HTA UMF Gatineau Dr Tinouch Haghighat Cardiologue CSSSG-Hull
Leading diagnoses resulting in visits to physician offices in Canada 25 20 15 10 Million visits/year Hypertension Depression Diabetes Routine medical exams Acute respiratory tract infection 5 0 Source: IMS HEALTH Canada 2 002. http://www.imshealthcanada.com/ 2006 Canadian Hypertension Education Prog ram Recom mendations 21
What percent of Canadians have hypertension? 60 % of Canadians 50 40 30 20 10 0 18-24 25-34 35-44 44-55 56-65 65-74 age CCHS CMAJ 1992 2008 Canadian Hypertension Education Prog ram Recom mendations 11
New onset hypertension in people with high normal blood pressure 80 60 New hypertension (%) 40 20 0 1 2 3 4 Year of Follow-up NEJM 2006;354:1685-97 2008 Canadian Hypertension Education Prog ram Recom mendations 15
II. Criteria for the diagnosis of hypertension and recommendations for follow-up Elevated Out of the Office BP measurement Elevated Random Office BP Measurement Hypertension Visit 1 BP Measuremen t, History and Physical examination Hypertensive Urgency / Emergency Hypertension Visit 2 Target Organ DamageD or Diabetes or Chronic Kidney Disease or BP >180/110? Yes Diagnosis of HTN No BP: 140-179 / 90-109 Clinic BPM ABPM (If available) Home BPM (If available) 2008 Canadian Hypertension Education Prog ram Recom mendations 19
II. Criteria for the diagnosis of hypertension and recommendations for follow-up BP: 140-179 / 90-109 Clinic BP ABPM (If avail able) Home BPM (If available) Hypertension visit 3 >160 SBP or >100 DBP <160 / 100 or Hypertension visit 4-5 Diagnosis of HTN ABPM or HBPM if available Awake BP <135/85 and 24-hour <130/80 Awake BP >135 SBP or >85 DBP or 24-hour >130 SBP or >80 DBP < 135/85 or >135/85 >140 SBP or >90 DBP < 140 / 90 Diagnosis of HTN Continue to follow-up Continue to follow-up Diagnosis of HTN Continue to followup Diagnosis of HTN Patients with high normal blood pressure (clinic SBP 130-139 and/or DBP 85-89) should be followed annually. 2008 Canadian Hypertension Education Program Recomm endations 21
Techniques recommandées pour la mesure de la TA technique Standardisée : Repos pendant 5 min Brassard adapté Utilisation de manomètre à mecure ou un appareil électronique validé
Mesure TA à domicile
VII. Home measurement of blood pressure Home BP measurement should be encouraged to increase patient involvement in care Which patients? Uncomplicated hypertension Diabetes mellitus Chronic kidney disease Suspected non adherence Office-induced blood pressure elevation (white coat effect) Masked hypertension Average BP equal to or over 135/85 mm Hg should be considered elevated 2008 Canadian Hypertension Education Prog ram Recom mendations 41
Potential advantages of home blood pressure measurement More rapid confirmation of the diagnosis of hypertension Improved ability to predict cardiovascular prognosis Improved blood pressure control Can screen for white coat hypertension (WCH) and masked hypertension Reduced medication use in some (WCH) Improved adherence to drug therapy in the non adherent 2008 Canadian Hypertension Education Prog ram Recom mendations 42
Not all patients are suited to home measurement Undue anxiety in response to high blood pressure readings Physical or mental impairment prevents accurate technique or recording Arm not suited to blood pressure cuff (e.g. conical shaped arm) Irregular pulse or arrhythmias prevent accurate readings Lack of interest The vast majority of patients can be trained to measure blood pressure 2008 Canadian Hypertension Education Prog ram Recom mendations 43
VII. Suggested Protocol for Home Measurement of Blood Pressure for the diagnosis of hypertension Home blood pressure values should be based on: - duplicate measures, - morning and evening, - for an initial 7-day period. Singular and first day home BP values should not be considered. Daytime average BP equal to or over 135/85 mmhg should be considered elevated. 2008 Canadian Hypertension Education Prog ram Recom mendations 44
