• Use thiazide diuretics for additional BP control, or loop diuretics for volume control.
• Use a combination of hydralazine and isosorbide dinitrate if unable to use an ACE inhibitor or ARB.
Hypertension and stroke/transient ischemic attack:
• If the patient is ineligible for thrombolytic therapy, do not treat hypertension in the first 72 hours as it may exacerbate or induce ischemia. If BP is extremely elevated (systolic >220 or diastolic >120),you can reduce BP by 15%, not greater than 25%, over a 24-hour period.
• If the patient is eligible for thrombolytic therapy, then concurrent treatment for very high BP (systolic >185 or diastolic >110) should be given to avoid secondary intracranial hemorrhage.
• Post stroke: Initiate treatment with an ACE inhibitor and/or a diuretic with a target BP <140/90.
Hypertension and left ventricular hypertrophy:
• Initial therapy with ACE inhibitor, ARB, calcium channel blocker, or thiazide.
• Avoid direct arterial vasodilators.
Hypertension and nondiabetic chronic kidney disease:
• If the patient has proteinuria, initial therapy should be an ACE inhibitor, or an ARB if intolerance to ACE inhibitors.
• Escalate with thiazide diuretic for BP control, loop diuretic for volume control.
• Target BP <140/90.
• Combination of an ACE inhibitor and an ARB is not recommended.
Hypertension and diabetes mellitus:
• Initiate therapy with ACE inhibitor, ARB, calcium channel blocker, or thiazide diuretic.
• Initiate therapy with ACE inhibitor or ARB if kidney disease, cardiovascular disease, or risk factors are present.
• Be cautious in initiating with two medications in elderly patients or those with autonomic neuropathy.
• The combination of an ACE inhibitor and a dihydropyridine calcium channel blocker is preferable to an ACE inhibitor and a thiazide diuretic.
Key points
The CHEP guidelines set specific and relatively conservative criteria for both diagnosing hypertension and starting antihypertensive medications. Delaying pharmacotherapy for low-risk patients while attempting lifestyle management is acceptable, and specific recommendations are made for pharmacologic therapy.
Reference: Hackam DG, Quinn RR, Ravani P, et al. The 2013 Canadian Hypertension Education Program (CHEP) recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can. J. Cardiol. 2013;29:528-42 (see www.hypertension.ca).
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Sepe is a first year resident in the Family Medicine Residency Program at Abington Memorial Hospital.