Canadian Hypertension Research Articles

Enhancing hypertension detection and control through a hypertension certification program for pharmacists: A cluster randomized trial (The RxPATH Study).

We designed an online educational program for primary care health care providers, the Hypertension Canada Professional Certification Program (HC-PCP), based upon its 2020 guidelines. The objective was to determine the effect of the HC-PCP, taken by pharmacists, on systolic blood pressure (BP) in patients with poorly controlled hypertension. Stepped wedge cluster randomized trial (unit of randomization was the pharmacy). Patients with poorly controlled hypertension (BP >140/90 mmHg or >130/80 mmHg [diabetes]) in community pharmacies in Alberta, Canada, were recruited by their pharmacist. Pharmacists completed the HC-PCP program, then provided care to their patients with poorly controlled hypertension according to what they learned in the course. Pharmacists were given a copy of the Hypertension Canada guidelines and provided their usual care to their patients prior to undertaking the HC-PCP later. The primary outcome was a difference in change in systolic BP at 3 months between groups, while the secondary outcome was patient satisfaction with using the Consultation Satisfaction Questionnaire. We enrolled 890 patients from 59 pharmacies (including 104 pharmacists). Using a linear mixed-effect model with BP reduction as the dependent variable and independent variables of treatment allocation, baseline BP, site effect and patient effect, the intervention was associated with a 4.76 mmHg (95% confidence interval, 2.02-7.50, p < 0.0001) systolic BP reduction at 3 months. Patient satisfaction with using the Consultation Satisfaction Questionnaire was high at 75.9 (/90). Most educational programs are not evaluated at the patient care level. The HC-PCP taken by pharmacists resulted in a 4.76 mmHg systolic BP reduction in their patients over 3 months. This would have major implications for public health, reducing heart disease, stroke and kidney failure.

COMMUNITY PHARMACY-BASED HYPERTENSION SCREENING: MAY MEASUREMENT MONTH 2023 IN 3 CANADIAN PROVINCES

Objective: Elevated blood pressure (BP) is the largest contributing risk factor for premature death and disability. Approximately 50% of individuals with hypertension are unaware they have the condition; therefore, BP screening is essential. Canadian health professionals have previously participated in the annual global BP screening campaign, May Measurement Month (MMM); however this has never been completed in community pharmacies, which have the advantage of being highly accessible to the public. Our objective was to examine the prevalence of elevated (BP) in Alberta (AB), British Columbia (BC), Newfoundland and Labrador (NL) during MMM 2023. Design and method: This cross-sectional study enrolled consenting members of the general public 18 years of age, recruited through signage, media and social media. Data collection took place between May 1 and July 31, 2023 in 52 community pharmacies across AB, BC, and NL. Participants completed a questionnaire that included demographic information, medical history, and use of antihypertensives. Pharmacy personnel completed 3 blood pressure readings, with readings 2 and 3 used to estimate BP. We used an automated blood pressure device recommended by Hypertension Canada's Device Recommendation Program. Elevated BP was defined as &gt;140/90mmHg or &gt;130/80mmHg for individuals with diabetes. Results: We enrolled 736 participants. The mean age of participants was 52 (SD 18.6) years, 66% were female, 34% had a history of hypertension, and 14% had diabetes. Overall, 21% (152/733) had elevated BP. In subgroups of interest, elevated BP was found in 20% (96/480) of females, 35% (88/251) of those with a history of hypertension (13% (64/482) in those with no history of hypertension), and 52% (53/103) in those with diabetes. Conclusions: Identifying individuals with elevated BP is the starting point for better BP management. Community pharmacy screening of BP was effective in identifying individuals with elevated BP warranting further assessment. Our experiences from MMM 2023 will guide the future scale-up of a national community pharmacy-based screening program for MMM 2024.

