar-
come of death or stroke-related disability at 90 macists should ensure they only use and sell
days when comparing the 2 SBP targets (odds validated blood pressure monitors. Validation
ratio [OR], 0.87; 95% CI, 0.75-1.01). These find- means that instruments have been tested against
ings are consistent with the ATACH-2 trial,38 a gold standard. Electronic (oscillometric) upper
where 1000 patients presenting with spontane- arm devices should be used preferentially due to
ous intracerebral hemorrhage were random- inaccuracies seen with manual (auscultatory)
ized to SBP targets of 110 to 139 mmHg or 140 blood pressure measurements (Grade C).42
to 179 mmHg. Treatment was initiated within Figure 1 illustrates the recommended diag-
4.5 hours after symptom onset and continued for nostic algorithm for hypertension. After an ini-
the next 24 hours.38 No difference in the primary tial finding of in-office elevated blood pressure,
outcome of death or stroke-related disability was it is recommended to use out-of-office blood
observed between the 2 arms; however, there pressure measurements to confirm the initial
was a trend toward greater adverse events in the diagnosis of hypertension, as it better predicts
lower SBP arm.38 cardiovascular outcomes compared to in-office
measurements.43 Moreover, out-of-office blood
Resistant hypertension pressure measurements can identify both white
coat and masked hypertension.43
The 2017 guidelines recognize resistant Ambulatory blood pressure monitoring is the
hypertension as an area of concern; however, preferred out-of-office measurement (Grade D)
due to a lack of event-related outcomes from as it provides a greater number of readings, as
the PATHWAY-2 trial,39 no specific guideline well as information regarding nocturnal blood
recommendations were made. pressure, and is considered a strong predictor of
cardiovascular events.44 When using this method,
Resistant hypertension affects 10% to 20% patients can be diagnosed with hypertension if
of patients treated for high blood pressure and the mean ambulatory 24-hour blood pressure
is associated with increased cardiovascular risk is ≥130/80 mmHg or the mean awake ambula-
compared to other forms of hypertension.40,41 It tory blood pressure is ≥135/85 mmHg (Grade
is defined as uncontrolled blood pressure despite C). If ambulatory blood pressure monitoring
the use of 3 or more antihypertensive agents is not available, cannot be tolerated or patient
from different classes (including a diuretic), or preference precludes use, home blood pressure
hypertension that is controlled with 4 or more monitoring can be used (Grade D). A diagnosis
agents.40,41 Optimal treatment strategies for this of hypertension can be made if the mean home
heterogeneous disorder remain uncertain. While blood pressure is ≥135/85 mmHg following
the PATHWAY-2 trial showed that spironolac- duplicate measures, morning and evening, for 7
tone was the most effective add-on drug in low- days, with the first day’s values excluded from the
ering SBP compared to doxazosin, bisoprolol and overall mean calculation (Grade C).
placebo (−12.8 mmHg [−13.8 to –11.8] for spi- Automated office blood pressure (AOBP)
ronolactone, −8.7 mmHg [−9.7 to −7.7] for doxa- is the preferred method for in-office measure-
zosin, −8.3 mmHg [–9.3 to −7.3] for bisoprolol ments (Grade D), with a mean blood pressure of
and −4.1 mmHg (−5.1 to −3.1] for placebo), this ≥135/85 mmHg considered elevated (Grade D).
trial did not assess cardiovascular outcomes.39 If the patients’ in-office blood pressure is
As such, no specific guideline recommendations elevated (AOBP ≥135/85 mmHg) and the mean
were generated on the basis of its results. awake home blood pressure is <135/85 mmHg

4  CPJ/RPC • MONTH/MONTH 2018 • VOL XX, NO X

 Practice guidelines

Figure 1  Hypertension diagnostic algorithm

Elevated BP Reading

1
YES
180/110

NO

No Diabetes Diabetes3
1. AOBP2 135/85 AOBP or
(preferred) non-AOBP2 Hypertension
No Hypertension6 NO OR 130/80
2. Non-AOBP2 140/90
(if AOBP unavailable)

