George Fodor

The relationship between macronutrients and cardiovascular disease and mortality is controversial. Most available data are from European and North American populations where nutrition excess is more likely, so their applicability to other populations is unclear.The Prospective Urban Rural Epidemiology (PURE) study is a large, epidemiological cohort study of individuals aged 35-70 years (enrolled between Jan 1, 2003, and March 31, 2013) in 18 countries with a median follow-up of 7·4 years (IQR 5·3-9·3). Dietary intake of 135 335 individuals was recorded using validated food frequency questionnaires. The primary outcomes were total mortality and major cardiovascular events (fatal cardiovascular disease, non-fatal myocardial infarction, stroke, and heart failure). Secondary outcomes were all myocardial infarctions, stroke, cardiovascular disease mortality, and non-cardiovascular disease mortality. Participants were categorised into quintiles of nutrient intake (carbohydrate, fats, and protein) based on percentage of energy provided by nutrients. We assessed the associations between consumption of carbohydrate, total fat, and each type of fat with cardiovascular disease and total mortality. We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random intercepts to account for centre clustering.During follow-up, we documented 5796 deaths and 4784 major cardiovascular disease events. Higher carbohydrate intake was associated with an increased risk of total mortality (highest [quintile 5] vs lowest quintile [quintile 1] category, HR 1·28 [95% CI 1·12-1·46], ptrend=0·0001) but not with the risk of cardiovascular disease or cardiovascular disease mortality. Intake of total fat and each type of fat was associated with lower risk of total mortality (quintile 5 vs quintile 1, total fat: HR 0·77 [95% CI 0·67-0·87], ptrend<0·0001; saturated fat, HR 0·86 [0·76-0·99], ptrend=0·0088; monounsaturated fat: HR 0·81 [0·71-0·92], ptrend<0·0001; and polyunsaturated fat: HR 0·80 [0·71-0·89], ptrend<0·0001). Higher saturated fat intake was associated with lower risk of stroke (quintile 5 vs quintile 1, HR 0·79 [95% CI 0·64-0·98], ptrend=0·0498). Total fat and saturated and unsaturated fats were not significantly associated with risk of myocardial infarction or cardiovascular disease mortality.High carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality. Total fat and types of fat were not associated with cardiovascular disease, myocardial infarction, or cardiovascular disease mortality, whereas saturated fat had an inverse association with stroke. Global dietary guidelines should be reconsidered in light of these findings.Full funding sources listed at the end of the paper (see Acknowledgments).

The present article represents the 2009 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease in the adult.

The Canadian Hypertension Education Program reviews the hypertension literature annually and provides detailed recommendations regarding hypertension diagnosis, assessment, prevention, and treatment. This report provides the updated evidence-based recommendations for 2015. This year, 4 new recommendations were added and 2 existing recommendations were modified. A revised algorithm for the diagnosis of hypertension is presented. Two major changes are proposed: (1) measurement using validated electronic (oscillometric) upper arm devices is preferred over auscultation for accurate office blood pressure measurement; (2) if the visit 1 mean blood pressure is increased but < 180/110 mm Hg, out-of-office blood pressure measurements using ambulatory blood pressure monitoring (preferably) or home blood pressure monitoring should be performed before visit 2 to rule out white coat hypertension, for which pharmacologic treatment is not recommended. A standardized ambulatory blood pressure monitoring protocol and an update on automated office blood pressure are also presented. Several other recommendations on accurate measurement of blood pressure and criteria for diagnosis of hypertension have been reorganized. Two other new recommendations refer to smoking cessation: (1) tobacco use status should be updated regularly and advice to quit smoking should be provided; and (2) advice in combination with pharmacotherapy for smoking cessation should be offered to all smokers. The following recommendations were modified: (1) renal artery stenosis should be primarily managed medically; and (2) renal artery angioplasty and stenting could be considered for patients with renal artery stenosis and complicated, uncontrolled hypertension. The rationale for these recommendation changes is discussed.

The association between intake of fruits, vegetables, and legumes with cardiovascular disease and deaths has been investigated extensively in Europe, the USA, Japan, and China, but little or no data are available from the Middle East, South America, Africa, or south Asia.We did a prospective cohort study (Prospective Urban Rural Epidemiology [PURE] in 135 335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-income, and high-income countries in seven geographical regions: North America and Europe, South America, the Middle East, south Asia, China, southeast Asia, and Africa. We documented their diet using country-specific food frequency questionnaires at baseline. Standardised questionnaires were used to collect information about demographic factors, socioeconomic status (education, income, and employment), lifestyle (smoking, physical activity, and alcohol intake), health history and medication use, and family history of cardiovascular disease. The follow-up period varied based on the date when recruitment began at each site or country. The main clinical outcomes were major cardiovascular disease (defined as death from cardiovascular causes and non-fatal myocardial infarction, stroke, and heart failure), fatal and non-fatal myocardial infarction, fatal and non-fatal strokes, cardiovascular mortality, non-cardiovascular mortality, and total mortality. Cox frailty models with random effects were used to assess associations between fruit, vegetable, and legume consumption with risk of cardiovascular disease events and mortality.Participants were enrolled into the study between Jan 1, 2003, and March 31, 2013. For the current analysis, we included all unrefuted outcome events in the PURE study database through March 31, 2017. Overall, combined mean fruit, vegetable and legume intake was 3·91 (SD 2·77) servings per day. During a median 7·4 years (5·5-9·3) of follow-up, 4784 major cardiovascular disease events, 1649 cardiovascular deaths, and 5796 total deaths were documented. Higher total fruit, vegetable, and legume intake was inversely associated with major cardiovascular disease, myocardial infarction, cardiovascular mortality, non-cardiovascular mortality, and total mortality in the models adjusted for age, sex, and centre (random effect). The estimates were substantially attenuated in the multivariable adjusted models for major cardiovascular disease (hazard ratio [HR] 0·90, 95% CI 0·74-1·10, ptrend=0·1301), myocardial infarction (0·99, 0·74-1·31; ptrend=0·2033), stroke (0·92, 0·67-1·25; ptrend=0·7092), cardiovascular mortality (0·73, 0·53-1·02; ptrend=0·0568), non-cardiovascular mortality (0·84, 0·68-1·04; ptrend =0·0038), and total mortality (0·81, 0·68-0·96; ptrend<0·0001). The HR for total mortality was lowest for three to four servings per day (0·78, 95% CI 0·69-0·88) compared with the reference group, with no further apparent decrease in HR with higher consumption. When examined separately, fruit intake was associated with lower risk of cardiovascular, non-cardiovascular, and total mortality, while legume intake was inversely associated with non-cardiovascular death and total mortality (in fully adjusted models). For vegetables, raw vegetable intake was strongly associated with a lower risk of total mortality, whereas cooked vegetable intake showed a modest benefit against mortality.Higher fruit, vegetable, and legume consumption was associated with a lower risk of non-cardiovascular, and total mortality. Benefits appear to be maximum for both non-cardiovascular mortality and total mortality at three to four servings per day (equivalent to 375-500 g/day).Full funding sources listed at the end of the paper (see Acknowledgments).

Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force provides annually updated, evidence-based recommendations to guide the diagnosis, assessment, prevention, and treatment of hypertension. This year, we present 4 new recommendations, as well as revisions to 2 previous recommendations. In the diagnosis and assessment of hypertension, automated office blood pressure, taken without patient-health provider interaction, is now recommended as the preferred method of measuring in-office blood pressure. Also, although a serum lipid panel remains part of the routine laboratory testing for patients with hypertension, fasting and nonfasting collections are now considered acceptable. For individuals with secondary hypertension arising from primary hyperaldosteronism, adrenal vein sampling is recommended for those who are candidates for potential adrenalectomy. With respect to the treatment of hypertension, a new recommendation that has been added is for increasing dietary potassium to reduce blood pressure in those who are not at high risk for hyperkalemia. Furthermore, in selected high-risk patients, intensive blood pressure reduction to a target systolic blood pressure ≤ 120 mm Hg should be considered to decrease the risk of cardiovascular events. Finally, in hypertensive individuals with uncomplicated, stable angina pectoris, either a β-blocker or calcium channel blocker may be considered for initial therapy. The specific evidence and rationale underlying each of these recommendations are discussed. Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force will continue to provide annual updates.

Since the last publication of the recommendations for the management and treatment of dyslipidemia, new clinical trial data have emerged that support a more vigorous approach to lipid lowering in specific patient groups. The decision was made to update the lipid guidelines in collaboration with the Canadian Cardiovascular Society. A systematic electronic search of medical literature for original research consisting of blinded, randomized controlled trials was performed. Meta-analyses of studies of the efficacy and safety of lipid-lowering therapies, and of the predictive value of established and emerging risk factors were also reviewed. All recommendations are evidence-based, and have been reviewed in detail by primary and secondary review panels. Major changes include a lower low-density lipoprotein cholesterol (LDL-C) treatment target (lower than 2.0 mmol/L) for high-risk patients, a slightly higher intervention point for the initiation of drug therapy in most low-risk individuals (LDL-C of 5.0 mmol/L or a total cholesterol to high-density lipoprotein cholesterol ratio of 6.0) and recommendations regarding additional investigations of potential use in the further evaluation of coronary artery disease risk in subjects in the moderate-risk category.

<h3>Background</h3> Analyses of medication databases indicate marked increases in prescribing of antihypertensive drugs in Canada over the past decade. This study was done to examine the trends in the prevalence of hypertension and in control rates in Canada between 1992 and 2009. <h3>Methods</h3> Three population-based surveys, the 1986–1992 Canadian Heart Health Surveys, the 2006 Ontario Survey on the Prevalence and Control of Hypertension and the 2007–2009 Canadian Health Measures Survey, collected self-reported health information from, and measured blood pressure among, community-dwelling adults. <h3>Results</h3> The population prevalence of hypertension was stable between 1992 and 2009 at 19.7%–21.6%. Hypertension control improved from 13.2% (95% confidence interval [CI] 10.7%–15.7%) in 1992 to 64.6% (95% CI 60.0%–69.2%) in 2009, reflecting improvements in awareness (from 56.9% [95% CI 53.1%–60.5%] in 1992 to 82.5% [95% CI 78.5%–86.0%] in 2009) and treatment (from 34.6% [95% CI 29.2%–40.0%] in 1992 to 79.0% [95% CI 71.3%–86.7%] in 2009) among people with hypertension. The size of improvements in awareness, treatment and control were similar among people who had or did not have cardiovascular comorbidities Although systolic blood pressures among patients with untreated hypertension were similar between 1992 and 2009 (ranging from 146 [95% CI 145–147] mm Hg to 148 [95% CI 144–151] mm Hg), people who did not have hypertension and patients with hypertension that was being treated showed substantially lower systolic pressures in 2009 than in 1992 (113 [95% CI 112–114] v. 117 [95% CI 117–117] mm Hg and 128 [95% CI 126–130] v. 145 [95% CI 143–147] mm Hg). <h3>Interpretation</h3> The prevalence of hypertension has remained stable among community-dwelling adults in Canada over the past two decades, but the rates for treatment and control of hypertension have improved markedly during this time.