Home measurement: Doing it right EQUIPMENT Validated device Look for the logo or go to www.hypertenion.ca/chs for a list of validated devices available in Canada Ensure the cuff size is appropriate Ensure the device is accurate in the patient at purchase and annually 2008 Canadian Hypertension Education Prog ram Recom mendations 50
Home measurement: Doing it right PREPARATION DO Read and carefully follow the instructions provided with the device Relax in a comfortable chair with back support for 5 minutes No talking or distractions (e.g. TV) DON T Measure if stressed, cold, in pain or if your bowel or bladder are uncomfortable Measure within 1 hour of heavy physical activity or a large meal Cross legs 2008 Canadian Hypertension Education Prog ram Recom mendations 51
Home measurement: Doing it right PREPARATION DO Put the cuff on a bare arm Support the arm on a table so it is at heart level Record two readings in the morning and evening daily for seven days (discarding the first day) to help diagnose hypertension Measure and record your blood pressure (as above) for several days before an appointment with a health care professional 2008 Canadian Hypertension Education Prog ram Recom mendations 52
MAPA
Hourly Means of Systolic and Diastolic Blood Pressure Derived from 24-Hour Ambulatory Blood- Pressure Recordings Obtained at Base Line (Visit 3) in the 1963 Participants Clement, D. L. et al. N Engl J Med 2003;348:2407-2415
VIII. Ambulatory BP Monitoring: Beyond the diagnosis of hypertension, ABPM measurement may also be considered for selected patients for the management of HTN Which patients? Untreated - Mild (Grade 1) to moderate (Grade 2) clinic BP elevation and without target organ damage. Treated patients - Blood pressure that is not below target values despite receiving appropriate chronic antihypertensive therapy. - Symptoms suggestive of hypotension. - Fluctuating office blood pressure readings. 2008 Canadian Hypertension Education Prog ram Recom mendations 55
VII. Home Measurement of BP: Confirm contradictory home measurement readings If office BP measurement is elevated and home BP is normal or vice versa Consider further assess using 24-h ambulatory blood pressure monitoring 2008 Canadian Hypertension Education Prog ram Recom mendations 54
VIII. Ambulatory BP Monitoring Specific Role in Selected Patients How to? Use validated devices How to interpret? Mean daytime ambulatory blood pressure >135/85 mmhg is considered elevated. Mean 24 h ambulatory blood pressure >130/80 mmhg is considered elevated. A drop in nocturnal BP of <10% is associated with increased risk of CV events 2008 Canadian Hypertension Education Prog ram Recom mendations 56
Follow up algorithm for high Blood Pressure Using Ambulatory Blood Pressure Measurement 30-40% of patients with white coat hypertension diagnosed based on a single ABPM session will have true hypertension on retesting. White coat hypertension is a risk for developing true hypertension Follow up results of ABPM with an appropriate combination of office, home and ABPM readings 2008 Canadian Hypertension Education Prog ram Recom mendations 59
The concept of masked hypertension 140 Home or ABPM SBP mmhg 135 Masked HTN True Normotensive True hypertensive White Coat HTN 135 140 Office SBP mmhg Derived from Pickering et al. Hypertension 2002: 40: 795-796. 2008 Canadian Hypertension Education Program Recommendations 23
The prognosis of masked hypertension Prevalence of masked hypertension is approximately 10% 2.5 2 Relatve risk of CVD 1.5 1 0.5 0 Normotension White Coat Hypertension Masked Hypertension Hypertension J Hypertension 2007;25:2193-98 2008 Canadian Hypertension Education Prog ram Recom mendations 24
Clinic, Home, Ambulatory (ABP) Blood Pressure Measurement equivalence numbers A clinic blood pressure of 140/90 mmhg has a similar risk of a: Description Blood Pressure mmhg Home pressure average 135 / 85 Daytime average ABP 135 / 85 24-hour average ABP 130 / 80 2008 Canadian Hypertension Education Prog ram Recom mendations 57
Reversible risks for developing hypertension Obesity Poor dietary habits High sodium intake Sedentary lifestyle High alcohol consumption High normal blood pressure 2008 Canadian Hypertension Education Prog ram Recom mendations 13
