V. Global vascular protection therapy for adults with hypertension without compelling indications for specific agents

Prevention and Treatment

Removed recommendations for 2020

  • The recommendation for the use of low-dose ASA in the primary prevention of cardiovascular disease has been removed.

Hypertension Canada guidelines previously recommended that low-dose ASA be considered in all adults with hyper-tension who are 50 years of age or older for the primary prevention of cardiovascular disease. In light of emerging ev-idence on the balance of risks and benefits of low-dose ASA in this population, the HCGC voted to remove this recom-mendation for 2020. This recommendation was almost entirely on the basis of the Hypertension Optimal Treatment (HOT) trial.54 This landmark trial in hypertensive patients showed that ASA use was associated with a 15% reduction in major adverse cardiovascular events but a 74% increase in major bleeds (although no difference in fatal bleeds) and no difference in all-cause mortality. This recommendation was maintained in the face of increasing concerns regarding the benefit (cardiovascular protection) to cost (major bleeds) in patients in the primary prevention of CAD complications.

However, as shown in the recent Effect of Aspirin on All-Cause Mortality in the Healthy Elderly (ASPREE) trial55 and several recent meta-analyses,56-58 ASA for primary prevention in patients with hypertension is associated with little overall effectiveness and significant risk of major bleeding. In light of this new evidence, Hypertension Canada decided to remove this recommendation, and aspirin is no longer recommended for primary prevention in individuals with hypertension.

Recommendations

  1. Statin therapy is recommended in hypertensive patients with 3 cardiovascular risk factors as defined in Supplemental Table S4 (Grade A in patients older than 40 years) or with established atherosclerotic disease (Grade A regardless of age).
  2. Tobacco use status of all patients should be updated on a regular basis and health care providers should clearly advise patients to quit smoking (Grade C).
  3. Advice in combination with pharmacotherapy (eg, varenicline, bupropion, nicotine replacement therapy) should be offered to all smokers with a goal of smoking cessation (Grade C).