OBJECTIVE:To update the evidence-based recommendations for the prevention and treatment of hypertension in adults for 2010.OPTIONS AND OUTCOMES: 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.EVIDENCE: 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.RECOMMENDATIONS: 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/m 2 to 24.9 kg/m 2 ) 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.

Herein, updated evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in Canadian adults are detailed. For 2014, 3 existing recommendations were modified and 2 new recommendations were added. The following recommendations were modified: (1) the recommended sodium intake threshold was changed from ≤ 1500 mg (3.75 g of salt) to approximately 2000 mg (5 g of salt) per day; (2) a pharmacotherapy treatment initiation systolic blood pressure threshold of ≥ 160 mm Hg was added in very elderly (age ≥ 80 years) patients who do not have diabetes or target organ damage (systolic blood pressure target in this population remains at < 150 mm Hg); and (3) the target population recommended to receive low-dose acetylsalicylic acid therapy for primary prevention was narrowed from all patients with controlled hypertension to only those ≥ 50 years of age. The 2 new recommendations are: (1) advice to be cautious when lowering systolic blood pressure to target levels in patients with established coronary artery disease if diastolic blood pressure is ≤ 60 mm Hg because of concerns that myocardial ischemia might be exacerbated; and (2) the addition of glycated hemoglobin (A1c) in the diagnostic work-up of patients with newly diagnosed hypertension. The rationale for these recommendation changes is discussed. In addition, emerging data on blood pressure targets in stroke patients are discussed; these data did not lead to recommendation changes at this time. The Canadian Hypertension Education Program recommendations will continue to be updated annually.

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2012. The new recommendations are: (1) use of home blood pressure monitoring to confirm a diagnosis of white coat syndrome; (2) mineralocorticoid receptor antagonists may be used in selected patients with hypertension and systolic heart failure; (3) a history of atrial fibrillation in patients with hypertension should not be a factor in deciding to prescribe an angiotensin-receptor blocker for the treatment of hypertension; and (4) the blood pressure target for patients with nondiabetic chronic kidney disease has now been changed to < 140/90 mm Hg from < 130/80 mm Hg. We also reviewed the recent evidence on blood pressure targets for patients with hypertension and diabetes and continue to recommend a blood pressure target of less than 130/80 mm Hg.

Clinical practice guidelines require continual reassessment in response to new information and changes in the pattern of disease. Challenges in Canada, as in all industrialized countries, include the increasing size of the elderly population and the rising prevalence of obesity and diabetes mellitus

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2013. This year's update includes 2 new recommendations. First, among nonhypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise does not adversely influence blood pressure (BP) (Grade D). Thus, such patients need not avoid this type of exercise for fear of increasing BP. Second, and separately, for very elderly patients with isolated systolic hypertension (age 80 years or older), the target for systolic BP should be < 150 mm Hg (Grade C) rather than < 140 mm Hg as recommended for younger patients. We also discuss 2 additional topics at length (the pharmacological treatment of mild hypertension and the possibility of a diastolic J curve in hypertensive patients with coronary artery disease). In light of several methodological limitations, a recent systematic review of 4 trials in patients with stage 1 uncomplicated hypertension did not lead to changes in management recommendations. In addition, because of a lack of prospective randomized data assessing diastolic BP thresholds in patients with coronary artery disease and hypertension, no recommendation to set a selective diastolic cut point for such patients could be affirmed. However, both of these issues will be examined on an ongoing basis, in particular as new evidence emerges.

To update the evidence-based recommendations for the prevention and management of hypertension in adults for 2009.For lifestyle and pharmacological interventions, evidence from randomized controlled trials and systematic reviews of trials was 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 lack of long-term morbidity and mortality data in this field. Progression of kidney dysfunction 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 2007 to August 2008 to update the 2008 recommendations. To identify additional published 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 less than 2300 mg (100 mmol)/day (and 1500 mg to 2300 mg [65 mmol to 100 mmol]/day in hypertensive patients); perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (smaller than 102 cm for men and smaller than 88 cm for women); limit alcohol consumption to no more than 14 units per week in men or nine units per week in women; follow a diet that is reduced in saturated fat and cholesterol, and that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on by the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to lower than 140/90 mmHg in all patients, and to lower than 130/80 mmHg in those 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, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor antagonists (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as the initial treatment of hypertension if the systolic blood pressure is 20 mmHg above the target or if the diastolic blood pressure is 10 mmHg above the target. The combination of ACE inhibitors and ARBs should not be used. Other agents appropriate for first-line therapy for isolated systolic hypertension include long- acting dihydropyridine CCBs or ARBs. In patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors 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. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered.All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2011. The major guideline changes this year are: (1) a recommendation was made for using comparative risk analogies when communicating a patient's cardiovascular risk; (2) diagnostic testing issues for renal artery stenosis were discussed; (3) recommendations were added for the management of hypertension during the acute phase of stroke; (4) people with hypertension and diabetes are now considered high risk for cardiovascular events if they have elevated urinary albumin excretion, overt kidney disease, cardiovascular disease, or the presence of other cardiovascular risk factors; (5) the combination of an angiotensin-converting enzyme (ACE) inhibitor and a dihydropyridine calcium channel blocker (CCB) is preferred over the combination of an ACE inhibitor and a thiazide diuretic in persons with diabetes and hypertension; and (6) a recommendation was made to coordinate with pharmacists to improve antihypertensive medication adherence. We also discussed the recent analyses that examined the association between angiotensin II receptor blockers (ARBs) and cancer.

