Rabi DM, McBrien KA, Sapir-Pichhadze R, Nakhla M, Ahmed SB, Dumanski SM, et al. Hypertension Canada’s 2020 comprehensive guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children. Can. J. Cardiol. 2020;36(5):596-624.
Supplementary Tables
Table of Contents
- Supplemental Table S1.
- Supplemental Table S2. Examples of hypertensive urgencies or emergencies
- Supplemental Table S3. Examples of exogenous substances that can induce/aggravate hypertension
- Supplemental Table S4. Cardiovascular risk factors for consideration of statin therapy in non-dyslipidemic patients with hypertension
- Supplemental Table S5. Dietary Approaches to Stop Hypertension (DASH) diet
- Supplemental Table S6. Possible reasons for poor response to antihypertensive therapy
- Supplemental Table S7. Standard approach to obtaining ABPM readings in children (Grade D)
Supplemental Tables
| SUPPLEMENTAL TABLE S1. | |
| RECOMMENDED TECHNIQUE FOR AUTOMATED OFFICE BLOOD PRESSURE (AOBP) | |
| 1. | Measurements should be taken with a validated sphygmomanometer known to be accurate. |
| 2. | Choose a cuff with an appropriate bladder size matched to the size of the arm. Select the cuff size as recommended by its manufacturer. |
| 3. | Place the cuff so that the lower edge is 3 cm above the elbow crease and the bladder is centered over the brachial artery. There is no rest period needed before measurement. The arm should be bare and supported with the BP cuff at heart level, as a lower position will result in an erroneously higher SBP and DBP. There should be no talking, and patients’ legs should not be crossed. |
| 4. | When using automated office oscillometric devices, the patient should be seated in a quiet room (no specified period of rest). With the device set to take measures at 1- or 2-minute intervals. The first measurement is taken by a health professional to verify cuff position and validity of the measurement. The patient is left alone after the first measurement while the device automatically takes subsequent readings. |
| 5. | Record the average BP as displayed on the electronic device as well as the arm used and whether the patient was supine, sitting or standing. Record the heart rate. |
| RECOMMENDED TECHNIQUE FOR OFFICE BLOOD PRESSURE MEASUREMENT (OBPM) | |
| 1. | Measurements should be taken with a sphygmomanometer known to be accurate. A validated electronic device should be used. If not available, a recently calibrated aneroid device can be used. Aneroid devices or mercury columns need to be clearly visible at eye level. |
| 2. | Choose a cuff with an appropriate bladder size matched to the size of the arm. For measurements taken by auscultation, bladder width should be close to 40% of arm circumference 9 and bladder length should cover 80 – 100% of arm circumference. When using an automated device, select the cuff size as recommended by its manufacturer. |
| 3. | Place the cuff so that the lower edge is 3 cm above the elbow crease and the bladder is centered over the brachial artery. The patient should be resting comfortably for 5 minutes in the seated position with back support. The arm should be bare and supported with the BP cuff at heart level, as a lower position will result in an erroneously higher SBP and DBP. There should be no talking, and patients’ legs should not be crossed. The first reading should be discarded and the latter two averaged. BP should also be assessed after 2 minutes standing (with arm supported) and at times when patients