III. Assessment of the overall cardiovascular risk Search for exogenous potentially modifiable factors that can induce/aggravate hypertension Prescription Drugs: NSAIDs, including Coxibs Corticosteroids and anabolic steroids Oral contraceptive and sex hormones Vasoconstricting/sympathomimetic decongestants Calcineurin inhibitors (cyclosporin, tacrolimus) Erythropoietin and analogues Monoamine oxidase inhibitors (MAOIs) Midodrine Other: Licorice root Stimulants including cocaine Salt Excessive alcohol use Sleep apnea 2008 Canadian Hypertension Education Prog ram Recom mendations 26
III. Assessment of the overall cardiovascular risk Search for target organ damage Cerebrovascular disease - transient ischemic attacks - ischemic or hemorrhagic stroke - vascular dementia Hypertensive retinopathy Left ventricular dysfunction Coronary artery disease - myocardial infarction - angina pectoris - congestive heart failure Chronic kidney disease - hypertensive nephropathy (G FR < 60 ml/min/1.73 m 2 ) - albuminuria Peripheral artery disease - intermittent claudication 2008 Canadian Hypertension Education Prog ram Recom mendations 25
III. Assessment of the overall cardiovascular risk Over 90% of hypertensive Canadians have other cardiovascular risks Assess and manage hypertensive patients for unhealthy eating, inactivity, abdominal obesity, dyslipidemia, and diabetes. 2008 Canadian Hypertension Education Prog ram Recom mendations 27
III. Assessment of the overall cardiovascular risk Cardiovascular Risk Factors Presence of Risk Factors - Increasing age - Male gender - Smoking - Family history of premature cardiovascular disease (age< 55 in men and < 65 in women) - Dyslipidemia - Sedentary lifestyle - Unhealthy eating - Abdominal obesity Presence of Diabetes Presence of Target Organ Damage - Microalbuminuria or proteinuria - Left ventricular hypertrophy - Chronic kidney disease (glomerular filtration rate < 60 ml/min/1.73 m 2 ) Presence of atherosclerotic vascular disease - Previous stroke or TIA - CHD - Peripheral arterial disease CV Risk Factors that may alter thresholds and targets in the treatment of HTN 2008 Canadian Hypertension Education Program Recommendations 29
Systematic Cardiovascular Evaluation 10-Year Risk of Fatal CVD in High-Risk Regions like Canada Women Men SC RE Canada Systolic blood pressure (mmhg) 15% and over 10% 14% 5% 9% 3% 4% 2% 1% <1% 10-year ri sk of fatal CV D in populati ons at hig h CVD risk Calibrated according to the 2002 Canadi an mortality data (Total Cholesterol / HDL-Cholesterol) Ratio Adapted from De Backer et al. Eur Heart J. 2003;24:1601-1610. 2008 Canadian Hypertension Education Prog ram Recom mendations 30
IV. Routine Laboratory Tests Preliminary Investigations of patients with hypertension 1. Urinalysis 2. Blood chemistry (potassium, sodium and creatinine) 3. Fasting glucose 4. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides 5. Standard 12-leads ECG Currently there is insufficient evidence to recommend routine testing of microalbuminuria in people with hypertension who do not have diabetes or kidney disease 2008 Canadian Hypertension Education Prog ram Recom mendations 31
IV. Routine Laboratory Tests Follow-up investigations of patients with hypertension During the maintenance phase of hypertension management, tests (including electrolytes, creatinine, glucose, and fasting lipids) should be repeated with a frequency reflecting the clinical situation. Diabetes develops in 1-3%/year of those with drug treated hypertension. The risk is higher in those treated with a diuretic or beta blocker, in the obese, sedentary, with higher fasting glucose and who have unhealthy eating patterns. Assess for diabetes more frequently in these patients. 2008 Canadian Hypertension Education Prog ram Recom mendations 32
IV. Optional Laboratory Tests Investigation for specific patient subgroups For those with diabetes or chronic kidney disease: assess urinary albumin excretion, since therapeutic recommendations differ if proteinuria is present. For those suspected of having an endocrine cause for the high blood pressure, or renovascular hypertension, see following slides. Other secondary forms of hypertension require specific testing. albumin:creatinine ratio [ACR] > 30 mg/mmol is abnormal 2008 Canadian Hypertension Education Prog ram Recom mendations 33