Objective To provide updated, evidence-based recommendations for the management of hypertension in adults. Options and outcomes For lifestyle and pharmacological interventions, evidence from randomized, controlled trials and systematic reviews of trials was preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. For lifestyle interventions, blood pressure (BP) lowering was accepted as a primary outcome given the lack of long-term morbidity/mortality data in this field. For treatment of patients with kidney disease, the development of proteinuria or worsening of kidney function was also accepted as a clinically relevant primary outcome. Evidence MEDLINE searches were conducted from November 2004 to October 2005 to update the 2005 recommendations. In addition, reference lists were scanned and experts were contacted to identify additional published studies. All relevant articles were reviewed and appraised independently by content and methodological experts using prespecified levels of evidence. Recommendations Lifestyle modifications to prevent and/or treat hypertension include the following: perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index of 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 in men or nine standard drinks per week in women; follow a diet that is reduced in saturated fat and cholesterol and that emphasizes fruits, vegetables and low-fat dairy products; restrict salt intake; and consider stress management in selected individuals. Treatment thresholds and targets should take into account each individual's global atherosclerotic risk, target organ damage and comorbid conditions. BP should be lowered to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease (regardless of the degree of proteinuria). Most adults with hypertension require more than one agent to achieve these target BPs. For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic hypertension with or without systolic hypertension include beta-blockers (in those younger than 60 years), angiotensin-converting enzyme (ACE) inhibitors (in nonblack patients), long-acting calcium channel blockers or angiotensin receptor antagonists. Other agents for first-line therapy for isolated systolic hypertension include long-acting dihydropyridine calcium channel blockers or angiotensin receptor antagonists. Certain comorbid conditions provide compelling indications for first-line use of other agents: in patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with diabetes mellitus, ACE inhibitors or angiotensin receptor antagonists (or in patients without albuminuria, thiazides or dihydropyridine calcium channel blockers) are appropriate first-line therapies; and in patients with nondiabetic chronic kidney disease, ACE inhibitors are recommended. All hypertensive patients should have their fasting lipids screened, and those with dyslipidemia should be treated using the thresholds, targets and agents recommended by the Canadian Hypertension Education Program Working Group on the management of dyslipidemia and the prevention of cardiovascular disease. Selected patients with hypertension, but without dyslipidemia, should also receive statin therapy and/or acetylsalicylic acid therapy. Validation All recommendations were graded according to strength of the evidence and voted on by the 45 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually. To provide updated, evidence-based recommendations for the management of hypertension in adults. For lifestyle and pharmacological interventions, evidence from randomized, controlled trials and systematic reviews of trials was preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. For lifestyle interventions, blood pressure (BP) lowering was accepted as a primary outcome given the lack of long-term morbidity/mortality data in this field. For treatment of patients with kidney disease, the development of proteinuria or worsening of kidney function was also accepted as a clinically relevant primary outcome. MEDLINE searches were conducted from November 2004 to October 2005 to update the 2005 recommendations. In addition, reference lists were scanned and experts were contacted to identify additional published studies. All relevant articles were reviewed and appraised independently by content and methodological experts using prespecified levels of evidence. Lifestyle modifications to prevent and/or treat hypertension include the following: perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index of 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 in men or nine standard drinks per week in women; follow a diet that is reduced in saturated fat and cholesterol and that emphasizes fruits, vegetables and low-fat dairy products; restrict salt intake; and consider stress management in selected individuals. Treatment thresholds and targets should take into account each individual's global atherosclerotic risk, target organ damage and comorbid conditions. BP should be lowered to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease (regardless of the degree of proteinuria). Most adults with hypertension require more than one agent to achieve these target BPs. For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic hypertension with or without systolic hypertension include beta-blockers (in those younger than 60 years), angiotensin-converting enzyme (ACE) inhibitors (in nonblack patients), long-acting calcium channel blockers or angiotensin receptor antagonists. Other agents for first-line therapy for isolated systolic hypertension include long-acting dihydropyridine calcium channel blockers or angiotensin receptor antagonists. Certain comorbid conditions provide compelling indications for first-line use of other agents: in patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with diabetes mellitus, ACE inhibitors or angiotensin receptor antagonists (or in patients without albuminuria, thiazides or dihydropyridine calcium channel blockers) are appropriate first-line therapies; and in patients with nondiabetic chronic kidney disease, ACE inhibitors are recommended. All hypertensive patients should have their fasting lipids screened, and those with dyslipidemia should be treated using the thresholds, targets and agents recommended by the Canadian Hypertension Education Program Working Group on the management of dyslipidemia and the prevention of cardiovascular disease. Selected patients with hypertension, but without dyslipidemia, should also receive statin therapy and/or acetylsalicylic acid therapy. All recommendations were graded according to strength of the evidence and voted on by the 45 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually. Objectif Fournir des recommandations probantes à jour pour la prise en charge de l’hypertension chez les adultes. Possibilités et issues Dans le cadre d’interventions pharmacologiques et touchant le mode de vie, les données probantes tirées d’essais aléatoires et contrôlés et d’analyses systématiques d’essais ont été évaluées de manière préférentielle. 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 maladie rénale, l’apparition d’une protéinurie ou l’aggravation de la fonction rénale était également accepté comme issue primaire pertinente d’un point de vue clinique. Données probantes Des recherches dans MEDLINE ont été exécutées entre novembre 2004 et octobre 2005 afin de mettre les recommandations de 2005 à jour. Les listes de référence ont été dépouillées, et on a communiqué avec des spécialistes pour repérer d’autres études publiées. Tous les articles pertinents ont été analysés et évalués de manière indépendante par des spécialistes du contenu et de la méthodologie, au moyen de niveaux de constatation préétablis. Recommandations Les modifications au mode de vie pour prévenir ou traiter l’hypertension s’établissent comme suit : de 30 à 60 minutes d’exercice aérobique de quatre à sept jours par semaine, le maintien d’un poids santé (indice de masse corporelle de 18,5 kg/m2 à 24,9 kg/m2) et d’un tour de taille sain (moins de 102 cm pour les hommes et de 88 cm pour les femmes), la consommation maximale de 14 unités de boissons alcooliques par semaine chez les hommes et de neuf chez les femmes, le respect d’un régime pauvre en gras saturé et en cholestérol axé sur les fruits, les légumes et les produits laitiers faibles en gras, une consommation restreinte de sel et la gestion du stress (chez certains individus). Les valeurs seuils et les valeurs cibles de traitement doivent tenir compte du risque athéroscléreux global de chaque individu, de l’atteinte des organes cibles et des pathologies comorbides présentes. La tension artérielle doit être abaissée à 140/90 mmHg ou moins chez tous les patients, et à 130/80 mmHg chez les diabétiques et les personnes atteintes d’une maladie rénale chronique (quel que soit le degré de protéinurie). La plupart des adultes hypertendus doivent prendre plus d’un médicament pour atteindre les valeurs cibles de tension artérielle. Chez les adultes sans indication impérative de prendre d’autres médicaments, le traitement initial devrait inclure des diurétiques thiazidiques. D’autres médicaments conviennent au traitement de première intention de l’hypertension diastolique associée ou non à une hypertension systolique, soit les bétabloquants (chez les personnes de moins de 60 ans), les inhibiteurs de l’enzyme de conversion de l’angiotensine (ECA, sauf chez les patients noirs), les inhibiteurs calciques à longue durée d’action et les antagonistes des récepteurs de l’angiotensine (ARA). D’autres médicaments conviennent au traitement de première intention de l’hypertension systolique isolée, soit les inhibiteurs calciques de la classe des dihydropyridines à longue durée d’action et les ARA. Certaines pathologies comorbides fournissent des indications convaincantes d’utilisation d’autres médicaments en première intention, Ainsi, chez les patients angineux ayant récemment subi un infarctus du myocarde ou atteints d’une insuffisance cardiaque, des bétabloquants et des inhibiteurs de l’ECA sont recommandés. Chez les patients diabétiques, les inhibiteurs de l’ECA ou les ARA (ou des diurétiques thiazidiques ou des inhibiteurs calciques de la classe des dihydropyridines chez les patients atteints de diabète sans albuminurie) conviennent. Enfin, chez les patients atteints d’une maladie rénale chronique non diabétique, les inhibiteurs de l’ECA sont recommandés. Tous les patients hypertendus devraient subir un dépistage de la lipidémie à jeun, et ceux qui souffrent de dyslipidémie devraient être traités à l’aide des valeurs seuils et des valeurs cibles et des médicaments recommandés par le groupe de travail du Programme d’éducation canadien sur l’hypertension pour la prise en charge de la dyslipidémie et la prévention des maladies cardiovasculaires. Certains patients hypertendus, avec ou sans dyslipidémie, devraient également recevoir un traitement aux statines ou à l’acide acétylsalicylique. Validation Toutes les recommandations ont été classées selon la solidité des données probantes, et les 45 membres du groupe de travail des recommandations du Programme d’éducation canadien sur l’hypertension ont exercé leur vote à cet égard. Toutes les recommandations publiées ont obtenu un consensus d’au moins 95%. Ces lignes directrices continueront d’être mises à jour chaque année. Fournir des recommandations probantes à jour pour la prise en charge de l’hypertension chez les adultes. Dans le cadre d’interventions pharmacologiques et touchant le mode de vie, les données probantes tirées d’essais aléatoires et contrôlés et d’analyses systématiques d’essais ont été évaluées de manière préférentielle. 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 maladie rénale, l’apparition d’une protéinurie ou l’aggravation de la fonction rénale était également accepté comme issue primaire pertinente d’un point de vue clinique. Des recherches dans MEDLINE ont été exécutées entre novembre 2004 et octobre 2005 afin de mettre les recommandations de 2005 à jour. Les listes de référence ont été dépouillées, et on a communiqué avec des spécialistes pour repérer d’autres études publiées. Tous les articles pertinents ont été analysés et évalués de manière indépendante par des spécialistes du contenu et de la méthodologie, au moyen de niveaux de constatation préétablis. Les modifications au mode de vie pour prévenir ou traiter l’hypertension s’établissent comme suit : de 30 à 60 minutes d’exercice aérobique de quatre à sept jours par semaine, le maintien d’un poids santé (indice de masse corporelle de 18,5 kg/m2 à 24,9 kg/m2) et d’un tour de taille sain (moins de 102 cm pour les hommes et de 88 cm pour les femmes), la consommation maximale de 14 unités de boissons alcooliques par semaine chez les hommes et de neuf chez les femmes, le respect d’un régime pauvre en gras saturé et en cholestérol axé sur les fruits, les légumes et les produits laitiers faibles en gras, une consommation restreinte de sel et la gestion du stress (chez certains individus). Les valeurs seuils et les valeurs cibles de traitement doivent tenir compte du risque athéroscléreux global de chaque individu, de l’atteinte des organes cibles et des pathologies comorbides présentes. La tension artérielle doit être abaissée à 140/90 mmHg ou moins chez tous les patients, et à 130/80 mmHg chez les diabétiques et les personnes atteintes d’une maladie rénale chronique (quel que soit le degré de protéinurie). La plupart des adultes hypertendus doivent prendre plus d’un médicament pour atteindre les valeurs cibles de tension artérielle. Chez les adultes sans indication impérative de prendre d’autres médicaments, le traitement initial devrait inclure des diurétiques thiazidiques. D’autres médicaments conviennent au traitement de première intention de l’hypertension diastolique associée ou non à une hypertension systolique, soit les bétabloquants (chez les personnes de moins de 60 ans), les inhibiteurs de l’enzyme de conversion de l’angiotensine (ECA, sauf chez les patients noirs), les inhibiteurs calciques à longue durée d’action et les antagonistes des récepteurs de l’angiotensine (ARA). D’autres médicaments conviennent au traitement de première intention de l’hypertension systolique isolée, soit les inhibiteurs calciques de la classe des dihydropyridines à longue durée d’action et les ARA. Certaines pathologies comorbides fournissent des indications convaincantes d’utilisation d’autres médicaments en première intention, Ainsi, chez les patients angineux ayant récemment subi un infarctus du myocarde ou atteints d’une insuffisance cardiaque, des bétabloquants et des inhibiteurs de l’ECA sont recommandés. Chez les patients diabétiques, les inhibiteurs de l’ECA ou les ARA (ou des diurétiques thiazidiques ou des inhibiteurs calciques de la classe des dihydropyridines chez les patients atteints de diabète sans albuminurie) conviennent. Enfin, chez les patients atteints d’une maladie rénale chronique non diabétique, les inhibiteurs de l’ECA sont recommandés. Tous les patients hypertendus devraient subir un dépistage de la lipidémie à jeun, et ceux qui souffrent de dyslipidémie devraient être traités à l’aide des valeurs seuils et des valeurs cibles et des médicaments recommandés par le groupe de travail du Programme d’éducation canadien sur l’hypertension pour la prise en charge de la dyslipidémie et la prévention des maladies cardiovasculaires. Certains patients hypertendus, avec ou sans dyslipidémie, devraient également recevoir un traitement aux statines ou à l’acide acétylsalicylique. Toutes les recommandations ont été classées selon la solidité des données probantes, et les 45 membres du groupe de travail des recommandations du Programme d’éducation canadien sur l’hypertension ont exercé leur vote à cet égard. Toutes les recommandations publiées ont obtenu un consensus d’au moins 95%. Ces lignes directrices continueront d’être mises à jour chaque année.

The majority of the population is inactive, and strategies to date for promoting regular physical activity have been limited in their effectiveness. Further research is needed to identify correlates of physical activity in different subgroups to design more efficacious interventions. This study sought to identify correlates of physical activity across men and women, urban and rural geographical locations, and four distinct age groups (18-25; 26-45; 46-59; and 60+).This study employed data from a large provincial household random sample (N = 20,606) of Canadians. Analyses were utilized to examine the amount of variance explained in self-reported physical activity by a number of demographic and/or biological, psychological, behavioral, social, and environmental variables within each subgroup.Proportion of friends who exercise, injury from past physical activity, educational level, perceived health status, and alcohol consumption were among the strongest correlates across subgroups.A number of correlates were identified as being significant across all subgroups examined. Most differences in the correlates of physical activity were found within different age groups rather than among urban and rural residents and gender.

In a Canadian population-based case-control study of 480 males and 152 female case-control pairs, the relative risk for development of bladder cancer for ever used versus never used cigarettes was 3.9 for males and 2.4 for females, with a dose-response relationship in both sexes. A reduced risk was associated with the use of filter cigarettes compared to nonfilter cigarettes. After control for cigarette usage, a significant risk was noted for male pipe smokers. For male ex-smokers the risk after 15 years of no smoking was less than one-half that of current male smokers. Bladder cancer risk was found for workers in the chemical, rubber, photographic, petroleum, medical, and food processing industries among males and for workers occupationally exposed to dust or fumes among both sexes. Bladder cancer risk was elevated for males consuming all types of coffee, regular coffee, and instant coffee and for females consuming instant coffee, but no dose-response relationship was found. Risk was found for males consuming water from nonpublic supples but not for females. No risk was observed in males or females consuming nitrate-containing foods, beverages other than coffee, or fiddlehead greens. Hair dye usage in females and phenacetin usage in males and females carried no risk. Divergent findings by area for aspirin suggested that an overall association was not causal. Reevaluation of the data on artificial sweeteners confirmed a significant bladder cancer risk in males and a dose-response relationship. The cumulated population attributable risk for bladder cancer was 90% for males from cigarette smoking, industrial exposure, and exposure to nonpublic water supplies and 29% for females from cigarette smoking, industrial exposure, and instant coffee consumption.

A positive association between the use of artificial sweetners, particularly saccharin, and risk of bladder cancer in males has been observed in a case-control study of 480 men and 152 women in three Provinces in Canada. The risk ratio for ever versus never used is 1-6 for males (P=0-009, one-tailed test), and a significant dose-response relationship was obtained for both duration and frequency of use. The population attributable risk for males is estimated at 7%, though for diabetics, who have a similar risk ratio for artificial sweetner use as non-diabetics, the attributable risk is 33%.

