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A 3-month evaluation of the efficacy of nedocromil sodium in asthma: a randomized, double-blind, placebo-controlled trial of nedocromil sodium conducted by a Canadian multicenter study group.

https://arctichealth.org/en/permalink/ahliterature229565
Source
J Allergy Clin Immunol. 1990 Mar;85(3):612-7
Publication Type
Article
Date
Mar-1990
Author
A S Rebuck
S. Kesten
L P Boulet
A. Cartier
D. Cockcroft
J. Gruber
F. Laberge
E. Lee-Chuy
M. Keshmiri
G F MacDonald
Author Affiliation
Edmonton General Hospital, Canada.
Source
J Allergy Clin Immunol. 1990 Mar;85(3):612-7
Date
Mar-1990
Language
English
Publication Type
Article
Keywords
Adult
Anti-Inflammatory Agents, Non-Steroidal - adverse effects - therapeutic use
Asthma - drug therapy - physiopathology
Canada
Chronic Disease
Double-Blind Method
Drug Therapy, Combination
Drug Tolerance
Female
Humans
Male
Middle Aged
Multicenter Studies as Topic
Nedocromil
Peak Expiratory Flow Rate - drug effects - physiology
Quinolones - adverse effects - therapeutic use
Randomized Controlled Trials as Topic
Time Factors
Abstract
Nedocromil sodium is a pyranoquinoline dicarboxylic acid derivative, formulated in a metered-dose inhaler. Because nedocromil sodium has in vitro and in vivo anti-inflammatory properties, it was evaluated in a group of steroid-dependent patients with asthma to observe how well it might be tolerated and for evidence of any beneficial effects. In a double-blind, group-comparative study, 127 patients received nedocromil sodium and 61 received placebo, administered as two puffs of 2 mg, four times per day, for 12 weeks. Ten patients developed adverse reactions, seven receiving active drug and three patients receiving placebo. Two patients of each group withdrew because of worsening asthma. Despite selecting patients whose asthma was stable, when they were receiving established therapeutic regimens that included steroids and bronchodilators, it was found that diary-card symptom scores, morning and evening peak expiratory flow rate values, and inhaled beta-agonist usage all demonstrated slight but significant benefit with addition of nedocromil sodium. It is concluded that the inhaled, anti-inflammatory agent, nedocromil sodium, may be added to asthma-treatment regimens with the reasonable expectation of further modest symptomatic benefit.
PubMed ID
2155958 View in PubMed
Less detail

[8,500 patients in clinical trials. Experiences from a study in primary health care]

https://arctichealth.org/en/permalink/ahliterature54911
Source
Lakartidningen. 1994 Mar 23;91(12):1236-8
Publication Type
Article
Date
Mar-23-1994

18F-FDG PET imaging of myocardial viability in an experienced center with access to 18F-FDG and integration with clinical management teams: the Ottawa-FIVE substudy of the PARR 2 trial.

