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To update the evidence-based recommendations for the prevention and treatment of hypertension in adults for 2010.
For lifestyle and pharmacological interventions, randomized trials and systematic reviews of trials were preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the general lack of long-term morbidity and mortality data in this field. Progressive renal impairment was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease.
A Cochrane Collaboration librarian conducted an independent MEDLINE search from 2008 to August 2009 to update the 2009 recommendations. To identify additional studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence.
For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to 1500 mg (65 mmol) per day in adults 50 years of age or younger, to 1300 mg (57 mmol) per day in adults 51 to 70 years of age, and to 1200 mg (52 mmol) per day in adults older than 70 years of age; perform 30 min to 60 min of moderate aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m2 to 24.9 kg/m2) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week for men or nine standard drinks per week for women; follow a diet that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources, and that is low in saturated fat and cholesterol; and consider stress management in selected individuals with hypertension.
For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on the patient’s global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in patients with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, considerations for initial therapy should include thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. The combination of ACE inhibitors and ARBs should not be used, unless compelling indications are present to suggest consideration of dual therapy.
Agents appropriate for first-line therapy for isolated systolic hypertension include thiazide diuretics, long-acting dihydropyridine CCBs or ARBs. In patients with coronary artery disease, ACE inhibitors, ARBs or beta-blockers are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. In selected high-risk patients in whom combination therapy is being considered, an ACE inhibitor plus a long-acting dihydropyridine CCB is preferable to an ACE inhibitor plus a thiazide diuretic. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian lipid treatment guidelines. Selected patients with hypertension who do not achieve thresholds for statin therapy, but who are otherwise at high risk for cardiovascular events, should nonetheless receive statin therapy. Once blood pressure is controlled, low-dose acetylsalicylic acid therapy should be considered.
All recommendations were graded according to the strength of the evidence and voted on by the 63 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 80% consensus. These guidelines will continue to be updated annually.
The Canadian Hypertension Education Program process is sponsored by the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the College of Family Physicians of Canada, the Canadian Pharmacists Association, the Canadian Council of Cardiovascular Nurses, and the Heart and Stroke Foundation of Canada.
Mettre à jour les recommandations probantes pour la prévention et la prise en charge de l’hypertension chez les adultes en 2010.
Dans le cadre d’interventions pharmacologiques et touchant le mode de vie, les auteurs ont procédé à une analyse préférentielle des données tirées d’essais aléatoires et contrôlés et d’analyses systématiques d’essais. Tandis que des modifications à la morbidité et à la mortalité cardiovasculaires constituaient les principales issues d’intérêt, dans le cas des interventions touchant le mode de vie, la diminution de la tension artérielle était acceptée comme issue primaire en raison de l’absence de données à long terme sur la morbidité et la mortalité dans ce secteur. Dans le cas des patients atteints d’une insuffisance rénale chronique, l’aggravation du dysfonctionnement rénal constituait également une issue primaire pertinente sur le plan clinique.
Un bibliothécaire de Collaboration Cochrane a effectué une recherche indépendante dans la base de données MEDLINE entre 2008 et août 2009 afin de mettre les recommandations de 2009 à jour. On a également dépouillé les listes de référence et communiqué avec des experts pour repérer d’autres études publiées. Tous les articles pertinents ont été analysés et évalués de manière indépendante par des experts du contenu et de la méthodologie, au moyen de qualités des preuves préétablies.