YES

1. ABPM (preferred)
Daytime mean 135/85
24-hour mean 130/80 YES
OR
2. Home BP Series5
Mean 135/85

NO

White Coat Hypertension6

ABPM, ambulatory blood pressure measurement; AOBP, automated office blood pressure; BP, blood pressure.
1
If AOBP is used, use the mean calculated and displayed by the device. If non-AOBP is used, take at least 3 readings, discard the first, and
calculate the mean of the remaining measurements. A history and physical exam should be performed and diagnostic tests ordered.
2
AOBP is performed with the patient unattended in a private area. Non-AOBP is performed using an electronic upper arm device with the
provider in the room.
3
Diagnostic thresholds for AOBP, ABPM and home BP in patients with diabetes have yet to be established (and might be lower than
130/80 mmHg).
4
Serial office measurements over 3 to 5 visits can be used if ABPM or home measurement is not available.
5
For a home BP series, 2 readings are taken each morning and evening for 7 days (28 total). Discard the first day readings and average the
last 6 days.
6
Annual BP measurement is recommended to detect progression to hypertension.
Adapted with permission from Leung AA, Daskalopoulou SS, Dasgupta K, et al. Hypertension Canada’s 2017 guidelines for diagnosis, risk
assessment, prevention and treatment of hypertension in adults. Can J Cardiol 2017;33(5):557-76.

or the mean 24-hour ambulatory blood pressure disease,47 further increasing the likelihood of an
is <130/80 mmHg, then a diagnosis of white coat event. As such, overall cardiovascular risk should
hypertension can be made (Grade D). Antihy- be assessed in all patients with hypertension.
pertensive therapy should not be initiated under Cardiovascular risk engines can be used to
these circumstances (Grade C) due to a lack of more accurately predict the patient’s overall car-
benefit and increased risk of adverse events. diovascular risk (Grade A) and improve the effi-
ciency of antihypertensive therapy (Grade D).
Assessment and management of overall Pharmacists may consider counselling patients
cardiovascular risk and vascular protection about their overall cardiovascular risk and con-
High blood pressure represents a major risk fac- sider using comparative risk analogies, such as
tor for premature death and disability.45,46 Fur- “cardiovascular age,” “heart age” or “vascular
thermore, 80% of patients with hypertension have age” (Grade B) to help advise patients about
at least 1 additional risk factor for cardiovascular their risk. This approach improves both the

CPJ/RPC • MONTH/MONTH 2018 • VOL XX, NO X 5

Practice guidelines

effectiveness of risk factor modification as well Pharmacist interventions included providing

