ABSTRACT

As the leading risk for death, population control of increased blood pressure represents a major challenge for all countries of the Americas. In the early 1990’s, Canada had a hypertension control rate of 13%. The control rate increased to 68% in 2010, accompanied by a sharp decline in cardiovascular disease. The unprecedented improvement in hypertension control started around the year 2000 when a comprehensive program to implement annually updated hypertension treatment recommendations started. The program included a comprehensive monitoring system for hypertension control. After 2011, there was a marked decrease in emphasis on implementation and evaluation and the hypertension control rate declined, driven by a reduction in control in women from 69% to 49%. A coalition of health and scientific organizations formed in 2011 with a priority to develop advocacy positions for dietary policies to prevent and control hypertension. By 2015, the positions were adopted by most federal political parties, but implementation has been slow.

This manuscript reviews key success factors and learnings. Some key success factors included having broad representation on the program steering committee, multidisciplinary engagement with substantive primary care involvement, unbiased up to date credible recommendations, development and active adaptation of education resources based on field experience, extensive implementation of primary care resources, annual review of the program and hypertension indicators and developing and emphasizing the few interventions important for hypertension control. Learnings included the need for having strong national and provincial government engagement and support, and retaining primary care organizations and clinicians in the implementation and evaluation.

Keywords
Cardiovascular diseases; hypertension; primary health care; education; Canada

RESUMEN

La hipertensión arterial representa el principal riesgo de muerte; controlarla a nivel de la población constituye un desafío importante para todos los países de la Región de las Américas. A principios de la década de 1990, Canadá presentaba una tasa de control de la hipertensión del 13%. La tasa de control aumentó al 68% en el 2010, lo que vino acompañado por una disminución importante de las enfermedades cardiovasculares. Esta mejora sin precedentes en el control de la hipertensión empezó alrededor del año 2000 cuando se inició un programa integral para aplicar las recomendaciones sobre el tratamiento de la hipertensión, actualizadas anualmente. El programa incluyó un sistema de monitoreo integral para el control de la hipertensión. Después del 2011, hubo una marcada disminución del énfasis en la implementación y la evaluación, y la tasa de control de la hipertensión disminuyó, impulsada por una reducción en el control en las mujeres, que pasó del 69% al 49%. En el 2011, se formó una coalición de organizaciones científicas y de salud con la prioridad de elaborar una campaña de defensa y promoción de las políticas alimentarias para prevenir y controlar la hipertensión. Para el año 2015, esta postura fue adoptada por la mayoría de los partidos políticos federales, aunque la implementación ha sido lenta.

En este artículo se revisan los factores clave de éxito y las lecciones aprendidas. Algunos factores clave de éxito fueron tener una amplia representación en el comité directivo del programa; el compromiso multidisciplinario con la participación sustantiva del sector de la atención primaria; unas recomendaciones creíbles, imparciales y actualizadas; el desarrollo y la adaptación activa de recursos educativos basados en la experiencia en el terreno; la amplia implementación de los recursos de la atención primaria; la revisión anual del programa y de los indicadores de hipertensión; y el desarrollo y el énfasis en unas pocas intervenciones importantes para el control de la hipertensión. Entre las lecciones aprendidas se encontró la necesidad de contar con un fuerte compromiso y apoyo del gobierno nacional y provincial, y de mantener a las organizaciones de atención primaria y al personal médico en la implementación y la evaluación.

Palabras clave
Enfermedades cardiovasculares; hipertensión; atención primaria de salud; educación; Canadá

RESUMO

O controle populacional da hipertensão arterial – o maior fator de risco de morte – representa um grande desafio para todos os países das Américas. No início da década de 1990, o Canadá tinha uma taxa de controle de hipertensão de 13%. Esse índice aumentou para 68% em 2010, acompanhado por um declínio acentuado das doenças cardiovasculares. A melhoria sem precedentes no controle da hipertensão começou por volta do ano 2000, quando teve início um programa abrangente para implementar recomendações de tratamento de hipertensão atualizadas anualmente. O programa incluía um sistema integral de monitoramento do controle da hipertensão. Após 2011, houve uma acentuada redução da ênfase na implementação e avaliação, e a taxa de controle de hipertensão caiu, principalmente às custas de uma redução deste controle em mulheres (de 69% para 49%). Uma coalizão de organizações científicas e de saúde formou-se em 2011 com a prioridade de desenvolver posições de defesa de políticas alimentares para prevenir e controlar a hipertensão. Até 2015, essas posições haviam sido adotadas pela maioria dos partidos políticos federais, mas a implementação tem sido lenta.