Prescription Trends of Thiazide Diuretics in a Canadian Primary Care Population From 2015 to 2021

BackgroundHypertension Canada 2017 guidelines favoured the use of thiazide (TZ)-like diuretics, such as CLTD (chlorthalidone) and indapamide (IND) over hydrochlorothiazide (HCTZ). Health Canada warned in 2019 that HCTZ may be associated with increased risk of skin cancer. Our study looked at the changes in TZ prescriptions from 2015 to 2021 in Ontario, Canada. MethodsA retrospective cohort study was conducted of adults with hypertension, using electronic medical record data from the University of Toronto Practice-Based Research Network database covering mostly the Greater Toronto area. Outcomes included the proportion of patients who received a prescription of HCTZ, CLTD, or IND each month. Interrupted time-series analysis was used to evaluate the change in outcomes after publication of the 2017 guidelines and 2019 safety warning. Prescription trends were stratified by prescribing physicians’ sex and year of medical school graduation. ResultsA total of 100,428 patients with hypertension were included in the cohort, with 31,700 patients who received at least one TZ prescription from 343 family physicians. We found a declining trend in HCTZ prescriptions over time, accompanied by an increase in IND and CLTD prescriptions, with statistically significant but transient changes in prescription rates after publication of the 2017 guidelines and the 2019 safety warning for all 3 medications. Female physician and early-career physician prescription rates changed faster than that of their counterparts immediately after the Health Canada safety warning was issued. ConclusionsTZ diuretic prescription patterns have changed in recent years, but Hypertension Canada’s 2017 guidelines and the 2019 Health Canada safety warning did not have a sustained significant impact on the change in prescription rates of HCTZ, IND, and CLTD.

Sex- and Gender-Based Reporting in Antihypertensive Medication Literature Informing Hypertension Guidelines.

Hypertension is the leading modifiable cardiovascular risk factor with recognized sex- and gender-based differences. We assessed the incorporation of sex and gender reporting in the antihypertensive medication literature informing hypertension guidelines. Literature cited in the International Society of Hypertension (2020), European Society of Cardiology/European Society of Hypertension (2018), American College of Cardiology/American Heart Association (2017), Latin American Society of Hypertension (2017), Pan-African Society of Cardiology (2020), and Hypertension Canada (2020) guidelines was systematically reviewed. Observational studies, randomized controlled trials, and systematic reviews involving antihypertensive medications were included. Studies with participants of a single sex, guidelines, and commentaries were excluded. Data on study participation-to-prevalence ratio by sex, analysis of baseline demographics and study outcomes by sex, and stratification of adverse events by sex were extracted. Of 1659 unique citations, 331 studies met inclusion criteria. Of those, 81% reported the sex of participants, and 22% reported a male-to-female participation-to-prevalence ratio of 0.8 to 1.2. Three percent of studies stratified baseline characteristics by sex, and 20% considered sex during analysis through statistical adjustment or stratification. Although 32% of studies reported adverse events, only 0.6% stratified adverse events by sex. Most(58%) studies reporting sex/gender used sex and gender terms interchangeably. Incorporation of sex- and gender-based considerations in study population, analysis, or reporting of results and adverse events is not common in the antihypertensive medication literature informing international hypertension guidelines. Greater attention to sex- and gender-based factors in research is required to optimally inform management of hypertension.

Temporal Trends in Practice Patterns After Introduction of Pediatric Hypertension Guidelines in Canada