as the patient’s perception of risk.48-52 advice and counselling to patients in either a
The RXEACH study randomized 723 patients one-on-one or a group setting. Pharmacologic
to receive pharmacist intervention (including therapy (nicotine replacement) was also provided
prescribing) or usual care.13 Pharmacist inter- in one study.54 Pharmacists’ interventions should
vention comprised individualized cardiovascu- include offering patients both advice and phar-
lar risk assessment and education regarding this macotherapy (e.g., nicotine replacement therapy,
risk.13 Compared to usual care, greater reduc- varenicline or bupropion) with a goal of tobacco
tions in cardiovascular risk (21%, p < 0.001) and cessation. Stead and colleagues55 demonstrated
blood pressure (–9.37/–2.92 mmHg, p < 0.001) that patients were more likely to have sustained
were observed in the pharmacist intervention smoking cessation when given brief advice on
group at 3 months.13 These findings highlight the quitting vs usual care (5.8% vs 3.7%). A Cochrane
importance of overall cardiovascular risk assess- network meta-analysis56 reported an even greater
ment in this patient population. likelihood of quitting and sustained tobacco cessa-
Statin therapy is recommended in hyperten- tion with a combination of advice and pharmaco-
sive patients who have ≥3 cardiovascular risk therapy compared to advice plus placebo.
factors (Grade A, in patients >40 years) or estab- Intensive blood pressure management to a SBP
lished atherosclerotic disease (Grade A, irrespec- target of ≤120 mmHg may be considered in select
tive of age). Risk factors include the following: high-risk patients who are 50 years or older and
whose blood pressure is ≥130 mmHg (Grade B).
•• Male sex This recommendation stems from the SPRINT
•• Age ≥55 years trial,18 which demonstrated a reduction in car-
•• Left ventricular hypertrophy diovascular events secondary to intensive blood
•• Electrocardiogram (ECG) abnormalities pressure lowering (SBP <120 mmHg). High-risk
•• Peripheral arterial disease patients are defined as those with the following18:
•• Previous stroke or transient ischemic attack
•• Albuminuria or proteinuria •• Clinical or subclinical cardiovascular disease
•• Diabetes •• Chronic kidney disease (nondiabetic
•• Tobacco use nephropathy, proteinuria <1 g/d, esti-
•• Family history of premature cardiovascu- mated glomerular filtration rate [eGFR]
lar disease 20-59 mL/min/1.73 m2)
•• Total cholesterol to high-density lipopro- •• Estimated 10-year cardiovascular risk
tein cholesterol ratio ≥6 ≥15% (Framingham Risk Score)
•• Age ≥75 years
Low-dose acetylsalicylic acid (ASA) therapy Pharmacists should ensure patient risk assess-
may also be considered for patients with hyper- ment is consistent with the above criteria before
tension who are 50 years or older (Grade B); how- initiating intensive treatment. In addition,
ever, caution should be used in patients whose patients should consent to receiving intensive
blood pressure remains uncontrolled (Grade C). treatment that includes multiple antihyperten-
Pharmacists should assess tobacco use regu- sive medications and an increased frequency of
larly and advise on tobacco cessation in all patients
follow-up visits. A careful risk-benefit analysis
(Grade C). Tobacco use represents a significant
should be performed due to the propensity for
contributor to elevated blood pressure and car-
adverse events with intensive blood pressure
diovascular risk.53 As such, tobacco cessation is
management. Moreover, such treatment should
crucial to reducing vascular risk. The pharma-
be avoided in certain high-risk groups (Grade B)
cists’ role in smoking cessation is supported by a
due to a lack of supporting evidence. These high-
meta-analysis conducted by Saba and colleagues.54
risk groups include the following:
Five randomized controlled trials with a total
of 1426 smokers were included in the analysis.54 •• Patients with heart failure (ejection frac-
Compared with control groups, pharmacist inter- tion <35%) or recent myocardial infarc-
ventions demonstrated greater abstinence rates tion (within the past 3 months)
(RR, 2.21; 95% CI, 1.49-3.29), including long- •• An indication for, but not currently receiv-
term abstinence (RR, 2.40; 95% CI, 1.37-4.23).54 ing, a beta-blocker

6  CPJ/RPC • MONTH/MONTH 2018 • VOL XX, NO X

 Practice guidelines

•• Frail or institutionalized elderly individuals as a result of an expanded scope of practice