We sought to determine the association of dietary factors and risk of cognitive decline in a population at high risk of cardiovascular disease.Baseline dietary intake and measures of the Mini-Mental State Examination were recorded in 27,860 men and women who were enrolled in 2 international parallel trials of the ONTARGET (Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial) and TRANSCEND (Telmisartan Randomised Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease) studies. We measured diet quality using the modified Alternative Healthy Eating Index. Cox proportional hazards regression was used to determine the association between diet quality and risk of ≥3-point decline in Mini-Mental State Examination score, and reported as hazard ratio with 95% confidence intervals with adjustment for covariates.During 56 months of follow-up, 4,699 cases of cognitive decline occurred. We observed lower risk of cognitive decline among those in the healthiest dietary quintile of modified Alternative Healthy Eating Index compared with lowest quintile (hazard ratio 0.76, 95% confidence interval 0.66-0.86, Q5 vs Q1). Lower risk of cognitive decline was consistent regardless of baseline cognitive level.We found that higher diet quality was associated with a reduced risk of cognitive decline. Improved diet quality represents an important potential target for reducing the global burden of cognitive decline.

Background. Elevated plasma homocysteine levels are reported to be associated with higher rates of vascular diseases. Plasma homocysteine increases in chronic kidney disease (CKD) and could contribute to the increased cardiovascular risk in CKD. Methods. Participants aged 55 years or older with CKD, defined as estimated GFR<60 ml/min and at high cardiovascular risk, were randomly assigned to the combination of folic acid, 2.5 mg, vitamin B6, 50 mg and vitamin B12, 1 mg (n = 307) or placebo (n = 312) daily for 5 years. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction and stroke. Results. Mean baseline plasma homocysteine was 15.9 ± 7.3 μmol/l in the active treatment group and 15.7 ± 5.7 µmol/l in placebo group and decreased to 11.9 ± 3.3 µmol/l (P < 0.001) on active treatment (15.5 ± 4.5 on placebo). Primary outcome events occurred in 90 participants (29.3%) on active therapy and in 80 (25.6%) on placebo (relative risk, 1.19; 95% confidence interval, 0.88–1.61; P = 0.25). There were no significant treatment benefits on death from cardiovascular causes (1.24; 0.84–1.83), myocardial infarction (1.10; 0.76–1.61) and stroke (1.00; 0.54–1.85). More participants in the active treatment group were hospitalized for heart failure (1.98; 1.21–3.26; P = 0.007) and for unstable angina (1.70; 1.02–2.83; P = 0.04). Incidence of primary outcome increased with decreasing GFR. Conclusions. Active treatment with B vitamins lowered homocysteine levels in participants with CKD but did not reduce cardiovascular risk.

To estimate the prevalence and distribution of elevated blood pressure (BP) among Canadian adults and to determine the level of control, treatment, awareness and prevalence of other risk factors among adults with high BP.Population-based cross-sectional surveys.Nine Canadian provinces, from 1986 to 1990.A probability sample of 26,293 men and women aged 18 to 74 years was selected from the health insurance registers in each province. For 20,582 subjects, BP was measured at least twice. Nurses administered a standard questionnaire and recorded two BP measurements using a standardized technique. Two further BP readings, anthropometric measurements and a blood specimen for lipid analysis were obtained from those subjects who attended a clinic.Mean values of systolic and diastolic BP, prevalence of elevated BP using different criteria, and prevalence of smoking, elevated blood cholesterol, body mass index, physical activity and presence of diabetes by high BP status are reported.Sixteen percent of men and 13% of women had diastolic BP of 90 mm Hg or greater or were on treatment (or both). About 26% of these subjects were unaware of their hypertension, 42% were being treated and their condition controlled, 16% were treated and not controlled, and 16% were neither treated nor controlled. Use of non-pharmacologic treatment of high BP with or without medication was low (22%). Hypertensive subjects showed a higher prevalence of elevated total cholesterol, high body mass index, diabetes and sedentary lifestyle than normotensive subjects. Most people with elevated BP were in the 90 to 95 mm Hg range for diastolic pressure and 140 to 160 mm Hg range for systolic pressure. Prevalence of high isolated systolic BP sharply increased in men (40%) and women (49%) 65 to 74 years old.The relatively low level of control of elevated BP calls for population and individual strategies, stressing a non-pharmacologic approach and addressing isolated systolic hypertension in the elderly.

To provide updated, evidence-based recommendations for the prevention and management of hypertension in adults.For lifestyle and pharmacological interventions, evidence was reviewed from randomized controlled trials and systematic reviews of trials. 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 lack of long-term morbidity and mortality data in this field. For treatment of patients with kidney disease, the progression of kidney dysfunction was also accepted as a clinically relevant primary outcome.A Cochrane collaboration librarian conducted an independent MEDLINE search from 2005 to August 2006 to update the 2006 Canadian Hypertension Education Program recommendations. In addition, reference lists were scanned and experts were contacted to identify additional published studies. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence.Dietary lifestyle modifications for prevention of hypertension, in addition to a well-balanced diet, include a dietary sodium intake of less than 100 mmol/day. In hypertensive patients, the dietary sodium intake should be limited to 65 mmol/day to 100 mmol/day. Other lifestyle modifications for both normotensive and hypertensive patients include: performing 30 min to 60 min of aerobic exercise four to seven days per week; maintaining a healthy body weight (body mass index of 18.5 kg/m2 to 24.9 kg/m2) and waist circumference (less than 102 cm in men and less than 88 cm in women); limiting alcohol consumption to no more than 14 units per week in men or nine units per week in women; following a diet reduced in saturated fat and cholesterol, and one that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and considering stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should take into account each individual's global atherosclerotic risk, target organ damage and any comorbid conditions: blood pressure should be lowered to lower than 140/90 mmHg in all patients and lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease. Most patients require more than one agent to achieve these blood pressure targets. In adults without compelling indications for other agents, initial therapy should include thiazide diuretics; other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin-converting enzyme (ACE) inhibitors (except in black patients), long-acting calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). First-line therapy for isolated systolic hypertension includes long-acting dihydropyridine CCBs or ARBs. Certain comorbid conditions provide compelling indications for first-line use of other agents: in patients with angina, recent myocardial infarction, or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor plus diuretic combination is preferred; in patients with nondiabetic chronic kidney disease, 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. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered.All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

To update the evidence-based recommendations for the prevention and management of hypertension in adults.For lifestyle and pharmacological interventions, evidence was preferentially reviewed from randomized controlled trials and systematic reviews of trials. 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 lack of long-term morbidity and mortality data in this field. Progression of kidney dysfunction 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 2006 to August 2007 to update the 2007 recommendations. To identify additional published studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by content and methodological experts using prespecified levels of evidence.For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium intake to less than 100 mmol/day (and 65 mmol/day to 100 mmol/day in hypertensive patients); perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (smaller than 102 cm for men and smaller than 88 cm for women); limit alcohol consumption to no more than 14 units per week in men or nine units per week in women; follow a diet that is reduced in saturated fat and cholesterol, and one that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on by the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to lower than 140/90 mmHg in all patients, and to lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin-converting enzyme (ACE) inhibitors (in nonblack patients), long-acting calcium channel blockers (CCBs), angiotensin receptor antagonists (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered for initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. Other agents appropriate for first-line therapy for isolated systolic hypertension include long-acting dihydropyridine CCBs or ARBs. In patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors 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 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. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension but who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered.All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

Nurses are the largest professional group within the health care workforce, and their work is perceived as being physically demanding. Regular physical activity helps to prevent or ameliorate cardiometabolic conditions (e.g. cardiovascular disease, diabetes). It is not known whether Canadian nurses are meeting current physical activity guidelines.To assess the influence of the workplace on the physical activity and cardiometabolic health of nurses from hospitals in the Champlain region of Ontario, Canada.A multi-centre, cross-sectional study.Hospitals in the Champlain Local Health Integration Network of Ontario.Nurses wore an ActiGraph accelerometer to objectively assess levels of moderate-to-vigorous intensity physical activity measured in minutes/day in bouts ≥10 min. All completed the Perceived Workplace Environment (PWE) scale and International Physical Activity Questionnaire (IPAQ). Height, body mass, waist circumference, blood pressure and heart rate were measured, and body mass index (BMI) was determined. Each nurse's 5-year cardiovascular risk was calculated using the Harvard Score.A total of 410 nurses (94% female; mean ± SD: age = 43 ± 12 years) from 14 hospitals participated. Nurses spent an average of 96 ± 100 min/week in bouts ≥10 min of moderate-to-vigorous intensity physical activity; 23% of nurses met recommended physical activity guidelines. Nurses working 8- vs. 12-h shifts (16 ± 16 vs. 10 ± 11 min/day, p = 0.026), fixed vs. rotating shifts (15 ± 15 vs. 12 ± 13 min/day, p = 0.012) and casual vs. full-time (29 ± 17 vs. 13 ± 15 min/day, p < 0.001) or vs. part-time (29 ± 17 vs. 13 ± 12 min/day, p = 0.001) accumulated more moderate-to-vigorous intensity physical activity in bouts ≥10 min. The average PWE score was 2.4 ± 0.9, with no association between PWE scores and moderate-to-vigorous intensity physical activity in bouts ≥10 min (p > 0.05). Nurses working 8-h shifts, fixed shifts and in urban hospitals reported better PWE scores (p < 0.05). Nurses working fixed vs. rotating shifts had higher systolic blood pressure (median: 114 vs. 112 mmHg, p = 0.043), and nurses working in rural vs. urban hospitals had higher BMI (median: 27.8 vs. 25.6 kg/m2, p = 0.007) and waist circumference (median: 82.3 vs. 78.6 cm, p = 0.015).Nurses are not meeting current physical activity guidelines (150 min of moderate-to-vigorous intensity physical activity per week in 10-min bouts), yet exceeded these recommendations when examining their continuous (i.e. non bouts) physical activity levels. No association between the PWE and moderate-to-vigorous intensity physical activity was observed. Rotating vs. fixed shifts, 12- vs. 8-h shifts, and/or full-time or part-time vs. casual hours may impede nurses' ability to meet recommended physical activity levels. The low physical activity levels and poor cardiometabolic health of Canadian nurses warrant attention.

Background Non-compliance with prescribed antihypertensive medication is an important contributor to the failure of antihypertensive therapy. Objective To assess the validity of a short questionnaire in the identification of non-compliant patients. Methods In three central-European countries, work-site screening for hypertension was conducted. Blood pressure was measured using an automatic electronic blood pressure measuring device (BpTRU). Respondents were interviewed by trained personnel and a short questionnaire focused on blood pressure awareness and treatment compliance was completed. Results A total of 2812 persons were screened: 841(29.9%) respondents were hypertensive, and out of these the total number of treated hypertensive subjects was 359 (42.6%). Mean systolic blood pressure and diastolic blood pressure were significantly lower in the compliant group than the non-compliant group (systolic blood pressure, 139.4 and 146.2 mmHg, respectively, P = 0.002; and diastolic blood pressure, 89.2 and 92.3 mmHg, respectively, P < 0.01). The non-compliant group was younger than the compliant group (mean age, 46.7 versus 48.9 years, respectively, P = 0.01). Females, patients on combined therapy and non-smokers were more compliant than males, those on mono-therapy and smokers (P = 0.01, P = 0.004 and P = 0.005, respectively). Conclusion Patients reporting strict compliance with prescribed drug therapy have significantly lower systolic blood pressure and diastolic blood pressure than those who admit even an occasional lapse in taking medication. A properly formulated questionnaire can identify non-compliant patients.