Este manuscrito examina fatores-chave de sucesso e aprendizados. Alguns fatores-chave de sucesso incluíram uma ampla representatividade no comitê diretor do programa, engajamento multidisciplinar (com envolvimento significativo da atenção primária), recomendações imparciais e confiáveis, elaboração e adaptação ativa de recursos didáticos com base na experiência de campo, ampla implementação dos recursos da atenção primária, revisão anual do programa e dos indicadores de hipertensão e desenvolvimento e ênfase das poucas intervenções realmente importantes para o controle da hipertensão. As lições aprendidas incluíram a necessidade de ter forte envolvimento e apoio dos governos nacional e subnacionais e manter organizações e médicos da atenção primária engajados na implementação e avaliação.

Palavras-chave
Doenças cardiovasculares; hipertensão; atenção primária à saúde; educação; Canadá

In Canada, the national hypertension control rate increased from 13% in the early 1990s to 68% in 2010, associated with a sharp decline in cardiovascular disease deaths and hospitalizations (¹1. Campbell N, Tobe S. The Canadian effort to prevent and control hypertension. Can other countries adopt Canadian strategies? Curr Opin Cardiol. 2010;25(4):366-72.

2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.

3. Campbell NRC, Ordunez P, Giraldo G, Rodriguez Morales YA, Lombardi C, Khan T, et al. WHO HEARTS: A global program to reduce cardiovascular disease burden: Experience implementing in the Americas and opportunities in Canada. Can J Cardiol. 2021;37(5):744-55.-⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). The improvement to both the highest and the largest increase in control rate ever reported for a national population started around the year 2000 and was largely attributed to the initiation of a comprehensive program to implement and adapt annually updated scientific hypertension treatment recommendations for all clinicians but focused on primary care, coupled with a surveillance system that evaluated the impact of the program (¹1. Campbell N, Tobe S. The Canadian effort to prevent and control hypertension. Can other countries adopt Canadian strategies? Curr Opin Cardiol. 2010;25(4):366-72.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). The program was overseen by a hypertension public health coalition including Blood Pressure Canada (BPC), Canadian Hypertension Society (CHS), College of Family Physicians of Canada (CFPC), Health Canada and the Heart and Stroke Foundation of Canada (HSF) (⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). In addition, the national pharmacists and nursing organizations (Canadian Pharmacists Association and Canadian Council of Cardiovascular Nurses, respectively) later became key stakeholders in oversight (⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). The steering committee organizations and their representatives were involved in knowledge translation and dissemination of the scientific recommendations into standardized tools and resources for primary care (⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). The program’s successes and failures were carefully evaluated each year and iterative revisions were made to improve the program (⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). The evaluation arm of the program identified critical ‘gaps’ in hypertension care (e.g., lower control of hypertension in people with diabetes (⁵5. Campbell NR, Leiter LA, Larochelle P, Tobe S, Chockalingam A, Ward R, et al. Hypertension in diabetes: a call to action. Can J Cardiol. 2009;25(5):299-302.)) and the implementation team subsequently focused on strategies to ‘close’ those gaps (⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ,⁶6. Campbell NR, McAlister FA, Quan H. Monitoring and evaluating efforts to control hypertension in Canada: Why, how, and what it tells us needs to be done about current care gaps. Can J Cardiol. 2013;29:564-70.). Between 2000 and 2010 there were approximately 350 publications on or about the program, its processes, recommendations or outcomes (⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). Detailed summaries of the key success factors of the program and how other countries could adopt the program have also been published (¹1. Campbell N, Tobe S. The Canadian effort to prevent and control hypertension. Can other countries adopt Canadian strategies? Curr Opin Cardiol. 2010;25(4):366-72.,²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). Importantly, many aspects of the Canadian program have been enhanced and integrated into the HEARTS in the America’s program led by the Pan American Health Organization.

In 2011, much of the government and some pharmaceutical industry support for the program and the primary care oversight was lost (⁷7. Tobe SW, Campbell NRC, Padwal RS, Khan NA, Singer J. Change of education strategy associated with slippage in Canadian hypertension awareness treatment and control rates. J Hum Hypertens. 2021;35(11):1054-1056.). The program emphasis shifted away from implementation and evaluation back towards a more traditional approach that focused on development of evidence-based guidelines. The resulting recommendations were often complex and difficult to implement in clinical practice (particularly within primary care). Subsequently, hypertension control rates declined to 58%, largely driven by a reduction in control rate in older women (69% in 2009-2011 to 49% in 2016-2017) (⁸8. Leung AA, Williams JVA, McAlister FA, Campbell NRC, Padwal RS, Tran K, et al. Worsening hypertension awareness, treatment, and control rates in Canadian women between 2007 and 2017. Can J Cardiol. 2020;36:732-9.). High rates of hypertension control in men were sustained but the rate of decline in cardiovascular disease has slowed in both men and women (³3. Campbell NRC, Ordunez P, Giraldo G, Rodriguez Morales YA, Lombardi C, Khan T, et al. WHO HEARTS: A global program to reduce cardiovascular disease burden: Experience implementing in the Americas and opportunities in Canada. Can J Cardiol. 2021;37(5):744-55.). The objective of this manuscript is to both inspire and caution other national hypertension control programs by summarizing the changes in Canadian programs to control hypertension and what were viewed as the success factors and learnings associated with the increases and decreases in hypertension control rate in Canada.

