To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension.
MEDLINE searches were conducted from November 2008 to October 2009 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed full-text articles only.
Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Changes to the recommendations for 2010 relate to automated office blood pressure measurements. Automated office blood pressure measurements can be used in the assessment of office blood pressure. When used under proper conditions, an automated office systolic blood pressure of 135 mmHg or higher or diastolic blood pressure of 85 mmHg or higher should be considered analogous to a mean awake ambulatory systolic blood pressure of 135 mmHg or higher and diastolic blood pressure of 85 mmHg or higher, respectively.
All recommendations were graded according to strength of the evidence and voted on by the 63 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. To be approved, all recommendations were required to be supported by at least 70% of task force members. These guidelines will continue to be updated annually.
CONTEXT: The worldwide explosive increase in type 2 diabetes mellitus and its cardiovascular morbidity are becoming major health concerns. OBJECTIVE: To evaluate the effect of decreasing postprandial hyperglycemia with acarbose, an alpha-glucosidase inhibitor, on the risk of cardiovascular disease and hypertension in patients with impaired glucose tolerance (IGT). DESIGN, SETTING, AND PARTICIPANTS: International, multicenter double-blind, placebo-controlled, randomized trial, undertaken in hospitals in Canada, Germany, Austria, Norway, Denmark, Sweden, Finland, Israel, and Spain from July 1998 through August 2001. A total of 1429 patients with IGT were randomized with 61 patients (4%) excluded because they did not have IGT or had no postrandomization data, leaving 1368 patients for a modified intent-to-treat analysis. Both men (49%) and women (51%) participated with a mean (SD) age of 54.5 (7.9) years and body mass index of 30.9 (4.2). These patients were followed up for a mean (SD) of 3.3 (1.2) years. INTERVENTION: Patients with IGT were randomized to receive either placebo (n = 715) or 100 mg of acarbose 3 times a day (n = 714). MAIN OUTCOME MEASURES: The development of major cardiovascular events (coronary heart disease, cardiovascular death, congestive heart failure, cerebrovascular event, and peripheral vascular disease) and hypertension (> or =140/90 mm Hg). RESULTS: Three hundred forty-one patients (24%) discontinued their participation prematurely, 211 in the acarbose-treated group and 130 in the placebo group; these patients were also followed up for outcome parameters. Decreasing postprandial hyperglycemia with acarbose was associated with a 49% relative risk reduction in the development of cardiovascular events (hazard ratio [HR], 0.51; 95% confidence interval [CI]; 0.28-0.95; P =.03) and a 2.5% absolute risk reduction. Among cardiovascular events, the major reduction was in the risk of myocardial infarction (HR, 0.09; 95% CI, 0.01-0.72; P =.02). Acarbose was also associated with a 34% relative risk reduction in the incidence of new cases of hypertension (HR, 0.66; 95% CI, 0.49-0.89; P =.006) and a 5.3% absolute risk reduction. Even after adjusting for major risk factors, the reduction in the risk of cardiovascular events (HR, 0.47; 95% CI, 0.24-0.90; P =.02) and hypertension (HR, 0.62; 95% CI, 0.45-0.86; P =.004) associated with acarbose treatment was still statistically significant. CONCLUSION: This study suggests that treating IGT patients with acarbose is associated with a significant reduction in the risk of cardiovascular disease and hypertension.
Our primary objective was to determine whether a novel 'active school' model--Action Schools! BC--improved the cardiovascular disease (CVD) risk profile in elementary-school children. Our secondary objective was to determine the percentage of children with elevated CVD risk factors.
We undertook a cluster-randomized controlled school-based trial with 8 elementary schools across 1 school year, in British Columbia, Canada, beginning in 2003. Boys and girls (n=268, age 9-11 years) were randomly assigned (by school) to usual practice (UP, 2 schools) or intervention (INT, 6 schools) groups. We assessed change between groups in cardiovascular fitness (20-m Shuttle Run), blood pressure (BP), and body mass index (BMI, wt/ht(2)). We evaluated total cholesterol (TC), total:high-density cholesterol (TC:HDL-C), low-density lipoprotein, apolipoprotein B, C-reactive protein and fibrinogen on a subset of volunteers (n=77).
