A new guideline from Hypertension Canada seeks to improve hypertension management within primary care by offering evidence-based and easily implemented recommendations. The guidance leverages the World Health Organization’s HEARTS framework, wiht the goal of enhancing hypertension control and alleviating cardiovascular burden.

Rémi Goupil,MD,University of Montreal,and Gregory Hundemer,MD,McGill University,both guideline committee co-chairs,told Medscape Medical news that the 2025 guideline uses “a new approach… in view of the declining rates of hypertension control in Canada.” According to them, “The first step is this Primary Care Hypertension Canada guideline, which is tailored specifically to primary care providers, who manage 90% of people with hypertension.” The previous guideline was published in 2020.

The guideline, which was published in the Canadian Medical Association Journal, was created with primary care in mind, with most of the writing committee coming from primary care, according to the co-chairs. The target audience includes family physicians, nurse practitioners, nurses, and pharmacists, in addition to policymakers, patients, and caregivers affected by hypertension.

According to Drs. Goupil and Hundemer, “The guideline provides pragmatic diagnostic and treatment algorithms, listing specific drugs, their dosage, and the sequence in which they should be prescribed.” They added that “Patient voices were included in all steps of the process, and a patient-specific guideline is published alongside the primary care guideline.”

Key Recommendations from the Hypertension Canada Guideline

The guideline includes nine recommendations regarding hypertension diagnosis and treatment. Goupil and Hundemer highlighted the following as most important:

1. Defining hypertension as a blood pressure (BP) ≥ 130/80 mm Hg, confirmed with an out-of-office BP assessment. The doctors stated that “Lowering of the hypertension diagnosis threshold will substantially increase the number of people labeled with hypertension in Canada, although only a small fraction is expected to require pharmacotherapy initiation,” and that “This new threshold reflects the growing evidence regarding the cardiovascular risk reduction associated with lower blood pressure levels.”
2. All adults with hypertension should begin treatment (lifestyle changes, pharmacotherapy, or both) to achieve a systolic BP < 130 mm Hg.
3. when pharmacotherapy is needed, start with low-dose combination therapy (ideally as a single pill). This includes drugs from two of the following three classes: Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), thiazide or thiazide-like diuretics, and long-acting dihydropyridine calcium channel blockers (CCBs).

Additional recommendations include:

• Healthy lifestyle changes for all adults with hypertension.
• Pharmacotherapy for adults with BP ≥ 140/90 mm Hg and for adults with systolic BP 130-139 mm Hg at high cardiovascular disease risk.
• if BP remains above target despite two-drug combination therapy, a three-drug combination of an ACEI or ARB, a thiazide or thiazide-like diuretic, and a long-acting dihydropyridine CCB is recommended.
• If BP remains above target despite three-drug combination therapy at maximally tolerated doses, adding spironolactone is recommended.

“Lowering of the hypertension diagnosis threshold will significantly increase the number of people labeled with hypertension in Canada.”

According to Goupil and Hundemer, “This guideline is only the first step in Hypertension Canada’s approach.” They anticipate a complete guideline in 2026, which will evaluate specific topics in-depth and provide recommendations for specific situations, such as hypertension management in diabetes or resistant hypertension.

HEARTS Framework Aims to Improve Implementation

Sheldon Tobe,MD,professor of medicine at the University of Toronto and Northern Ontario School of Medicine,toronto,and Canadian Cardiovascular Society spokesperson,offered his outlook on the guideline for Medscape Medical News.

According to Dr. Tobe, “We have evidence that Canada’s position of best blood pressure awareness, treatment, and control in the world has been slipping, and that was before the pandemic.” He added that “One of the reasons is loss of support for dissemination and implementation by the public Health Agency of Canada more than a decade ago. The promotion of the HEARTS framework will help to bring policymakers into the implementation of blood pressure control again. The simplified approach to one BP target will facilitate dissemination efforts as well.”

Tobe,who was not involved in the guideline’s development,expressed concern about the small number of people involved in creating it. “In the past, a very large part of the hypertension community was involved, which ensured that there was widespread agreement with the process and results,” he said. “This included the interprofessional community of nurses and dietitians, in addition to pharmacists and doctors. If the HEARTS framework is formally adopted by Canada, this will be very helpful.”

Regarding specific recommendations,tobe noted that “The guideline has suggested that the preferred initial combination therapy