Self-reported sleep quality and exercise in polycystic ovary syndrome: A secondary analysis of a pilot randomized controlled trial.

OBJECTIVE: To examine the proportion of participants with poor sleep quality, evaluate the associations between sleep quality and anthropometric and cardiometabolic health markers, and evaluate the effect of high intensity interval training (HIIT) and continuous aerobic exercise training (CAET) on sleep quality in polycystic ovary syndrome (PCOS). DESIGN: Secondary analysis of a pilot randomized controlled trial. PATIENTS: Women with PCOS aged 18-40 years. MEASUREMENTS: The Pittsburgh Sleep Quality Index (PSQI) was measured at baseline and following a 6-month exercise intervention. A PSQI score >5 indicates poor sleep. Linear regression was used to evaluate the associations between PSQI score and anthropometric and cardiometabolic health markers, and the effect of exercise training on these associations. RESULTS: Thirty-four participants completed the PSQI at baseline, and 29 postintervention: no-exercise control (n = 9), HIIT (n = 12) and CAET (n = 8). At baseline, 79% had poor sleep quality. Baseline PSQI score was positively correlated with body mass index, waist circumference, body weight, haemoglobin A1c and insulin resistance. Mean PSQI score changes were -0.4 (SD 1.1), -0.7 (SD 0.6) and -0.5 (SD 0.9) for control, HIIT and CAET, respectively. For HIIT participants, change in PSQI score was associated with changes in body weight (B = .27, 95% CI 0.10-0.45) and waist circumference (B = .09, 95% CI 0.02-0.17). CONCLUSION: Most participants had poor sleep quality which was associated with poorer anthropometric and cardiometabolic health markers. There were no statistically significant changes in PSQI score with exercise training. With HIIT training, decreases in the sleep efficiency score were associated with reductions in body weight and waist circumference. Further studies are needed to determine the effect of exercise training on sleep quality.

Sociodemographic Factors Associated With Objectively Measured Moderate- to Vigorous-intensity Physical Activity in Adults With Type 2 Diabetes: Cross-sectional Results From the Canadian Health Measures Survey (2007 to 2017).

OBJECTIVES: Individuals with type 2 diabetes should engage in ≥150 min of moderate- to vigorous-intensity physical activity (MVPA) weekly, but most do not meet this guideline. Understanding how social determinants correlate with physical activity in adults with type 2 diabetes may improve development and delivery of physical activity interventions. This study aimed to explore associations between objectively measured MVPA with sociodemographic characteristics in adults with type 2 diabetes. METHODS: Cross-sectional data from cycles 1 through 5 of the Canadian Health Measures Survey were analyzed. Participants (N=876) 20 to 79 years of age with type 2 diabetes and ≥4 days of valid activity monitor wear were included. Proportions with 95% confidence intervals for objectively measured MVPA were compared according to sociodemographic characteristics. Ordinal logistic regression was used. Secondary outcomes included light-intensity physical activity, screen time and proportion of activity monitor wear time spent sedentary. RESULTS: Only 15.5% of women and 26.2% of men met Diabetes Canada physical activity guidelines, and approximately 75% of activity monitor wear time was spent in a sedentary state. Higher odds of achieving low levels of physical activity were observed among women who were former or current smokers (odds ratio [OR], 4.51; p<0.001), and among men who were ≥65 years of age (OR, 2.92; p<0.001), of middle (OR, 2.20; p<0.05) and lowest (OR, 3.06; p<0.05) income tertiles and current or former smokers (OR, 3.01; p<0.05). CONCLUSIONS: Sociodemographic factors are strongly associated with levels of MVPA in adults with type 2 diabetes. Sociodemographic information should be routinely collected by clinicians and used to inform more tailored and effective interventions for this patient population.

Approaches to Psychosocial Care Within Tertiary Diabetes Care Centres in Canada: An Environmental Scan.