INT children had a 20% greater increase in fitness and a 5.7% smaller increase in BP compared with children attending UP schools (P
To assess the utilization of antihypertensive drugs among uncomplicated hypertensive patients in Finland between 2000 and 2006 and to calculate the achievable reduction in cardiovascular morbidity, with intensified antihypertensive treatment.
From the databases of the Social Insurance Institution of Finland, 428,986 treated hypertensives without diabetes or cardiac disease (further named uncomplicated hypertensives) in 2000 and 591,206 in 2006, respectively, were identified. In addition, from the Health 2000 survey representing the whole Finnish adult population, 729 uncomplicated hypertensives were determined to assess their characteristics and control of hypertension. Applying Law's meta-analyses we calculated the reduction of blood pressure (BP) by intensifying the treatment with low-dose antihypertensive regimens for those with a BP =140/90?mmHg.
The nationwide data suggests a relative overuse of beta-blockers. Combination antihypertensive treatment increased relatively 8%, while at least three drug combinations increased from 19.8% to 21.6% between 2000 and 2006. However, calculated prevalence of controlled BP (
Dietary antioxidants such as vitamin E, vitamin C, beta carotene and flavonoids may retard atherosclerosis by preventing low density lipoprotein oxidation. Observational epidemiological studies, including ecological correlations, case control and prospective studies, indicate that high vitamin E levels may be associated with decreased cardiovascular disease. Beta carotene may be protective among smokers and the elderly. Few studies have been able to show that vitamin C has a protective effect. A handful of intervention studies have examined the effects of vitamin E and beta carotene with mixed results. While few side effects of antioxidant supplementation are known, the results of current, large-scale studies in primary intervention must be awaited before recommendations can be made. Increased intake of fruits and vegetables that are rich in antioxidants is recommended.
One in five Canadians has high blood pressure. The prevalence is as high as 58% in women between the ages of 65 and 74 years. Approximately 40% of stroke cases, 39% of myocardial infarction cases and 28% of end stage renal diseases are attributable to hypertension. Despite the burden that hypertension places on women, the effect of antihypertensive therapy on cardiovascular complications has not been well established. To address this knowledge gap, two meta-analyses with sex-specific results, including the most current randomized, controlled trials to evaluate hypertension treatment, were reviewed. The Individual Data Analysis of Antihypertensive (INDANA) intervention trials group and Quan and colleagues analyzed treatment benefits in 23,000 women and 19,975 men according to subgroup meta-analyses from 12 randomized, controlled trials that compared antihypertensive drug therapy with placebo. The meta-analyses demonstrated a statistically significant treatment benefit for all of the reported clinical outcomes in men of all ages and in black women. In women over the age of 54 years, antihypertensive treatment was associated with a significant reduction of fatal and nonfatal stroke, cardiovascular events and cardiovascular mortality. Overall, there was no significant difference in the relative treatment benefit in women and men; however, the absolute treatment benefit was lower in women than in men. Thus, the number needed to treat for the end points of fatal stroke, nonfatal stroke and cardiovascular events was one- to threefold higher for women than for men. Furthermore, white women between the ages of 30 and 54 years showed no treatment benefit or harm. Data from the 6.7-year follow-up in the Hypertension Detection and Follow-up Program (HDFP) trial suggested that this group of younger women might benefit from a longer duration of treatment. Indications for pharmacological intervention seem quite clear for all subgroups, excluding these younger women. Until further evidence is available for this low risk subgroup, the current recommendations for lifestyle modification cannot be challenged.
The purpose of this study was to apply obesity treatment algorithms to a representative sample of Canadians to determine their potential impact on the population.
The Canadian Heart Health Surveys (1986-1992) were used to describe the prevalence of adults (18-64 y) that would be eligible for weight loss treatment according to the US NIH algorithm, which uses body mass index (BMI), waist circumference (WC), and the presence of two or more cardiovascular disease (CVD) risk factors. Similar algorithms based on CVD risk factors and a single measure of either BMI or WC alone were also evaluated.
Using the NIH algorithm, 24% of Canadians (28% men, 19% women) would be identified for weight loss treatment. Virtually, all subjects received the same treatment recommendations when using BMI and CVD risk factors only, while 22% (23% men, 21% women) would meet the criteria for treatment using WC and CVD risk factors only.