Calprotectin represents an interesting peptide known to be involved in the pathophysiology of various inflammatory processes. Being secreted from activated neutrophils and monocytes under various conditions, it can also be found in the extracellular fluids and serve as a biomarker of ongoing inflammation, which property is currently used in the monitoring of inflammatory bowel diseases. Recent studies, however, suggest that calprotectin could serve as an important prognostic factor for cardiovascular and cardiometabolic diseases, since these are occurring on the basis of low-grade chronic inflammation. We assume that calprotectin may represent a useful marker in predicting the course of atherosclerotic process, coronary artery disease and acute coronary syndromes. Our review is focused on the importance of calprotectin in the diagnosis and prognostic stratification in the field of cardiometabolic risk.

Cholesterol and blood pressure (BP) can be effectively and safely lowered with statin drugs and BP-lowering drugs, reducing major cardiovascular (CV) events by 20%-30% within 5 years in high-risk individuals. However, there are limited data in lower-risk populations. The Heart Outcomes Prevention Evaluation-3 (HOPE-3) trial is evaluating whether cholesterol lowering with a statin drug, BP lowering with low doses of 2 antihypertensive agents, and their combination safely reduce major CV events in individuals at intermediate risk who have had no previous vascular events and have average cholesterol and BP levels.A total of 12,705 women 65 years or older and men 55 years or older with at least 1 CV risk factor, no known CV disease, and without any clear indication or contraindication to the study drugs were randomized to rosuvastatin 10 mg/d or placebo and to candesartan/hydrochlorothiazide 16/12.5 mg/d or placebo (2 × 2 factorial design) and will be followed for a mean of 5.8 years. The coprimary study outcomes are the composite of CV death, nonfatal myocardial infarction (MI), and nonfatal stroke and the composite of CV death, nonfatal MI, nonfatal stroke, resuscitated cardiac arrest, heart failure, and arterial revascularization.Participants were recruited from 21 countries in North America, South America, Europe, Asia, and Australia. Mean age at randomization was 66 years and 46% were women.The HOPE-3 trial will provide new information on cholesterol and BP lowering in intermediate-risk populations with average cholesterol and BP levels and is expected to inform approaches to primary prevention worldwide (HOPE-3 ClinicalTrials.gov NCT00468923).

A study of the prevalence of kidney stone formers and the relationship of genetic factors and drinking-water composition to prevalence was completed in six districts in Newfoundland where 82% of stone formers have calcium-containing stones. One thousand one hundred and twelve adult (age ≥ 25) informants were interviewed in a random sample of households. The mean prevalence of stone formers among males was 15.5% (range 2.3–28.6%) and, among females, 8.3% (range 3.7–11.7%). There was no detectable association between district prevalence (male or female) and the mean district drinking-water hardness nor its content of calcium, magnesium, silica, zinc, manganese, iron or copper. There was a significant excess of affected parents of female stone formers compared to affected parents of female non-formers (p < 0.001) while the differences were not significant between parents of male stone formers and non-formers (p > 0.1). There was a higher, though not statistically significant, prevalence among the parents of female stone formers as compared to parents of male stone formers (0.2 > p > 0.1). The family history data in these first-degree relatives of affected and non-affected individuals is consistent with a polygenic mode of inheritance.

We evaluated the association of body weight with the prevalence of hypertension by age and sex, as well as the treatment and control rates in obese and nonobese hypertensives among adults in the province of Ontario, Canada.Cross-sectional, population-based survey of 2,510 adults, 20-79 years of age representative of the Ontario population of 7,996,653. Height, weight, arm and waist circumference, and blood pressure (BP) were directly measured by a trained nurse.Prevalence of obesity (body mass index (BMI) > or =30) increased from 16% in the 20-39 years age-group to 33% in the 60-79 years age group, similarly in men and women. Prevalence of hypertension increased as BMI and age increased: in the older age group (60+) from 36% in the lean to 51% for the overweight, 59% in the obese stage I, and 68% in the obese stage II/III. Prevalence of self-reported diabetes followed a similar pattern. Presence of other risk factors (diabetes and dyslipidemia) was independently associated with higher hypertension rates. Treatment and control rates of hypertension varied by BMI and gender. Lean hypertensive males had the lowest control rates (42%) and the highest systolic BPs compared to overweight (79%) and obese (64%) males. This difference was not apparent in females.Obesity is associated with markedly higher prevalence of hypertension and diabetes with age. If obesity per se is indeed a contributing factor, public health strategies to reduce the obesity epidemic would also markedly reduce the burden of hypertension and diabetes.

To evaluate whether efficacious counseling methods on sodium restriction can be successfully incorporated into primary care models for the management of hypertension.We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects and Health Technology Assessment to identify randomized controlled trials of dietary counseling for salt intake reduction that reported significant reduction in 24-h urinary sodium and blood pressure levels among adults with untreated hypertension. Data extraction and assessment of reproducibility and feasibility were done in duplicate and any disagreements were resolved by consensus.Six trials were included for assessment of methods as they were efficacious in reducing sodium intake (24-h urinary sodium excretion) by 73 to 93 mmol/day (intervention) vs. 3.2 to 12.5 mmol/day (control). This was paralleled with a reduction in blood pressure (-4 to -27 mmHg) between groups. In four of the six trials, the methods were described in sufficient detail to be reproducible, but in none of these trials were the 'counseling methods' feasible for application in primary care settings. Apart from multiple sessions of counseling, the reported interventions were supplemented with provision of prepared food, community cooking classes, and intensive inpatient training sessions.Despite the availability of efficacious counseling methods for the reduction of sodium intake among newly diagnosed hypertensive patients (feasible within a clinical trial setting), none of these methods, in their present form, are suitable for incorporation into existing primary care settings in countries such as Canada, United States, and UK.

To provide updated, evidence-based recommendations for the therapy of hypertension in adults.For patients with hypertension, a number of antihypertensive agents may control blood pressure. Randomized trials evaluating first-line therapy with thiazides, beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers, centrally acting agents or angiotensin II receptor antagonists were reviewed.The health outcomes that were considered were changes in blood pressure, cardiovascular morbidity, and cardiovascular and/or all-cause mortality rates. Economic outcomes were not considered due to insufficient evidence.MEDLINE was searched for the period March 1999 to October 2001 to identify studies not included in the 2000 revision of the Canadian Recommendations for the Management of Hypertension. Reference lists were scanned, experts were polled, and the personal files of the subgroup members and authors were used to identify other published studies. All relevant articles were reviewed and appraised, using prespecified levels of evidence, by content experts and methodological experts.A high value was placed on the avoidance of cardiovascular morbidity and mortality.Various antihypertensive agents reduce the blood pressure of patients with sustained hypertension. In certain settings, and for specific classes of drugs, blood-pressure lowering has been associated with reduced cardiovascular morbidity and/or mortality.The present document contains detailed recommendations pertaining to treatment thresholds, target blood pressures, and choice of agents in various settings in patients with hypertension. The main changes from the 2000 Recommendations are the addition of a section on the treatment of hypertension in patients with diabetes mellitus, the amalgamation of the previous sections on treatment of hypertension in the young and old into one section, increased emphasis on the role of combination therapies over repeated trials of single agents and expansion of the section on the treatment of hypertension after stroke. Implicit in the recommendations for therapy is the principle that treatment for an individual patient should take into consideration global cardiovascular risk, the presence and/or absence of target organ damage, and comorbidities.All recommendations were graded according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group. Individuals with potential conflicts of interest relative to any specific recommendation were excluded from voting on that recommendation. Only those recommendations achieving high levels of consensus are reported here. These guidelines will continue to be updated annually.

To provide updated, evidence-based recommendations for the management of hypertension in adults.For lifestyle and pharmacological interventions, evidence from randomized controlled trials and systematic reviews of trials was preferentially reviewed. While changes in cardiovascular morbidity and mortality were the primary outcomes of interest, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity/mortality data in this field, and for certain comorbid conditions, other relevant outcomes, such as development of proteinuria or worsening of kidney function, were considered.MEDLINE searches were conducted from November 2003 to October 2004 to update the 2004 recommendations. Reference lists were scanned, experts were contacted, and the personal files of the subgroup members and authors were used to identify additional published studies. All relevant articles were reviewed and appraised independently, using prespecified levels of evidence, by content and methodology experts. As per previous years, only studies that had been published in the peer-reviewed literature were included; evidence from abstracts, conference presentations and unpublished personal communications was not included.Lifestyle modifications to prevent and/or treat hypertension include the following: perform 30 min to 60 min of aerobic exercise on four to seven days of the week; maintain a healthy body weight (body mass index of 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 units per week in men or nine units per week in women; follow a reduced fat, low cholesterol diet with an adequate intake of potassium, magnesium and calcium; restrict salt intake; and consider stress management (in selected individuals). Treatment thresholds and targets should take into account each individual's global atherosclerotic risk, target organ damage and any comorbid conditions. Blood pressure should be lowered to 140/90 mmHg or less in all patients, and to 130/80 mmHg or less in those with diabetes mellitus or chronic kidney disease. Most adults with hypertension require more than one agent to achieve target blood pressures. For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic hypertension with or without systolic hypertension include beta-blockers (in those younger than 60 years), angiotensin-converting enzyme (ACE) inhibitors (except in black patients), long-acting calcium channel blockers and angiotensin receptor antagonists. Other agents appropriate for first-line therapy for isolated systolic hypertension include long-acting dihydropyridine calcium channel blockers and angiotensin receptor antagonists. Certain comorbid conditions provide compelling indications for first-line use of other agents: in patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with diabetes mellitus, ACE inhibitors or angiotensin receptor antagonists (or thiazides in patients with diabetes mellitus without albuminuria) are appropriate first-line therapies; and in patients with nondiabetic chronic kidney disease, ACE inhibitors are recommended. All hypertensive patients should have their fasting lipids screened, and those with dyslipidemia should be treated using the thresholds, targets and agents recommended by the Canadian Hypertension Education Program Working Group on the management of dyslipidemia and the prevention of cardiovascular disease. Selected patients with hypertension, but without dyslipidemia, should also receive statin therapy and/or acetylsalicylic acid therapy.All recommendations were graded according to the strength of the evidence and voted on by the 43 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

To estimate the prevalence and distribution of the coexistence of major cardiovascular disease (CVD) risk factors among Canadian adults.Population-based cross-sectional surveys.Nine Canadian provinces, from 1986 to 1990.A probability sample of 26,293 men and women, aged 18 to 74 years, was selected from provincial health insurance registries. For 20,582 of these participants, at least two blood pressure (BP) measurements were taken using a standardized technique. At a subsequent visit to a clinic, two additional BP readings, anthropometric measurements and a blood specimen for plasma lipid analysis were obtained.The percentage distribution of subjects by number of major risk factors (smoking, high BP and elevated blood cholesterol level) and by concomitant factors (body mass index [BMI], ratio of waist to hip circumference [WHR], physical activity, diabetes, awareness of CVD risk factors and education).Sixty-four percent of men and 63% of women had one or more of the major risk factors. Prevalence increased with age to reach 80% in men and 89% in women aged 65 to 74 years. Prevalence of two or three risk factors was highest among men in the 45-54 age group (34%) and in women in the 65-74 age group (37%). The most common associations were between smoking and high blood cholesterol level (10%) and between high BP and high blood cholesterol level (8%). Prevalence of high BP and elevated blood cholesterol, alone or in combination, increased with BMI and WHR. Smoking, elevated blood cholesterol, BMI and prevalence of one or more risk factors increased with lower level of education. Less than 48% of participants mentioned any single major risk factor as a cause of heart disease. Awareness was lowest in the group with fewest years of education.The findings of this study call for an approach to reduce CVD that stresses collaboration of the different health sectors to reach both the population as a whole and the individuals at high risk.