Les modifications au mode de vie pour prévenir ou traiter l’hypertension consistent à réduire la quantité de sel d’origine alimentaire à 1 500 mg (65 mmol) par jour chez les adultes de 50 ans et moins, à 1 300 mg (57 mmol) par jour chez les adultes de 51 à 70 ans et à 1 200 mg (52 mmol) par jour chez ceux de plus de 70 ans, à pratiquer de 30 à 60 minutes d’exercice aérobique modéré de quatre à sept jours par semaine, à maintenir un poids santé (indice de masse corporelle de 18,5 kg/m2 à 24,9 kg/m2) et un tour de taille sain (inférieur à 102 cm chez les hommes et à 88 cm chez les femmes), à limiter la consommation d’alcool à 14 unités par semaine chez les hommes et à neuf unités par semaine chez les femmes, à respecter un régime alimentaire riche en fruits et légumes, en produits laitiers à faible teneur en matières grasses, en fibres alimentaires et solubles ainsi qu’en grains entiers et en protéines d’origine végétale, et à envisager des techniques de maîtrise du stress pour certaines personnes hypertendues.
Pour ce qui est de la prise en charge pharmacologique de l’hypertension, les valeurs seuils et les valeurs cibles de traitement doivent dépendre du risque athéroscléreux global du patient, de l’atteinte des organes cibles et des pathologies comorbides. Il faut abaisser la tension artérielle à moins de 140/90 mmHg chez tous les patients et à moins de 130/80 mmHg chez les patients diabétiques ou atteints d’une insuffisance rénale chronique. La plupart des patients devront prendre plus d’un médicament pour parvenir aux valeurs cibles. Il faut envisager la prescription d’antihypertensifs chez tous les patients adultes, quel que soit leur âge (en faisant preuve de prudence chez les patients âgés fragiles). Dans le cas des adultes chez qui il n’y pas d’indication impérieuse d’administrer d’autres médicaments, il faudrait envisager comme traitement initial des diurétiques thiazidiques, des inhibiteurs de l’enzyme de conversion de l’angiotensine (ECA, sauf chez les patients noirs), des inhibiteurs calciques (IC) à action prolongée, des antagonistes des récepteurs de l’angiotensine (ARA) ou des bétabloquants (chez les personnes de moins de 60 ans). On peut également envisager deux médicaments de première intention pour le traitement initial de l’hypertension si la tension artérielle systolique dépasse la cible d’au moins 20 mmHg ou si la tension artérielle diastolique la dépasse de 10 mmHg. Il faut éviter d’associer des inhibiteurs de l’ECA à des ARA, à moins de motifs probants incitent à envisager une bithérapie.
Les médicaments qui conviennent au traitement de première intention de l’hypertension systolique isolée sont les IC dihydropyridines à action prolongée ou les ARA. Chez les patients ayant une coronaropathie, les inhibiteurs de l’ECA, les ARA ou les bêta-bloquants sont recommandés en première intention, tandis que chez ceux atteints d’une maladie vasculaire cérébrale, l’association d’un inhibiteur de l’ECA et d’un diurétique est à privilégier. Chez les patients atteints d’une insuffisance rénale chronique non diabétique avec protéinurie, les inhibiteurs de l’ECA ou les ARA (en cas d’intolérance aux inhibiteurs de l’ECA) sont recommandés et chez les diabétiques, les inhibiteurs de l’ECA ou les ARA (ou, chez les patients ne présentant pas d’albuminurie, les thiazidiques ou les IC dihydropyridines) conviennent en première intention. Chez certains patients très vulnérables pour qui une polythérapie est envisagée, un inhibiteur de l’ECA associé à un IC dihydropyridine à action prolongée est préférable à un inhibiteur de l’ECA associé à un diurétique thiazidique. Tous les patients hypertendus dyslipidémiques doivent être traités selon les seuils, les valeurs cibles et les médicaments proposés dans les lignes directrices canadiennes sur le traitement de la dyslipidémie. Certains patients hypertendus qui n’atteignent pas les seuils justifiant un traitement aux statines mais néanmoins très vulnérables à des événements cardiovasculaires devraient tout de même recevoir ce traitement. Une fois la tension artérielle stabilisée, un traitement à l’acide acétylsalicylique à faible dose pourra être envisagé.
Toutes les recommandations sont classées selon la solidité des données probantes, et les 63 membres du groupe de travail des recommandations probantes du Programme éducatif canadien sur l’hypertension ont exercé leur vote à leur égard. Toutes les recommandations ont obtenu un consensus d’au moins 80 %. Les présentes lignes directrices continueront d’être mises à jour chaque année.