•• Diabetes mellitus and the growing strain on the health care sys-
•• Previous stroke tem. Research has demonstrated the benefits of
•• eGFR <20 mL/min/1.73 m2 pharmacist-led interventions for hypertension
•• Unwilling or unable to adhere to multiple management.7-12 Indeed, Hypertension Canada
medications is exceedingly supportive of the pharmacist’s
•• Standing SBP <110 mmHg expanded role to improve hypertension detec-
•• Inability to measure SBP accurately tion and management, as well as reduce the risk
•• Known secondary cause(s) of hypertension of cardiovascular events.
A systematic review and meta-analysis of
Adherence 39 randomized controlled trials comprising
Patient nonadherence to antihypertensive therapy over 14,000 patients showed that pharmacists’
is common and has a significant impact on blood interventions—namely, patient education,
pressure control and cardiovascular complica- recommendations to physicians and medica-
tions.57-59 Early discontinuation of treatment is one tion management—resulted in greater reduc-
of the most common causes of nonadherence.60 tions of both SBP (−7.6 mmHg; 95% CI, –9 to
One systematic review and meta-analysis found −6.3) and DBP (−3.9 mmHg; 95% CI, −5.1 to
that 45% of patients with hypertension were not −2.8) compared with usual care.9 Interestingly,
taking their antihypertensive therapy, and a higher the most pronounced effect on blood pressure
proportion (83.7%) of patients with uncontrolled reduction was seen when the pharmacist led
hypertension were nonadherent to therapy.57 Thus, the intervention, resulting in a SBP reduction
evaluating and assisting patients with adherence is of –8.5 mmHg and a DBP reduction of –4.6
a crucial step in the management of hypertension. mmHg. Results from the RxACTION trial dem-
Health care providers can improve patient adher- onstrated an even greater effect on blood pres-
ence using a comprehensive approach addressing sure reduction when pharmacist interventions
factors relating to patients, medications and them- included independent prescribing for hyperten-
selves.58,59 Moreover, pharmacist intervention and sion (mean SBP reduction 18.3 mmHg, adjusted
management of blood pressure has been shown to difference 6.6 mmHg).10 In addition, patients in
improve adherence rates.61 the pharmacist prescribing arm were 2.3 times
more likely to achieve target blood pressures. A
•• To address patient factors: recent economic analysis evaluating the cost-
|| Educate patients, family members and effectiveness of pharmacist care for managing
caregivers about the condition and hypertension found that pharmacist-led inter-
associated treatments ventions were economically dominant, being
|| Encourage patients to monitor their more effective (i.e., reduced blood pressure)
blood pressure regularly at home and with a lifetime cost savings of $6364.62
•• To address medication factors: When extrapolated to just half of Canadians
|| Encourage the use of once-daily
with poorly controlled hypertension, that fig-
regimens, single-pill combination and ure expands to an extraordinary $15.7 billion
unit-of-dose packaging to simplify the in lower costs—a compelling reason to engage
treatment regimen
pharmacists in the fight against hypertension.
|| Tailor the patient’s medication-taking
Indeed, Hypertension Canada is extremely sup-
schedule to fit his or her daily routine
portive of expanding the role of pharmacists in
•• To address health care provider factors:
|| Assess adherence to therapy at every
hypertension management.
patient encounter Readers are encouraged to consult the full
|| Use a multidisciplinary team approach, guidelines in the Canadian Journal of Cardiol-
including work-site health care ogy2 or at www.hypertension.com, where they
providers, to improve adherence will find additional professional and patient
resources. Pharmacists interested in education
Evidence for pharmacist-led relating to hypertension assessment and man-
interventions agement can refer to the Hypertension Canada
The pharmacists’ role in chronic disease man- website for education materials, including pre-
agement is becoming increasingly prominent sentations, videos and documents. ■

CPJ/RPC • MONTH/MONTH 2018 • VOL XX, NO X 7

Practice guidelines

From the Faculty of Pharmacy and Pharmaceutical Sciences (Lamb), Department of Medicine (Al Hamarneh, Tsuyuki), Faculty
of Medicine and Dentistry, University of Alberta, Edmonton, Alberta; the School of Pharmacy (Houle), University of Waterloo,
Ontario; and the Department of Medicine (Leung), University of Calgary, Alberta. Contact [email protected].

