Abstract Hypertension Canada provides annually-updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension. This year, we introduce 10 new guidelines. ...Three previous guidelines have been revised and 5 have been removed. Previous age and frailty distinctions have been removed as considerations for when to initiate antihypertensive therapy. In the presence of macrovascular target organ damage, or in those with independent cardiovascular risk factors, antihypertensive therapy should be considered for all individuals with elevated average systolic blood pressure readings ≥140 mmHg. For individuals with diastolic hypertension (with or without systolic hypertension), fixed-dose single pill combinations are now recommended as an initial treatment option. Preference is given to pills containing an angiotensin converting enzyme inhibitor or angiotensin receptor blocker in combination with either a calcium channel blocker or diuretic. Whenever a diuretic is selected as monotherapy, longer-acting agents are preferred. In patients with established ischemic heart disease, caution should be exercised in lowering diastolic pressure ≤60 mmHg, especially in the presence of left ventricular hypertrophy. Following a hemorrhagic stroke, in the first 24 hours, systolic blood pressure lowering to <140 mmHg is not recommended. Finally, guidance is now provided for screening, initial diagnosis, assessment, and treatment of renovascular hypertension arising from fibromuscular dysplasia. The specific evidence and rationale underlying each of these guidelines are discussed.
Abstract Hypertension Canada's CHEP Guidelines Task Force provides annually-updated, evidence-based recommendations to guide the diagnosis, assessment, prevention, and treatment of hypertension. This ...year, we present four new recommendations, as well as revisions to two previous recommendations. In the diagnosis and assessment of hypertension, automated office blood pressure, taken without patient-health provider interaction, is now recommended as the preferred method of measuring in-office blood pressure. Also, while a serum lipid panel remains part of the routine laboratory testing for patients with hypertension, both fasting and non-fasting collections are now considered acceptable. For individuals with secondary hypertension arising from primary hyperaldosteronism, adrenal vein sampling is recommended for those who are candidates for potential adrenalectomy. With respect to the treatment of hypertension, a new recommendation that has been added is for increasing dietary potassium to reduce blood pressure in those who are not at high risk for hyperkalemia. Furthermore, in selected high-risk patients, intensive blood pressure reduction to a target systolic blood pressure ≤120 mmHg should be considered to lower the risk of cardiovascular events. Finally, in hypertensive individuals with uncomplicated, stable angina pectoris, either a β blocker or calcium channel blocker may be considered for initial therapy. The specific evidence and rationale underlying each of these recommendations are discussed. Hypertension Canada's CHEP Guidelines Task Force will continue to provide annual updates.
Abstract Background Direct-acting oral anticoagulants (DOACs) are widely prescribed for stroke prevention in patients with atrial fibrillation. An important advantage of DOACs is that routine ...monitoring of anticoagulation response is not necessary. Nevertheless, due to their mechanism of action, DOAC anticoagulation effect can be inferred based on observed plasma concentration. However, there is paucity of data relating to observed interpatient variation in DOAC plasma concentrations in the post-market clinical setting. Methods We determined rivaroxaban and apixaban plasma concentrations in atrial fibrillation patients during routine clinic visits. Results Among 243 patients (rivaroxaban, n=94; apixaban, n=149) enrolled in this study, 60- and 50-fold interpatient variation in plasma concentration was observed for rivaroxaban and apixaban respectively. Approximately 12% of rivaroxaban and 13% of apixaban patients exceeded the 95th percentile for predicted maximum plasma concentration observed in clinical trials. Conclusions In this routine care setting, rivaroxaban and apixaban plasma concentrations tended to be more variable than those observed in clinical trials. Identification of additional clinical and molecular determinants that more fully predict patients at risk for excessively high or low DOAC concentrations may enable a more precise DOAC dosing regimen for the individual patient.
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