BACKGROUND: Patients with diabetes facing psychosocial challenges often struggle with diabetes self-management, and thereby are at risk of complications arising from hyperglycemia and hypoglycemia. Despite the Diabetes Canada Clinical Practice Guidelines' recommendations for diabetes centres to offer psychosocial services for the screening and support of patients with psychosocial barriers, the extent to which these recommendations have been implemented in centres across Canada is unknown. METHODS: Tertiary adult diabetes centres affiliated with academic institutions were invited to participate in our quantitative survey (n=40). At each centre, a structured telephone interview was administered to a manager, as well as a social worker and psychologist (if employed at the centre), to inquire regarding the psychosocial services offered. RESULTS: Thirty diabetes centres (75%) completed at least one questionnaire. Participating diabetes centres varied considerably in capacity, employing from 3 to more than 50 diabetes educators and from 0 to 20 endocrinologists. Approximately 80% of centres reported providing patients with access to psychosocial services, but only about 50% had a dedicated, internal psychosocial team. Stratified results showed centres that are the main centres affiliated with academic teaching hospitals were more likely to have embedded psychosocial services and to make referrals for psychosocial concerns when compared with satellite centres. The majority of managers reported that their staffing and funding model provided inadequate psychosocial support and that increased funding for psychosocial care was either somewhat of a priority or a high priority. CONCLUSIONS: Diabetes centres across Canada struggle to offer adequate psychosocial services; greater funding and training for staff is required to uphold the Diabetes Canada Clinical Practice Guidelines.

Prevalence of and risk factors for excess weight gain in pregnancy: a cross-sectional study using survey data.

BACKGROUND: Maternal weight gain during pregnancy is required for fetal development; however, excess gestational weight gain is associated with increased maternal and neonatal morbidity. We aimed to determine the proportion of Canadian women who gained excess weight during pregnancy and to identify risk factors for excess gestational weight gain. METHODS: Self-reported data on maternal weight gain were collected from the 2015/16 and 2017/18 cycles of the Canadian Community Health Survey (CCHS), a cross-sectional population-based survey. We included females aged 15 to 54 years with data on height, prepregnancy weight and gestational weight gain. We defined excess gestational weight gain in terms of preconception body mass index (BMI) according to the 2009 guideline of the US Institute of Medicine. We used logistic regression to evaluate potential risk factors for excess gestational weight gain. RESULTS: Of 1 335 615 Canadian women (weighted from approximately 9300 survey respondents), 422 043 (32%) gained excess weight during pregnancy. Women with obesity had 33% lower odds of gaining excess weight relative to women with overweight (odds ratio 0.67, 95% confidence interval 0.48-0.94). Risk factors for excess gestational weight gain were lower education level, white or Indigenous identity, smoking, mood disorder, anxiety disorder and Canadian citizenship. INTERPRETATION: One-third of Canadian women in this survey had excess gestational weight gain during pregnancy, and women with obesity had lower odds of gaining excess weight during pregnancy relative to women with overweight. Strategies are needed to reduce the proportion of Canadian women who gain excess weight during pregnancy, regardless of preconception BMI.

Sexual Activity After Acute Coronary Syndrome: A Qualitative Approach to Patient and Partner Experiences.

BACKGROUND: Little is known about how best to support both patients and their partners in the reengagement of sexual activity (SA) after acute coronary syndrome (ACS), with sparse direct data from the partner on their needs and concerns in the area of SA support. OBJECTIVES: We undertook a qualitative study to address this gap in the literature through 3 objectives from a patient and partner perspective: (1) to characterize the experience of reengaging in SA post ACS, (2) to identify needs and priorities in the area of SA support post ACS, and (3) to determine whether cardiac rehabilitation (CR) could be an acceptable point of intervention for SA support. METHODS: Semistructured qualitative interviews were conducted with 6 male patients who were post ACS and their partners (age range, 47-81 years). Patients were criterion sampled from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease database. Inductive thematic data analysis was conducted. RESULTS: Four themes were identified: "importance," "support received," "on their own," and "wanting support." Couples reaffirmed the importance of SA pre and post ACS, reported SA support as currently insufficient but articulated ways it could be improved, and reported CR as a current source of SA support but thought there could be room for improvement on the content and delivery of such information. CONCLUSIONS: This study illustrates the potential value of promoting SA support for both patients who are post ACS and their partners and reports that SA support provided at CR would be viewed as important, needed, and acceptable.