References
1. Campbell NR, Burgess E, Choi BCK, et al. Methods 15. Padwal R, Straus S, McAlister F. Cardiovascular risk fac-
and overview of the Canadian recommendations. CMAJ tors and their effects on the decision to treat hypertension:
1999;160(9 suppl):S1-S6. evidence based review. BMJ 2001;322(7292):977-80.
2. Leung AA, Daskalopoulou SS, Dasgupta K, et al. Hyper- 16. Warwick J, Falaschetti E, Rockwood K, et al. No evidence
tension Canada’s 2017 guidelines for diagnosis, risk assess- that frailty modifies the positive impact of antihypertensive
ment, prevention and treatment of hypertension in adults. treatment in very elderly people: an investigation of the
Can J Cardiol 2017;33(5):557-76. impact of frailty upon treatment effect in the HYpertension
3. Hua D, Carter S, Bellerive J. Bridging the gap: innovative in the Very Elderly Trial (HYVET) study, a double-blind,
knowledge translation and the Canadian Hypertension Edu- placebo-controlled study of antihypertensives in people with
cation Program. Can J Cardiol 2012;8:258-61. hypertension aged 80 and over. BMC Med 2015;13:78.
4. Padwal RS, Bienek A, McAlister FA, Campbell NR. Epide- 17. Williamson JD, Supiano MA, Applegate WB, et al. Inten-
miology of hypertension in Canada: an update. Can J Cardiol sive vs standard blood pressure control and cardiovascular
2016;32:687-94. disease outcomes in adults aged ≥75 years: a randomized
5. McAlister FA, Wilkins K, Joffres M, et al. Changes in the clinical trial. JAMA 2016;315:2673-82.
rates of awareness, treatment and control of hypertension in 18. Wright JT Jr, Williamson JD, Whelton PK, et al. A ran-
Canada over the past two decades. CMAJ 2011;183:1007-13. domized trial of intensive versus standard blood-pressure
6. Shiu J, Simpson S, Johnson J, Tsuyuki RT. Quantifying control. N Engl J Med 2015;373:2103-16.
opportunities to affect diabetes management in the commu- 19. Xie X, Atkins E, Lv J, et al. Effects of intensive blood
nity. Can Pharm J (Ott) 2006;139(3):37-8. pressure lowering on cardiovascular and renal outcomes:
7. Chisholm-Burns MA, Kim Lee J, Spivey CA, et al. US updated systematic review and meta-analysis. Lancet
pharmacists’ effect as a team member on patient care: sys- 2016;387:435-43.
tematic review and meta-analyses. Med Care 2010;48:923-33. 20. Olde Engberink RH, Frenkel WJ, van den Bogaard B,
8. Santschi V, Chiolero A, Burnand A, et al. Impact of phar- Brewster LM, Vogt L, van den Born BJ. Effects of thiazide-
macist care in the management of cardiovascular disease risk type and thiazide-like diuretics on cardiovascular events and
factors: a systematic review and meta-analysis of random- mortality: systematic review and meta-analysis. Hyperten-
ized trials. Arch Intern Med 2011;171:1441-53. sion 2015;65:1033-40.
9. Santschi V, Chiolero A, Paradis G, et al. Pharmacist inter- 21. Roush GC, Ernst ME, Kostis JB, Tandon S, Sica DA.
ventions to improve cardiovascular disease risk factors in Head-to-head comparisons of hydrochlorothiazide with
diabetes: a systematic review and meta analysis of random- indapamide and chlorthalidone: antihypertensive and meta-
ized controlled trials. Diabetes Care 2012;35:2706-17. bolic effects. Hypertension 2015;65:1041-6.
10. Santschi V, Chiolero A, Colosimo AL, et al. Improving 22. Pareek AK, Messerli FH, Chandurkar NB, et al. Effi-
blood pressure control through pharmacist interventions: a cacy of low-dose chlorthalidone and hydrochlorothiazide
meta-analysis of randomized controlled trials. J Am Heart as assessed by 24-h ambulatory blood pressure monitoring.
Assoc 2014;3:e000718. J Am Coll Cardiol 2016;67:379-89.
11. Tsuyuki R, Houle S, Charrois T, et al. A randomized trial of 23. Gradman AH, Parise H, Lefebvre P, et al. Initial combi-
the effect of pharmacist prescribing on improving blood pres- nation therapy reduces the risk of cardiovascular events in
sure in the community: the Alberta Clinical Trial in Optimiz- hypertensive patients: a matched cohort study. Hypertension
ing Hypertension (RxACTION). Circulation 2015;132:93-100. 2013;61:309-18.
12. Pojskic N, Jackson M, Malek A, Cimino S. Impact of 24. Wald DS, Law M, Morris JK, et al. Combination ther-
community pharmacist interventions in hypertension man- apy versus monotherapy in reducing blood pressure: meta-
agement on patient outcomes: a randomized controlled trial. analysis on 11,000 participants from 42 trials. Am J Med
Can Pharm J (Ott) 2014;147:S17. 2009;122:290-300.
13. Tsuyuki RT, Al Hamarneh YN, Jones CA, Hemmelgarn 25. Feldman RD, Zou GY, Vandervoort MK, et al. A simpli-
BR. Effectiveness of community pharmacist prescribing and fied approach to the treatment of uncomplicated hyperten-
care on cardiovascular risk reduction: randomized controlled sion: a cluster randomized, controlled trial. Hypertension
RxEACH trial. J Am Coll Cardiol 2016;67(24):2846-54. 2009;53:646-53.
14. Houle SKD, Tsuyuki RT, Campbell NRC. The Canadian 26. Jamerson K, Weber MA, Bakris GL, et al. Benazepril
Hypertension Education Program (CHEP) 2011 guidelines plus amlodipine or hydrochlorothiazide for hypertension in
for pharmacists. Can Pharm J (Ott) 2011;144:295-304. high-risk patients. N Engl J Med 2008;359:2417-28.