In 2016 and 2017, respectively, new Canadian and US guidelines for diagnosis and management of pediatric hypertension (HTN) were published. Six years after their publication, it is unknown whether the recommendations have led to changes in primary care practice patterns. To determine whether HTN guidelines are associated with changes in practice patterns among primary care clinicians. This retrospective, multicenter, population-based cohort study was conducted across 3 phases: January 1, 2011, to December 31, 2015 (era 1), January 1, 2016, to December 31, 2017 (washout period), and January 1, 2018, to December 31, 2019 (era 2). Data were collected from 7 Canadian provinces using the Canadian Primary Care Sentinel Surveillance Network Electronic Medical Record database. Eligible participants included children and adolescents (aged ≥3 to <18 years) with 1 or more encounters in the database. Data analysis was conducted from February 2022 to February 2023. Implementation of the 2016 Hypertension Canada and 2017 American Academy of Pediatrics guidelines. The primary outcomes were annual BP screening documentation, high BP follow-up documentation at 6 months and 1-year, HTN prevalence, laboratory testing rates, and medication prescription rates. Interrupted time series analysis was used to assess the association of the introduction of the Canadian and US guidelines with outcomes. The study included 343 191 children and adolescents (mean [SD] age at first encounter, 6.7 (4.6) years; 173 290 female [50.5%]; 169 901 male [49.5%]), including 235 094 patients in era 1 and 193 473 patients in era 2. In era 1, 55 550 patients (23.6%) had at least 1 BP measurement, and in era 2, 45 006 patients (23.3%) had at least 1 BP measurement. There was a significant increase in BP screening in era 2 from 26 876 of 148 554 screenings (18.1%) to 28 556 of 141 192 screenings (20.2%; β = 0.202; 95% CI, 0.009 to 0.390; P = .04), and the increasing trend was sustained. There was a significant decrease in the trend of follow-up of high BP measurement at 6 months (1265 of 4941 patients with BP measurements [25.6%] to 1718 of 7321 patients with BP measurements [23.5%]; β = -0.490; 95% CI, -0.758 to -0.223; P = .001) and 1 year (1974 of 4941 measurements [40.0%] to 2314 of 7321 measurements [31.6%]; β = -1.392; 95% CI, -1.573 to -1.212; P < .001) in era 2. The proportion of patients meeting HTN criteria significantly increased from 2540 of 55 550 patients (4.6%) in era 1 to 5690 of 45 006 patients (12.6%) in era 2 (β = 0.0210; 95% CI, 0.0021 to 0.0410; P = .03). There was no significant change in the trend of laboratory testing rates in era 2 (949 of 4941 patients tested [19.2%] to 1149 of 7321 patients tested [15.7%]; β = -0.159; 95% CI, -0.364 to 0.046; P = .12). The trend in prescribing of medications to patients with HTN also decreased in era 2 (1305 of 4941 patients prescribed medication [26.4%] to 1415 of 7321 patients prescribed medication [19.3%]; β = -0.605; 95% CI, -0.830 to -0.358; P < .001). The findings of this cohort study within the Canadian primary care setting suggest that there was a significant increase in BP screening and HTN prevalence after the publication of national and international HTN guidelines; however, the follow-up of high BP was still suboptimal. Increasing rates of pediatric HTN emphasize the need for better adherence to pediatric HTN guidelines to improve care and outcomes.

Validity of Home Blood Pressure Devices Sold in Canada

BackgroundMeasurement of home blood pressure is an important tool for the management of hypertension. However, the validity of home devices is of concern. The Recommended Blood Pressure Devices Program of Hypertension Canada reviews and recommends blood pressure devices using international validation standards. We sought to determine the proportion of Hypertension Canada-recommended devices available for purchase in pharmacies and online. MethodsWe visited 16 community pharmacies in the Edmonton area to record the blood pressure devices they sold. We also reviewed the 50 most popular devices from online retailers (Amazon, Walmart, Best Buy, and Canadian Tire). All devices were referenced against the Recommended Blood Pressure Device Program of Hypertension Canada (www.hypertension.ca/bpdevices) to determine if the models were recommended. ResultsWe reviewed 170 devices. Of those sold in pharmacies, 61 of 68 (89.7%) were Hypertension Canada-recommended devices, whereas online retailers had only 46 of 102 (45.1%) recommended devices; P < 0.001. ConclusionsMost blood pressure devices sold in pharmacies are Hypertension Canada recommended, in contrast to less than one-half from online retailers. The lack of validation of many home blood pressure devices could have important clinical implications, leading to over- or undertreatment of hypertension. Clinicians should advise patients on the importance of home blood pressure device validation and direct them to resources such as Hypertension Canada (https://hypertension.ca/public/recommended-devices) for guidance.