Comparative Success of Recruitment Strategies for an Exercise Intervention Trial Among Women With Polycystic Ovary Syndrome: Observational Study.

BACKGROUND: Effective and efficient participant recruitment is a key determinant of the success of a research program. Previously reported recruitment strategies have displayed variable success rates in studies on women with polycystic ovary syndrome (PCOS). OBJECTIVE: This study aimed to evaluate the effectiveness and cost per participant of the recruitment strategies that we used in a prospective randomized controlled trial to examine the effects of exercise training among inactive women with PCOS, who are aged 18-40 years. METHODS: The 4 recruitment methods we used were as follows: (1) referral by health care providers or by word of mouth, (2) media (eg, local newspaper stories and radio interviews), (3) Facebook advertisements, and (4) unpaid advertisements including posters and websites. The proportions of potential, eligible, and enrolled participants recruited with each method were determined and compared using tests of proportion. The time investment and cost per participant enrolled were calculated for each recruitment strategy. RESULTS: Of 200 potential participants screened, 98 (49%) were recruited from unpaid advertisements (posters and websites), 70 (35%) from Facebook advertisements, 16 (8%) by referral, and 16 (8%) from traditional media (newspaper and radio). Every potential participant was recruited from separate means (ie, no participant was approached through more than one recruitment method). A total of 109 (54.5%) women were deemed eligible for participation in the trial, and 60 (30.0%) were enrolled. The proportion of potential participants who completed the trial was higher for those recruited from traditional media than from Facebook advertisements (n=7/16, 44% vs n=13/70, 19%, respectively; P=.03) or unpaid advertisements (n=7/16, 44% vs n=13/98, 13%, respectively; P=.002). The cost per participant was Can $18.21 (US $14.46) for Facebook advertisements and Can $43.88 (US $34.85) for unpaid advertisements. There were no direct trial costs for referrals or traditional media. CONCLUSIONS: For this trial, each method was important for recruiting inactive women with PCOS because no participant reported learning about the trial through more than one method. Unpaid advertisements and Facebook advertisements helped recruit the largest number of participants in the trial, the former resulting in a higher cost per participant than the latter. TRIAL REGISTRATION: ClinicalTrials.gov NCT03362918; https://clinicaltrials.gov/ct2/show/NCT03362918.

Systematic review and meta-analysis: SGLT2 inhibitors, blood pressure and cardiovascular outcomes.

OBJECTIVE: Clinical trials suggest that SGLT2 inhibitors reduce the risk of cardiovascular mortality in patients with type 2 diabetes, however the mechanism is unclear. Our objective was to test the hypothesis that blood pressure reduction is one potential mechanism underlying the observed improvements in cardiovascular outcomes with SGLT2 inhibitors. METHODS: We searched MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (inception-June 2019) for randomized controlled trials that reported the effect of SGLT2 inhibitors compared with placebo on cardiovascular outcomes in adults with type 2 diabetes. Two reviewers independently extracted data and assessed study quality. Random effects meta-analyses, stratified meta-analyses and meta-regressions were conducted to evaluate the association between blood pressure reduction in SGLT2 inhibitor treated patients and cardiovascular outcomes. RESULTS: Of 11,232 articles identified, 40 articles (n = 54,279 participants) were included. The relative risk of cardiovascular mortality was reduced by 18% with the use of SGLT2 inhibitors compared with placebo (RR 0.82; 95%CI 0.74, 0.91, I2 = 0.0%). Meta-regression analysis revealed no detectable difference in cardiovascular mortality (RR 0.93; 95%CI 0.88, 1.13, p = 0.483), 3-point major adverse cardiovascular events (p = 0.839) or congestive heart failure hospitalizations (p = 0.844) with change in mean systolic blood pressure. CONCLUSIONS: Cardiovascular events are reduced in participants with type 2 diabetes treated with SGLT2 inhibitors compared with placebo. There was no significant relationship between the risk of developing adverse cardiovascular events and blood pressure reduction with SGLT2 inhibitors. There is insufficient evidence to suggest that blood pressure reduction is a significant contributor to the cardiovascular benefits observed.