A panel consisting of lipidologists, epidemiologists, cardiologists, internists, general practitioners, and public health and government representatives used the evidence-based approach to examine the rationale for a draft of recommendations for medical management of lipid disorders. The proposed recommendations deal with assessment of cardiovascular risk based on history, physical examination and laboratory findings; assessment of the fasting lipid profile; diagnosis and treatment of secondary risk factors; calculation of the 10-year risk of a cardiac event; initiation of lifestyle modifications in patients in whom low density lipoprotein cholesterol (LDL-C), total:high density lipoprotein cholesterol (HDL-C) ratio or triglycerides exceeds target values based on a patient's risk category; follow-up; treatment with drugs; and choices of drugs. In contrast to previous recommendations, there are new, considerably lower, cholesterol level targets for secondary prevention, with a less important emphasis on total cholesterol value than on LDL-C or total:HDL-C ratio and triglyceride levels, and an emphasis on determining the likelihood of a cardiac event by evaluating all relevant risk factors and sharpening the focus on nondrug treatment, which should result in treating a greater percentage of at-risk patients.

Adherence or compliance, in the context of medical treatment, refers to how well a patient follows and sticks to the management plan developed with her/his health care provider, which may include pharmacologic agents as well as changes in lifestyle. Adherence is of great concern in asymptomatic conditions such as hypertension, where lack of control may have serious ramifications including end organ damage and premature mortality. To address this issue, the Canadian Coalition for High Blood Pressure Prevention and Control established a national Advisory Committee on Adherence to the Management of High Blood Pressure. The Advisory Committee consisted of 11 members from different disciplines of health care providers. The Committee reviewed all evidences to date and drew up four practical recommendations with respect to patient, provider and environment. Based on Canadian Task Force on Periodic Health Examination’s guidelines, all four recommendations can be classified as ‘level C’ with a quality of evidence of II.

To provide updated, evidence-based recommendations for the therapy of hypertension in adults.For patients with hypertension, there are a number of lifestyle manoeuvres and antihypertensive agents that may control blood pressure. Randomized trials evaluating first- line therapy with thiazides, beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers, centrally acting agents or angiotensin II receptor antagonists were reviewed.The health outcomes considered were changes in blood pressure, cardiovascular morbidity, and cardiovascular and/or all-cause mortality rates. Economic outcomes were not considered due to insufficient evidence.Medline searches were conducted from the period of the last revision of the Canadian Recommendations for the Management of Hypertension (May 1998 to October 2000). Reference lists were scanned, experts were polled, and the personal files of the subgroup members and authors were used to identify other studies. All relevant articles were reviewed and appraised, using prespecified levels of evidence, by content experts and methodological experts.A high value was placed on the avoidance of cardiovascular morbidity and mortality.Various lifestyle manoeuvres and antihypertensive agents reduce the blood pressure of patients with sustained hypertension. In certain settings, and for specific classes of drugs, blood pressure lowering has been associated with reduced cardiovascular morbidity and/or mortality.The present document contains detailed recommendations pertaining to all aspects of the therapy of patients with hypertension, including lifestyle modifications proven to lower blood pressure, treatment thresholds, target blood pressures, choice of agents in various settings and strategies to enhance adherence. Lower thresholds for blood pressure treatment are advocated for people with other cardiovascular risk factors or established hypertensive target organ damage. Implicit in the recommendations for therapy is the principle that treatment should be individualized for each patient and the choice of agent should be dictated by coexistent conditions. For the treatment of uncomplicated essential hypertension, thiazides, beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors or calcium channel blockers may be appropriate, depending on individual circumstances.All recommendations were graded according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group. Only those recommendations achieving high levels of consensus are reported here. These guidelines will be updated annually.

Although statins are widely used to reduce low density lipoprotein cholesterol (LDL-C), there is little information about patient profiles, treatment patterns and goal achievement among statin-treated patients in Canada.To assess the profile of statin-treated patients and to determine whether they are achieving recommended targets for LDL-C.The Canadian Lipid Study -- Observational (CALIPSO) was a cross-sectional study involving Canadian physicians who were among the top statin prescribers. Each physician enrolled up to 15 patients who were at least 18 years of age with a diagnosis of hyper-cholesterolemia and who had been using a statin for at least eight weeks. Sociodemographics, coronary artery disease (CAD) risk factors, pretreatment and current lipid levels, and history of lipid-lowering therapy were reported for 3721 patients.Sixty-eight per cent of statin-treated patients were at high CAD risk according to the 2003 Canadian guidelines, 46.4% had established cardiovascular disease, 33.9% had diabetes and 59.5% had hypertension. Average LDL-C reductions of 32% (37% for high-risk patients) were initially required to reach goal. At the study visit, patients had been treated for an average of 4.3 years and 24.2% were using a high statin dose. Despite statin therapy, 27.2% of all patients and 36.4% of those at high CAD risk had not achieved LDL-C targets. For 67.4% of these patients, the current therapy was not modified at the study visit.Despite effective therapies, many treated patients are not achieving recommended LDL-C targets. Strategies should be implemented to promote achievement of lipid treatment goals for high-risk patients, thereby reducing the risk of cardiovascular events and their associated clinical and economic burdens.

The impact of treating hypertension on coronary artery disease has been less than anticipated from epidemiologic studies of cardiovascular risk factors. It has been suggested that adverse effects on lipids of traditional diuretic or β-blocker regimens may diminish the potential benefits of antihypertensive therapy. Patients with mild to moderate systemic hypertension and normal serum lipids (n = 191) were randomly assigned to doxazosin or atenolol. After dose titration to goal diastolic blood pressure of ≤ 90 mm Hg, patients continued treatment for a further 24 weeks. The principal outcome measurement was overall coronary artery disease risk using the Framingham formula. Relative risk of coronary artery disease was reduced to 92.4% of baseline (p = 0.144) for evaluable patients taking atenolol (n = 71), and to 74.6% (p = 0.0001) for patients taking doxazosin (n = 51): atenolol versus doxazosin, p = 0.0074. In patients who met the strict Framingham criteria for age, total cholesterol and high density lipoprotein cholesterol, the relative risk of coronary artery disease for patients taking atenolol (n = 23) was reduced to 86.2% of baseline (p = 0.082), and to 67.4% (p = 0.0004) for patients taking doxazosin (n = 18): atenolol versus doxazosin, p = 0.049. Alpha blockade with doxazosin was more effective than β blockade with atenolol in reducing the risk of coronary artery disease in hypertensive patients because of the beneficial effects of doxazosin on highdensity lipoprotein cholesterol. Overall withdrawal rate was greater in the α-blocker group because of a lower response rate and more adverse events.

To evaluate lifestyle changes and their impact on hypertension control in a sample of hypertensive respondents in Ontario, Canada, diet, physical activity, and other nonpharmacologic measures were recorded using a structured questionnaire during the 2006 Ontario Survey on the Prevalence and Control of Hypertension. Responses were weighted to the total adult population of 7,996,653 in Ontario. The prevalence of hypertension was 21%; 42% of hypertensive persons received therapy with antihypertensive drugs and lifestyle changes, and 41% received therapy with drugs only. Blood pressure was controlled in 85% of respondents who used only drugs and in 78% of those who stated that they received therapy with combined drug treatment and lifestyle changes. Fewer than half of hypertensive respondents practiced lifestyle changes (in combination with drug treatment) for blood pressure control. Lifestyle measures in addition to medication use did not result in better control of hypertension compared to only medication use.

What are the effects of pharmacologic cholesterol-lowering interventions in persons at low, medium, and high risk of CHD? What are the effects of a reduced- or modified-fat diet in persons at risk of CHD?

This study compared the effectiveness of physician advice versus dietitian advice for a fat-reduced diet, and of dietitian advice for a fat-reduced diet versus a soluble fibre-enhanced diet in patients with moderate dyslipidemia. A total of 111 men and women took part in this 26-week, three-group, randomized, clinical trial. The physician advice fat-reduced diet group (n = 38) and the dietitian advice fat-reduced diet group (n = 35) received dietary advice based on the American Heart Association (AHA) Step II guidelines. The dietitian advice soluble fibre-enhanced diet group (n = 38) consumed one-third cup per day of psyllium-containing cereal and was advised to increase soluble fibre intake to over 10 grams a day. LDL-C, TC/HDL-C ratio and body weight reductions over six months were -5.3%, -4.6%, and -1.9%, respectively, regardless of whether a physician or a dietitian provided advice, or whether advice was focused on a fat-reduced diet or a soluble fibre-enhanced diet. Both dietitians and physicians can help moderately dyslipidemic patients make clinically meaningful changes in blood lipid levels. Soluble fibre enhancement of the usual diet leads to similar reductions in LDL-C and TC/HDL-C ratio compared to interventions focused on fat reduction.

The incidence of dyslipidaemia is high: in 2000, approximately 25% of adults in the USA had total cholesterol greater than 6.2 mmol/L or were taking lipid-lowering medication. Primary prevention in this context is defined as long-term management of people at increased risk but with no clinically overt evidence of CVD - such as acute MI, angina, stroke, and PVD - and who have not undergone revascularisation.We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of pharmacological cholesterol-lowering interventions in people at low risk (less than 0.6% annual CHD risk); at medium risk (0.6-1.4% annual CHD risk); and at high risk (at least 1.5% annual CHD risk)? What are the effects of reduced or modified fat diet? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).We found 16 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.In this systematic review we present information relating to the effectiveness and safety of the following interventions: ezetimibe, fibrates, niacin (nicotinic acid), reduced- or modified-fat diet, resins, and statins.