report symptoms suggestive of postural hypotension. Supine BP measurements may also be helpful in the assessment of elderly and diabetic patients. When using automated office oscillometric devices such as the BpTRU (VSM MedTech Ltd, Vancouver, Canada), the patient should be seated in a quiet room (no specified period of rest). With the device set to take measures at 1- or 2-minute intervals, the first measurement is taken by a health professional to verify cuff position and validity of the measurement. The patient is left alone after the first measurement while the device automatically takes subsequent readings. The BpTRU automatically discards the first measure and averages the next 5 measures. For auscultation, at least three measurements should be taken in the same arm with the patient in the same position. The first reading should be discarded and the latter two averaged. Steps 4-7 are specific to auscultation. |
| 4. | Increase the pressure rapidly to 30 mmHg above the level at which the radial pulse is extinguished (to exclude the possibility of a systolic auscultatory gap). |
| 5. | Place the bell or diaphragm of the stethoscope gently and steadily over the brachial artery. |
| 6. | Open the control valve so that the rate of deflation of the cuff is approximately 2 mmHg per heart beat. A cuff deflation rate of 2 mmHg per beat is necessary for accurate systolic and diastolic estimation. |
| 7. | Read the systolic level -the first appearance of a clear tapping sound (phase I Korotkoff) and the diastolic level- the point at which the sounds disappear (phase V Korotkoff). If Korotkoff sounds persist as the level approaches 0 mmHg, then the point of muffling of the sound is used (phase IV) to indicate the diastolic pressure. Leaving the cuff partially inflated for too long will fill the venous system and make the sounds difficult to hear. To avoid venous congestion, it is recommended that at least one minute should elapse between readings. |
| 8. | Record the BP to the closest 2 mmHg on the manometer (or 1 mmHg on electronic devices) as well as the arm used and whether the patient was supine, sitting or standing. Avoid digit preference by not rounding up or down. Record the heart rate. The seated BP is used to determine and monitor treatment decisions. The standing BP is used to examine for postural hypotension, if present, which may modify the treatment. |
| 9. | In the case of arrhythmia, additional readings with auscultation may be required to estimate the average systolic and diastolic pressure. Isolated extra beats should be ignored. Note the rhythm and pulse rate. |
| 10. | BP should be taken in both arms on at least one visit and if one arm has a consistently higher pressure, that arm should be subsequently used for BP measurement and interpretation. |
| RECOMMENDED TECHNIQUE FOR AMBULATORY BLOOD PRESSURE MONITORING (ABPM) | |
| 1. | The appropriate sized cuff should be applied to the non-dominant arm unless the SBP difference between arms is >10 mm Hg, in which case the arm with the highest value obtained should be used. |
| 2. | The device should be set to record for a duration of at least 24 hours with the measurement frequency set at 20-30 minute intervals (revised guideline). |
| 3. | A patient-reported diary to define daytime (awake), night-time (sleep), activities, symptoms and medication administration is useful for study interpretation. |
