Abstract β-Adrenergic receptor blockers or β-blockers represent one of the oldest classes of cardiovascular agents and have been considered a cornerstone therapy for hypertension and heart disease ...for the past 5 decades. They are advocated as a first-line treatment for uncomplicated essential hypertension in patients younger than 60 years of age as recommended by the Canadian Hypertension Education Program. However, despite the well-established antihypertensive and cardiovascular benefits of β-blockers, a number of studies argue that they might not have the same clinical advantages of other classes of agents in terms of morbidity/mortality outcomes. This review will focus on the heterogeneity of the pharmacologic characteristics of β-blockers, and we will discuss the metabolic and hemodynamic differences within the β-blocker class and try to assess the potential implications of these differences for optimal selection in hypertension.
Abstract Following the 2016 guidelines for blood pressure measurement, diagnosis and investigation of pediatric hypertension, we now present evidence-based guidelines for the prevention and treatment ...of hypertension in children. These guidelines were developed by Hypertension Canada’s Guideline Committee pediatric subgroup after thorough evaluation of the available literature. Included are 10 guidelines specifically addressing health behaviour management, indications for drug therapy in children with hypertension, choice of therapy for children with primary hypertension and goals of therapy for children with hypertension. While the pediatric literature is inherently limited by small numbers of participants, fewer trials, and a prolonged latency to the development of vascular outcomes, this manuscript reflects the current and highest level of evidence and provides guidance for primary care practitioners on the management of pediatric hypertension. Studies of therapeutic lifestyle modifications in children are available to guide current management and more antihypertensive drugs have been studied in children since the Food and Drug Administration Modernization Act. Consistent with Hypertension Canada’s guideline policy, diagnostic and therapeutic algorithm tools will be developed and the guidelines will be reviewed annually and updated according to new evidence.
Objectives The present study investigated whether initiating therapy with a combination of losartan (L) and hydrochlorothiazide (HCTZ) allows for faster blood pressure (BP) control and fewer ...medications than the usual stepped-care approach in patients with stage 2 or 3 hypertension and ambulatory systolic hypertension. Methods : Patients with a mean daytime systolic ambulatory BP (ABP) of 135 mmHg or higher were randomly assigned to receive L 50 mg plus HCTZ 12.5 mg titrated to L 100 mg plus HCTZ 25 mg versus HCTZ 12.5 mg plus atenolol 50 mg. Amlodipine 5 mg was then added, if needed, to achieve a BP goal of less than 130 mmHg. Treatment titration was based on ABP. Results Significantly more patients randomly assigned to L/HCTZ (63.5%) than stepped-care (37.5%; P = 0.008) achieved the primary end point (daytime systolic BP of less than 130 mmHg). Initial L/HCTZ induced significantly greater decreases in ABP during each 24 h period after six weeks of therapy. Although reductions in systolic and diastolic ABP were not statistically different at the end of the study, ABP reduction was significantly greater (P<0.001) with the L/HCTZ-based regimen. Twice as many patients in the L/HCTZ group achieved the goal ABP with no more than two drugs (30.0% versus 14.7%; P = 0.03). Moreover, tolerability was significantly better (P = 0.006) in the L/HCTZ group, with a 40.0% incidence of adverse events, versus 65.6% in the stepped-care group. Conclusion Initiating antihypertensive therapy with the combination of L/HCTZ in patients with stage 2 or 3 hypertension and ambulatory systolic hypertension reaches a target BP faster in a higher proportion of patients, with fewer adverse events and less need for a third drug regimen than the conventional stepped-care approach.
Abstract β-Adrenergic blocking agents (or β-blockers) have been widely used for the treatment of hypertension for the past 50 years, and continue to be recommended as a mainstay of therapy in many ...national guidelines. They have also been used in a variety of cardiovascular conditions commonly complicating hypertension, including angina pectoris, myocardial infarction (MI), acute and chronic heart failure, as well as conditions like essential tremor and migraine. Moreover, they have played a primary role in controlling blood pressure in patients with these specific comorbidities and in reducing cardiovascular risk with regard to the composite outcome of death, stroke, and MI among patients younger than 60 years of age. However, in patients 60 years of age or older, β-blockers were not associated with significantly lower rates of MI, heart failure or death, and demonstrated higher rates of stroke compared with other first-line therapies. Consequently, the Canadian Hypertension Education Program recommends the use of β-blockers as first-line therapy in hypertensive patients younger than 60 years of age but not for those age 60 and older, with the exception of patients with concomitant β-blocker-requiring cardiac diseases. Several reports suggest that the lack of consistent outcome data may relate to the use of traditional β-blockers such as atenolol and their ability only to reduce cardiac output, without beneficial effect on peripheral vascular resistance. The present report will describe the clinically relevant mechanisms of action of β-blockers, their pharmacological differences, their metabolic effects, and their usefulness in patients with hypertension.