The efficacy of a number of non-pharmacologic interventions in the therapy of primary hypertension has been firmly established. Most prominently, weight reduction, sodium restriction, and alcohol restriction have significant effects on lowering blood pressure. Increased physical activity contributes to management of hypertensive patients in a variety of ways: apart from having a direct impact on blood pressure level, it is an important supportive factor in a weight-reducing regime. The success in applying these non-pharmacologic measures in standard patient population is rather limited. A salient example is the lack of success in weight reduction. Reduction of sodium in the diet is somewhat more successful, however, the problem is that most of the salt intake is non-discretionary. Adherence to physical activity regimes is in the range of what has been observed in pharmacologic therapy. Research and experience in the past few years are providing a better understanding of the factors determining compliance with prescribed therapeutical regimes. Further research is needed to develop innovative strategies for providing efficacious non-pharmacologic measures to hypertensive patients.

Cardiovascular disease is a major health issue for the elderly patient. Many diagnostic, therapeutic and ethical issues are specific for the the older adult with heart disease. The Canadian Cardiovascular Society 2002 Consensus Conference provides recommendations for the most frequently encountered cardiac problems in the elderly patient. A common theme of the recommendations is the need to apply the best evidence based medicine together with an assessment of frailty, comorbidity and quality of life. A major goal of the conference was to identify treatments that are not optimally used in the older patient.

Several randomized controlled trials indicate that a low density lipoprotein cholesterol (LDL-C) target <2.0 mmol/L is appropriate for individuals at high risk of coronary artery disease (CAD). Recently released Canadian lipid management guidelines (2006) have incorporated this evidence into their recommendations. A cross-sectional study of patients treated with statins for at least 8 weeks (CALIPSO) was used as a basis to project the ability of statin monotherapy in getting high CAD-risk patients to an LDL-C level <2.0 mmol/L.The analysis was restricted to CALIPSO patients on statin monotherapy who were at high CAD-risk (including patients with established CAD). Assuming all patients could have their statin titrated up to the maximum dose, the proportion of patients that would reach an LDL-C level of <2.0 mmol/L was projected. To do this, the additional LDL-C reduction patients would achieve with maximal titration of their statin was estimated based on a meta-analysis of clinical trials evaluating LDL-C responses to various statin regimens, and applied to patients' current LDL-C level.A total of 1795 high CAD-risk patients treated with statin monotherapy were included in the analysis, of whom 69.8% had an LDL-C > or =2.0 mmol/L. Depending on the statin that was used, it was projected that between 28.2% and 62.7% of high CAD-risk patients would not attain an LDL-C of <2.0 mmol/L following statin titration to maximum dose.Although the accuracy of our projections may be limited by the application of clinical trials data to an external sample of patients, our results suggest that for 38% of patients at high CAD-risk, titration of statin monotherapy will not be sufficient to achieve an LDL-C target of <2.0 mmol/L. For these patients, additional treatment approaches may be needed to further reduce the risk of coronary events.

Hypertension is highly prevalent among adults, and is the most important modifiable risk factor for cardiovascular events, in particular stroke. Decreasing sodium intake has the potential to prevent or delay the development of hypertension and improve blood pressure control, independently of blood pressure lowering drugs, among hypertensive patients. Despite guidelines recommending a low sodium diet, especially for hypertensive individuals, sodium intake remains higher than recommended. A recent systematic review indicated that the efficacious counselling methods described in published trials are not suitable for hypertension management by primary care providers in Canada in the present form. The primary reason for the lack of feasibility is that interventions for sodium restriction in these trials was not limited to counselling, but included provision of food, prepared meals, or intensive inpatient training sessions. This is a parallel, randomized, controlled, open-label trial with blinded endpoints. Inclusion criteria are adult patients with hypertension with high dietary sodium intake (defined as ≥100 mmol/day). The control arm will receive usual care, and the intervention arm will receive usual care and an additional structured counselling session by a registered dietitian, with four follow-up telephone support sessions over four weeks. The two primary outcomes are change in sodium intake from baseline, as measured by a change in 24-hour urinary sodium measurements at four weeks and one year. Secondary outcomes include change in blood pressure (as measured by 24-hour ambulatory monitoring), change in 24-hour urinary potassium, and change in body weight at the same time points. Though decreasing sodium intake has been reported to be efficacious in lowering blood pressure, there exists a gap in the evidence for an effective intervention that could be easily translated into clinical practice. If successful, our intervention would be suitable for outpatient programs such as hypertension clinics or interprofessional family practices (family health teams). A negative, or partially negative (positive effect at four weeks with attrition by 12 months) trial outcome also has significant implications for healthcare delivery and use of resources. The trial was registered with Clinicaltrials.gov (identifier: NCT02283697 ) on 2 November 2014.

Alexander A. Leung, MD MPH, Kara Nerenberg, MD MSc, Stella S. Daskalopoulou, MD PhD, Kerry McBrien, MD MPH, Kelly B. Zarnke, MD MSc, Kaberi Dasgupta, MD MSc, Lyne Cloutier, RN PhD, Mark Gelfer, MD, Maxime Lamarre-Cliche, MD, Alain Milot, MD MSc MD, Peter Bolli, MD, Guy Tremblay, MD, Donna McLean, RN NP PhD, Sheldon W. Tobe, MD MSc(HPTE), Marcel Ruzicka, MD PhD, Kevin D. Burns, MD, Michel Vallee, MD PhD, G.V. Ramesh Prasad, MBBS MSc, Marcel Lebel, MD, Ross D. Feldman, MD, Peter Selby, MBBS MHSc, Andrew Pipe, CM MD, Ernesto L. Schiffrin, MD PhD, Philip A. McFarlane, MD PhD, Paul Oh, MD, Robert A. Hegele, MD, Milan Khara, MBChB, Thomas W. Wilson, MD, S. Brian Penner, MD, Ellen Burgess, MD, Robert J. Herman, MD, Simon L. Bacon, PhD, Simon W. Rabkin, MD, Richard E. Gilbert, MD PhD, Tavis S. Campbell, PhD, Steven Grover, MD MPA, George Honos, MD, Patrice Lindsay, RN PhD, Michael D. Hill, MD MSc, Shelagh B. Coutts, MD, Gord Gubitz, MD, Norman RC. Campbell, MD, Gordon W. Moe, MD MSc, Jonathan G. Howlett, MD, Jean-Martin Boulanger, MD, Ally Prebtani, MD, Pierre Larochelle, MD, Lawrence A. Leiter, MD, Charlotte Jones, MD PhD, Richard I. Ogilvie, MD, Vincent Woo, MD, Janusz Kaczorowski, PhD, Luc Trudeau, MD, Robert J. Petrella, MD PhD, Swapnil Hiremath, MD MPH, Denis Drouin, MD, Kim L. Lavoie, PhD, Pavel Hamet, MD PhD, George Fodor, MD PhD, Jean C. Gregoire, MD, Richard Lewanczuk, MD PhD, George K. Dresser, MD PhD, Mukul Sharma, MD MSc, Debra Reid, PhD RD, Scott A. Lear, PhD, Gregory Moullec, PhD, Milan Gupta, MD, Laura A. Magee, MD MSc, Alexander G. Logan, MD, Kevin C. Harris, MD MHSc, Janis Dionne, MD, Anne Fournier, MD, Genevieve Benoit, MD, Janusz Feber, MD, Luc Poirier, BPharm MSc, Raj S. Padwal, MD MSc, Doreen M. Rabi, MD MSc, for the CHEP Guidelines Task Force

To determine whether statins are underprescribed in the Canadian military. The cost effectiveness of statin therapy in patients identified by the 1998 Canadian cholesterol interim guidelines was also explored.Charts of 1424 Canadian military personnel (age 45 or older) were reviewed at 11 Canadian bases. Risk factors and cholesterol values were used to identify drug therapy candidates. Cost effectiveness ratios and health benefits in terms of years of life saved for statin therapy were estimated for the candidates using a validated cardiovascular disease life expectancy model.Of the 1313 personnel not on lipid lowering medication, 172 were identified as drug therapy candidates. An average of 2.89 years of life saved was forecast for the identified personnel, at an average cost of less than 10,000 dollars per year of life saved.The health benefits of statin therapy in this population are substantial and the cost effectiveness is acceptable. Statin therapy warrants greater attention as a preventive strategy for coronary artery disease.

A two-stage random probability sampling survey of the medical charts of family physicians in Newfoundland and Labrador was done; the first stage sampled physicians randomly, in proportion to the 5 health districts of the province; the second stage took a quota sample of the physicians' charts. The survey revealed a total population minimal prevalence rate of diagnosed diabetics of 3.55% (95% confidence limits 2.55, 4.55). This rate is higher than that found in the only other provincial survey done in Canada (the Prince Edward Island survey). Of diagnosed diabetics, 40% were found to be using insulin. This proportion is higher than other rates in North America. The prevalence rate was slightly higher in males (3.7%) than in females (3.4%).

The global risk assessment became an important tool in the prevention strategy of cardiovascular diseases (CVD).According to the recent guidelines, a correction of the risk equations in relation to countryspecific mortality or risk profile is recommended.Bulgaria is a country among those with highest CVD mortality and morbidity.Purpose: To correct the SCORE formula for high risk populations in Europe for the Bulgarian female population and to apply it to a sample of healthy Bulgarian women.Methods: The 2001 gender-specific cardiovascular mortality in Bulgaria was used as baseline hazard in the original SCORE formula for high risk populations.The country specific mortality data in five-year age periods was logarithmically transformed and then linear regression was applied on thus transformed data.The original variables coefficients in SCORE were used.A graphical version was created.The modified formula was applied to a sample of 393 women from two large cities of Bulgaria without evidence of CVD.The correlation coefficient estimation, as well as Cohen's kappa analysis was used to compare the original and modified SCORE tables and ROC curve was created.Results: The mean age of the sample used for the validation was 57.8±7.3 years, range 40--69.The modified SCORE table showed that the Bulgarian women reach the higher risk levels approximately 2.5 years earlier than their European counterparts and the level of their global CV risk is generally higher.The median global CV risk of the sample rises from 2.0% to 2.95% after adjustment.The modified and the original formula correlate excellently with Spearman's r=0.969, p<0.0001 and AUC=0.88,95% CI=0.85--0.94(?<0.0001).Only in 2.3% of the participants the two ways of calculating the CV risk totally disagree.Conclusion: The Bulgarian women have higher levels of global risk for CVD and reach them approximately 2.5 years earlier in their life than the women in other European high-risk countries.Although there is a good agreement between the corrected and the original equation, there is an obvious need for modification of the SCORE model for the Bulgarian population.