| 4. | Daytime and night-time should preferentially be defined using the patient’s diary. Alternatively, pre-defined thresholds can be used (e.g. 8 AM to 10 PM for awake and 10 PM and 8 AM for night-time). |
| 5. | The ambulatory BP monitoring report should include all of the individual BP readings (both numerically and graphically), the percentage of successful readings, the averages for each time frame (daytime, night-time, 24 hours) and the “dipping” percentage (the percentage the average BP changed from daytime to night-time). |
| 6. | Criteria for a successful ambulatory BP monitoring study are:
|
| RECOMMENDED TECHNIQUE FOR HOME BLOOD PRESSURE MEASUREMENT (HBPM) | |
| 1. | Measurements should be taken with a validated electronic device. |
| 2. | Choose a cuff with an appropriate bladder size matched to the size of the arm. Bladder width should be close to 40% of arm circumference and bladder length should cover 80 – 100% of arm circumference. Select the cuff size as recommended by its manufacturer. |
| 3. | Cuff should be applied to the non-dominant arm unless the SBP difference between arms is >10 mmHg, in which case the arm with the highest value obtained should be used. |
| 4. | The patient should be resting comfortably for 5 minutes in the seated position with back support. |
| 5. | The arm should be bare and supported with the BP cuff at heart level. |
| 6. | Measurement should be performed before breakfast and 2 hours after dinner, before taking medication. |
| 7. | No caffeine or tobacco in the hour and no exercise 30 minutes preceding the measurement. |
| 8. | Duplicate measurement should be done in the morning and in the evening for seven days (i.e., 28 measurements in total). |
| 9. | Average the results excluding the first day’s readings. |
| Abbreviations: BP, blood pressure; DBP, diastolic BP; SBP, systolic BP. Unless otherwise mentioned, steps apply to measurement by auscultation and oscillometry using an upper arm cuff.Reprinted with permission from Hypertension Canada. | |
| SUPPLEMENTAL TABLE S2. EXAMPLES OF HYPERTENSIVE URGENCIES OR EMERGENCIES |
| Asymptomatic diastolic BP ≥130 mmHg |
Severe elevation of BP in the setting of any of:
|
| Abbreviations: BP, blood pressure Reprinted with permission from Hypertension Canada. |
| SUPPLEMENTAL TABLE S3. EXAMPLES OF EXOGENOUS SUBSTANCES THAT CAN INDUCE/AGGRAVATE HYPERTENSION | |
| Prescription Drugs |
|
| Other substances |
|
| SUPPLEMENTAL TABLE S4. CARDIOVASCULAR RISK FACTORS FOR CONSIDERATION OF STATIN THERAPY IN NON-DYSLIPIDEMIC PATIENTS WITH HYPERTENSION |
| Male sex |
| Age ≥55 years |
| Left ventricular hypertrophy |
| Other electrocardiographic abnormalities: left bundle branch block, left ventricular strain pattern, abnormal Q-waves or ST-T changes compatible with ischemic heart disease |
| Peripheral arterial disease |
| Previous stroke or transient ischemic attack |
| Microalbuminuria or proteinuria |
| Diabetes mellitus |
| Smoking |
| Family history of premature cardiovascular disease |
| Total cholesterol to high-density lipoprotein ratio ≥6 |
| If hypertensive patients have ≥3 of these risk factors, statins should be considered. Reprinted with permission from Hypertension Canada. |
| SUPPLEMENTAL TABLE S5. DIETARY APPROACHES TO STOP HYPERTENSION (DASH) DIET | ||
| Food Group | Daily Serving | Examples and Notes |
| Whole Grains | 6-8 | Whole wheat breads, cereal, oatmeal, rice, pasta, quinoa, barley, low-fat, low-sodium crackers |
| Vegetables | 4-5 | Dark green and orange fresh or frozen vegetables: Tomatoes, leafy greens, carrots, peas, squash, spinach, peppers, broccoli, sweet potatoes |