BRIEF HISTORY OF HYPERTENSION CONTROL EFFORTS IN CANADA

Around 1980, Canada recognized cardiovascular diseases (CVD) including stroke as a leading cause of death and disability and prioritized its prevention and control (³3. Campbell NRC, Ordunez P, Giraldo G, Rodriguez Morales YA, Lombardi C, Khan T, et al. WHO HEARTS: A global program to reduce cardiovascular disease burden: Experience implementing in the Americas and opportunities in Canada. Can J Cardiol. 2021;37(5):744-55.). The Canadian Heart Health Initiative (CHHI) conducted an extensive national survey of cardiovascular risks (1985-1992) as well as a large number of pilot interventions for CVD prevention and control (⁹9. Stachenko S. The Canadian Heart Health Initiative: a countrywide cardiovascular disease prevention strategy. J Hum Hypertens. 1996;10(Suppl 1):S5-S8.). The survey estimated a hypertension prevalence rate of 21% and a control rate of 13% (at <140/90 mmHg) (¹⁰10. Joffres MR, Hamet P, MacLean DR, L'Italien GJ, Fodor G. Distribution of blood pressure and hypertension in Canada and the United States. Am J Hypertens. 2001;14(11 Pt 1):1099-105.). The hypertension control rate (at <140/90 mmHg) in those with diabetes was much lower at 9% (¹⁰10. Joffres MR, Hamet P, MacLean DR, L'Italien GJ, Fodor G. Distribution of blood pressure and hypertension in Canada and the United States. Am J Hypertens. 2001;14(11 Pt 1):1099-105.). Nearly all the CHHI pilot interventions were discontinued following the end of the funding in 1992. In the late 1990s, BPC developed a strategy for prevention and control of hypertension (¹¹11. Chockalingam A, Campbell N, Ruddy T, Taylor G, Dry V. High blood pressure prevention and control: A Canadian national strategy. CVD Prevention. 2000;3(1):81-93.). Subsequently in 1998, an innovative approach to controlling hypertension was proposed by BPC and developed with the support of major Canadian health and scientific organizations (²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ,¹²12. Zarnke KB, Campbell NR, McAlister FA, Levine M. A novel process for updating recommendations for managing hypertension: Rationale and methods. Can J Cardiol. 2000;16(9):1094-102.,¹³13. Campbell NRC, Nagpal S, Drouin D. Implementing hypertension recommendations. Can J Cardiol. 2001;17(8):851-6.). CHS had a relatively long history of strong evidence-based hypertension pharmacological treatment recommendations that were published episodically (²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,¹²12. Zarnke KB, Campbell NR, McAlister FA, Levine M. A novel process for updating recommendations for managing hypertension: Rationale and methods. Can J Cardiol. 2000;16(9):1094-102.). BPC provided a mix of evidence- and opinion-based recommendations focused on lifestyle, blood pressure measurement (including home monitoring) and adherence to management (⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ,¹⁴14. Campbell NRC, Drouin D, Feldman R. A brief history of canadian hypertension recommendations. Hypertension Canada. 2005;82:1, 5, 7-8.). BPC had an evolving but limited implementation plan for its recommendations (⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ,¹⁴14. Campbell NRC, Drouin D, Feldman R. A brief history of canadian hypertension recommendations. Hypertension Canada. 2005;82:1, 5, 7-8.). Unfortunately, the CHS and BPC recommendation processes were not associated with any marked changes in hypertension control indicators (⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ).