In a re-analysis of data collected during the 2006 Ontario Survey on the Prevalence and Control of Hypertension (Leenen et al, CMAJ 2008), we focussed on the actual blood pressures in treated and untreated older and middle-aged hypertensives. In the older (60-79 years of age) population of 1,426,752 subjects, using traditional definitions the prevalence of hypertension was 49% compared to 21% in the middle-aged (40-59 years of age) population. Hypertension treatment and control rates were similarly high in middle-aged and older hypertensives at 67% and 64% respectively. 39% of older hypertensives were treated with a single antihypertensive drug, and of these 54% had a systolic BP level of &lt; 130 mmHg, and 23% had a systolic BP &lt; 120 mmHg. Of the 61% treated with combination therapy, 44% had a systolic BP &lt; 120 mmHg. 13% of older hypertensives were untreated, and out of those approximately 90% had Stage 1 hypertension, with ~70% without additional risk factors. Considering that monotherapy may lower systolic BP by &lt; 10 mmHg, these findings suggest that there may be a major problem of over-diagnosis and/or over-treatment of hypertension in older adults overestimating substantially the actual prevalence of hypertension, creating an unnecessary burden on the health care system and exposing many older subjects to unnecessary risks of drug therapy.

Ten international long-term hypertension intervention trials between 1980 and 1987 have resulted in significant reduction in the incidence of stroke in the treatment groups. Yet, eight of these studies have shown disappointing results in the prevention of coronary heart disease (CHD). Five hypertension intervention trials revealed high average cholesterol values at baseline. No cholesterol treatment was provided and the incidence of CHD was high. In four other trials with stratification into 'low' and 'high' baseline cholesterol levels, the incidence of CHD was considerably less in the 'low' cholesterol groups. Only the 10th, the Gothenburg trial, has demonstrated a marked reduction in CHD by combining antihypertensive medication with cholesterol lowering treatment. Failure to reduce cholesterol in hypertensives with hypercholesterolaemia may be one explanation for the limited efficacy of antihypertensive treatment in the reduction of CHD. We postulate that successful treatment of hypercholesterolaemia will reduce the incidence of CHD in well-controlled hypertensive patients to the same extent as it lowers the incidence of CHD in normotensive people.

There are contradictory reports concerning the relation of smoking to hypertension (HTN). Some studies observed increased risk of developing HTN while other findings consistently indicate lower blood pressure (BP) in smokers.1Bowman T.S. Gaziano J.M. Buring J.E. Sesso H.D. Am Coll Cardiol. 2007; 50: 2085Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar, 2Mikkelsen K.L. Wiinberg N. Høegholm A. et al.Am J Hypertens. 1997; 10: 483Crossref PubMed Scopus (91) Google Scholar We investigated the association of smoking and HTN in two groups of employees in Hungary. We recruited “blue collar” employees (BC) in a salami factory (n = 1011) and “white collar” (WC) employees in a bank (n=1000) for BP screening. BP and pulse rate were measured with an automated BPTRu instrument. The smoking habits were ascertained by completing a structured questionaire administered by an interviewer. HTN was defined as SBP ≥140 and /or DBP≥90 mm Hg and/or use of antihypertensive medications. Statistical analysis was performed by chi-squared tests, multinomial logsitic regression model, and analysis of covariance. The smoking prevalence was significantly higher in BC (43 %) compared with the WC employees (29 %; p< 0.0001). The prevalence of smokers in WC normotensives was 26% and 33.7% in WC hypertensives (ns). The coresponding figures in BC employees were 45% in normotensives and 39% in HTN(ns). Smoking status had no significant effect on prevalence of HTN in WC and BC employees. However, BP values were higher in each age category in smoking WC female workers.

Approximately one third of prehypertensives (PH) develop hypertension (HTN) within four years (1). We investigated the association of PH and HTN with heart rate (HR) speculating that increased HR may have a prognostic significance. Method: 1000 bank employees (mean age = 32.6) were screened for their blood pressure (BP), HR and other cardiovascular risk factors at their worksite. The respondents included 304 males (mean age = 30.8) and 696 females (mean age = 33.2). Respondents were classified as normotensives (NT), prehypertensives (PH) and hypertensives (HTN) according to their BP levels. The BP and HR were measured using an automated instrument (BpTRU®) which is performing 6 measurements of BP and HR, discards the first value and displays the average of the remaining 5 measurements. Results: A progressive and significant increase in HR was ascertained as BP levels increased (Table). Considering 75 beats per min (bpm) or higher as a threshold for high HR, increased HR was found in 7.6% of male and 35.0% of female NT. In the PH group, 14.8 % of males and 48.0% of females belonged to this category. The corresponding values for the HTN group were 27.7% and 49.7% for males and females, respectively. In this sample, a significantly higher proportion of women compared to men in the NT (p < 0.05) and PH groups (p < 0.0001) had high HR. Conclusion: Respondents with PH and HTN have significantly higher HR than NT. The prevalence of high HR progressively increased from 42.6% in NT to 62.7% in PH and 77.4% in HTN. Further studies are planned to evaluate the prognostic significance of elevated HR.

BACKGROUND An automated sphygmomanometer, the BpTRU, was used in a blood pressure (BP) survey of 2,551 residents in the province of Ontario. Automated BP readings were compared with measurements taken by a mercury sphygmomanometer under standardized conditions in a random 10% sample. METHODS BP was recorded in 238 individuals in random order using both a standard mercury device and an automated BP recorder, the BpTRU. All subjects rested for 5 min prior to the first BP reading, which was then discarded. The mean of the next three readings was obtained using the mercury device whereas the BpTRU was set to record a mean of five readings taken at 1 min intervals with subjects resting alone in a quiet room. RESULTS The mean s.d. BP with the automated device was 115 ± 16/71 ± 10mm Hg compared to 118 ± 16/74 ± 10 mm Hg for the manual BP (P < 0.001). A systolic BP ≥140 mm Hg was present for 16 automated and 19 manual readings. Similarly, the diastolic BP was ≥90 mm Hg for 9 automated and 14 manual readings. Linear regression analysis showed that automated BP was a significant (P < 0.001) predictor of both manual systolic and diastolic BP. CONCLUSION Conventional manual BP readings can be replaced by readings taken using a validated, automated BP recorder in population surveys. The slightly lower readings obtained with the BpTRU device (in the context of reduced observer-subject interaction) may be a more accurate estimate of BP status.

Effects of a Protein Optimized Diet Combined with Moderate Resistance Training on the Postoperative Course in Older Patients with Hip Fracture

Between 1979 and 1984 two major hypertension intervention studies involving 14,000 patients have demonstrated convincing evidence for the effectiveness of blood pressure reduction on both primary and secondary prevention of ischemic heart disease. Previous treatment trials using insufficient numbers and shorter observation periods had produced inconclusive results as far as coronary heart disease is concerned. More recently, warnings have been voiced that untoward effects of diuretics on serum lipids might possibly harm the hypertensive patient because of transient slight increases of cholesterol levels. In this regard, two antihypertensive treatment studies, one lasting 5 years and the other 6 years, are reassuring as they provide unequivocal proof that there is no undesirable increase in lipid levels. The myocardium and its coronary arteries today appear as the major target organ among patients with untreated hypertension. 'Mild' blood pressure elevation is very frequent and, since poorly controlled hypertension was shown to contribute the largest number of cases of fatal and nonfatal ischemic heart disease, it is recommended that the present conservative therapeutic approach toward 'mild' hypertension should be re-evaluated.

Dans le contexte medical, le respect ou l’observance therapeutique designe la mesure dans laquelle le patient se conforme au plan de traitement etabli par le soignant qui le traite, plan qui peut inclure un traitement medicamenteux ou des changements de mode de vie. L’observance revet une grande importance dans les cas d’affections asymptomatiques telles que l’hypertension arterielle, ou un controle deficient peut avoir des consequences graves, par exemple des atteintes aux organes cibles et la mort prematuree. Pour s’attaquer a ce probleme, la Coalition canadienne pour la prevention et le controle de l’hypertension arterielle a mis sur pied un comite consultatif national sur l’observance du traitement de l’hypertension arterielle. Le comite consultatif est forme de 11 membres de differentes disciplines de la sante. Apres avoir examine toutes les etudes publiees a ce jour, le comite a formule quatre recommendations pratiques portant sur trois facteurs principaux: le patient, le soignant et l’environnement. Selon les lignes directrices du Groupe de travail canadien sur l’examen medical periodique, les quatre recommendations sont de «niveau C» et sont basees sur des preuves de qualite II.

642 Objectives: A pilot study to determine (1) if there is a need expressed by FHCP's to participate in a structured walking program (SWP) offered by their health care facility, & (2) if the prescribed interventions improved physical fitness & health-related quality of life (HRQoL). Methods: Pre & post measurements of weight (Wt), height, waist & hip, a fitness appraisal (FA)[a 1-mile walk test, HR & BP at rest (R), exercise (Ex), & recovery] & self-administered questionnaires (re: health, activity, & HRQoL [SF-36]). 111 FHCPs (24 to 61 yrs) volunteered for the 24 wk program (25% of total FHCP population) & were randomized to an experimental (n=54) {EG} or control (n=57) group {CG}. EG & CG were provided with a SWP. CG followed the SWP with no further supervision; EG received a pedometer, stopwatch, exercise diary, access to a computer phone-in system to record activity, and 6 motivational lectures. Results: 81 FHCPs completed the study (73%). A significant difference was observed in the mean age of the drop-outs vs those who completed the study (38 vs 42 yrs, p<0.05). (Table)TableConclusions: Mean values of key variables (*) for EG demonstrated a trend (NS) towards improvement compared to CG. There is a need expressed by FHCP's for exercise programs and the results suggested the intervention was effective.

Tumor growth-rate affects prognosis and treatment planning. The injection of bromodeoxyuridine in dogs and cats permits determination of the potential doubling time following a biopsy of neoplastic tissue and flow cytometric analysis. The essentially non-invasive method gives exact results within 24 hours. This report describes a method to measure potential tumor doubling time of different tumors, and presents results of canine and feline tumors.

Dans le contexte médical, le respect ou l’observance thérapeutique désigne la mesure dans laquelle le patient se conforme au plan de traitement établi par le soignant qui le traite, plan qui peut inclure un traitement médicamenteux ou des changements de mode de vie. L’observance revêt une grande importance dans les cas d’affections asymptomatiques telles que l’hypertension artérielle, où un contrôle déficient peut avoir des consequences graves, par exemple des atteintes aux organes cibles et la mort prématurée. Pour s’attaquer à ce problème, la Coalition canadienne pour la prévention et le contrôle de l’hypertension artérielle a mis sur pied un comité consultatif national sur l’observance du traitement de l’hypertension artérielle. Le comité consultatif est formé de 11 membres de différentes disciplines de la santé. Après avoir examiné toutes les études publiées à ce jour, le comité a formulé quatre recommendations pratiques portant sur trois facteurs principaux: le patient, le soignant et l’environnement. Selon les lignes directrices du Groupe de travail canadien sur l’examen médical périodique, les quatre recommendations sont de «niveau C» et sont basées sur des preuves de qualité II.