Le processus du Programme éducatif canadien sur l’hypertension est commandité par la Société canadienne d’hypertension artérielle, Pression artérielle Canada, l’Agence de la santé publique du Canada, Le Collège des médecins de famille du Canada, l’Association des pharmaciens du Canada, le Conseil canadien des infirmères(iers) en nursing cardiovasculaire et la Fondation des maladies du cœur du Canada.
Worldwide, 7.6 million premature deaths each year and 92 million disability-adjusted life years are attributed to high blood pressure (1). Overall, 54% of strokes and 47% of coronary artery diseases worldwide are attributable to high blood pressure (1). High blood pressure affects one in five Canadian adults and the majority of these will require pharmacological therapy to control their blood pressure (2,3). Each year, the Canadian Hypertension Education Program (CHEP) Recommendations Task Force reviews hypertension treatment studies in an effort to alert primary care providers of new clinical advances in the management of hypertension.
This year, four landmark clinical trials inform evidence-based decision making and expand the range of options for patients with hypertension. These trials are the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) (4), the Telmisartan Randomised Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease (TRANSCEND) (5), the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial (6) and the Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial (7). Evidence has also evolved in the area of single-pill combination strategies to improve adherence and salt intake targets to prevent and treat hypertension (8,9).
The present scientific report outlines the complete 2010 recommendations for the lifestyle and pharmacological management of hypertension as well as the evidence and rationale supporting all new recommendations. Summary documents of these recommendations, along with a freely downloadable slide kit, are available on the Canadian Hypertension Society Web site (www.hypertension.ca). Although we mention individual antihypertensive agents when discussing hypertension trials, the reader may assume that all drug-specific recommendations are applicable to the entire drug class in question, unless otherwise stated. Finally, while these recommendations are based on best evidence, health care providers must also use their own clinical judgement and consider patient preferences when applying these recommendations for their patients.
A Cochrane Collaboration librarian conducted a MEDLINE search using a highly sensitive search strategy for randomized trials and systematic reviews published from 2008 to August 2009. To ensure that all relevant studies were included, bibliographies of identified articles were manually searched. (Details of search strategies and retrieved articles are available on request.)
Each subgroup, consisting of national and international hypertension experts (see Appendix), reviewed all identified articles relevant to their topic area. Members of the Canadian Stroke Network, the Canadian Diabetes Association Guidelines Committee and the Canadian Society of Nephrology collaborated with CHEP subgroup members for the 2010 recommendations process. The subgroups appraised the quality of relevant studies using a standardized algorithm developed by CHEP (10). Subsequently, the central review committee comprised of clinical epidemiologists reviewed draft recommendations from each subgroup and, in an iterative process, helped to refine and standardize all recommendations and their grading across subgroups (Table 1).
The draft recommendations from each subgroup were then formally vetted by task force committee members at the 2010 consensus conference held in Edmonton, Alberta. Based on the deliberations at the consensus conference, the 2010 recommendations were finalized and then submitted to all 63 voting members of the CHEP Evidence-Based Recommendations Task Force for approval. Members with conflicts of interest for certain recommendations were recused from voting. As in previous years, only those recommendations approved by more than 70% of the Task Force were included in the final recommendations; in the actual vote, all recommendations received at least 80% approval.
Lifestyle modification is a critical component for preventing and treating hypertension. The lifestyle modification guidelines this year include a new recommendation for lower dietary sodium intake targets. The new targets are harmonized with Health Canada’s recommendation for daily sodium intake and are consistent with the Institute of Medicine report on dietary reference intake values for electrolytes and water (11). A recently published systematic review of prospective cohort studies found that an 86 mmol (5 g) difference in daily sodium intake was associated with a 23% difference in stroke risk and a 17% difference in total cardiovascular disease risk (9). Evidence from long-term follow-up of two randomized trials showed a 25% to 30% reduction in the risk of cardiovascular events in patients with prehypertension assigned to a sodium reduction intervention (12). Population modelling of reductions in sodium intake from current levels to the targets recommended in the CHEP guidelines are estimated to reduce the prevalence of hypertension in Canada by up to 30% (13).