| Fruits | 4-5 | Have fruit more often than juice: Apples, apricots, bananas, grapes, oranges, melons, peaches, berries, mango |
| Low-fat or fat-free milk<br> foods or alternatives | 2-3 | Skim, 1% milk, fortified soy beverage, or yogurt, 6-18% milk fat (MF) cheese |
| Meats, poultry, fish | <6 ounces | Select only lean meats. Choose fish like char, herring, mackerel, salmon, sardines and trout. Trim away fats. Broil, roast or boil. No frying. Remove skin from poultry. Low-sodium, low-fat deli meats |
| Nuts, seeds, legumes | 4-5/week | Almonds, peanuts, walnuts, sunflower seeds, soybeans, lentils, chick peas, dried peas and beans, tofu |
| Fats and oils | 2-3 tsp | Soft margarines, mayonnaise, vegetable oil (olive, corn, canola, or safflower), salad dressing |
| Sweets | ≤5 Tbsp/ week | Sugar, jelly, jam, hard candy, syrups, sorbet, chocolate |
| DASH eating plan available at http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf Examples of serving sizes are listed in Canada’s Food Guide (comparable to DASH) available at: http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php . | ||
| SUPPLEMENTAL TABLE S6. POSSIBLE REASONS FOR POOR RESPONSE TO ANTIHYPERTENSIVE THERAPY | |
| Poor adherence | Dietary Physical activity Medication |
| Associated conditions | Obesity Tobacco use Excessive alcohol consumption Sleep apnea Chronic pain |
| Drug interactions | Nonsteroidal anti-inflammatory drugs (including cyclo-oxygenase-2 inhibitors) Oral contraceptives Corticosteroids and anabolic steroids Sympathomimetics and decongestants Cocaine Amphetamines Erythropoietin Cyclosporine, tacrolimus Licorice Over-the-counter dietary supplements (e.g. ephedra, ma huang, bitter orange) Monoamine oxidase inhibitors, certain selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors |
| Suboptimal treatment regimens | Dosage too low Inappropriate combinations of antihypertensive agents |
| Volume overload | Excessive salt intake Renal sodium retention (pseudotolerance) |
| Secondary hypertension | Renal insufficiency Renovascular disease Primary hyperaldosteronism Thyroid disease Pheochromocytoma and other rare endocrine causes Obstructive sleep apnea |
| Note that causes of ‘pseudo-resistance’ (such as white coat hypertension or pseudo-hypertension in the elderly) should be ruled out first. | |
| SUPPLEMENTAL TABLE S7. STANDARD APPROACH TO OBTAINING ABPM READINGS IN CHILDREN (GRADE D) | |
| 1. | ABPM should be performed by a health care professional with specific training in application of the device and interpretation of ABPM data in children. |
| 2. | Monitor should be applied to the nondominant arm unless contraindicated or on the arm with the higher BP (if a significant discrepancy between the extremities exist). |
| 3. | BP should be recorded every 15-20 minutes during waking hours and every 20-30 minutes during sleep. |
| 4. | BP measured with the device should be compared with resting, clinic BP by the same technique used by ABPM (ausculatory or oscillometric). These resting BP measurements made immediately after the application of the ABPM device should be edited out. |
| 5. | Patients should record activity, sleep/wake times and antihypertensive medication administration in a diary. |
| 6. | A minimum of 1 reading per hour (including during sleep) and at least 40-50 readings for a full 24-hour report are needed to consider the study optimal for interpretation. |