SPATIAL VARIABILITY IN THE PREVALENCE OF HYPERTENSION: A CANADIAN PERSPECTIVE

Objective: Despite significant improvements in hypertension treatment, high blood pressure (HBP) still affects 22.6% of Canadians (Hypertension Canada, 2016). However, disparities associated with risk factors like, age, sex, and lifestyle can impact global prevalence in population. It is also a well-known fact that prevalence varies geographically. Thus, spatial location can give us a different perspective of hypertension in population. Reliable information about trends in hypertension rate is needed at regional scale to support the development of health programs. Geographic information systems (GIS) can provide that information by detecting spatial clusters of high or low HTN rate at health regions scale. The objectives of the study were to identify health regions with significantly high or low HTN rate using geostatistics and compare evolution from 2005 to 2019. It also seeks out to identify their populations’ characteristics using statistical analysis. Canadian Community Health Survey (2005, 2015 &amp; 2019) data were used for the analysis. Design and method: For the analysis, we used Canadian Community Health Survey from 2005, 2015 and 2019. The 130,000 respondents representing the whole population are located according to health regions and data can be analyzed using a GIS. Using age and gender as subgroups criteria creation, we applied spatial autocorrelation analysis and Getis-Ord hot analysis to identify geographically contiguous health regions with high or low HTN rates. We then extracted the records in CCHS database for all respondents living in these regions for supplemental statistical analysis. Results: HTN is still a problem in Canada. This is especially true for people aged 65 and older although 72.9% considered themselves in good health. Increase in HTN rate is spread all over Canada, although some regions showed a rate decrease. Getis-ord analysis located regions with low HTN rates while regions with high rates were also located. Cluster of health regions with high HTN rates shows more diabetes and more obese people even though 38.4% declared being in good health. Conclusions: Hypertension is still a major problem in Canada. Age and gender are still significant risk factors. Geographical variations in HTN rate are presents at health regions scale.

HOW DOES THE ANTIHYPERTENSIVE THERAPY OF EVERYDAY PATIENTS FOLLOW THE DIFFERENT GUIDELINES?

Objective: The different guidelines have got therapeutic recommendations for different conditions with hypertension. It sounds perfect. But what is the situation in the real life? How does the antihypertensive therapy of everyday patients follow the different guidelines? Design and method: Medications of alltogether 453 patients were analysed retrospectively from case reports. The selection of the patients was not based on specific criteria, but they arrived for their next visit at one of the Hypertension Outpatient Clinics of the Nephrology-Hypertension Center of the University of Szeged between 06/01/2021 and 31/12/2021. The authors used the guidelines valid in 2021 of the European Hypertension Society, the Hungarian Hypertension Society, the American Heart Association, the Hypertension Canada and the NICE as a base. Diabetes mellitus, angina pectoris, acute myocardial infarction, atrial fibrillation, congestive heart failure, chronic kidney disease without proteinuria, renal failure with proteinuria and stroke/TIA were the analysed conditions. Results: The rates of recommendation follow-up are summarized in the table. Conclusions: The antihypertensive medication of the patients proved to follow recommendations well. There were only non-significant differences between the following recommendations. In cardiovascular conditions, which can be considered more serious, it was completely the same.

KNOWLEDGE, PERCEPTION, AND PRACTICE OF QUEBEC HEALTH PROFESSIONALS REGARDING AMBULATORY AND CLINIC BLOOD PRESSURE MEASUREMENT METHODS

Objective: Hypertension Canada Guidelines recommend using standardized methods of blood pressure measurement (BPM), namely home (HBPM), ambulatory (ABPM), office (OBPM), and automated (AOBP) for hypertension management. Health professionals (HP), namely nurses, physicians, and pharmacists, routinely perform BPM, but their knowledge, perception, and practice concerning all methods is understudied, including in Canada, and results show critical gaps with the guidelines. This descriptive study is the first to establish a portrait primary care HP's in Quebec concerning the four BPM methods. Design and method: All licensed primary care HP's in Quebec were targeted. A validated and pretested investigator-initiated BPM questionnaire in English and French was used for data collection. In December 2019, physicians and pharmacists were recruited through their associations’ monthly newsletter, while nurses received a personalized email invitation with a link to a secured platform. UQTR issued the certificate of ethics. Results: A total of 453 nurses, 45 physicians, and 30 pharmacists participated in the study. The median age was 40 ± 11 years for nurses, 50 ± 13 years for physicians, and 42 ± 12 for pharmacists. The overall knowledge and perception scores for BPM methods are presented in Table 1. In practice, physicians frequently use HBPM for diagnostic purposes (73%), treatment (91%), and follow-up (86%), while HBPM was recommended by 47% of nurses and 53% of pharmacists. Overall, ABPM was used less frequently (&lt;50% of the time) by all HP's. In the clinic, the auscultatory method is still used by a significant percentage of nurses (11%), physicians (32%) and pharmacists (7%), while only 25% nurses, 13% physicians and 30% pharmacists use the AOBP method. Conclusions: Overall, knowledge was suboptimal for nurses and somewhat optimal for physicians and pharmacists. Practice was unsatisfactory for all HPs. Training and continuing education should be encouraged and should be renewed with the newest education methods along with practice assessment.