A. Recommendations for individuals with diastolic and/or systolic hypertension
B. Recommendations for individuals with isolated systolic hypertension
Because there has not been a substantial change in the evidence base, these guidelines are unchanged from our previous recommendations (14,15). For further guidance, readers are referred to the 2009 Canadian Cardiovascular Society/Canadian guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease in the adult (16).
ACE inhibitors are recommended for moderate- to high-risk patients with coronary artery disease. This year, CHEP includes ARBs as an option in this setting based on published randomized trials evaluating the role of ARBs in patients with coronary artery disease and hypertension. ONTARGET (4) compared telmisartan 80 mg per day with ramipril 10 mg per day in 25,620 patients with vascular disease or diabetes with end-organ damage. Overall, 75% of patients had a history of coronary disease and 69% had a history of hypertension. The primary outcome was a composite of cardiovascular death, myocardial infarction, stroke or hospitalization for heart failure. During a median follow-up of 56 months, the primary outcome occurred in 16.7% of patients in the telmisartan group and 16.5% of patients in the ramipril group (telmisartan versus ramipril risk ratio [RR] 1.01; 95% CI 0.94 to 1.09). The mean blood pressure throughout the study period was 0.9/0.6 mmHg lower in patients treated with telmisartan than in those treated with ramipril. Adjustment for this small difference in blood pressure did not materially affect the results for the primary outcome (RR 1.02; 95% CI 0.95 to 1.10). Total mortality (RR 0.99; 95% CI 0.91 to 1.07) and the composite of cardiovascular death, myocardial infarction or stroke (RR 0.98; 95% CI 0.90 to 1.07) were similar.
Two additional trials compared ARB with placebo in high-risk patients (5,6). TRANSCEND (5) assigned 5926 patients intolerant to ACE inhibitors to receive telmisartan 80 mg per day or placebo, and outcomes were identical to those studied in ONTARGET (4). At baseline, 77% of patients had a history of hypertension and 75% had coronary artery disease. Throughout the study, blood pressure was lower in the telmisartan group than in the placebo group (mean difference between groups was 4.0/2.2 mmHg). After a median follow-up period of 56 months, the primary outcome occurred in 15.7% of patients in the telmisartan group and 17.0% of patients in the placebo group (telmisartan versus placebo RR 0.92; 95% CI 0.81 to 1.05). The composite of cardiovascular death, myocardial infarction or stroke occurred in 13.0% of patients in the telmisartan group and 14.8% of patients assigned to the placebo group (RR 0.87; 95% CI 0.76 to 1.00). Fewer patients in the telmisartan group (30.3%) were hospitalized for cardiovascular cause compared with the placebo group (33.0%; RR 0.92, 95% CI 0.85 to 0.99).
In a comparison similar to TRANSCEND, PRoFESS (6) assigned 20,332 patients with cerebrovascular disease (74% and 19% of whom had hypertension and extracranial atherosclerosis, respectively) to telmisartan 80 mg per day or placebo in a two-by-two factorial comparison (the other factor being assignment to clopidogrel or low-dose acetylsalicylic acid in combination with extended-release dipyridamole) (6). Throughout the study, the mean blood pressure was 3.8/2.0 mmHg lower in the telmisartan group than in the placebo group. During a mean follow-up period of 2.5 years, the primary outcome of first recurrent stroke occurred in 880 patients (8.7%) in the telmisartan group compared with 934 patients (9.2%) in the placebo group (RR 0.95; 95% CI 0.86 to 1.04). The secondary outcome of stroke, myocardial infarction or death from cardiovascular causes occurred in 1367 patients (13.5%) in the telmisartan group and 1463 patients (14.4%) in the placebo group (RR 0.94; 95% CI 0.87 to 1.01).