In 2000, the new annual hypertension control program was launched to 1) increase the scientific rigor of recommendations and maintain them up to date, 2) adapt the recommendations for primary care with widespread dissemination and 3) evaluate the program and hypertension control indicators (introduced in 2003) (²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,¹²12. Zarnke KB, Campbell NR, McAlister FA, Levine M. A novel process for updating recommendations for managing hypertension: Rationale and methods. Can J Cardiol. 2000;16(9):1094-102.). When the Knowledge to Action framework was published in 2006, it was found to fit closely to the principles developed in this program (https://rnao.ca/leading-change-toolkit/knowledge-to-action, accessed July 12, 2022). The new program was launched by BPC, CHS, HSF, CFPC and Health Canada (Federal government) immediately following the 1999 release of the hypertension lifestyle and management recommendations. The new process was iterative, expanding and revising prior recommendations, based on an annual critical review of the previous year’s program (¹1. Campbell N, Tobe S. The Canadian effort to prevent and control hypertension. Can other countries adopt Canadian strategies? Curr Opin Cardiol. 2010;25(4):366-72.,²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,¹⁶16. Campbell NR, Kaczorowski J, Lewanczuk RZ, Feldman R, Poirier L, Kwong MM, et al. 2010 Canadian Hypertension Education Program (CHEP) recommendations: the scientific summary - an update of the 2010 theme and the science behind new CHEP recommendations. Can J Cardiol. 2010;26(5):236-40.).The program was also annually refocused on a critical care gap identified through on-going program evaluation (⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ,⁶6. Campbell NR, McAlister FA, Quan H. Monitoring and evaluating efforts to control hypertension in Canada: Why, how, and what it tells us needs to be done about current care gaps. Can J Cardiol. 2013;29:564-70.). In 2006, the primary care program oversight was expanded from primary care physicians to include national organizations for nursing and pharmacy and the target audience expanded to include the public (²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). The evaluation system rapidly evolved to include new and revised surveys and methodologies (²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ,⁶6. Campbell NR, McAlister FA, Quan H. Monitoring and evaluating efforts to control hypertension in Canada: Why, how, and what it tells us needs to be done about current care gaps. Can J Cardiol. 2013;29:564-70.). Increasing support came from federal government organizations and the pharmaceutical industry to expand the program (⁶6. Campbell NR, McAlister FA, Quan H. Monitoring and evaluating efforts to control hypertension in Canada: Why, how, and what it tells us needs to be done about current care gaps. Can J Cardiol. 2013;29:564-70.).The HSF developed a parallel implementation and evaluation program in Ontario (which contains approximately one-third of the Canadian population) that collaborated with and leveraged the national program (²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). The HSF and the federal government developed new physical measures surveys on representative samples of the Canadian population reporting hypertension indicators every 2 years (²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,⁸8. Leung AA, Williams JVA, McAlister FA, Campbell NRC, Padwal RS, Tran K, et al. Worsening hypertension awareness, treatment, and control rates in Canadian women between 2007 and 2017. Can J Cardiol. 2020;36:732-9.,¹⁷17. Bryan S LM, Campbell N, Clarke J, Tremblay MS. Resting blood pressure and heart rate measurement in the Canadian Health Measures Survey, cycle 1. Health Reports. 2010;21:1-8.). The surveys showed a stable prevalence of hypertension (~21% of adults) and marked improvements in rates of awareness of the diagnosis, treatment and control. Control rates (<140/90 mmHg) fluctuated from 64% to 68% between 2006 to 2010 with the control rate in people with diabetes increasing to over 80% (¹⁸18. McAlister FA, Robitaille C, Gillespie C, Yuan K, Rao DP, Grover S, et al. The impact of cardiovascular risk factor profiles on blood pressure control rates in adults from Canada and the United States. Can J Cardiol. 2013;29:598-605.,¹⁹19. McAlister FA, Wilkins K, Joffres M, Leenen FH, Fodor G, Gee M, et al. Changes in the rates of awareness, treatment and control of hypertension in Canada over the past two decades. CMAJ. 2011;183(9):1007-13.). There were much higher control rates in patients with increased cardiovascular risk (¹⁸18. McAlister FA, Robitaille C, Gillespie C, Yuan K, Rao DP, Grover S, et al. The impact of cardiovascular risk factor profiles on blood pressure control rates in adults from Canada and the United States. Can J Cardiol. 2013;29:598-605.,²⁰20. McAlister FA, Feldman RD, Wyard K, Brant R, Campbell NR. The impact of the Canadian Hypertension Education Programme in its first decade. Eur Heart J. 2009;30(12):1434-9.). The increase in hypertension control was not associated with an improvement in lifestyles but was strongly associated with an increase in prescriptions of antihypertensive medications (²⁰20. McAlister FA, Feldman RD, Wyard K, Brant R, Campbell NR. The impact of the Canadian Hypertension Education Programme in its first decade. Eur Heart J. 2009;30(12):1434-9.,²¹21. Neutel CI, Campbell NR. Changes in lifestyle after hypertension diagnosis in Canada. Can J Cardiol. 2008;24(3):199-204.).