The present article is a summary of the theme, the key recommendations for management of hypertension and the supporting clinical evidence of the 2010 Canadian Hypertension Education Program (CHEP). ...In 2010, CHEP emphasizes the need for health care professionals to stay informed about hypertension through automated updates at www.htnupdate.ca . A new interactive Internet-based lecture series will be available in 2010 and a program to train community hypertension leaders will be expanded. Patients can also sign up to receive regular updates in a pilot program at www.myBPsite.ca . In 2010, the new recommendations include consideration for using automated office blood pressure monitors, new targets for dietary sodium for the prevention and treatment of hypertension that are aligned with the national adequate intake values, and recommendations for considering treatment of selected hypertensive patients at high risk with calcium channel blocker/angiotensin-converting enzyme inhibitor combinations and the use of angiotensin receptor blockers.
Abstract This is a summary of the theme, key new recommendations, and supporting science of the 2011 Canadian Hypertension Education Program (CHEP). In 2011, the ACCORD trial challenged current blood ...pressure treatment targets for people with diabetes. After consideration of multiple factors relating to the ACCORD trial design and its reporting, the current treatment target of <130/80 mm Hg was not changed. A meta-analysis implicated angiotensin receptor blockers in causing cancer; however, weaknesses in the meta-analysis and ongoing close scrutiny of the issue by the U.S. Food and Drug Administration precluded any changes in current CHEP recommendations. New expert opinion–based recommendations were added to assist the management of hypertension in the setting of acute stroke. To promote healthier blood pressure in Canadians, CHEP emphasizes the need for all Canadians—in particular, health care professionals and their organizations—to more actively work with different levels of government to implement healthy public policies. These should build community capacity to promote healthy behaviours with the goal of the prevention of hypertension and its consequences. To aid a substantive knowledge translation gap, health care professionals and people with hypertension can now receive regular CHEP updates by signing up at the Web sites htnupdate.ca and www.myBPsite.ca.
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.
Background Blood pressure (BP) control is frequently difficult to achieve in patients with predominantly elevated systolic BP. Consequently, these patients frequently require combination therapy ...including a thiazide diuretic such as hydrochlorothiazide (HCTZ) and an agent blocking the renin-angiotensin-aldosterone system. Current clinical practice usually limits the daily dose of HCTZ to 25 mg. This often leads to the necessity of using additional antihypertensive agents to control BP in a high proportion of patients. Objectives To compare the efficacy of two doses of losartan (LOS)/HCTZ combinations in patients with uncontrolled ambulatory systolic hypertension after six weeks of treatment with LOS 100 mg/HCTZ 25 mg (LOS100/HCTZ25). Methods Following a two- to four-week washout period, subjects with a mean clinic sitting systolic BP of 160 mmHg or higher and a mean ambulatory daytime systolic BP (MDSBP) of 135 mmHg or higher on LOS100/HCTZ25 (n = 105; 33 women and 72 men) were randomly assigned to receive LOS 150 mg/HCTZ 25 mg (group 1; n = 53) or LOS 150 mg/HCTZ 37.5 mg (LOS150/HCTZ37.5, group 2; n = 52). The primary end point was the difference in MDSBP reductions. Results At the end of the six-week treatment period, the respective additional decreases in MDSBP were 1.2 mmHg (P = 0.335) on LOS 150 mg/HCTZ 25 mg and 5.6 mmHg (P < 0.0001) on LOS150/HCTZ37.5 (difference of 4.4 mmHg; P = 0.011). Daytime systolic ambulatory BP goal (lower than 130 mmHg) achievement tended to be higher (25% versus 17%; P = 0.313) with LOS150/HCTZ37.5, while it was significantly higher (65% versus 43%; P = 0.024) for mean daytime diastolic BP (lower than 80 mmHg). No deleterious metabolic changes were observed. Conclusions In patients with uncontrolled systolic ambulatory hypertension receiving LOS100/HCTZ25, increasing both HCTZ and LOS dosages simultaneously to LOS150/HCTZ37.5 may be an effective strategy that does not affect metabolic parameters.
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