The neutral findings in TRANSCEND and PRoFESS likely reflect their low event rate and insufficient power to detect differences between telmisartan and placebo (5,6). In a prespecified pooled analysis of both trials, 12.8% of patients in the telmisartan group experienced a stroke, myocardial infarction or cardiovascular death compared with 13.8% in the placebo group (RR 0.91; 95% CI 0.85 to 0.98); efficacy was particularly accentuated after the first six months of follow-up (RR 0.85; 95% CI 0.78 to 0.92). Collectively, this evidence base provides support for the use of an ARB in patients with hypertension in association with coronary artery disease. However, as was the case before these trials, the accumulated weight of placebo-controlled trial evidence supports the provision of ACE inhibitor therapy for this indication. As in the previous iteration of our guidelines, we continue to discourage the use of combination therapy with both ACE inhibitors and ARBs for most patients, unless other compelling indications exist (such as systolic heart failure) (14,15).
ACCOMPLISH (7,17) enrolled 11,506 patients aged 68.4±6.9 years with hypertension who were at high risk for cardiovascular events by virtue of concomitant coronary artery disease (46%), stroke (13%), renal disease (6%), peripheral arterial disease (8%) or diabetes mellitus (60%). Patients were randomly assigned to receive the combination of benazepril and amlodipine, or the combination of benazepril and hydrochlorothiazide. The primary end point was the composite of death from cardiovascular causes, nonfatal myocardial infarction, non-fatal stroke, hospitalization for angina, resuscitation after sudden cardiac arrest and coronary revascularization. Although control to less than 140/90 mmHg was achieved in a remarkable 74% of trial participants, the mean reduction in blood pressure was slightly greater for the benazepril-amlodipine group than the benazepril-hydrochlorothiazide group (difference of −0.9 mmHg systolic and −1.1 mmHg diastolic; P<0.001 for both systolic and diastolic pressure differences).
The trial was terminated early after a mean follow-up period of 36 months. The primary outcome occurred in 9.6% of patients in the benazepril-amlodipine group compared with 11.8% of patients in the benazepril-hydrochlorothiazide group (hazard ratio 0.80; 95% CI 0.72 to 0.90). Although the majority of these events were coronary revascularization procedures, benazepril-amlodipine was also superior in reducing the risk of hard clinical end points including the traditional composite of death from cardiovascular causes, myocardial infarction and stroke (RR 0.79; 95% CI 0.67 to 0.92). The risk of serious drug-related adverse events was low and similar in both groups. Thus, results of ACCOMPLISH demonstrate the benefits and tolerability of combination therapy in patients with poorly controlled blood pressure. Combination therapy should be individualized and, for selected patients at high risk for cardiovascular events similar to those enrolled in the ACCOMPLISH trial (17), an ACE inhibitor/dihydropyridine CCB combination is preferable to an ACE inhibitor/thiazide diuretic combination.
A new class of antihypertensive agents, the direct renin inhibitors, recently emerged as a potential treatment for hypertension (18). These agents primarily act by blocking renin-dependent cleavage of angiotensinogen to the decapeptide angiotensin I. In 2009, a randomized trial (19) of a direct renin inhibitor (aliskiren) in patients with left ventricular hypertrophy was reported (the Aliskiren in Left Ventricular Hypertrophy [ALLAY] trial). In ALLAY, 465 patients with hypertension, increased ventricular wall thickness and a body mass index of greater than 25 kg/m2 were assigned to receive aliskiren 300 mg/day, losartan 100 mg/day or a combination of both for nine months. The primary hypothesis in ALLAY was that the combination of aliskiren and losartan would be superior to losartan alone in reducing left ventricular mass index as measured by cardiac magnetic resonance imaging. At nine months, slightly greater reductions in systolic and diastolic blood pressure were seen in the combination group than the two monotherapy groups, but the reduction in left ventricular hypertrophy with combination therapy did not exceed that of patients treated with either therapy alone (P=0.52). To date, no cardiovascular end point data for the direct renin inhibitor class are available; however, four large hardend point randomized trials are currently in progress (20–23). Given the lack of evidence pertaining to the effects of renin inhibitors on morbidity and mortality, we make no recommendation regarding this class of antihypertensive agents at this time. Recommendations for patients with left ventricular hypertrophy are unchanged from previous iterations (14,15).