In 2010, the hypertension control program integrated with BPC, and the CHS to form Hypertension Canada (⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). Coincidently, many of the name brand antihypertensive drugs were losing patent protection resulting in less financial support from the pharmaceutical industry, resulting in less amplification of key messages for hypertension control and the federal government withdrew its involvement and all support from the hypertension control program (⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ,⁷7. Tobe SW, Campbell NRC, Padwal RS, Khan NA, Singer J. Change of education strategy associated with slippage in Canadian hypertension awareness treatment and control rates. J Hum Hypertens. 2021;35(11):1054-1056.). Nevertheless, in 2010 Hypertension Canada retained 10-fold higher funding for hypertension control than was available in the early 2000s. However, the newly formed Hypertension Canada removed primary care and the HSF from the oversight role of the hypertension control program and put the individual components of the previously integrated recommendations, implementation and evaluation program on an operations committee that had multiple functions competing with hypertension control (⁷7. Tobe SW, Campbell NRC, Padwal RS, Khan NA, Singer J. Change of education strategy associated with slippage in Canadian hypertension awareness treatment and control rates. J Hum Hypertens. 2021;35(11):1054-1056.). The support for and processes of implementation and evaluation were markedly reduced, and integrated annual program review ceased. Key clinician opinion leaders in primary care and specialties, who had participated as volunteers largely due to their passion and interest in blood pressure control, were largely replaced by or put under supervision of paid staff who had relatively little influence, hypertension expertise, or clinical training. Many clinicians disengaged from Hypertension Canada and replacements amongst the next generation of clinical leaders in hypertension had not been identified. Many of the implementation resources were no longer updated and disseminated and publications and other implementation efforts were no longer documented. The annual surveillance evaluation was no longer regularly conducted.

Given much of hypertension is attributed to dietary risks (high sodium, low potassium and obesity), in 2011 a coalition of major national health and scientific organizations reformed and developed a national strategy for prevention and control of hypertension with an emphasis on the prevention and control of hypertension through dietary policies (https://hypertension.ca/advocacy/, accessed Feb 15, 2022) (⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). The coalition developed a broad array of evidence-based consensus positions for advocacy (https://hypertension.ca/wp-content/uploads/2018/12/Final-Call-for-healthy-Food_EN_with-supporters_April-1-2016.pdf, accessed Feb 15, 2022). Supported by the Heart and Stroke Foundation, Dietitians of Canada, Food Secure Canada, and the Childhood Obesity Network, the dietary policies were adopted by all but one federal political party. However, the implementation of the policies has been slow and limited until recently, outside of efforts to reduce dietary sodium.

When an updated evaluation of the Canadian Health Measures Survey was performed, hypertension control in women was found to have declined from 69.0% in 2009-2011 to 49.2% in 2016-2017, while the control rate in men remained relatively unchanged (65.2% and 67.4%, respectively) (⁸8. Leung AA, Williams JVA, McAlister FA, Campbell NRC, Padwal RS, Tran K, et al. Worsening hypertension awareness, treatment, and control rates in Canadian women between 2007 and 2017. Can J Cardiol. 2020;36:732-9.). The precise reasons for the gender difference in control rate remains unexplained but resistant hypertension is more common in Canadian women than men explaining a small proportion of the lack of control (²²22. Leung AA, Williams JVA, Tran KC, Padwal RS. Epidemiology of resistant hypertension in Canada. Can J Cardiol. 2022;38:681-7.). Women have currently unexplained declining rates of awareness and treatment (²³23. Leung AA, Bell A, Tsuyuki RT, Campbell NRC. Refocusing on hypertension control in Canada. CMAJ. 2021;193(23):E854-E5.). Similar gender differences in hypertension control were also found in the United States (²⁴24. Muntner P, Hardy ST, Fine LJ, Jaeger BC, Wozniak G, Levitan EB, et al. Trends in blood pressure control among US adults with hypertension, 1999-2000 to 2017-2018. JAMA. 2020;324(12):1190-200.). The Surgeon General of the United States responded with a national call to action to enhance hypertension control, while the Canadian Federal Agencies remain disengaged (³3. Campbell NRC, Ordunez P, Giraldo G, Rodriguez Morales YA, Lombardi C, Khan T, et al. WHO HEARTS: A global program to reduce cardiovascular disease burden: Experience implementing in the Americas and opportunities in Canada. Can J Cardiol. 2021;37(5):744-55.,²⁵25. U.S. Department of Health and Human Services. The Surgeon General's call to action to control hypertension. Washington, DC: U.S. Department of Health and Human Services; 2020:1-48.). New recommendations that define hypertension control as <130/80 mmHg in people with high cardiovascular risk will result in many more Canadians with hypertension being defined as ‘uncontrolled’, emphasizing the need for urgent action (²⁶26. Campbell NRC, Paccot Burnens M, Whelton PK, Angell SY, Jaffe MG, Cohn J, et al. 2021 World Health Organization guideline on pharmacological treatment of hypertension: Policy implications for the region of the Americas. Lancet Reg Health Am. 2022;9:100219.).