https://arctichealth.org/en/permalink/ahliterature144812
Source
J Nucl Med. 2010 Apr;51(4):567-74
Publication Type
Article
Date
Apr-2010
Author
Arun Abraham
Graham Nichol
Kathryn A Williams
Ann Guo
Robert A deKemp
Linda Garrard
Ross A Davies
Lloyd Duchesne
Haissam Haddad
Benjamin Chow
Jean DaSilva
Rob S B Beanlands
Author Affiliation
National Cardiac PET Centre and Division of Cardiology, Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
Source
J Nucl Med. 2010 Apr;51(4):567-74
Date
Apr-2010
Language
English
Publication Type
Article
Keywords
Canada
Coronary Artery Disease - physiopathology - radionuclide imaging
Female
Fluorodeoxyglucose F18 - diagnostic use
Heart - physiopathology - radionuclide imaging
Heart Failure - physiopathology - radionuclide imaging
Humans
Male
Middle Aged
Myocardial Revascularization
Patient care team
Positron-Emission Tomography
Professional Competence
Radiopharmaceuticals - diagnostic use
Randomized Controlled Trials as Topic
Survival Analysis
Tissue Survival
Ventricular Dysfunction, Left - physiopathology - radionuclide imaging
Abstract
(18)F-FDG PET may assist decision making in ischemic cardiomyopathy. The PET and Recovery Following Revascularization (PARR 2) trial demonstrated a trend toward beneficial outcomes with PET-assisted management. The substudy of PARR 2 that we call Ottawa-FIVE, described here, was a post hoc analysis to determine the benefit of PET in a center with experience, ready access to (18)F-FDG, and integration with clinical teams.
Included were patients with left ventricular dysfunction and suspected coronary artery disease being considered for revascularization. The patients had been randomized in PARR 2 to PET-assisted management (group 1) or standard care (group 2) and had been enrolled in Ottawa after August 1, 2002 (the date that on-site (18)F-FDG was initiated) (n = 111). The primary outcome was the composite endpoint of cardiac death, myocardial infarction, or cardiac rehospitalization within 1 y. Data were compared with the rest of PARR 2 (PET-assisted management [group 3] or standard care [group 4]).
In the Ottawa-FIVE subgroup of PARR 2, the cumulative proportion of patients experiencing the composite event was 19% (group 1), versus 41% (group 2). Multivariable Cox proportional hazards regression showed a benefit for the PET-assisted strategy (hazard ratio, 0.34; 95% confidence interval, 0.16-0.72; P = 0.005). Compared with other patients in PARR 2, Ottawa-FIVE patients had a lower ejection fraction (25% +/- 7% vs. 27% +/- 8%, P = 0.04), were more often female (24% vs. 13%, P = 0.006), tended to be older (64 +/- 10 y vs. 62 +/- 10 y, P = 0.07), and had less previous coronary artery bypass grafting (13% vs. 21%, P = 0.07). For patients in the rest of PARR 2, there was no significant difference in events between groups 3 and 4. The observed effect of (18)F-FDG PET-assisted management in the 4 groups in the context of adjusted survival curves demonstrated a significant interaction (P = 0.016). Comparisons of the 2 arms in Ottawa-FIVE to the 2 arms in the rest of PARR 2 demonstrated a trend toward significance (standard care, P = 0.145; PET-assisted management, P = 0.057).
In this post hoc group analysis, a significant reduction in cardiac events was observed in patients with (18)F-FDG PET-assisted management, compared with patients who received standard care. The results suggest that outcome may be benefited using (18)F-FDG PET in an experienced center with ready access to (18)F-FDG and integration with imaging, heart failure, and revascularization teams.
Notes
Comment In: J Nucl Med. 2010 Apr;51(4):505-620237024
PubMed ID
20237039 View in PubMed
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The 2001 Canadian recommendations for the management of hypertension: Part two--Therapy.

https://arctichealth.org/en/permalink/ahliterature189434
Source
Can J Cardiol. 2002 Jun;18(6):625-41
Publication Type
Article
Date
Jun-2002
Author
Finlay A McAlister
Kelly B Zarnke
Norman R C Campbell
Ross D Feldman
Mitchell Levine
Jeff Mahon
Steven A Grover
Richard Lewanczuk
Frans Leenen
Sheldon Tobe
Marcel Lebel
James Stone
Ernesto L Schiffrin
Simon W Rabkin
Richard I Ogilvie
Pierre Larochelle
Charlotte Jones
George Honos
George Fodor
Ellen Burgess
Pavel Hamet
Robert Herman
Jane Irvine
Bruce Culleton
James M Wright
Author Affiliation
University of Alberta Hospital, Edmonton, Canada.
Source
Can J Cardiol. 2002 Jun;18(6):625-41
Date
Jun-2002
Language
English
Publication Type
Article
Keywords
Antihypertensive Agents - administration & dosage - therapeutic use
Canada
Cardiovascular Diseases - prevention & control
Humans
Hypertension - prevention & control
Randomized Controlled Trials as Topic
Abstract
To provide updated, evidence-based recommendations for the therapy of hypertension in adults.
For patients with hypertension, a number of antihypertensive agents may control blood pressure. Randomized trials evaluating first-line therapy with thiazides, beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers, centrally acting agents or angiotensin II receptor antagonists were reviewed.
The health outcomes that were considered were changes in blood pressure, cardiovascular morbidity, and cardiovascular and/or all-cause mortality rates. Economic outcomes were not considered due to insufficient evidence.
MEDLINE was searched for the period March 1999 to October 2001 to identify studies not included in the 2000 revision of the Canadian Recommendations for the Management of Hypertension. Reference lists were scanned, experts were polled, and the personal files of the subgroup members and authors were used to identify other published studies. All relevant articles were reviewed and appraised, using prespecified levels of evidence, by content experts and methodological experts.
A high value was placed on the avoidance of cardiovascular morbidity and mortality.
Various antihypertensive agents reduce the blood pressure of patients with sustained hypertension. In certain settings, and for specific classes of drugs, blood-pressure lowering has been associated with reduced cardiovascular morbidity and/or mortality.
The present document contains detailed recommendations pertaining to treatment thresholds, target blood pressures, and choice of agents in various settings in patients with hypertension. The main changes from the 2000 Recommendations are the addition of a section on the treatment of hypertension in patients with diabetes mellitus, the amalgamation of the previous sections on treatment of hypertension in the young and old into one section, increased emphasis on the role of combination therapies over repeated trials of single agents and expansion of the section on the treatment of hypertension after stroke. Implicit in the recommendations for therapy is the principle that treatment for an individual patient should take into consideration global cardiovascular risk, the presence and/or absence of target organ damage, and comorbidities.
All recommendations were graded according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group. Individuals with potential conflicts of interest relative to any specific recommendation were excluded from voting on that recommendation. Only those recommendations achieving high levels of consensus are reported here. These guidelines will continue to be updated annually.
PubMed ID
12107420 View in PubMed
Less detail

