Hypertension Canada's 2020 Evidence Review and Guidelines for the Management of Resistant Hypertension.

We present Hypertension Canada's inaugural evidence-based recommendations for the diagnosis and management of resistant hypertension. Hypertension is present in 21% of the Canadian population, and among those with hypertension, resistant hypertension has an estimated prevalence from 10% to 30%. This subgroup of hypertensive individuals is important, because resistant hypertension portends a high cardiovascular risk. Because of its importance, Hypertension Canada formed a Guidelines Committee to conduct a review of the evidence and develop recommendations for the diagnosis and management of resistant hypertension. The Hypertension Canada Guidelines Committee recommends that patients with blood pressure above target, despite use of 3 or more blood pressure-lowering drugs at optimal doses, preferably including a diuretic, be identified as those with apparent resistant hypertension. Patients identified with apparent resistant hypertension should be assessed for white coat effect, nonadherence, and therapeutic inertia, investigated for secondary hypertension, and referred to a provider with expertise in hypertension. There is no randomized controlled trial evidence for better cardiovascular outcomes with any class of antihypertensive agent at this time, so recommendations for a preferred drug class cannot be made. Furthermore, we provide a summary of the current evidence concerning the role of device therapy in the management of resistant hypertension. We will continue updating the guidelines as additional high-quality evidence with relevance to daily practice becomes available.

Hypertension Canada's 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children.

Hypertension Canada's 2020 guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children provide comprehensive, evidence-based guidance for health care professionals and patients. Hypertension Canada develops the guidelines using rigourous methodology, carefully mitigating the risk of bias in our process. All draft recommendations undergo critical review by expert methodologists without conflict to ensure quality. Our guideline panel is diverse, including multiple health professional groups (nurses, pharmacy, academics, and physicians), and worked in concert with experts in primary care and implementation to ensure optimal usability. The 2020 guidelines include new guidance on the management of resistant hypertension and the management of hypertension in women planning pregnancy.

Chronic sleep disorders in survivors of the acute respiratory distress syndrome.

PURPOSE: Sleep disruption is well recognized in the Intensive Care Unit. Poor sleep quality likely continues following discharge from hospital in several patients and becomes a chronic disorder in some. The aim of this study was to describe the etiology of chronic sleep complaints in survivors of ARDS. METHODS: Seven ARDS survivors with no previous sleep complaints who reported difficulty sleeping 6 months or more following discharge from hospital were evaluated. Sleep quality was assessed subjectively with a sleep history and the Insomnia Severity Index and objectively with polysomnography. Daytime sleepiness was assessed with the Epworth Sleepiness Scale. RESULTS: A chronic sleep disorder was identified in each patient who reported difficulty sleeping. The primary sleep disorder was chronic conditioned insomnia (5 patients), parasomnia (1 patient) and obstructive sleep apnea (1 patient). In addition, 4 patients had periodic leg movements, which was of uncertain clinical significance. CONCLUSION: Chronic sleep disorders, which originate during the acute illness, are present in some ARDS survivors several months after discharge from hospital. If unrecognized, lack of treatment may contribute to impaired quality of life and incomplete rehabilitation from their critical illness.

Contribution of the intensive care unit environment to sleep disruption in mechanically ventilated patients and healthy subjects.

Recent studies have challenged the traditional hypothesis that excessive environmental noise is central to the etiology of sleep disruption in the intensive care unit (ICU). We characterized potentially disruptive ICU noise stimuli and patient-care activities and determined their relative contributions to sleep disruption. Furthermore, we studied the effect of noise in isolation by placing healthy subjects in the ICU in both normal and noise-reduced locations. Seven mechanically ventilated patients and six healthy subjects were studied by continuous 24-hour polysomnography with time-synchronized environmental monitoring. Sound elevations occurred 36.5 +/- 20.1 times per hour of sleep and were responsible for 20.9 +/- 11.3% of total arousals and awakenings. Patient-care activities occurred 7.8 +/- 4.2 times per hour of sleep and were responsible for 7.1 +/- 4.4% of total arousals and awakenings. Healthy subjects slept relatively well in the typically loud ICU environment and experienced a quantitative, but not qualitative, improvement in sleep in a noise-reduced, single-patient ICU room. Our data indicate that noise and patient-care activities account for less than 30% of arousals and awakenings and suggest that other elements of the critically ill patient's environment or treatment should be investigated in the pathogenesis of ICU sleep disruption.

Daytime sleepiness in patients with CRF: impact of nocturnal hemodialysis.

BACKGROUND: Patients with end-stage renal disease (ESRD) have a high prevalence of sleep disorders, which are not improved by conventional hemodialysis (CHD). Although sleep disorders are commonly associated with complaints of excessive daytime sleepiness, the severity and pathogenesis of daytime sleepiness has not been evaluated objectively in patients with ESRD. Nocturnal hemodialysis (NHD) is a new technique that provides better clearance of uremic toxins than CHD and, consequently, may improve sleep quality and daytime sleepiness. The authors wished to determine the severity and pathogenesis of daytime sleepiness in patients with ESRD and evaluate the impact of NHD. METHODS: Sleep quality was monitored by overnight polysomnography, and daytime sleepiness was assessed by the multiple sleep latency test (MSLT). These measurements were performed in 24 patients (15 men and 9 women, 44 +/- 10 years) while on treatment with CHD and were repeated in 15 patients after conversion to NHD. RESULTS: The majority (54%) of patients on CHD were pathologically sleepy (somnolent group, mean sleep latency <5 minutes), and, in comparison with the remaining patients (alert group, mean sleep latency >5 minutes), their blood urea nitrogen (BUN; 77.9 +/- 9.8 v 60.2 +/- 12.0 mg/dL, P < 0.001; 27.8 +/- 3.5 v 21.5 +/- 4.3 mmol/L; P < 0.001), and periodic limb movement (PLM) index (57 +/- 47 v 6 +/- 10/hr; P = 0.002) were significantly higher. Furthermore, sleep latency was correlated with BUN (R = 0.58, P = 0.008). After conversion to NHD, there was a significant fall in BUN and the severity of sleep apnea, but the overall frequency of PLM and sleep fragmentation remained elevated. Nevertheless, there was a trend for the Somnolent group to become less sleepy on NHD, and this was associated with a modest reduction in the frequency of PLM. CONCLUSION: Excessive daytime sleepiness occurs in approximately 50% of patients with ESRD. The etiology appears to be related both to uremia and sleep fragmentation associated with PLM.