KEY SUCCESS FACTORS FOR ENHANCING HYPERTENSION CONTROL

The key success factors with enhanced control have been evaluated qualitatively and are documented more extensively in other publications (¹1. Campbell N, Tobe S. The Canadian effort to prevent and control hypertension. Can other countries adopt Canadian strategies? Curr Opin Cardiol. 2010;25(4):366-72.,²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). Table 1 shows selected learnings from the program. In Canada, primary care is relatively strong and evolving and this is considered essential for hypertension control (²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.).

Implementation of the recommendations is viewed as vital (¹1. Campbell N, Tobe S. The Canadian effort to prevent and control hypertension. Can other countries adopt Canadian strategies? Curr Opin Cardiol. 2010;25(4):366-72.,²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ,²⁷27. Campbell N, Feldman R, Drouin D. Hypertension guidelines: Criteria that might make them more clinically useful. Am J Hypertens. 2003;16(8):698-9.,²⁸28. Drouin D, Campbell NR, Kaczorowski J. Implementation of recommendations on hypertension: The Canadian Hypertension Education Program. Can J Cardiol. 2006;22(7):595-8.). The hypertension control program in 2000 included primary care oversight and the rapidly evolving implementation program had extensive leadership and engagement of primary care key opinion leaders and included formal ties to their national organizations (¹1. Campbell N, Tobe S. The Canadian effort to prevent and control hypertension. Can other countries adopt Canadian strategies? Curr Opin Cardiol. 2010;25(4):366-72.,²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ,¹²12. Zarnke KB, Campbell NR, McAlister FA, Levine M. A novel process for updating recommendations for managing hypertension: Rationale and methods. Can J Cardiol. 2000;16(9):1094-102.,¹⁴14. Campbell NRC, Drouin D, Feldman R. A brief history of canadian hypertension recommendations. Hypertension Canada. 2005;82:1, 5, 7-8.,²⁹29. Campbell N, Drouin D, McAlister F, Onysko J, Tobe S, Touyz R. CHEP: A national program to improve the treatment and control of hypertension. Hypertension Canada. 2005;84:3,6.). These organizations and individuals used their communications systems to endorse and to help disseminate relevant hypertension resources (¹1. Campbell N, Tobe S. The Canadian effort to prevent and control hypertension. Can other countries adopt Canadian strategies? Curr Opin Cardiol. 2010;25(4):366-72.,²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ,¹³13. Campbell NRC, Nagpal S, Drouin D. Implementing hypertension recommendations. Can J Cardiol. 2001;17(8):851-6.,²⁸28. Drouin D, Campbell NR, Kaczorowski J. Implementation of recommendations on hypertension: The Canadian Hypertension Education Program. Can J Cardiol. 2006;22(7):595-8.). The adaptation of the scientific recommendations was based on important gaps in clinical care with extensive involvement of primary care to ensure relevance to their practices (⁶6. Campbell NR, McAlister FA, Quan H. Monitoring and evaluating efforts to control hypertension in Canada: Why, how, and what it tells us needs to be done about current care gaps. Can J Cardiol. 2013;29:564-70.). New themes were developed based on important ‘clinical gaps’ in care (e.g., poor hypertension control in people with diabetes) (¹1. Campbell N, Tobe S. The Canadian effort to prevent and control hypertension. Can other countries adopt Canadian strategies? Curr Opin Cardiol. 2010;25(4):366-72.). Each year implementation resources were revised by multidisciplinary and interprofessional volunteers, based on field experience and also to tailor new evidence and the new theme for local and regional needs (¹1. Campbell N, Tobe S. The Canadian effort to prevent and control hypertension. Can other countries adopt Canadian strategies? Curr Opin Cardiol. 2010;25(4):366-72.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). Hence, educational resources were optimized over time based on their usefulness in clinical practice. Standardized slide sets and educational materials were designed to align health care professionals and the public with the importance of achieving hypertension control and widely disseminated through lectures and publications (²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). Five key messages on how to achieve control were developed and annually one or two additional key messages were added to reflect the annual themes (e.g., key messages from 2009, Table 2) (¹1. Campbell N, Tobe S. The Canadian effort to prevent and control hypertension. Can other countries adopt Canadian strategies? Curr Opin Cardiol. 2010;25(4):366-72.,²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ). All implementation resources emphasized the key messages. There were approximately 30-50 mainly Canadian publications on the hypertension recommendations most years and most national primary care meetings contained sessions on the recommendations and hypertension control (¹1. Campbell N, Tobe S. The Canadian effort to prevent and control hypertension. Can other countries adopt Canadian strategies? Curr Opin Cardiol. 2010;25(4):366-72.,²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ).