Preliminary survey report on the clinical validation of in-use electronic sphygmomanometers in China

Objective: To explore the percentage of in-use electronic sphygmomanometers independently validated clinically in China. Methods: We conducted a cross-sectional survey and Beijing, Shenzhen, Shijiazhuang, Datong, and Shihezi were selected according to the geographical location and economic level. In each site, one tertiary hospital, two community health centers, and 20 families with electronic sphygmomanometers in use were chosen. The information of electronic sphygmomanometers including brand, model, manufacturer and production date were obtained by the trained staff. Ten electronic sphygmomanometers from each hospital, five electronic sphygmomanometers from each community health center, and one electronic sphygmomanometer from each family were surveyed, and the user's subjective judgment results and judgment basis on the accuracy of the electronic sphygmomanometer measurement were collected. We searched six registration websites (Medaval, Stride BP, dabl Educational Trust, British and Irish Hypertension Society, American Medical Association and Hypertension Canada) and two research databases (PubMed and CNKI) for the clinical validation status of each electronic sphygmomanometer. Results: A total of 200 electronic sphygmomanometers were investigated in this study, of which only 29.0% (58/200) passed independent clinical validation. When stratified by users, the percentage of being clinical validated was 46.0% (23/50) for electronic sphygmomanometers in hospitals, 42.0% (21/50) for those in community health centers and 14.0% (14/100) for those in home use, respectively, and the proportions between the three groups were significantly difference (P<0.001). Doctors in tertiary hospitals and community health service centers judged the accuracy of electronic sphygmomanometers mainly on the basis of "regular correction" (41.0% (41/100)) and "comparison with other electronic sphygmomanometers" (20.0% (20/100)), while among home users, 41.0% (41/100) were not clear about the accuracy of electronic sphygmomanometers, and 40.0% (40/100) made the judgment by "comparison with the devices in hospitals". Conclusion: The clinical validation of in-use electronic sphygmomanometers in China is low. Most of users, including healthcare professionals, are not aware of clinical validation of electronic sphygmomanometers.

The impact of updated clinical blood pressure guidelines on hypertension prevalence among children and adolescents.

To date, population estimates of hypertension prevalence among children and adolescents in Canada have been based on clinical guidelines in the National High Blood Pressure Education Program's 2004 Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents (NHBPEP 2004). In 2017, the American Academy of Pediatrics published updated guidelines in Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents (AAP 2017), followed by Hypertension Canada in 2020 with its publication of Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children (HC 2020). This study compares national child and adolescent hypertension prevalence estimates based on NHBPEP 2004, AAP 2017 and HC 2020. Six cycles of data spanning 2007 to 2019 from the Canadian Health Measures Survey were used to compare blood pressure (BP) categories and the prevalence of hypertension by sex and age group under all sets of guidelines for children and adolescents aged 6 to 17. The impact of applying AAP 2017 across time and selected characteristics, the resulting reclassification into a higher BP category under AAP 2017, and differences in hypertension prevalence resulting from applying HC 2020 versus AAP 2017 were examined. Prevalence of Stage 1 hypertension was higher among children and adolescents aged 6 to 17 under AAP 2017 and HC 2020 than under NHBPEP 2004. Overall hypertension prevalence was also higher, and obesity was a major factor associated with being reclassified into a higher BP category under AAP 2017. Implementation of AAP 2017 and HC 2020 is associated with significant changes in the epidemiology of hypertension. Understanding the impact of applying updated clinical guidelines may help inform population surveillance efforts to track hypertension prevalence among Canada's children and adolescents.

Is a unified blood pressure threshold feasible in the current scenario?: Commentary on the article"130/80mmHg as a unifying hypertension threshold for office brachial, office central and ambulatory daytime brachial blood pressure": Commentary on the article"130/80mmHg as a unifying hypertension threshold for office brachial, office central and ambulatory daytime brachial blood pressure".