2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada.

https://arctichealth.org/en/permalink/ahliterature187810
Source
CMAJ. 2002 Nov 12;167(10 Suppl):S1-34
Publication Type
Article
Date
Nov-12-2002
Author
Jacques P Brown
Robert G Josse
Author Affiliation
Division of Rheumatology, Centre de recherche du CHUL, Université Laval, Canada.
Source
CMAJ. 2002 Nov 12;167(10 Suppl):S1-34
Date
Nov-12-2002
Language
English
Publication Type
Article
Keywords
Adult
Aged
Bone Density
Canada
Child
Diet
Diphosphonates - therapeutic use
Estrogens, Non-Steroidal
Female
Humans
Isoflavones
Male
Middle Aged
Osteoporosis - diagnosis - drug therapy - prevention & control
Phytoestrogens
Plant Preparations
Practice Guidelines as Topic
Prognosis
Randomized Controlled Trials as Topic
Risk factors
Abstract
To revise and expand the 1996 Osteoporosis Society of Canada clinical practice guidelines for the management of osteoporosis, incorporating recent advances in diagnosis, prevention and management of osteoporosis, and to identify and assess the evidence supporting the recommendations.
All aspects of osteoporosis care and its fracture complications - including classification, diagnosis, management and methods for screening, as well as prevention and reducing fracture risk - were reviewed, revised as required and expressed as a set of recommendations.
Strategies for identifying and evaluating those at high risk; the use of bone mineral density and biochemical markers in diagnosis and assessing response to management; recommendations regarding nutrition and physical activity; and the selection of pharmacologic therapy for the prevention and management of osteoporosis in men and women and for osteoporosis resulting from glucocorticoid treatment.
All recommendations were developed using a justifiable and reproducible process involving an explicit method for the evaluation and citation of supporting evidence.
All recommendations were reviewed by members of the Scientific Advisory Council of the Osteoporosis Society of Canada, an expert steering committee and others, including family physicians, dietitians, therapists and representatives of various medical specialties involved in osteoporosis care (geriatric medicine, rheumatology, endocrinology, obstetrics and gynecology, nephrology, radiology) as well as methodologists from across Canada.
Earlier diagnosis and prevention of fractures should decrease the medical, social and economic burdens of this disease.
This document outlines detailed recommendations pertaining to all aspects of osteoporosis. Strategies for identifying those at increased risk (i.e., those with at least one major or 2 minor risk factors) and screening with central dual-energy x-ray absorptiometry at age 65 years are recommended. Bisphosphonates and raloxifene are first-line therapies in the prevention and treatment of postmenopausal osteoporosis. Estrogen and progestin/progesterone is a first-line therapy in the prevention and a second-line therapy in the treatment of postmenopausal osteoporosis. Nasal calcitonin is a second-line therapy in the treatment of postmenopausal osteoporosis. Although not yet approved for use in Canada, hPTH(1-34) is expected to be a first-line treatment for postmenopausal women with severe osteoporosis. Ipriflavone, vitamin K and fluoride are not recommended. Bisphosphonates are the first-line therapy for the prevention and treatment of osteoporosis in patients requiring prolonged glucocorticoid therapy and for men with osteoporosis. Nasal or parenteral calcitonin is a first-line treatment for pain associated with acute vertebral fractures. Impact-type exercise and age-appropriate calcium and vitamin D intake are recommended for the prevention of osteoporosis.
All recommendations were graded according to the strength of the evidence; where the evidence was insufficient and recommendations were based on consensus opinion alone, this is indicated. These guidelines are viewed as a work in progress and will be updated periodically in response to advances in this field.
Notes
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Comment In: CMAJ. 2007 Oct 23;177(9):1069; author reply 1069-7017954901
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PubMed ID
12427685 View in PubMed
Less detail

The 2006 K/DOQI guidelines for peritoneal dialysis adequacy are not adequate.