Proceedings From The 11th Annual University Of Calgary Leaders In Medicine Research Symposium.

On November 8th, 2019, the Cumming School of Medicine at the University of Calgary hosted the 11th annual Leaders in Medicine (LIM) Research Symposium. Dr. Donald A. Redelmeier, Professor at the University of Toronto and Canada Research Chair in Medical Decision Sciences, served as the keynote speaker with a talk entitled "Pitfalls of Reasoning and Clinical Medicine". In addition, there were five oral and 64 poster presentations. These presentations covered topics ranging from health promotion to neuroimaging. The event celebrated the continuing success and diversity of the LIM program and the training of clinician-scientists at the University of Calgary.

Exercise training and reproductive outcomes in women with polycystic ovary syndrome: A pilot randomized controlled trial.

OBJECTIVE: Exercise is recommended for polycystic ovary syndrome (PCOS), but the most effective exercise prescription is unclear. This trial compared effects of high-intensity interval training (HIIT), continuous aerobic exercise training (CAET) and no-exercise control on reproductive, anthropometric and cardiometabolic outcomes in PCOS. DESIGN: Pilot randomized controlled trial. PARTICIPANTS: Previously inactive women aged 18-40 years with PCOS. MEASUREMENTS: Feasibility outcomes included recruitment, retention, adherence to exercise and daily ovulation prediction kit (OPK) testing. Preliminary efficacy outcomes included reproductive, anthropometric and cardiometabolic health markers. RESULTS: Forty-seven women were randomized to no-exercise control (n = 17), HIIT (n = 16), or CAET (n = 14). Forty (85%) participants completed the trial. Median exercise adherence was 68% (IQR 53%, 86%). Median daily OPK-testing adherence in the first half of the intervention was 87% (IQR 61%, 97%) compared with 65% (IQR 0%, 96%) in the second half. Body mass index decreased significantly in CAET compared with control (-1.0 kg/m2 , p = .01) and HIIT (-0.9 kg/m2 , p = .04). Mean waist circumference decreased in all groups (-7.3 cm, -6.9 cm, -4.5 cm in HIIT, CAET and control) with no significant between-group differences. Mean LDL-C was significantly reduced for HIIT compared to CAET (-0.33 mmol/L, p = .03). HDL-C increased in HIIT compared with control (0.18 mmol/L, p = .04). CONCLUSIONS: There were feasibility challenges with adherence to daily ovulation assessment limiting the ability to analyse the effect of the exercise interventions on ovulation. CAET and HIIT were both effective at improving anthropometrics and some cardiometabolic health markers. Further studies need to determine optimal and acceptable exercise prescriptions for this population.

Malignancy risk of hyperfunctioning thyroid nodules compared with non-toxic nodules: systematic review and a meta-analysis.

BACKGROUND: Hyperfunctioning or hot nodules are thought to be rarely malignant. As such, current guidelines recommend that hot nodules be excluded from further malignancy risk stratification. The objective of this systematic review and meta-analysis is to compare the malignancy risk in hot nodules and non-toxic nodules in observational studies. METHODS: Ovid MEDLINE Daily and Ovid MEDLINE, EMBASE, Scopus, and Web of Science databases were searched. Observational studies which met all of the following were included: (1) use thyroid scintigraphy for nodule assessment, (2) inclusion of both hyperfunctioning and non-functioning nodules based on scintigraphy, (3) available postoperative histopathologic nodule results, (4) published up to November 12, 2020 in either English or French. The following data was extracted: malignancy outcomes include malignancy rate, mapping of the carcinoma within the hot nodule, inclusion of microcarcinomas, and presence of gene mutations. RESULTS: Among the seven included studies, overall incidence of malignancy in all hot thyroid nodules ranged from 5 to 100% in comparison with non-toxic nodules, 3.8-46%. Odds of malignancy were also compared between hot and non-toxic thyroid nodules, separated into solitary nodules, multiple nodules and combination of the two. Pooled odds ratio (OR) of solitary thyroid nodules revealed a single hot nodule OR of 0.38 (95% confidence interval (CI) 0.25, 0.59), toxic multinodular goiter OR of 0.51 (95% CI 0.34, 0.75), and a combined hot nodule OR of 0.45 (95% CI 0.31, 0.65). The odds of malignancy are reduced by 55% in hot nodules; however, the incidence was not zero. CONCLUSIONS: Odds of malignancy of hot nodules is reduced compared with non-toxic nodules; however, the incidence of malignancy reported in hot nodules was higher than expected. These findings highlight the need for further studies into the malignancy risk of hot nodules.