Is a unified blood pressure threshold feasible in the current scenario?: Commentary on the article"130/80mmHg as a unifying hypertension threshold for office brachial, office central and ambulatory daytime brachial blood pressure": Commentary on the article"130/80mmHg as a unifying hypertension threshold for office brachial, office central and ambulatory daytime brachial blood pressure".

Static cutoffs or tables for the diagnosis of hypertension? Effect on identification of organ damage in youths with obesity

Background and aimRecently, the European Society of Cardiology task force released a Consensus document (ESC-CD) on pediatric hypertension (HTN) supporting the use of normative tables (age range 6–16 years) for the diagnosis of HTN, while the Hypertension Canada Guidelines (HTN-CGs) proposed static cutoffs. We aimed to assess the prevalence of HTN by ESC-CD or HTN-CGs and their association with glomerular function and left ventricular (LV) geometry in youths with overweight/obesity (OW/OB). Methods and resultsData of 3446 youths were analyzed. HTN by was defined using normative tables (ESC-CD) or static cutoffs of BP ≥ 120/80 in children (age <12 years) and ≥130/85 mmHg in adolescents (age ≥12 years) (HTN-CGs). Mildly reduced glomerular filtration rate was defined by GFR <90 ≥ 60 mL/min/1.73 m2. Concentric LV hypertrophy (cLVH) was assessed in 500 youths and defined by LVH and high relative wall thickness as proposed by ESC-CD. Prevalence of HTN was 27.9% by ESC-CD and 22.7% by HTN-CGs. The association with mildly reduced glomerular filtration rate was significant only in hypertensive adolescents classified by HTN-CGs [Odds Ratio (OR), 95%Cl] 2.16 (1.44–3.24), whereas the association with cLVH was significant using both criteria: children OR 2.18 (1.29–3.67) by ESC-CD and 2.27 (1.32–3.89) by HTN-CGs; adolescents OR 2.62 (1.17–5.84) by ESC-CD and 2.83 (1.14–7.02) by HTN-CGs. ConclusionAlthough static cutoffs may represent a simplification for HTN identification, tables by ESC-CD detect a higher number of hypertensive youths before a clear appearance of glomerular impairment, which offers advantages in terms of primary cardiovascular prevention.

PS-BPP04-9: THE RXPATH RANDOMIZED TRIAL OF THE HYPERTENSION CANADA PROFESSIONAL CERTIFICATION PROGRAM: A NOVEL IMPLEMENTATION STRATEGY FOR HYPERTENSION GUIDELINES

The uptake of clinical practice guidelines into practice is poor for many chronic conditions, including hypertension. We designed a guidelines-based educational program for primary care clinicians, the Hypertension Canada Professional Certification Program (HC-PCP, www.hypertension.ca/professional-certification-program). It consists of four online modules, an online prospective patient registry, and expert evaluations of the blood pressure measurement technique and case management by the learner. We then evaluated its impact on patient level outcomes. Objective: The objective of RxPATH was to determine the effect of the HC-PCP for pharmacists on systolic blood pressure reduction in patients with poorly controlled hypertension. Design and Methods: Design: Stepped wedge cluster randomized trial (unit of randomization was the pharmacy). Setting: Community pharmacies in Alberta, Canada Population: Pharmacists with prescriptive authority volunteered to participate. We enrolled patients with poorly controlled hypertension (BP &gt; 140/90mmHg or &gt; 130/80mmHg in those with diabetes), identified by their pharmacist. Intervention: Pharmacists were enrolled in the HC-PCP. They then provided this care to their patients with poorly controlled hypertension. Control: Pharmacists were given a copy of the Hypertension Canada Guidelines and provided usual care to their patients prior to undertaking the HC-PCP. Outcomes: The primary outcome was difference in change in systolic blood pressure between intervention and control groups at 3 months. We also evaluated patient satisfaction using the Consultant Satisfaction Questionnaire (CSQ). Results: We enrolled 890 patients from 61 pharmacies (104 pharmacists). Mean age was 61.6 (SD 14.1) years, 46% were female, 35.5% had diabetes, and mean baseline BP was 152.4 (SD 13.8)/87.0 (SD 10.6)mmHg. Change in systolic BP was 9.9 (SD 16.5) for the intervention group, compared to 9.9 (SD 16.2) mmHg in the control group, p = 0.29. Patient satisfaction using the CSQ was high at 76 (of 90 maximum). Conclusions: Most educational programs do not get evaluated at the patient level. RxPATH demonstrated that the HC-PCP intervention did not result in a greater reduction in systolic BP compared to control. While both groups did have clinically meaningful reductions in BP, possible reasons for lack of a difference with the intervention include: COVID-19 staffing/workload issues in pharmacies, selection bias for pharmacists interested in hypertension/contamination of usual care group, and short follow-up duration. Feedback on the HC-PCP from pharmacists was positive, patient satisfaction was high, and we plan to make this program widely available to primary care providers.