https://arctichealth.org/en/permalink/ahliterature166065
Source
Blood Purif. 2007;25(1):103-5
Publication Type
Article
Date
2007
Author
James F Winchester
Nikolas Harbord
Patrick Audia
Alan Dubrow
Stephen Gruber
Donald Feinfeld
Richard Amerling
Author Affiliation
Division of Nephrology and Hypertension, Beth Israel Medical Center, 350 East 17th Street, New York, NY 10003, USA. jwinches@bethisraelny.org
Source
Blood Purif. 2007;25(1):103-5
Date
2007
Language
English
Publication Type
Article
Keywords
Body mass index
Canada
Humans
Metabolic Clearance Rate
Peritoneal Dialysis - methods - standards
Practice Guidelines as Topic - standards
Randomized Controlled Trials as Topic
Reproducibility of Results
United States
Urea - metabolism
Abstract
The 2006 National Kidney Foundation K/DOQI guidelines have lowered the peritoneal dialysis adequacy standard of Kt/V(urea) from 2.1 to 1.7 in anuric patients, largely based on the patient survival results of 2 clinical trials in Mexico and Hong Kong. It is our contention that the guidelines may be misleading since they have chosen to ignore the bias in these trials and have ignored the adverse outcomes in control groups in the trials on which the guidelines are based, as well as the body size of the subjects in these trials. Body size has changed in the US and Canada over the last few decades and there are similar changes worldwide. We suggest that the minimum targets for peritoneal dialysis be reinstituted at the previous standard Kt/V(urea) of 2.0.
PubMed ID
17170545 View in PubMed
Less detail

The 2007 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 - therapy.

https://arctichealth.org/en/permalink/ahliterature163300
Source
Can J Cardiol. 2007 May 15;23(7):539-50
Publication Type
Conference/Meeting Material
Article
Date
May-15-2007
Author
Nadia A Khan
Brenda Hemmelgarn
Raj Padwal
Pierre Larochelle
Jeff L Mahon
Richard Z Lewanczuk
Finlay A McAlister
Simon W Rabkin
Michael D Hill
Ross D Feldman
Ernesto L Schiffrin
Norman R C Campbell
Alexander G Logan
Malcolm Arnold
Gordon Moe
Tavis S Campbell
Alain Milot
James A Stone
Charlotte Jones
Lawrence A Leiter
Richard I Ogilvie
Robert J Herman
Pavel Hamet
George Fodor
George Carruthers
Bruce Culleton
Kevin D Burns
Marcel Ruzicka
Jacques deChamplain
George Pylypchuk
Norm Gledhill
Robert Petrella
Jean-Martin Boulanger
Luc Trudeau
Robert A Hegele
Vincent Woo
Phil McFarlane
Rhian M Touyz
Sheldon W Tobe
Author Affiliation
Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia. nakhan@shaw.ca
Source
Can J Cardiol. 2007 May 15;23(7):539-50
Date
May-15-2007
Language
English
Publication Type
Conference/Meeting Material
Article
Keywords
Antihypertensive Agents - therapeutic use
Canada
Diet, Sodium-Restricted
Health promotion
Humans
Hypertension - drug therapy - prevention & control - therapy
Patient Education as Topic
Randomized Controlled Trials as Topic
Risk Reduction Behavior
Abstract
To provide updated, evidence-based recommendations for the prevention and management of hypertension in adults.
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.
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.
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.
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.
Notes
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Comment In: Can J Cardiol. 2007 May 15;23(7):603-417593584
PubMed ID
17534460 View in PubMed
Less detail

The 2009 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 1--blood pressure measurement, diagnosis and assessment of risk.