Sex Differences in Endovascular Treatment for Stroke: A Population-based Analysis.

BACKGROUND: Acute ischemic stroke may affect women and men differently. We aimed to evaluate sex differences in outcomes of endovascular treatment (EVT) for ischemic stroke due to large vessel occlusion in a population-based study in Alberta, Canada. METHODS AND RESULTS: Over a 3-year period (April 2015-March 2018), 576 patients fit the inclusion criteria of our study and constituted the EVT group of our analysis. The medical treatment group of the ESCAPE trial had 150 patients. Thus, our total sample size was 726. We captured outcomes in clinical routine using administrative data and a linked database methodology. The primary outcome of our study was home-time. Home-time refers to the number of days that the patient was back at their premorbid living situation without an increase in the level of care within 90 days of the index stroke event. In adjusted analysis, EVT was associated with an increase of 90-day home-time by an average of 6.08 (95% CI -2.74-14.89, p-value 0.177) days in women compared to an average of 11.20 (95% CI 1.94-20.46, p-value 0.018) days in men. Further analysis revealed that the association between EVT and 90-day home-time in women was confounded by age and onset-to-treatment time. CONCLUSIONS: We found a nonsignificant nominal reduction of 90-day home-time gain for women compared to men in this province-wide population-based study of EVT for large vessel occlusion, which was only partially explained by confounding.

Harassment in the Field of Medicine: Cultural Barriers to Psychological Safety.

Psychologically safe organizational cultures are inherently inclusive and promote healthy sharing of power and knowledge. These conditions allow innovation to thrive and optimize member performance. Unfortunately, despite its evidence-based nature, the field of medicine continues to struggle with providing safe environments for its members. Several cultural barriers to psychological safety permit endemic harassment. These include having large power gradients, a weak ethical climate, and a number of enabling structural factors that maintain a toxic culture. Moving toward psychological safety will be challenging work, as it requires a difficult and complex analysis of the shared value system that enables the status quo. Programs and policies that promote equity, diversity, and inclusion are an important start, but they are likely insufficient on their own to achieve psychological safety. Leadership that models difficult reflection and supports inclusive transformation is the key to a safe culture shift.

Les cultures organisationnelles qui favorisent la sécurité psychologique sont intrinsèquement inclusives et favorisent le partage sain du pouvoir et des connaissances. Ces conditions sont un terreau fertile pour l'innovation et l'optimisation du rendement. Malheureusement, bien qu'elle soit par sa nature même fondée sur des données probantes, la médecine est un domaine où l'on peine encore à offrir un environnement sécuritaire. Plusieurs obstacles culturels à la sécurité psychologique permettent un harcèlement endémique, notamment les grands écarts hiérarchiques, un climat éthique déficient et un certain nombre de facteurs structurels favorables au maintien d'une culture toxique. Le cheminement vers la sécurité psychologique est une gageure, car il exige une analyse complexe et difficile du système de valeurs partagées qui donne lieu au statu quo. La mise en place de programmes et de politiques axés sur l'équité, la diversité et l'inclusion constitue un premier pas important, mais ne suffira probablement pas à assurer la sécurité psychologique. Un leadership qui s'engage ouvertement dans une réflexion difficile et soutient une transformation inclusive est la clé du passage à une culture sécuritaire.

The Challenges of Identifying Environmental Determinants of Type 1 Diabetes: In Search of the Holy Grail.