Monitoring and evaluation of the program was also viewed as important (¹1. Campbell N, Tobe S. The Canadian effort to prevent and control hypertension. Can other countries adopt Canadian strategies? Curr Opin Cardiol. 2010;25(4):366-72.,²2. Campbell N, Young ER, Drouin D, Legowski B, Adams MA, Farrell J, et al. A framework for discussion on how to improve prevention, management and control of hypertension in Canada. Can J Cardiol. 2012;28:262-9.,⁴4. Campbell N, Young E, Adams M, Baclic O, Drouin D, Farrell J, et al. Pan Canadian Framework on the Prevention and Control of Hypertension: a discussion paper on the way forward; 2012. Available from: https://hypertension.ca/wp-content/uploads/2017/11/2012_Final_Hypertension_Framework_English.pdf Accessed on July 12 2022.
https://hypertension.ca/wp-content/uploa... ,⁶6. Campbell NR, McAlister FA, Quan H. Monitoring and evaluating efforts to control hypertension in Canada: Why, how, and what it tells us needs to be done about current care gaps. Can J Cardiol. 2013;29:564-70.,³⁰30. Campbell NR, Onysko J. The Outcomes Research Task Force and the Canadian Hypertension Education Program. Can J Cardiol. 2006;22(7):556-8.). The vast majority of the work was done by health care professional volunteers. Early in the program, the volunteers were dismayed and discouraged by the amount of work required but, once early success was demonstrated, many more volunteers and especially more influential volunteers joined. The demonstration of success, particularly of markedly enhanced hypertension control associated with reductions in total mortality, CVD mortality and hospitalization also resulted in greater engagement of the federal and provincial governments, HSF and pharmaceutical industry (¹⁹19. McAlister FA, Wilkins K, Joffres M, Leenen FH, Fodor G, Gee M, et al. Changes in the rates of awareness, treatment and control of hypertension in Canada over the past two decades. CMAJ. 2011;183(9):1007-13.,²⁰20. McAlister FA, Feldman RD, Wyard K, Brant R, Campbell NR. The impact of the Canadian Hypertension Education Programme in its first decade. Eur Heart J. 2009;30(12):1434-9.,³¹31. Campbell NR, McAlister FA, Brant R, Levine M, Drouin D, Feldman R, et al. Temporal trends in antihypertensive drug prescriptions in Canada before and after introduction of the Canadian Hypertension Education Program. J Hypertens. 2003;21(8):1591-7.,³²32. Campbell NR, Brant R, Johansen H, Walker RL, Wielgosz A, Onysko J, et al. Increases in antihypertensive prescriptions and reductions in cardiovascular events in Canada. Hypertension. 2009;53(2):128-34.). Improved surveillance through the federal and provincial governments allowed more nuanced targeting of implementation resources towards demonstrated clinical care gaps (⁶6. Campbell NR, McAlister FA, Quan H. Monitoring and evaluating efforts to control hypertension in Canada: Why, how, and what it tells us needs to be done about current care gaps. Can J Cardiol. 2013;29:564-70.,¹⁹19. McAlister FA, Wilkins K, Joffres M, Leenen FH, Fodor G, Gee M, et al. Changes in the rates of awareness, treatment and control of hypertension in Canada over the past two decades. CMAJ. 2011;183(9):1007-13.,²⁰20. McAlister FA, Feldman RD, Wyard K, Brant R, Campbell NR. The impact of the Canadian Hypertension Education Programme in its first decade. Eur Heart J. 2009;30(12):1434-9.,³²32. Campbell NR, Brant R, Johansen H, Walker RL, Wielgosz A, Onysko J, et al. Increases in antihypertensive prescriptions and reductions in cardiovascular events in Canada. Hypertension. 2009;53(2):128-34.).