8  CPJ/RPC • MONTH/MONTH 2018 • VOL XX, NO X

 Practice guidelines

27. Lonn EM, Bosch J, Lopez-Jaramillo P, et al. Blood-pres- 41. Myat A, Redwood SR, Qureshi AC, et al. Resistant hyper-
sure lowering in intermediate-risk persons without cardio- tension. BMJ 2012;345:e7473.
vascular disease. N Engl J Med 2016;374:2009-20. 42. Myers MG, Kaczorowski J, Dawes M, Godwin M. Auto-
28. Sherrill B, Halpern M, Khan S, et al. Single-pill vs free- mated office blood pressure measurement in primary care.
equivalent combination therapies for hypertension: a meta- Can Fam Phys 2014;60:127-32.
analysis of health care costs and adherence. J Clin Hypertens 43. Daskalopoulou SS, Rabi DM, Zarnke KB, et al. The 2015
(Greenwich) 2011;13:898-909. Canadian Hypertension Education Program recommenda-
29. Law MR, Wald NJ, Morris JK, Jordan RE. Value of low tions for blood pressure measurement, diagnosis, assessment
dose combination treatment with blood pressure lowering of risk, prevention, and treatment of hypertension. Can J
drugs: analysis of 354 randomised trials. BMJ 2003;326:1427. Cardiol 2015;31:549-68.
30. Corrao G, Nicotra F, Parodi A, et al. Cardiovascular 44. Clement DL, De Buyzere ML, De Bacquer DA, et al.
protection by initial and subsequent combination of anti- Prognostic value of ambulatory blood-pressure record-
hypertensive drugs in daily life practice. Hypertension ings in patients with treated hypertension. N Engl J Med
2011;58:566-72. 2003;348:2407-15.
31. Dasgupta K, Quinn RR, Zarnke KB, et al. The 2014 Cana- 45. Lawes CMM, Vander Hoorn S, Rodgers A, for the Inter-
dian Hypertension Education Program recommendations national Society of Hypertension. Global burden of blood-
for blood pressure measurement, diagnosis, assessment of pressure-related disease, 2001. Lancet 2008;371:1513-8.
risk, prevention, and treatment of hypertension. Can J Car- 46. Forouzanfar MF, Liu P, Roth GA, et al. Global burden of
diol 2014;30:485-501. hypertension and systolic blood pressure of at least 110 to
32. Bangalore S, Messerli FH, Wun CC, et al. J-curve revis- 115 mm hg, 1990-2015. JAMA 2017;317(2):165-82.
ited: an analysis of blood pressure and cardiovascular events 47. Gee ME, Bienek A, McAlister FA, et al. Factors associated
in the Treating to New Targets (TNT) Trial. Eur Heart J with lack of awareness and uncontrolled high blood pressure
2010;31:2897-908. among Canadian adults with hypertension. Can J Cardiol
33. Bangalore S, Qin J, Sloan S, et al. What is the optimal 2012;28:375-82.
blood pressure in patients after acute coronary syndromes? 48. Grover SA, Lowensteyn I, Joseph L, et al. Patient knowl-
Relationship of blood pressure and cardiovascular events in edge of coronary risk profile improves the effectiveness of
the PRavastatin OR atorVastatin Evaluation and Infection dyslipidemia therapy: the CHECK-UP study: a randomized
Therapy–Thrombolysis In Myocardial Infarction (PROVE controlled trial. Arch Intern Med 2007;167:2296-303.
IT-TIMI) 22 trial. Circulation 2010;122:2142-51. 49. Benner JS, Erhardt L, Flammer M, et al. A novel pro-
34. Messerli FH, Mancia G, Conti CR, et al. Dogma disputed: gramme to evaluate and communicate 10-year risk of CHD
can aggressively lowering blood pressure in hypertensive reduces predicted risk and improves patients’ modifiable risk
patients with coronary artery disease be dangerous? Ann factor profile. Int J Clin Pract 2008;62:1484-98.
Intern Med 2006;144:884-83. 50. D’Agostino RB, Vasan RS, Pencina MJ, et al. General car-
35. Rabkin SW, Shiekh IA, Wood DA. The impact of left diovascular risk profile for use in primary care: the Framing-
ventricular mass on diastolic blood pressure targets for ham Heart Study. Circulation 2007;117:743-53.
patients with coronary artery disease. Am J Hypertens. 51. Soureti A, Hurling R, Murray P, et al. Evaluation of a car-
2016;29:1085-93. diovascular disease risk assessment tool for the promotion of
36. Rabkin SW. Considerations in understanding the coro- healthier lifestyles. J Cardiovasc Prev Rehabil 2010;17:519-23.
nary blood flow–left ventricular mass relationship in patients 52. Grover SA, Lowensteyn I, Joseph L, et al. Patient knowl-
with hypertension. Curr Cardiol Rev. 2017;13:75-83. edge of coronary risk profile improves the effectiveness of
37. Anderson CS, Heeley E, Huang Y, et al. Rapid blood- dyslipidemia therapy. Arch Intern Med 2007;167:2296-30.
pressure lowering in patients with acute intracerebral hem- 53. Teo KK, Ounpuu S, Hawken S, et al. Tobacco use and
orrhage. N Engl J Med. 2013;368:2355-65. risk of myocardial infarction in 52 countries in the INTER-
38. Qureshi AI, Palesch YY, Barsan WG, et al. Intensive HEART study: a case-control study. Lancet 2006;368:647-58.
blood-pressure lowering in patients with acute cerebral hem- 54. Saba M, Diep J, Saini B, Dhippayom T. Meta-analysis of
orrhage. N Engl J Med. 2016;375:1033-43. the effectiveness of smoking cessation interventions in com-
39. Williams B, MacDonald TM, Morant S, et al. Spirono- munity pharmacy. J Clin Pharm Ther 2014;39:240-7.
lactone versus placebo, bisoprolol, and doxazosin to deter- 55. Stead LF, Hartmann-Boyce J, Perera R, Lancaster T. Tele-
mine the optimal treatment for drug-resistant hypertension phone counselling for smoking cessation. Cochrane Data-
(PATHWAY-2): a randomised, double-blind, crossover trial. base Syst Rev 2013;(8):CD002850.
Lancet. 2015;386:2059-68. 56. Cahill K, Lancaster T. Workplace interventions for
40. Calhoun DA, Jones D, Textor S, et al. Resistant hyperten- smoking cessation. Cochrane Database Syst Rev 2014;(4):
sion: diagnosis, evaluation, and treatment: a scientific state- CD003440.
ment from the American Heart Association Professional 57. Abegaz TM, Shehab A, Gebreyohannes EA, et al. Nonad-
Education Committee of the Council for High Blood Pres- herence to antihypertensive drugs: a systematic review and
sure Research. Circulation 2008;117:e510-26. meta-analysis. Medicine Open 2017;96(4):e5641-9.