Type 1 diabetes is the result of autoimmune-mediated destruction and inflammation of the insulin-producing ß-cells of the pancreas. The excess morbidity and mortality from its complications coupled with its increasing incidence emphasize the importance to better understand the etiology of this condition. It has a strong genetic component, but a genetic predisposition is not the sole contributor to disease development as only 30% to 50% of identical twins both develop the disease. In addition, there are multiple lines of evidence to support that environmental factors contribute to the pathogenesis of type 1 diabetes. Environmental risk factors that have been proposed include infections, dietary factors, air pollution, vaccines, location of residence, childhood obesity, family environment and stress. Researchers have conducted many observational studies to identify and characterize these potential environmental factors, but findings have been inconsistent or inconclusive. Many studies have had inherent methodological issues in recruitment, participation, defining cases and exposures, and/or data analysis which may limit the interpretability of findings. Identifying and addressing these limitations may allow for greatly needed advances in our understanding of type 1 diabetes. As such, the purpose of this article is to review and discuss the limitations of observational studies that aim to determine environmental risk factors for type 1 diabetes and propose recommendations to overcome them.

Frequency of laboratory testing and associated abnormalities in patients with hypertension.

Clinical practice guidelines recommend several routine laboratory tests in patients diagnosed with hypertension. However, the rates of clinically relevant laboratory abnormalities are unknown. Therefore, we conducted a retrospective cohort study using administrative and laboratory data of patients diagnosed with hypertension between April 2010 and March 2015 in Alberta, Canada. Laboratory investigations for renal function, serum electrolytes (sodium and potassium), low-density lipoprotein (LDL) cholesterol, and diabetes (fasting blood glucose and hemoglobin A1c), measured within 1 year of diagnosis, were examined, and the frequency of abnormalities determined. A total of 225 296 cases of incident hypertension were identified. Of these, 74.3% received at least one of the four guideline-recommended laboratory tests, but only 42.3% received all four tests. Patients who received any testing, compared to subjects who did not, were on average older (median age 55.9 vs 51.2 years, P < .001) and had more comorbidity (14.5% vs 2.8% with a Charlson comorbidity index ≥ 3, P < .001). Laboratory abnormalities with the potential to affect clinical decision-making were more common among multi-comorbid patients. Patients with renal dysfunction (6.7% vs 11.6%, 26.3%, P < .001), electrolyte abnormalities (9.8% vs 12.6%, 20.5%, P < .001), and diabetes (13.4% vs 25.1% vs 38.8%, P < .001) were found in patients with Charlson scores of 0 vs 1-2 vs ≥3, respectively. Our study found most patients diagnosed with hypertension received some laboratory testing, but rates of laboratory testing and frequency of abnormalities varied by clinical context. Testing and abnormalities detected were both more common among older patients and patients with comorbidities.

Long-Term Physical Activity Levels After the End of a Structured Exercise Intervention in Adults With Type 2 Diabetes and Prediabetes: A Systematic Review.

OBJECTIVES: Randomized, controlled trials have shown that exercise interventions reduce the incidence of type 2 diabetes in people with impaired glucose tolerance, and improve glycemic control, body composition and cardiorespiratory fitness in people with type 2 diabetes. We undertook the present systematic review to determine the extent to which participants in structured exercise trials continue to be physically active after the end of the interventions. METHODS: We systematically searched MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Central Register of Controlled Trials for randomized, controlled trials that reported objective or self-reported physical activity levels in people with type 2 diabetes or prediabetes a minimum of 3 months after the end of a structured exercise intervention. This systematic review was registered on PROSPERO (PROSPERO CRD42018089468). RESULTS: Of 14,649 articles retrieved, 5 randomized, controlled trials (including 549 participants) were included in this systematic review. One study revealed significant improvements in self-reported physical activity levels in the intervention group compared with the control group 1, 3 and 5 years after baseline assessments, and decreased waist circumference, weight and body mass index at 1 year, but not 3 or 5 years. The 4 remaining studies did not find between-group differences at follow-up timepoints between 6 months and 3 years. CONCLUSIONS: Future research should report physical activity levels at follow up to determine whether participation in a structured exercise intervention results in sustained increased physical activity levels. In addition, interventions should be evaluated for their effectiveness in improving adherence to long-term physical activity.

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.