Diet or additional supplement to increase potassium intake: protocol for an adaptive clinical trial

BackgroundHigh blood pressure is the leading cause of cardiovascular disease worldwide. The prevalence of high blood pressure is steadily rising as the population grows amongst older adults with the ageing population. Therapeutical treatments are widely available to decrease blood pressures, in addition to many lifestyle options, such as dietary changes and exercise. There is a marked preference amongst patients, as reiterated by Hypertension Canada, for more research into non-therapeutic methods for controlling blood pressure or to reduce the burden of taking many pills to control high blood pressure. Indeed, effective options do exist, especially with diet, specifically decreasing sodium and increasing potassium intake. Current public health outreach primarily focusses on sodium intake, even though potassium intake remains low in the Western world. Excellent data exist in published research that increasing potassium intake, either via dietary modification or supplements, reduces blood pressure and reduces risk of cardiovascular outcomes such as stroke. However, the advice most often provided by medical professionals is to ‘eat more fruits and vegetables’ which has little impact on patient outcomes.MethodsWe propose to do a clinical trial in two stages with an adaptive trial design. In the first stage, participants with high blood pressure and proven low potassium intake (measured on the basis of a 24-h urine collection) will get individually tailored dietary advice, reinforced by weekly supportive phone/email support. At 4 weeks, if there has not been a measured increase in potassium intake, participants will be prescribed an additional potassium supplement. Testing will be conducted again at 8 weeks, to confirm the efficacy of the potassium supplement. Final measurements will be planned at 52 weeks to observe and measure the persistence of the effect of diet or additional supplement. Concurrent measurements of sodium intake, blood pressure, participant satisfaction, and safety measures will also be done.DiscussionThe results of the study will help determine the most effective method of increasing potassium intake, thus reducing blood pressure and need for blood pressure-lowering medicines, and at the same time potentially increasing participant satisfaction. The current guidelines recommend changes in diet, not a potassium supplement, to increase potassium intake; hence, the two-stage design will only add supplements if the most rigorous dietary advice does not work.Trial registrationThis study has been registered on ClinicalTrials.govNCT03809884. Registered on January 18, 2019

Канадські настанови з гіпертензії (2017) щодо діагностики, обстеження, профілактики та лікування гіпертензії у дітей

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Knowledge, perception and practice of Québec nurses for ambulatory and clinic blood pressure measurement methods: are we there yet?

Guidelines regarding blood pressure measurement (BPM) methods, namely home (HBPM), ambulatory (ABPM), office (OBPM) and automated (AOBP) are published by Hypertension Canada and rely on accurate measurement technique. Nurses commonly perform BPM but their knowledge, perception and practice considering all methods is understudied. This study is the first to establish the picture of Québec nurses working in primary care settings concerning the four BPM methods. All nurses licensed to practice in primary care in Québec were targeted in our survey. Data were collected using a validated and pretested investigator-initiated questionnaire in English and French. A personalized e-mail invitation, and two reminders, including a link to a secured platform was sent in December 2019. A certificate of ethics was issued by UQTR. A total of 453 nurses participated in the study. Median age was 40 ± 11 years, and 92% were women. The overall score on BPM methods knowledge was slightly below 50% (46% ± 23). The perception was mostly positive, with an overall score above 50% (73% ± 8). In practice, HBPM was recommended by 47% of nurses, and ABPM by 18%. Although AOBP is the preferred method in Canada, only 25% of the nurses use it, including the 57% that use an oscillometric device and 11% that use manual auscultation. Nurses working in primary care play a central role in BPM. Our results highlight that overall knowledge and practice are suboptimal. Resources should, therefore, be allocated to ensure that initial training and continuing education are addressed.

