Hypertension on the CCFP exam

Approach

• Measure blood pressure at the right primary care visits in every adult. Higher-risk groups may need checks more often: South Asian, Indigenous or African ancestry, or more than one heart risk factor.
• You need not measure at every visit if nothing calls for it.
• A high reading at a pharmacy, at home or in the office raises the question. Then measure it properly in the office.
• Office average under 130/80: no hypertension. Keep checking yearly, or when the chance comes up.
• Normal in the office but high at home suggests masked hypertension. Get readings outside the office when you suspect it.
• The 2025 Canadian primary care guideline is for adults 18 and older. It is not for children or pregnancy.

Approach

• Use a validated automated upper-arm device. Hypertension Canada keeps a list of recommended devices.
• Before you start: a quiet room, and no caffeine, tobacco or exercise in the 30 minutes before.
• Seat the patient with the back supported, legs uncrossed and feet flat on the floor.
• Bare, supported arm. Middle of the cuff at heart level, lower edge 3 cm above the elbow crease.
• Choose the cuff by the size of the arm. Keep a full range of cuff sizes.
• Rest 1 to 5 minutes if you can. Take 3 readings 1 minute apart, with no talking. Average and record them all.
• Careless office readings run 5 to 10 mm Hg high on average. Use a manual cuff for a persistent irregular heartbeat.

Approach

• The line is 130/80 or higher, on standardized readings. A reading of exactly 130/80 counts.
• A high office average means suspected hypertension. It is not the diagnosis yet.
• Confirm with home readings: two readings, twice a day, for one week. Or use the daytime average from an ambulatory monitor (a cuff worn for a day that reads automatically).
• Average outside the office 130/80 or more: hypertension. Below that: white-coat hypertension. Keep checking yearly.
• White-coat hypertension shows up in 15 to 30% of people with a high office reading.
• If readings outside the office are not possible, repeat standardized office readings at a separate visit. This is less exact.

Approach

• After the diagnosis, run routine tests for heart risk and organ damage.
• Ask about heart disease, heart failure, stroke and leg artery disease. Each one makes the risk high.
• Ask about diabetes, type 1 or type 2, and about smoking. Counsel every smoker to quit.
• Examine for signs of the same conditions, such as heart failure or weak leg pulses.
• Check kidney function and urine albumin. An estimated filtration rate (eGFR) under 60, or albumin to creatinine of 3 mg/mmol or more, is high risk.
• Check lipids and work out a 10-year Framingham risk (a score for the chance of heart disease in 10 years). A score of 20% or more is high risk.
• Age 75 or older is high risk on its own.

Approach

• Confirm the hypertension first. The search for a cause comes after.
• Clues to another cause: low potassium, an adrenal nodule, a whooshing sound (bruit) heard over the abdomen, or onset at a young age.
• More clues: sudden unexplained worsening, severe hypertension, or kidney injury after treatment starts.
• Resistant hypertension: above target on all three first-line classes at the highest doses tolerated, taken as prescribed.
• Screen resistant hypertension for other causes. Primary aldosteronism, too much of the hormone aldosterone, is common in this group.
• Check aldosterone and renin (a kidney hormone that controls aldosterone), ideally before starting spironolactone.
• Refer to a specialist when the clues point to another cause.

Approach

• Offer lifestyle change to every adult with hypertension, with or without drugs.
• Ask what the patient eats, drinks and does. Target the habits they actually have.
• Sodium: under 2 g a day. Over 70% comes from processed food, not the salt shaker.
• So the change must reach whoever buys and cooks the food.
• Eat more fruit and vegetables for potassium. Monitor potassium with kidney disease or a drug that raises it.
• Counsel every smoker to quit, mainly for heart risk.

Approach

• Start a drug at 140/90 or more, or at systolic 130 to 139 with high heart risk. Not high risk at 130 to 139: lifestyle, and recheck in 3 to 6 months.
• High risk: heart or artery disease, diabetes, chronic kidney disease, 10-year Framingham risk 20% or more, or age 75 or older.
• Aim for systolic under 130 if tolerated. Frailty, falls, dizziness on standing or goals of care can justify a higher goal.
• Start with two low-dose drugs, ideally in one pill. One drug is reasonable if a sharp drop in pressure is a real risk.
• Pick two of three classes: an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB); a thiazide-type diuretic; a long-acting dihydropyridine calcium channel blocker. Dihydropyridine means the amlodipine type. Still above target: add the third.
• Beta-blockers are not first line unless there is a reason: heart failure, angina, after a heart attack, or heart rate or rhythm control.
• Never combine an ACE inhibitor with an ARB. Avoid both in pregnancy or when trying to conceive, and counsel anyone who could become pregnant.

Approach

• Severe or malignant hypertension is a clue to another cause. Refer once the patient is safe.
• Malignant hypertension means very high pressure that is damaging organs.

Approach

• See the patient every 1 to 3 months until at target, then every 6 to 12 months.
• Judge the response on standardized office or home readings.
• Ask how the pills are taken before adding a drug. Two drugs in one pill help people take them.
• Monitor potassium with kidney disease or on an ACE inhibitor, an ARB or spironolactone.
• Ramipril can raise potassium. Salt substitutes that contain potassium should be used with caution on it.
• Check potassium 2 to 4 weeks after starting spironolactone or changing its dose. Warn men about breast growth.
• Thiazide-type diuretics can lower potassium. Chlorthalidone does so more often than hydrochlorothiazide.
• Ask about dizziness, falls and fainting. Tighter control raises these risks a little. They matter most in frail patients.