CPJ/RPC • MONTH/MONTH 2018 • VOL XX, NO X 9

Practice guidelines

58. Chockalingam A, Bacher M, Campbell N, et al. Adher- longitudinal study of electronically compiled dosing histo-
ence to management of high blood pressure: recommenda- ries. BMJ 2008;336(7653):1114-7.
tions of the Canadian Coalition for High Blood Pressure 61. Faulkner MA, Wadibia EC, Lucas BD, Hilleman DE.
Prevention and Control. Can J Public Health 1998;89(Suppl Impact of pharmacy counseling on compliance and effec-
2):15-6. tiveness of combination lipid-lowering therapy in patients
59. Fodor JG, Cutler H, Irvine J, et al. Adherence to non- undergoing coronary artery revascularization: a random-
pharmacological therapy for hypertension: problems and ized, controlled trial. Pharmacotherapy 2000;20:410-6.
solutions. Can J Public Health 1998;89(Suppl 2):112-5. 62. Marra C, Johnston K, Santschi V, et al. Cost-effectiveness
60. Vrijens B, Vincze G, Kristanto P, Urquhart J, Burnier M. of pharmacist care for managing hypertension in Canada.
Adherence to prescribed antihypertensive drug treatments: Can Pharm J (Ott) 2017;150(3):184-97.

10  CPJ/RPC • MONTH/MONTH 2018 • VOL XX, NO X