It is critical that the recommendations process be credible. The process had multiple steps to reduce commercial and other sources of bias (³³33. Tobe SW, Touyz RM, Campbell NR, Canadian Hypertension Education Program. The Canadian Hypertension Education Program - a unique Canadian knowledge translation program. Can J Cardiol. 2007;23(7):551-5.). At the start, annually updated recommendations were viewed as important as results of major clinical trials were being frequently published and there was a perception that guidelines became quickly out of date. The recommendations process incorporated a diverse spectrum of expertise (e.g., evidence-based medicine experts, nursing, pharmacy, family medicine, psychology, sociology, exercise physiology) in addition to traditional clinical specialists and scientists ensuring they were credible and addressed the needs and views of a broad audience. Adding to the impact (and global influence) of the Canadian recommendations was pioneering work in blood pressure measurement, including recognition of the pivotal role that automated office blood pressure measurement can play to standardize in-office measurement, early adoption of guidelines emphasizing the central importance of out-of-office measurement, and the use of initial combination drug treatment (¹⁶16. Campbell NR, Kaczorowski J, Lewanczuk RZ, Feldman R, Poirier L, Kwong MM, et al. 2010 Canadian Hypertension Education Program (CHEP) recommendations: the scientific summary - an update of the 2010 theme and the science behind new CHEP recommendations. Can J Cardiol. 2010;26(5):236-40.,³⁴34. Cloutier L, Daskalopoulou SS, Padwal RS, Lamarre-Cliche M, Bolli P, McLean D, et al. A new algorithm for the diagnosis of hypertension in Canada. Can J Cardiol. 2015;31(5):620-30.,³⁵35. Khan NA, Hemmelgarn B, Herman RJ, Rabkin SW, McAlister FA, Bell CM, et al. The 2008 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 - therapy. Can J Cardiol. 2008;24(6):465-75.).

CAN CANADA DO BETTER?

The Canadian program achieved success between 2000 and 2010, long before the WHO HEARTS program was developed. The WHO HEARTS program outlines what are currently understood to be state-of-the-art interventions to control hypertension. Key WHO HEARTS recommendations such as using highly simplified directive treatment algorithms, and regular monitoring of treatment and control at the clinic level were not part of the Canadian intervention (³3. Campbell NRC, Ordunez P, Giraldo G, Rodriguez Morales YA, Lombardi C, Khan T, et al. WHO HEARTS: A global program to reduce cardiovascular disease burden: Experience implementing in the Americas and opportunities in Canada. Can J Cardiol. 2021;37(5):744-55.). Primary care is relatively strong and getting stronger in Canada. Many primary care clinics are multidisciplinary and have advanced information systems capable of performance reporting on hypertension control. These WHO HEARTS interventions would be very important to further enhance hypertension control in Canada. Over the timeframe of the Canadian program, clinical programs supported by commercial sources have become much less accepted emphasizing the critical nature of sustained government support. Health and scientific organizations need to sustain advocacy for health food policies to prevent and control hypertension and to engage federal and provincial governments in prioritizing hypertension control vis-a-vis WHO HEARTS (³3. Campbell NRC, Ordunez P, Giraldo G, Rodriguez Morales YA, Lombardi C, Khan T, et al. WHO HEARTS: A global program to reduce cardiovascular disease burden: Experience implementing in the Americas and opportunities in Canada. Can J Cardiol. 2021;37(5):744-55.). Although more research is needed to better understand the decline of hypertension control in Canadian women after 2011, the previous hypertension control program (2000-2010) had unprecedented success in closing a variety of hypertension control clinical gaps at a national population level. Recently there has been a call for the Canadian federal and provincial governments to collaborate with the health and scientific sectors to develop and implement a strategic approach to hypertension control along the lines of the WHO HEARTS program and based on initial successes of that program in a diverse group of countries in the Americas (³3. Campbell NRC, Ordunez P, Giraldo G, Rodriguez Morales YA, Lombardi C, Khan T, et al. WHO HEARTS: A global program to reduce cardiovascular disease burden: Experience implementing in the Americas and opportunities in Canada. Can J Cardiol. 2021;37(5):744-55.). The need has become even more compelling due to the expected negative impact of the pandemic.

Conclusion

The unprecedented improvement in hypertension control in Canada, achieved by intensive implementation of simplified hypertension recommendations, adopted for and heavily supported by primary care organizations, may inspire other national programs that success is achievable. The more recent decline in Canadian hypertension control rate was associated with a loss of governmental and primary care oversight, a loss of governmental and commercial financial support and a loss of programmatic focus on hypertension control. A critical lesson for all population hypertension control programs is the need for sustained programmatic primary care and governmental support if success in hypertension control is to be achieved and sustained.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH or the Pan American Health Organization (PAHO).

REFERENCES

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