Monitoring blood pressure at home: guidance for Canadian patients.

Most home blood pressure monitors sold commercially (> 85% worldwide) do not measure blood pressure accurately.[1][1] Hypertension Canada has a list of recommended devices that have been tested, are known to give valid readings and can be recognized in stores by their Recommended by Hypertension

Assessment of the educational competencies for the Hypertension Canada Professional Certification Program (HC-PCP) designed for implementation of hypertension guidelines into primary care.

Background:The uptake of clinical practice guidelines into practice is limited for many chronic conditions, including hypertension. The aim of this study was to ascertain the importance of the educational competencies for the development of the Hypertension Canada Professional Certification Program (HC-PCP) among frontline, primary care professionals (e.g., pharmacists, physicians, nurses).Methods:A group of hypertension experts developed 15 competencies believed to be important for primary care professionals to master when providing hypertension management. These competencies were surveyed for consensus by frontline clinicians through the Hypertension Canada e-newsletter in 2018. Clinicians were asked to rank the importance of each competency for a primary care provider to acquire when undertaking a certification in hypertension management, using a Likert scale from 1 (not important) to 5 (very important).Results:A total of 121 clinicians responded to the survey. Of these, 38% were pharmacists, 31.4% were registered nurses, 10.7% were physicians and 7% were nurse practitioners. There was at least 1 respondent from each Canadian province and territory, except for the Northwest Territories. All 15 competencies received a mean rank of at least 4. The competency with the highest ranking was Competency 6: Ability to screen and identify hypertension (mean 4.83 [0.04]). The competencies with the lowest average ranks were Competency 1: Demonstrates a sound knowledge of the epidemiology of hypertension (mean 4.07 [0.85]) and Competency 5: Demonstrates an understanding of the validation process for blood pressure devices (mean 4.15 [0.08]).Conclusions:Clinicians generally ranked all 15 competencies to be of high importance for a provider who is certified in hypertension management to possess. These competencies and the current Hypertension Canada guidelines were used as the foundation for the development of an education program called the Hypertension Canada Professional Certification Program. Can Pharm J (Ott) 2021;154:xx-xx.

THE HYPERTENSION CANADA PROFESSIONAL CERTIFICATION PROGRAM: A NOVEL IMPLEMENTATION STRATEGY FOR HYPERTENSION GUIDELINES

Objective: The uptake of clinical practice guidelines into practice is poor for many chronic conditions, including hypertension. What is missing is an implementation strategy for incorporating guidelines into primary care practice. Herein, we describe the development of the Hypertension Canada Professional Certification Program (HC-PCP), a novel approach to guidelines implementation. Design and method: First, we identified 15 competencies believed to be important for primary care professionals to master when providing hypertension care. These competencies were surveyed for consensus by front-line clinicians through the Hypertension Canada e-newsletter. Clinicians were asked to rank the importance (on a Likert scale from 1 = not important to 5 = very important) of each competency for a primary care provider when undertaking a certification in hypertension management. Results: A total of 121 clinicians responded to the survey. Of these, 38% were pharmacists, 31.4% were registered nurses, 10.7% were physicians, and 7% were nurse practitioners. There was at least one respondent from each Canadian province and territory, except for the Northwest Territories. All 15 competencies received a mean rank of at least 4. The competencies with the lowest rank was “Demonstrates a sound knowledge of the epidemiology of hypertension” (mean 4.07 (SD 0.85)) and the highest was “Ability to screen and identify hypertension” (mean 4.83 (SD 0.04)). We then used these competencies to develop an online certification program, the HC-PCP. Some features include regular quizzes, submission of a video outlining the learner's blood pressure measurement technique, and submission of 3 patient cases for expert review. The program was launched recently: www.hypertension.ca/professional-certification-program/. Conclusions: We have developed a novel online hypertension certification program based upon the Hypertension Canada guidelines. The HC-PCP has been launched to pharmacists first, and is also being tested in a stepped wedge randomized trial called RxPATH (www.epicore.ualberta.ca/home/rxpath/).