29-05-2025
Canada Targets PCPs With New Hypertension Guideline
Hypertension Canada has released a guideline that aims to enhance the standard of hypertension management in primary care settings with evidence-based, pragmatic, and easy-to-implement recommendations.
The guidance is based on the World Health Organization's HEARTS framework to improve hypertension control and reduce cardiovascular burden.
The previous guideline was published in 2020. 'For the 2025 guideline, a new approach was selected in view of the declining rates of hypertension control in Canada,' guideline committee co-chairs Rémi Goupil, MD, University of Montreal, and Gregory Hundemer, MD, McGill University, both in Montreal, told Medscape Medical News . 'The first step is this Primary Care Hypertension Canada guideline, which is tailored specifically to primary care providers, who manage 90% of people with hypertension.'
Gregory Hundemer, MD
The guideline, published online in the Canadian Medical Association Journal, was designed from inception with primary care in mind, and most members of the writing committee were primary care providers, they said. The target users are family physicians, nurse practitioners, nurses, and pharmacists, as well as policymakers and patients and caregivers affected by hypertension.
'The guideline provides pragmatic diagnostic and treatment algorithms, listing specific drugs, their dosage, and the sequence in which they should be prescribed,' they added. 'Patient voices were included in all steps of the process, and a patient-specific guideline is published alongside the primary care guideline.'
Rémi Goupil, MD
Key Recommendations
The guideline committee made nine recommendations covering hypertension diagnosis and treatment. The most important recommendations , according to Goupil and Hundemer, are:
1. Defining hypertension as a blood pressure (BP) ≥ 130/80 mm Hg, provided it is confirmed with an out-of-office BP assessment. 'Lowering of the hypertension diagnosis threshold will significantly increase the number of people labeled with hypertension in Canada, although only a small fraction is expected to require pharmacotherapy initiation,' they said. 'This new threshold reflects the growing evidence regarding the cardiovascular risk reduction associated with lower blood pressure levels.' All adults with hypertension should initiate treatment (healthy lifestyle changes with or without pharmacotherapy) to target a systolic BP < 130 mm Hg. Start with low-dose combination therapy (ideally as a single pill combination) when pharmacotherapy initiation is needed. Specifically, this includes drugs from two of the following three complementary classes of medications: Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), thiazide or thiazide-like diuretics, and long–acting dihydropyridine calcium channel blockers (CCBs).
Other recommendations include:
Healthy lifestyle changes for all adults with hypertension.
Pharmacotherapy initiation for hypertension for adults with BP ≥ 140/90 mm Hg and for adults with systolic BP 130-139 mm Hg at high cardiovascular disease risk.
If BP remains above the target despite the recommended two-drug combination therapy, three-drug combination therapy consisting of an ACEI or ARB, a thiazide or thiazide-like diuretic, and a long–acting dihydropyridine CCB is recommended.
If BP remains above target despite three-drug combination therapy at maximally tolerated doses, the addition of spironolactone is recommended.
'This guideline is only the first step in Hypertension Canada's approach,' Goupil and Hundemer said. 'The next step is the comprehensive guideline, in which specific topics will be evaluated in-depth to provide recommendations for more specific situations, such as the optimal management of hypertension in diabetes or in resistant hypertension.' The comprehensive guideline is expected in 2026.
HEARTS to Boost Implementation
Canadian Cardiovascular Society spokesperson Sheldon Tobe, MD, professor of medicine at the University of Toronto and Northern Ontario School of Medicine, Toronto, commented on the guideline for Medscape Medical News .
Sheldon Tobe, MD
'We have evidence that Canada's position of best blood pressure awareness, treatment, and control in the world has been slipping, and that was before the pandemic,' he said. 'One of the reasons is loss of support for dissemination and implementation by the Public Health Agency of Canada more than a decade ago. The promotion of the HEARTS framework will help to bring policymakers into the implementation of blood pressure control again. The simplified approach to one BP target will facilitate dissemination efforts as well.'
A concern, however, is the small number of people involved in creating the guideline. 'In the past, a very large part of the hypertension community was involved, which ensured that there was widespread agreement with the process and results,' said Tobe, who was not involved in developing the guideline. 'This included the interprofessional community of nurses and dietitians, in addition to pharmacists and doctors. If the HEARTS framework is formally adopted by Canada, this will be very helpful.'
Regarding specific recommendations, he said, 'The guideline has suggested that the preferred initial combination therapy will be irbesartan and hydrochlorothiazide, including splitting the pill, which strays off-label. This might be off-putting to some Canadians who don't realize that almost all of our antihypertensives are now generic and are fairly inexpensive.'
Furthermore, he said, 'I was disappointed that the issue of drug shortages, which have greatly impacted blood pressure management in Canada recently, was not mentioned in more detail. There does not seem to be any focus by policymakers on a sustainable supply for these lifesaving medications.'
The funding for this initiative was provided by Hypertension Canada.
Goupil reported receiving research grants from the Canadian Institutes of Health Research (CIHR), the Kidney Foundation of Canada, Fonds de recherche du Québec — Santé, and Université de Montréal, as well as holding unpaid positions as a board member of the Canadian Society of Nephrology and vice president of the Société québécoise d'hypertension artérielle.
Hundemer reported receiving research grants from the CIHR, the Kidney Foundation of Canada, and The Ottawa Hospital Academic Medical Organization, and is the Lorna Jocelyn Wood Chair for Kidney Research at The Ottawa Hospital Research Institute.
Tobe reported receiving honoraria for lectures and payments to support accredited continuing medical education programs from AstraZeneca, Bayer, Boehringer Ingelheim, CHEP+, Eisai, GSK, Janssen Pharmaceuticals, KMH, Novo Nordisk, and Otsuka. He also reported participation in a living kidney donor safety study sponsored by the CIHR, serving as a volunteer board member for the American Hypertension Specialist Certification Program, a volunteer co-chair for C-Change, and serving as physician organization chair of the implementation arm of C-Change for CHEP+.