| 7. | ABPM software should be programmed to discard values that fall outside of the following range:
|
| 8. | Standard calculations should be reported during the 24-hour, awake and sleep periods:
Abbreviations: BP, blood pressure; DBP, diastolic BP; SBP, systolic BP. |
| Supplemental Appendix S1: Members of the Hypertension Canada 2020 Guidelines Committee |
| Co-Chairs: DM. Rabi, S.S. Daskalopolou |
| Central Review Committee (CRC): S.S. Daskalopoulou (Chair), S. Ahmed, S. Butalia, S. Dumanski, K. Harris, A. Leung, K. McBrien, M. Nakhla, R. Sapir-Pichhadze |
| Adherence Strategies for Patients: T. Campbell, R. Feldman, K. Lavoie, R. Tsuyuki |
| Echocardiography: G. Honos |
| E-Health & Hypertension (in development): S. Grover |
| Endocrinological Forms of Hypertension: A. Prebtani, E. Schiffrin, F. Hannah-Shmouni, A Don-Wauchope |
| Hypertension & Diabetes: S. Tobe, J. Bittman, R. Gilbert, L. Leiter, C. Jones, V. Woo |
| Vascular Protection: R. Feldman, M. Gupta, R. Hegele, P. McFarlane, A. Pipe, E. Schiffrin, P. Selby |
| Health Behaviours and Hypertension: S. Bacon, J. Kaczorowski, L. Trudeau, S. Hiremath, M. Roerecke, J. Arcand |
| BP Measurement: L. Cloutier, K. Zarnke, J. Alfonsi, P. Bolli, M. Lamarre-Cliche, B. Mangat, D. McLean, A. Michaud, A. Milot, K. Tran, R. Townsend |
| Pharmacotherapy for Hypertensive Patients with CVD: S. Rabkin, G. Moe, J. Howlett |
| Pharmacotherapy for Hypertensive Patients Without Compelling Indications: G. Dresser, E. Burgess, J. Grégoire, S. Gryn, R. Herman, R. Lewanczuk |
| Renal and Renovascular Hypertension: M. Ruzicka, S. Tobe, C. Edwards, G. Hundemer, M. Vallée, |
| Resistant Hypertension: S. Hiremath, J. Gabor, L. Kuyper, N. Khan, M. Ruzicka, S. Tobe, K. Tran. |
| Routine Laboratory Tests: E. Burgess, B. Penner, P. Sivapalan |
| Hypertension & Stroke: P. Lindsay, M. Hill, A. Poppe, M. Sharma, A. Shoamanesh |
| Hypertension & Pediatrics: A. Fournier, G. Benoît, L. Cloutier, J. Dionne, K. Harris, |
| Hypertension & Pregnancy: K. Nerenberg, F. Audibert, A.M. Côté, T. Firoz, A. Logan, L. Magee, E. Rey Primary Care Advisor: A. Bell |
| Supplemental Appendix S2: Commercial Conflicts of Interest | |
| Bacon, Simon | Investigator-initiated grants: GSK, Abbvie
Consultancy/speaker fees: Schering-Plough, Merck, AstraZeneca, Sygesa, Novartis, Janssen Advisory Boards: Bayer, Sanofi |
| Bell, Alan | Consultancy/Speaker fees/Research and Travel support: Amgen, BMS, Janssen, AstraZeneca, Novartis, Pfizer, Bayer, Lilly, BI, Canopy, Sanofi, Servier |
| Bittman, Jesse | Speaker fees: Bausch Health Canada, Novo Nordisk
Travel support: Novo Nordisk |
| Campbell, Tavis | Consultancy/speaker fees/honoraria: Janssen, Novo Nordisk |
| Cloutier, Lyne | Travel support/Honoraria: Servier Canada |
| Don-Wauchope, Andrew | Employment by LifeLabs |
| Dresser, George K. | Honoraria: Pfizer, Servier, Mayer, Ferring, Janssen, Novartis, BMS, Novo Nordisk, BI |
| Feldman, Ross | Speakers Bureau: Servier Canada |
| Gabor, Jonathan | Honoraria: Bayer, BMS-Pfizer, BI, Novartis, Servier |
| Gilbert, Richard E. | Research Grants: AstraZeneca, BI, Janssen, Merck
Advisory Boards/Honoraria: AstraZeneca, BI, Janssen Stockholder: Fibrocor Therapeutics, OccuRx and Certa Therapeutics |
| Grégoire, Jean | Consultancy/Speaker Fees: Amgen, AZ, Bayer, BI, BMS, HLS Therapeutics, Merck, Novartis, Pfizer,
Sanofi, Servier, |
| Grover, Steven | Founding Director of McGill Comprehensive Health Improvement Program (CHIP); Principal and CEO of Clinemetrica Inc |