II. Goals of Therapy Blood pressure target values for treatment of hypertension Condition Target SBP and DBP mmhg Isolated systolic hypertension Systolic/Diastolic Hypertension Systolic BP Diastolic BP Diabetes or Chronic Kidney Disease Systolic Diastolic <140 <140 <90 <130 <80 2008 Canadian Hypertension Education Prog ram Recom mendations 13
Lifestyle Therapies in Hypertensive Adults: Summary Intervention Reduce foods with added sodium Weight loss Alcohol restriction Physical activity Dietary patterns Smoking cessation Waist Circumference - Europid, Sub-Saharan African, Middle Eastern - South Asian, Chinese - Japanese < 2300 mg /day BMI <25 kg/m 2 Less or equal to 2 drinks/day at least 30 minutes 4 times/week DASH diet Target Smoke free environment Men Women <94 cm <80 cm <90 cm <80 cm <85 cm <90 cm 2008 Canadian Hypertension Education Prog ram Recom mendations 31
Recommendations for daily salt intake Less than: 2,300 mg sodium (Na) 100 mmol sodium (Na) 5,8 g of salt (NaCl) 1 teaspoon of table salt 2,300 mg sodium = 1 level teaspoon of table salt 2008 Canadian Hypertension Education Prog ram Recom mendations 20
Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults Intervention Reduce foods with added sodium Weight loss Alcohol intake Aerobic exercise Dietary patterns Amount - 1800 mg sodium hypertensive per kg lost - 3.6 drinks/day 120-150 min/week DASH diet Hypertensive Normotensive SBP/DBP -5.1 / -2.7-1.1 / -0.9-3.9 / -2.4-4.9 / -3.7-11.4 / -5.5-3.6 / -1.8 Applying the 2005 Canadian Hypertension Education Program recommendations: 3. Lifestyle modifications to prevent and treat hypertension Padwal R. et al. CMAJ? SEPT. 27, 2005; 173 (7) 749-751 2008 Canadian Hypertension Education Program Recommendations 30
V. Choice of Pharmacological Treatment Uncomplicated Associated risk factors? or Target organ damage/complications? or Concomitant diseases/conditions? NO YES Treatment in the absence of specific indication Individualized Treatment (and compelling indications) 2008 Canadian Hypertension Education Program Recommendations 34
V. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling Indications TARGET <140/90 mmhg INITIAL TREATMENT AND MONOTHERAPY Lifestyle modification therapy A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmhg systolic or >10 mmhg diastolic above target Thiazide ACE-I ARB Betablocker* Longacting CCB * BBs are not indicated as first line therapy for age 60 and above ACEI and ARB are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential 2008 Canadian Hypertension Education Program Recommendations 36
V. Considerations Regarding the Choice of First-Line Therapy Use caution in initiating therapy with 2 drugs where substantive blood pressure lowering is more likely or more poorly tolerated (e.g. those with postural hypotension). ACE inhibitors and ARBs are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential. Beta adrenergic blockers are not recommended for patients age 60+ without another compelling indication. Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agent if required. ACE-I are not recommended (as monotherapy) for black patients without another compelling indication. 2008 Canadian Hypertension Education Prog ram Recom mendations 37
V. Add-on Therapy for Systolic/Diastolic Hypertension without Other Compelling Indications If partial response to monotherapy 1. Add-on Therapy 2. Triple or Quadruple Therapy CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect? If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers or centrally acting agents). 2008 Canadian Hypertension Education Program Recommendations 38
Most HTN Pts need more than 1 drug (data from ALLHAT) 2008 Canadian Hypertension Education Prog ram Recom mendations 41
BP lowering effects from antihypertensive drugs Dose response curves for efficacy are relatively flat 80% of the BP lowering efficacy is achieved at half-standard dose Combinations of standard doses have additive blood pressure lowering effects Law. BMJ 2003 2008 Canadian Hypertension Education Program Recommendations 43
Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications TARGET <140 mmhg INITIAL TREATMENT AND MONOTHERAPY Lifestyle modification therapy Thiazide diuretic ARB Long-acting DHP CCB 2008 Canadian Hypertension Education Program Recommendations 45
Choice of Pharmacological Treatment for Hypertension Individualized treatment Compelling indications: Ischemic Heart Disease Recent ST Segment Elevation-MI or non-st Segment Elevation-MI Left Ventricular Systolic Dysfunction Cerebrovascular Disease Left Ventricular Hypertrophy Non Diabetic Chronic Kidney Disease Renovascular Disease Smoking Diabetes Mellitus With Diabetic Nephropathy Without Diabetic Nephropathy Global Vascular Protection for Hypertensive Patients Statins if 3 or more additional cardiovascular risks Aspirin once blood pressure is controlled 2008 Canadian Hypertension Education Prog ram Recom mendations 49
VI. Treatment of Hypertension in Patients with Ischemic Heart Disease Stable angina 1. Beta-blocker 2. Long-acting CCB ACE-I are recommended for most patients with established CAD* Caution should be exercised when combining a non DHP-CCB and a beta-blocker If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or Diltiazem) Those at low risk with well controlled risk factors may not benefit from ACEI therapy Short-acting nifedipine 2008 Canadian Hypertension Education Program Recommendations 50
VII. Treatment of Hypertension with Left Ventricular Systolic Dysfunction Systolic cardiac dysfunction ACE-I and Beta blocker if ACE-I intolerant: ARB Titrate doses of ACEI and ARB to those used in clinical trials If additional therapy is needed: Diuretic (Thiazide for hypertension; Loop for volume control) for CHF class III-IV or post MI: Aldosterone Antagonist If ACE-I and ARB are contraindicated: Hydralazine and Isosorbide dinitrate in combination Non dihydropyridine CCB If additional antihypertensive therapy is needed: ACE-I / ARB Combination Long-acting DHP-CCB (Amlodipine or Felodipine) Beta-blockers used in clinical trials were bisoprolol, carvedilol and metoprolol. 2008 Canadian Hypertension Education Program Recommendations 52
VIII. Treatment of Hypertension for Patients with Cerebrovascular Disease Strongly consider blood pressure reduction in all patients after the acute phase of non disabling stroke or TIA. Stroke TIA An ACE-I / diuretic combination is preferred 2008 Canadian Hypertension Education Program Recommendations 53
IX. Treatment of Hypertension in Patients with Left Ventricular Hypertrophy Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events. Left ventricular hypertrophy - ACE-I - ARB, - CCB - Thiazide Diuretic - BB (if age below 60)* Vasodilators: Hydralazine, Minoxidil can increase LVH 2008 Canadian Hypertension Education Program Recommendations 54
XI. Treatment of Hypertension in Patients with Renovascular Disease Renovascular disease Does not imply specific treatment choice Caution in the use of ACE-I/ARB in bilateral renal artery stenosis or unilateral disease with solitary kidney Close follow-up and early intervention (angioplasty and stenting or surgery) should be considered for patients with: uncontrolled hypertension despite therapy with three or more drugs, or deteriorating renal function, or bilateral atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a single kidney), or recurrent episodes of flash pulmonary edema. 2008 Canadian Hypertension Education Program Recommendations 56
X. Treatment of Hypertension in Patients with Non Diabetic Chronic Kidney Disease Target BP: < 130/80 mmhg Chronic kidney disease and proteinuria * 1. ACE-I 2. Alternate if ACE-I not tolerated: ARB Additive therapy: Thiazide diuretic. Alternate: If volume overload: loop diuretic Combination with other agents * albumin:creatinine ratio [ACR] > 30 mg/mmol or urinary protein > 500 mg/24hr ACE-I/ARB: Bilateral renal artery stenosis Monitor potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB 2008 Canadian Hypertension Education Program Recommendations 55
