Cardiovascular Disease

sec_arr Hypertension
SECTIONS

Hypertension

The relationship between blood pressure (BP) and risk of CVD events (heart attacks, strokes, heart failure, etc.) is continuous, consistent, and independent of other risk factors.3 Therefore, BP must be monitored on an annual basis following the procedures outlined by the American Heart Association4,5 (see Appendix A).

Self (home) and ambulatory BP measurements are useful for monitoring CVD.6 However, given the LEO’s possible conflicting interests, clinic or office readings must be used to determine duty status. In addition, LEOs on anti-hypertensive medications must be evaluated and questioned about any possible job-impairing side effects, such as electrolyte disturbances or orthostatic hypotension (see LEO chapter on Medications). The association between increasing BP and cardiovascular events rises with the presence of additional CVD risk factors and end-organ damage due to hypertension.5,7-17 Therefore, all LEOs with hypertension should be screened for: a) other CVD risk factors (diabetes mellitus, smoking, hyperlipidemia, obesity, and lack of exercise); and b) hypertensive renal, cardiovascular or eye damage (see Appendix B).

The following discussion addresses work restrictions and frequency of monitoring for three stages of hypertension. It is important to note that the criteria used are from the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-6),3 rather than the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7),7 or the Eighth Joint National Committee (JNC-8) because criteria relevant for job restrictions is found under Stage 3 in JNC-6.3

Stage I (Mild): Systolic 140-159 millimeters of mercury (mmHg) or diastolic 90-99 mmHg.

  • No restrictions.
  • Screen for other CVD risk factors (age, sex, total cholesterol, high-density cholesterol, systolic BP, use of anti-hypertensive therapy, diabetes, and current smoking). For the LEO ≥40 years of age, use this information to estimate a 2-year or 10-year risk for atherosclerotic cardiovascular disease (ASCVD) defined as coronary death, fatal stroke, nonfatal myocardial infarction, or nonfatal stroke. LEOs assessed at intermediate or high risk (>2% ASCVD risk over the next 2 years or ≥10% ASCVD risk over the next 10 years) should be restricted until a symptom-limiting exercise stress test (EST) to 12 metabolic equivalents (METs) can be performed (see section on Coronary Artery Disease).18,19
  • Screen for end-organ damage – if end-organ damage is present (see Appendix B), an EST to 12 METs should be performed (see section on Coronary Artery Disease).8-17
  • Referral to treating physician for evaluation and treatment.
  • Recheck BP and 2-year or 10-year risk for ASCVD 19
  • Screen for end-organ damage annually if hypertension persists.9

Stage II (Moderate): Systolic 160-179 mmHg or diastolic 100-109 mmHg

  • No restrictions.
  • Screen for other CVD risk factors (age, sex, total cholesterol, high-density cholesterol, systolic BP, use of anti-hypertensive therapy, diabetes, and current smoking). For the LEO ≥40 years of age, use this information to estimate a 2-year or 10-year risk for atherosclerotic cardiovascular disease (ASCVD) defined as coronary death, fatal stroke, nonfatal myocardial infarction, or nonfatal stroke. LEOs assessed at intermediate or high risk (>2% ASCVD risk over the next 2 years or ≥10% ASCVD risk over the next 10 years) should be restricted until a symptom-limiting EST to 12 METs can be performed (see section on coronary artery disease).18,19
  • Screen for end-organ damage – if end-organ damage is present (see Appendix B), an EST test to 12 METs should be performed (see section on coronary artery disease).8-17,19
  • Referral to treating physician for evaluation and treatment.
  • Recheck BP in 1 month:
    • If BP is <140/90 mmHg, then no restriction and recheck BP every 3 months for 1 year.
    • If BP is reduced to Stage I, then no restriction and, recheck BP in 1 month (see section on Stage I for further evaluation). If BP remains in Stage II, provide restrictions until blood pressure is reduced to Stage I or below.

Stage III (Severe): Systolic ≥180 mmHg or diastolic ≥110 mmHg

  • Provide restrictions.
  • Screen for other CVD risk factors (age, sex, total cholesterol, high-density cholesterol, systolic BP, use of anti-hypertensive therapy, diabetes, and current smoking). For LEOs ≥40 years of age, use this information to estimate a 2- and 10-year risk for atherosclerotic cardiovascular disease (ASCVD) defined as coronary death, fatal stroke, nonfatal myocardial infarction, or nonfatal stroke. LEOs assessed at intermediate or high risk (>2% ASCVD risk over the next 2 years or ≥10% ASCVD risk over the next 10 years) should be restricted until a symptom-limiting EST to 12 METs can be performed (see section on coronary artery disease).18,19
  • Screen for end-organ damage – if end-organ damage is present (see Appendix B), an EST to 12 METs should be performed (see section on coronary artery disease).8-17,19
    • Refer to treating physician for evaluation and treatment.
    • On recheck:
      • If BP is <140/90 mmHg, then no restrictions and recheck BP every 3 months.
    • If BP is in Stage I, then no restrictions, and recheck BP in 1 month (see section on Stage I for further evaluation).
      • If BP is in Stage II or III, provide restrictions until blood pressure is reduced to Stage I or a,5,20-23

aThis represents a consensus of the Task Force regarding the guidance documents developed by other organizations.20-23