Hypertension

Rationale

Hypertension is a common condition that presents with elevation in either systolic or diastolic blood pressure and represents a major risk factor for morbidity and mortality in Canada. In some cases, it can constitute a medical emergency with life-threatening consequences. Hypertension in pregnancy may be life-threatening for both mother and fetus. Appropriate investigation and management of hypertension are expected to improve health outcomes.

Causal Conditions

(list not exhaustive)

1. Essential hypertension
2. Secondary hypertension
   1. renal parenchymal disease (e.g., kidney injury, polycystic kidney disease)
   2. metabolic or endocrine (e.g., adrenal adenoma/hyperplasia, thyroid disease)
   3. vascular (e.g., unilateral renal artery stenosis, coarctation of the aorta, renal vein thrombosis)
   4. catecholamine excess (e.g., pheochromocytoma, anxiety)
   5. intracranial hypertension (e.g., brain tumour, cerebral edema)
   6. obstructive sleep apnea
   7. prescription drug or recreational substance use (e.g., alcohol, nicotine, corticosteroids, stimulants)
   8. pregnancy (e.g., gestational hypertension, eclampsia, HELLP [hemolysis, elevated liver enzymes, low platelets] syndrome

Key Objectives

Given a patient with hypertension, the candidate will diagnose the cause, severity, and complications, and will initiate an appropriate management plan. Particular attention should be paid to other cardiac risk factors, existing target organ damage, and the identification of patients with hypertensive urgencies and emergencies.

Enabling Objectives

Given a patient with hypertension, the candidate will

1. list and interpret key clinical findings, including those derived from
   1. an appropriate assessment technique to correctly diagnose hypertension and its severity,
   2. an appropriate history aimed at eliciting risk factors (e.g., family history),
   3. an appropriate physical examination aimed at eliciting evidence of acute and chronic target organ damage and secondary causes, and
   4. a gestational history for pregnant patients and assessment of fetal well-being;
2. list and interpret critical investigations, including
   1. baseline investigations (e.g., creatinine, electrolytes, urinalysis),
   2. tests for risk factors (e.g., lipids, glucose),
   3. tests for secondary causes where indicated (e.g., urinary catecholamines, thyrotropin [thyroid-stimulating hormone]),
   4. imaging studies where indicated (e.g., computed tomography of the head, magnetic resonance imaging of the brain, abdominal ultrasonography, echocardiography), and
   5. tests for end organ damage (e.g., urinalysis, electrocardiography); and
3. construct an effective initial management plan, including
   1. reduction in modifiable risk factors (e.g., sodium reduction, weight loss, smoking cessation),
   2. antihypertensive medication, taking into consideration concomitant conditions (e.g., diabetes mellitus, renal disease),
   3. an antihypertensive medication regimen, taking into consideration individual characteristics (e.g., child, older adult [≥ 65 years], pregnant patient), adherence, and potential for adverse effects,
   4. parenteral agents for hypertensive emergencies and appropriate titration and monitoring,
   5. strategies for the prevention of complications,
   6. consideration of psychosocial aspects of taking lifelong medications (e.g., cost, adherence), and
   7. collaboration with specialists as indicated (e.g., paediatrics, nephrology, high-risk obstetrics).