This year, we strengthen our recommendation for replacing multiple antihypertensive agents with fixed-dose combination therapy (grade C; Table 5). To limit pill burden, patients taking several pills should ideally be treated with single-pill combinations. Clinicians can achieve this by converting short-acting drugs to once-daily agents and adopting combination therapy whenever possible. In the recent Simplified Treatment Intervention to Control Hypertension (STITCH) trial (8), 2104 patients with uncontrolled hypertension in 45 family practices in southwestern Ontario were randomly assigned, at the practice level, to receive either simplified treatment consisting of fixed-dose combination therapy with a low-dose ACE inhibitor or ARB and diuretic combination, or management according to prevailing hypertension guidelines. The proportion of patients achieving target blood pressure was significantly higher in the simplified treatment group (64.7% versus 52.7%; absolute difference 12.1% [95% CI 1.5% to 22.4%]). These data should be viewed in concert with supportive results from a meta-analysis of 42 randomized trials showing that the incremental blood pressure reduction achieved by combining drugs from two different classes (ie, combination therapy) is approximately five times greater than doubling the dose of one drug (ie, step therapy) (24).
The present paper (see Table 6 for the summary) represents the 11th iteration of the annually updated CHEP recommendations for the management of hypertension and we will continue to conduct yearly systematic reviews of the clinical trial evidence to annually update our recommendations for therapy.
|Co-Chairs: S Tobe, M Lebel|
|Central Review Committee: B Hemmelgarn (Chair), D Hackam, M Hill, N Khan, J Mahon, R Padwal, R Quinn|
|Ambulatory Blood Pressure Monitoring: M Myers (Chair), M Dawes|
|Lifestyle Modification in Hypertension: R Touyz (Chair), N Campbell, L Trudeau, S Bacon, R Petrella|
|Adherence Strategies for Patients: T Campbell (Chair), R Feldman, A Milot, J Stone, D Drouin|
|Accurate Measurement of Blood Pressure: L Cloutier (Chair), K Mann, M Lamarre-Cliche|
|Cardiovascular Risk Assessment: S Grover (Chair), G Tremblay, A Milot|
|Pharmacotherapy for Hypertensive Patients with Cardiovascular Disease: S Rabkin (Chair), M Arnold, G Moe, J Howlett|
|Echocardiography: G Honos (Chair)|
|Pharmacotherapy for Hypertensive Patients Without Compelling Indications: R Herman (Chair), P Hamet, G Fodor, G Dresser, G Carruthers, G Pylypchuk, E Burgess|
|Endocrinological Forms of Hypertension: EL Schiffrin (Chair)|
|Renal and Renovascular Hypertension: M Ruzicka (Chair), K Burns, S Tobe, M Vallée, R Prasad, M Lebel|
|Follow-up on Patients with Hypertension: P Bolli (Chair), G Tremblay|
|Routine Laboratory Tests: T Wilson (Chair), B Penner|
|Hypertension & Diabetes: P Larochelle (Chair), R Gilbert, L Leiter, C Jones, R Ogilvie, S Tobe, V Woo|
|Self Measurement of Blood Pressure: D McKay (Chair), A Chockalingam, D McLean|
|Vascular Protection: R Feldman (Chair), EL Schiffrin, R Hegele, P McFarlane|
|Pharmacotherapy for Hypertensive Patients with Cerebrovascular Disease: P Lindsay (Chair), J-M Boulanger, M Sharma|