| Gryn, Steven | Consultancy/Speaker Fees: Servier Canada |
| Hegele, Robert | Advisory Boards: Amgen, Sanofi, HLS Therapeutics Honoraria: Amgen, Sanofi |
| Honos, George | Advisory Boards/Honoraria: BMS-Pfizer, AZ, Novartis, Servier, Janssen, Novo Nordisk, Eli Lilly |
| Howlett, Jonathan | Consultancy/Speaker Fees: Amgen, Akcea, Alnylam, AstraZeneca, Novartis, Medtronic, BI, Sevier, Janssen, Lilly, Bayer, Pfizer
Research Grants: AstraZeneca, Novartis, Medtronic, BI, Servier, Janssen, Lilly, Bayer, Pfizer |
| Kuyper, Laura | Honoraria: Servier |
| Lavoie, Kim | Consultancy/Speaker Fees: AbbVie, Merck, AstraZeneca, Novartis, Janssen, BI, Astellas |
| Leiter, Lawrence A. | Advisory Boards/Research Grants/Honoraria: AstraZeneca, Bayer, BI, Eli Lilly, Esperion, HLS, Janssen, Kowa, the Medicine Company, Merck, Novartis, Novo Nordisk, Sanofi, Servier |
| Magee, Laura | Honoraria: Alexion Pharmaceuticals |
| Mangat, Birinder | Speaker Fees: Bausch Health, Servier |
| McFarlane, Phil | Consultancy: Amgen, AstraZeneca, Bayer, BI, Janssen, Lilly, Otsuka, Sanofi-Aventis
Grants/Research: AstraZeneca, Bayer, BI, GSK, Janssen, Novartis, Otsuka Speaking Fees: Bayer, BMS, BI, GSK, Janssen, Novartis, Otsuka, Sanofi, Servier |
| Pipe, Andrew | Intellectual Property Rights: Ottawa Model for Smoking Cessation |
| Prebtani, Ally | Advisory Board/Speaker Fees: Servier |
| Selby, Peter | Advisory Boards/Consultancy: Pfizer, Johnson & Johnson Group, NVision Insight Group, Medcan Clinic
Grants/Honoraria: Pfizer, Bhasin Consulting Fund Inc. BMS Research Studies: Johnson & Johnson, Novartis, Pfizer Inc. |
| Sharma, Mike | Speaker’s Honorarium and/or Advisory Board: BI, Bayer, BMS, Daiichi Sankyo, AZ Therapies
Research Funding: Bayer, BMS |
| Shoamanesh, Ashkan | Advisory Board: Bayer, Daiichi Sankyo Company Ltd.
Honoraria: Bayer, Servier Canada |
| Sivapalan, Praveena | Honoraria: Servier Canada |
| Tobe, Sheldon | Research: CIHR
Honoraria: Janssen, BMS-Pfizer, CHEP+ Principal Investigator: Bayer, AbbVie, Eli Lilly, AstraZeneca |
| Townsend, Ray | Consultancy: Medtronic SPYRAL Studies
DSMB Member for AXIO; Royalties from UpToDate |
| Trudeau, Luc | Advisory Boards: Bayer, Servier, Lilly, Janssen
Research: BI, Bayer, Novartis Speakers Bureau: BI, Lilly, Servier, Amgen, Sanofi, Bayer, Valeant |
| Tsuyuki, Ross | Research Grants: Merck, Sanofi, AstraZeneca
President, SMHEART CONSULTING INC. |
| Vallée, Michel | Consultancy: Servier, Valencia, Idorsia, Otsuka, Valeant, Janssen, Takeda, BI, BMS, Pfizer, Merck |
| NO CONFLICTS | |
| Ahmed, Sofia | Lamarre-Cliche, Maxime |
| Alfonsi, Jeffrey E. | Leung, Alexander |
| Arcand, JoAnne | Lewanczuk, Richard |
| Audibert, François | Lindsay, Patrice |
| Benoît, Geneviève | Logan, Alexander G. |
| Bolli, Peter | McBrien, Kerry |
| Burgess, Ellen | McLean, Donna |
| Butalia, Sonia | Michaud, André |
| Côté, Anne Marie | Milot, Alain |
| Daskalopoulou, Stella | Moe, Gordon |
| Dionne, Janis | Nakhla, Meranda |
| Dumanski, Sandra | Nerenberg, Kara |
| Edwards, Cedric | Penner, Brian |
| Firoz, Tabassum | Sapir-Pichhadze, Ruth |
| Fournier, Anne | Poppe, Alexandre |
| Gupta, Milan | Rabi, Doreen |
| Hannah-Shmouni, Fady | Rabkin, Simon |
| Harris, Kevin | Rey, Evelyne |
| Herman, Robert J. | Roerecke, Michael |
| Hill, Michael D. | Ruzicka, Marcel |
| Hiremath, Swapnil | Schiffrin, Ernesto |
| Hundemer, Gregory | Tran, Karen |
| Jones, Charlotte | Woo, Vincent |
| Kaczorowski, Janusz | Zarnke, Kelly |
| Khan, Nadia | |