https://arctichealth.org/en/permalink/ahliterature151165
Source
Can J Cardiol. 2009 May;25(5):279-86
Publication Type
Article
Date
May-2009
Author
Raj S Padwal
Brenda R Hemmelgarn
Nadia A Khan
Steven Grover
Donald W McKay
Thomas Wilson
Brian Penner
Ellen Burgess
Finlay A McAlister
Peter Bolli
Machael D Hill
Jeff Mahon
Martin G Myers
Carl Abbott
Ernesto L Schiffrin
George Honos
Karen Mann
Guy Tremblay
Alain Milot
Lyne Cloutier
Arun Chockalingam
Simon W Rabkin
Martin Dawes
Rhian M Touyz
Chaim Bell
Kevin D Burns
Marcel Ruzicka
Norman R C Campbell
Michel Vallée
Ramesh Prasad
Marcel Lebel
Sheldon W Tobe
Author Affiliation
Division of General Internal Medicine, University of Alberta, Edmonton, Canada. rpadwal@ualberta.ca
Source
Can J Cardiol. 2009 May;25(5):279-86
Date
May-2009
Language
English
Publication Type
Article
Keywords
Adult
Aged
Antihypertensive Agents - therapeutic use
Blood Pressure Determination - standards
Canada
Clinical Competence
Combined Modality Therapy
Education, Medical, Continuing - standards
Female
Guideline Adherence
Health Promotion - organization & administration
Humans
Hypertension - diagnosis - therapy
Life Style
Male
Middle Aged
Prognosis
Randomized Controlled Trials as Topic
Risk Management
Treatment Outcome
Abstract
To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension.
The diagnosis of hypertension is dependent on appropriate blood pressure measurement, the timely assessment of serially elevated readings, the degree of blood pressure elevation, the method of measurement (office, ambulatory, home) and associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk and determine the urgency, intensity and type of treatment required.
MEDLINE searches were conducted from November 2007 to October 2008 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. Key messages include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of global risk assessment and the need for ongoing monitoring of hypertensive patients to identify incident type 2 diabetes.
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 were required to be supported by at least 70% of task force members. These guidelines will continue to be updated annually.
Notes
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PubMed ID
19417858 View in PubMed
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The 2009 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 2--therapy.

https://arctichealth.org/en/permalink/ahliterature151164
Source
Can J Cardiol. 2009 May;25(5):287-98
Publication Type
Article
Date
May-2009
Author
Nadia A Khan
Brenda Hemmelgarn
Robert J Herman
Chaim M Bell
Jeff L Mahon
Lawrence A Leiter
Simon W Rabkin
Michael D Hill
Raj Padwal
Rhian M Touyz
Pierre Larochelle
Ross D Feldman
Ernesto L Schiffrin
Norman R C Campbell
Gordon Moe
Ramesh Prasad
Malcolm O Arnold
Tavis S Campbell
Alain Milot
James A Stone
Charlotte Jones
Richard I Ogilvie
Pavel Hamet
George Fodor
George Carruthers
Kevin D Burns
Marcel Ruzicka
Jacques DeChamplain
George Pylypchuk
Robert Petrella
Jean-Martin Boulanger
Luc Trudeau
Robert A Hegele
Vincent Woo
Phil McFarlane
Michel Vallée
Jonathan Howlett
Simon L Bacon
Patrice Lindsay
Richard E Gilbert
Richard Z Lewanczuk
Sheldon Tobe
Author Affiliation
Division of General Internal Medicine, University of British Columbia, Vancouver, Canada. nakhan@shaw.ca
Source
Can J Cardiol. 2009 May;25(5):287-98
Date
May-2009
Language
English
Publication Type
Article
Keywords
Adult
Aged
Antihypertensive Agents - therapeutic use
Blood Pressure Determination - standards
Canada
Case Management - standards
Combined Modality Therapy
Diet, Sodium-Restricted
Female
Health Promotion - organization & administration
Humans
Hypertension - diagnosis - therapy
Life Style
Male
Middle Aged
Patient Education as Topic
Prognosis
Program Evaluation
Randomized Controlled Trials as Topic
Treatment Outcome
Abstract
To update the evidence-based recommendations for the prevention and management of hypertension in adults for 2009.
For lifestyle and pharmacological interventions, evidence from randomized controlled trials and systematic reviews of trials was 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 lack of long-term morbidity and mortality data in this field. Progression of kidney dysfunction was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease.
A Cochrane collaboration librarian conducted an independent MEDLINE search from 2007 to August 2008 to update the 2008 recommendations. To identify additional published 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.
For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to less than 2300 mg (100 mmol)/day (and 1500 mg to 2300 mg [65 mmol to 100 mmol]/day in hypertensive patients); perform 30 min to 60 min of 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 (smaller than 102 cm for men and smaller than 88 cm for women); limit alcohol consumption to no more than 14 units per week in men or nine units per week in women; follow a diet that is reduced in saturated fat and cholesterol, and that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on by the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to lower than 140/90 mmHg in all patients, and to lower than 130/80 mmHg in those 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, 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 (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor antagonists (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as the initial treatment of hypertension if the systolic blood pressure is 20 mmHg above the target or if the diastolic blood pressure is 10 mmHg above the target. The combination of ACE inhibitors and ARBs should not be used. Other agents appropriate for first-line therapy for isolated systolic hypertension include long- acting dihydropyridine CCBs or ARBs. 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/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. 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.
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.
Notes
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PubMed ID
19417859 View in PubMed
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