Primary Care Hypertension Management: Guidelines From Hypertension Canada

Hypertension is the most common modifiable risk factor for cardiovascular disease (CVD) in Canada, affecting 1 in 4 adults. Hypertension treatment rates have declined in Canada in recent years, possibly due to uncertainty about blood pressure (BP) targets, overly complex guideline recommendations, inadequate implementation strategies, and suboptimal engagement with primary care clinicians. Hypertension Canada published guidelines to provide streamlined, pragmatic, evidence-based recommendations for primary care management of hypertension.

Office. Automated oscillometric BP monitors are recommended over auscultatory sphygmomanometers due to ease of use, reproducibility, and decreased human error. Devices must be validated by the manufacturer.

The measurement procedure should be standardized to increase accuracy:

• Patient sits with back supported and legs uncrossed, with feet flat on the floor
• Use appropriately sized cuff for arm
• Arm should be bare and supported with middle of cuff at heart level and lower edge of cuff about 1 inch (3 cm) above elbow crease
• 1- to 5-minute rest period before BP measurement
• Patient should not talk or move from the beginning of the rest period to the final measurement
• Quiet and calm room
• No caffeine, tobacco, or exercise 30 minutes before measurements
• Obtain three measurements at 1-minute intervals; record all three and average

Standardized automated office BP measurements closely approximate daytime ambulatory and home measurements. Manual measurements are often 5 to 10 mm Hg higher.

Out of Office. Out-of-office BP assessment should comprise ambulatory monitoring every 20 to 30 minutes throughout the day and night or home monitoring with two measurements taken twice daily for 1 week. Out-of-office measurements correlate more closely with cardiovascular events and death than office readings. Hypertension Canada strongly recommends out-of-office monitoring to confirm hypertension and reveal masked hypertension. When out-of-office BP measurement is not feasible, hypertension can be confirmed with repeat standardized office measurements.

The guidelines define hypertension as BP of 130/80 mm Hg or greater. This is based on meta-analysis data that demonstrated a relative risk for major adverse cardiovascular events as 1.5 to 2 times higher than in people with BP less than 120/80 mm Hg. Although risks are higher at 120 to 129 mm Hg systolic and 80 to 84 mm Hg diastolic, this increased risk is substantially less.