XII. Treatment of Hypertension in association with Diabetes Mellitus Threshold equal or over 130/80 mmhg and Target below 130/80 mmhg Diabetes with Nephropathy* *Urina ry albumin to cre atinine ratio > 2.0 mg/mmol in men or > 2.8mg/mmol in women or chronic kidney dis ease* without Nephropathy** Systolicdiastolic Hypertension Isolated Systolic Hypertension **Urinary albumin to creatinine ratio <2.0 mg/mmol in men or <2.8mg/mmol in women * based on at least 2 of 3 measurements 2008 Canadian Hypertension Education Prog ram Recom mendations 58
XII. Treatment of Hypertension in association with Diabetic Nephropathy THRESHOLD equal or over 130/80 mmhg and TARGET below 130/80 mmhg DIABETES with Nephropathy ACE Inhibitor or ARB IF ACE-I and ARB are contraindicated or not tolerated, SUBSTITUTE Long-acting CCB or Thiazide diuretic Addition of one or more of Thiazide diuretic or Long-acting CCB 3-4 drugs combination may be needed Monitor potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB If Creatinine over 150 µmol/l or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired 2008 Canadian Hypertension Education Prog ram Recom mendations 59
XII. Treatment of Systolic-Diastolic Hypertension without Diabetic Nephropathy Threshold equal or over 130/80 mmhg and TARGET below 130/80 mmhg Diabete s without Nephropat hy 1. ACE-Inhibitor or ARB or 2. Thiazide diuretic or Dihydropyridine CCB Combination of first line agents DHP: dihydropyridine IF ACE-I and ARB and DHP- CCB or Thiazide are contraindicated or not tolerated, SUBSTITUTE Cardioselective BB* or Long-acting NON DHP-CCB Addition of one or more of: Cardioselective BB or Long-acting CCB * Cardioselective BB: Acebutolol, Atenolol, Bisoprolol, Metoprolol More than 3 drugs may be needed to reach target values for diabetic patients 2008 Canadian Hypertension Education Prog ram Recom mendations 60
XIII. Treatment of Hypertension for Patients Who Use Tobacco Smoking Beta-blocker The benefits of treating smokers with beta-blockers remain uncertain in the absence of a specific indications like angina or post-mi 2008 Canadian Hypertension Education Program Recommendations 62
XIV. Vascular Protection for Hypertensive Patients: Statins In addition to current Canadian recommendations on management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria: Male Age 55 or older Smoking Total-C/HDL-C ratio of 6 mmol/l or higher Family History of Premature CV disease LVH ECG abnormalities Microalbuminuria or Proteinuria ASCOT-LLA Lancet 2003;361:1149-58 2008 Canadian Hypertension Education Program Recommendations 65
90% of Hypertensive Canadians have other Cardiovascular Risk factors 10% Reduction in BP + 10% Reduction in Total-C = 45% Reduction in CVD 2006 Emberson Canadian Hypertension et al. Eur Education Heart J. Prog 2004;25:484-491. ram Recom mendations 17
XIV. Vascular Protection for Hypertensive Patients: ASA Consider low dose ASA Caution should be exercised if BP is not controlled. 2008 Canadian Hypertension Education Program Recommendations 66
Adherence to anti-hypertensive management can be improved by a multi-pronged approach Assess adherence to pharmacological and non-pharmacological therapy at every visit Teach patients to take their pills on a regular schedule associated with a routine daily activity e.g. brushing teeth. Simplify medication regimens using longacting once-daily dosing Utilize fixed-dose combination pills Utilize unit-of-use packaging e.g. blister packaging 2008 Canadian Hypertension Education Prog ram Recom mendations 67
Adherence to anti-hypertensive management can be improved by a multi-pronged approach Encourage greater patient responsibility/autonomy in regular monitoring of their blood pressure Educate patients and patients' families about their disease/treatment regimens verbally and in writing 2008 Canadian Hypertension Education Prog ram Recom mendations 68
NEW PATIENT RESOURCES FOR HYPERTENSION ON LINE www.heartandstroke.ca/bp To monitor home blood pressure and encourage self management of lifestyle www.hypertension.ca To access up to date downloadable patient information on hypertension 2008 Canadian Hypertension Education Prog ram Recom mendations 69