Approximately one in four Canadians would be eligible for weight loss treatment using the NIH obesity treatment algorithm. However, the algorithm may be improved through the incorporation of more sensitive WC thresholds.
BACKGROUND: There is substantial evidence that treatment with lipid-lowering agents can decrease cardiovascular morbidity and total mortality in patients with elevated serum lipid values and/or prior ischaemic heart disease. However, only a minority of these high-risk patients are believed to receive treatment, and among those who do receive pharmaceutical treatment the majority do not reach the therapeutic goal. Our goal was to investigate if this translates to a higher risk of cardiovascular events in real clinical practice. DESIGN: A retrospective cohort study using linkage of electronic medical records, the Swedish national inpatient registry and cause of death registry was performed, enrolling a total of 4976 patients who received treatment with a lipid-lowering agent at any time between 1 January 1993 and 1 December 2001. METHODS: Cox proportional hazards regression was used to evaluate the impact of goal attainment along with potential confounding factors. RESULTS: Patients who reached treatment goals were 24% less likely to suffer a cardiovascular event (relative risk: 0.76, 95% confidence interval: 0.60-0.96) than patients who did not reach treatment goals. A substantial proportion of patients treated with lipid-lowering agents do not achieve the treatment goals. CONCLUSIONS: Failure to reach treatment goals translates into a higher risk of cardiovascular events, and it is thus of importance to ensure that patients reach goals.
AIMS: To investigate associations between CVD risk factors and socio-economic status (SES) in middle-age men during a period of economic changes. METHODS: Crossectional surveys at age 37, 40 and 43 in a birth cohort of men in Helsingborg, Sweden. All male residents born 1953-4 (n = 1460) were invited; participation rates were 68% (n = 991) at baseline. Of these enrolled, 78% (n = 770) were re-examined after three years and 71% (n = 702) again after six years follow-up. Main outcome measures were body mass index (BMI), S-cholesterol, HDL-cholesterol, systolic and diastolic blood pressure (SBP, DBP), smoking and leisure time physical activity (LTPA), education, employment, ethnicity. RESULTS: Baseline unemployment rate was low, n = 23 (2.4%), but three and six years later it had increased to 61 (8.2%) and 51 (7.5%) respectively. At baseline, BMI and S-cholesterol were significantly higher in unemployed than in employed men (deltaBMI 1.6 kg/m2, CI: 0.2; 2.9, delta S-cholesterol 0.6 mmol/L, CI: 0.1; 1.0), and in men with short versus long education (delta BMI 0.9 kg/m2, CI: 0.4; 1.4, delta S-cholesterol 0.2 mmol/L, CI: 0.03: 0.4), independent of other SES factors. Over the study period crossectional associations with employment status disappeared for BMI, but remained between short education and BMI. Short education was also associated with a significant increase in BMI (delta = 0.4 kg/m2, CI: 0.1; 0.7) during 6-year follow-up. CONCLUSIONS: This study shows that associations between unemployment and CVD risk factors were lost when unemployment rates increased. When the attributable risk of unemployment associated with CVD risk factors is estimated, it is vital to consider the general unemployment rates in society.
The extremely high mortality of cardiovascular diseases in the 1960s in Finland, particularly in the Eastern Province of North Karelia and especially that of coronary heart disease in men, caused great concern among the local population. Action to reduce the problem was demanded in a petition signed in 1971 by the representatives of the population. In response, the North Karelia Project was launched in 1972 to carry out a comprehensive preventive project, first only in North Karelia as a national pilot (1972 to 1977), and thereafter continuing in North Karelia but at the same time transferring the experiences to a national level. The intervention was based on the at-that-time relatively new scientific information on the main causal risk factors. A comprehensive population-based intervention was carried out, aiming especially at the reduction of the high levels of serum cholesterol, blood pressure, and tobacco use, emphasizing general dietary changes and smoking reduction. A comprehensive monitoring and evaluation program was designed and implemented to learn from the experience in preparation for national and international use. Presented here are the background, principles, and general experiences of this project, which has made major contributions both to the contemporary public health work for the prevention and control of heart disease and noncommunicable diseases and for research in the area.